A systematic review and meta-analysis of the effects of non-pharmacological interventions in improving psychological status and sleep quality among hemodialysis patients

Abstract

Background Patients receiving maintenance hemodialysis (MHD) experience substantial physical and psychological burdens. Non-pharmacological interventions have been increasingly explored as potential approaches for improving psychological symptoms and sleep quality in this population. Objective To systematically evaluate the effects of non-pharmacological interventions on depression, anxiety, and sleep quality in patients receiving MHD. Methods Systematic searches were conducted in PubMed, Embase, CINAHL Complete, Cochrane Library, and Web of Science from January 2000 to February 2026 for English-language randomized controlled trials (RCTs). The Cochrane Risk of Bias 2 (RoB 2) tool was used to assess the risk of bias in included trials. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were used as effect estimates for continuous outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence. Meta-analyses were performed using RevMan 5.4 and R version 4.5.2. Result Fourteen randomized controlled trials were included. Meta-analyses comprised 9 studies (570 participants) for depression, 11 studies (647 participants) for anxiety, and 14 studies (871 participants) for sleep quality. Compared with usual care, non-pharmacological interventions significantly improved depression (SMD = −0.62, 95% CI: −0.87 to −0.37, I2 = 52%), anxiety (SMD = −0.86, 95% CI: −1.23 to −0.49, I2 = 79%), and sleep quality (SMD = −0.94, 95% CI: −1.33 to −0.55, I2 = 87%). Leave-one-out sensitivity analyses did not materially reduce heterogeneity for anxiety or sleep quality. Exploratory subgroup analyses revealed no statistically significant differences in effect estimates according to intervention type or duration (P > 0.05). Potential publication bias was suggested for depression, whereas no statistically significant evidence of publication bias was identified for anxiety or sleep quality. Based on the GRADE framework, the certainty of evidence was moderate for depression and low for anxiety and sleep quality. Conclusion The available evidence suggests that non-pharmacological interventions may improve depressive symptoms, anxiety symptoms, and sleep quality in patients receiving MHD. However, the certainty of evidence was low for anxiety and sleep quality outcomes and moderate for depressive symptoms, and these findings should be interpreted cautiously. Systematic Review Registration Identifier CRD420261370746.