This study discusses the effectiveness of complementary therapies in reducing anxiety in patients with chronic kidney disease (CKD) undergoing hemodialysis (HD). Through a systematic review of 32 out of 6,711 articles obtained from various databases (2015–2025), it was found that therapies such as Benson relaxation, lavender aromatherapy, music therapy, acupressure, guided imagery, spiritual interventions (dhikr and reading the Qur'an), as well as technologies like Virtual Reality (VR) and brain stimulation (tDCS), are effective in reducing anxiety. These therapies encompass physical, psychological, spiritual, and technological aspects. Although promising, further research is needed to support their clinical implementation.
Chronic kidney disease (CKD) is defined as kidney damage or a
reduction in the glomerular filtration rate (GFR) below 60 mL/min/1.73
m² for at least three months, regardless of its underlying cause
(Yonata
≥30 mg per 24 hours or the presence of kidney abnormalities, such
as hematologic disorders, structural anomalies, polycystic kidney
disease, or dysplasia (Chen, Knicely and Grams, 2019; Elendu
The number of CKD patients in stages 3–5 is expected to reach 4
million by 2036 (Evans
According to the 2018 Basic Health Research (Riskesdas) of the
Republic of Indonesia, the prevalence of chronic kidney failure in
Indonesia increased from 2% in 2013 to 3.8% in 2018, reaching a total
of 713,783 patients, reflecting a 1.8% rise (Riskesdas, 2018). Along
with the growing number of chronic kidney failure patients, the demand
for hemodialysis therapy in Indonesia has also risen. In 2018, there
were 66,433 new patients undergoing hemodialysis, while the number of
active patients receiving this treatment reached 132,142 (Indonesian
Renal Registry, 2018). Hemodialysis serves as a replacement therapy
for patients with kidney failure, functioning to remove excess
metabolic waste or uremic toxins from the blood, including water,
sodium, potassium, hydrogen, urea, creatinine, uric acid, and other
substances. This process occurs through a semipermeable membrane via
diffusion, osmosis, and ultrafiltration (UF) mechanisms while
preserving essential substances such as glucose, electrolytes, and
amino acids (Swarnalatha and Kumar, 2015; Hidayah
The hemodialysis procedure typically lasts between three and four
hours. It is performed three times a week in developed countries,
whereas in developing countries, it is generally conducted twice a
week (Ali
Good mental health in hemodialysis patients is reflected in their
ability to accept the disease, manage complications, handle stress,
adopt effective coping strategies, and receive adequate social
support, all of which influence their psychological well-being. A high
level of disease acceptance, a healthy coping style, and strong social
support are positively associated with better mental health conditions
(Wen
Based on these findings, this study aims to conduct a systematic literature review to explore and evaluate the effectiveness of complementary therapies in reducing anxiety in hemodialysis patients.
Complementary therapies are treatments or therapies that are used as a complement to conventional medical treatment, not as a substitute. These therapies aim to improve the physical, mental, and emotional well-being of patients, often used to reduce symptoms, improve quality of life, or help cope with the side effects of primary treatment.
Anxiety is a psychological condition characterized by feelings of restlessness, excessive worry, tension, or fear of something that has not happened or is considered a threat, either real or imagined. Anxiety is a normal response of the body to stress, but if it occurs continuously, excessively, or interferes with daily activities, it can become a health problem that needs to be addressed.
Hemodialysis is a medical procedure used to replace kidney function in patients with chronic or acute kidney failure, especially when the kidneys are no longer able to filter waste and excess fluid from the blood effectively.
The steps of a systematic review are to explore comparative questions, identify relevant articles, assess the quality of the studies, and summarize and interpret the results. The research question of this review is how complementary therapies reduce anxiety in chronic kidney failure patients undergoing hemodialysis.
The researcher collected information from the Google Scholar, ProQuest, EBSCO, ScienceDirect, and PubMed databases in March 2025. The keywords used in this study are: "Complementary Therapies" OR "Therapy, Complementary" OR "Complementary Medicine" OR "Therapies, Alternative" AND "Anxiety" AND "Renal Dialysis" OR "hemodialysis"—inclusion and exclusion criteria to ensure suitability with the research objectives. Inclusion criteria include literature that focuses on chronic kidney failure patients undergoing hemodialysis, discusses complementary therapies to reduce anxiety, is published between 2015 and 2025, and uses quantitative research methods. English-language articles are also one of the selection criteria. On the other hand, articles that do not discuss hemodialysis patients, published before 2015, or are literature reviews and preliminary investigations will be excluded from the review.
The initial step in study selection involves establishing a logical framework using the PICO model to determine relevant keywords based on inclusion criteria. The components of PICO are as follows: P (Population) – Hemodialysis patients experiencing anxiety, I (Intervention) – Complementary therapy, C (Comparison) – Standard care or no complementary treatment, and O (Outcome) – Reduction in anxiety levels measured using standardized assessment tools. Reference management software, Mendeley, is utilized to organize and filter data by entering relevant database directories. Any detected duplicates are merged. Valid papers are stored in a "potential folder" if they meet the title and abstract selection criteria. The designated reviewer (M) independently examines the folder to determine which studies qualify for inclusion in the review. Reviewers (M) then extract information from each selected study independently. The extracted data include study characteristics (year of publication, language, and country), participant characteristics (number of participants and type of intervention), intervention details (training and duration), and study outcomes related to anxiety reduction.
The data synthesized in a systematic review consists of findings from individual studies relevant to the research question, specifically the implementation of complementary therapies to reduce anxiety. The authors present the main results by summarizing key findings from the included studies. This synthesis highlights that most reviews acknowledge heterogeneity by outlining various criteria for implementing complementary therapies.
Reviewers (RMs) evaluate the quality of articles in the journals they choose to review. Using the JBI critical appraisal tool.
Articles were obtained from Google Scholar, ProQuest, EBSCO, ScienceDirect, and PubMed with specific inclusion criteria, covering the period 2015–2025, full-text access, journal type, and quantitative and mixed methods, resulting in 6,711 articles. After eliminating 19 duplicates through Mendeley, 6,692 articles remained. Initial screening based on title, abstract, and relevance excluded 5,328 articles due to inappropriate design, topic, language, or population. A total of 1,364 articles proceeded to the full-text access stage, but 1,201 of these were unavailable, leaving 163 articles for eligibility assessment. After further review, 131 articles were eliminated due to the inappropriateness of the study concept, and finally, 32 articles were included in the systematic review.
The ages of respondents ranged from 18–77 years, with the majority in the range of 46–65 years. The mean age of the intervention group varied from 50.75
± 18.02 to 61.85 ± 7.93 years, while the control group had a mean age between
54.61 ± 5.89 to 63.00 ± 9.80 years.
The literature from these 32 articles was analyzed, involving a total of 2.062 respondents.
This study was conducted in various countries, including the Middle East, such as Iran, Turkey, and Egypt; Southeast Asia, such as Indonesia and Malaysia; Europe, including Poland, Hungary, and Spain; and Latin America, especially Brazil.
Among the 32 reviewed articles, the State-Trait Anxiety Inventory (STAI) was the most commonly used anxiety measurement tool, appearing in 8 studies. This was followed by the Hospital Anxiety and Depression Scale (HADS), used in 7 studies, and the Hamilton Anxiety Rating Scale (HARS), utilized in 5 studies. Additionally, both the Beck Anxiety Inventory (BAI) and the Depression Anxiety Stress Scale (DASS-21) were employed in 4 studies each.
Other measurement tools, such as the Covi Anxiety Scale, Visual Analogue Scale (VAS), State Anxiety Inventory (SAI), Zung Self-Rating Anxiety Scale (ZSRAS), and the Hamilton Rating Scale for Anxiety, were used in a smaller number of studies. Despite the variation in instruments, all tools included in the review are relevant and appropriate for assessing anxiety levels in respondents.
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1 |
Holy Qur’an Recitation |
(Babamohama di |
Iran |
60 Patient. |
The intervention group listened to a recording of
Surah Yasin recited by Qari Shateri for 20 minutes (5 minutes before + 15 minutes during dialysis), 3x/week for 1 month.
The control group received no intervention— evaluation
after 1 month. |
Average age 53 years. | Listening to the recitation of the Qur'an was proven to be effective in reducing anxiety in hemodialysis patients, with a significant decrease compared to the control group (F = 15.5, p = 0.0002, Cohen's d = 1.03). |
STAI |
2 |
Virtual Reality Exercises on Anxiety |
(Turoń- Skrzypińska |
Poland |
85 Patient. |
The intervention group performed VR exercises with
NefroVR for 20 minutes during hemodialysis, while the
control group only underwent hemodialysis without
intervention. |
Intervent ion age 57 years and control 62 years. | Low-intensity virtual reality cycling training for 3 months was effective in reducing Beck and GAD-7 scores (p < 0.001), while the control group experienced an increase in |
General Anxiety Disorder-7 (GAD-7) |
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GAD-7 scores (p = 0.002). |
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3 |
Guided Imagery |
(Afshar 2018) |
Iran |
70 Patient. |
The intervention group received GI therapy 6x a week
for 4 weeks. They listened to a GI guidance CD for 25
minutes per session. The control group received only
routine care without relaxation therapy. |
18-70 years |
Analysis of covariance showed significant differences in status anxiety (p < 0.001). Guided imagery was effective in reducing anxiety. |
State-Trait Anxiety Inventory (STAI) |
4 |
Spiritual Care |
(Durmuş and Ekinci, 2022) |
Türkiye |
71 Patient. |
The intervention group received an intensive
spirituality training program for 8 weeks (total of 16
sessions, 2 times/week for 20-30 minutes). The control
group continued with the standard treatment protocol
without additional intervention and post-test (after the
16th session). |
The average age of patients was 56.09 ± 12.66 years. |
Post- intervention anxiety scores in the experimental group were lower than those in the control group. Changes in the experimental group were significant (p < 0.05), while those in the control group were not significant (p > 0.05). | Hospital Anxiety and Depression Scale (HADS) |
5 |
Education and Art Therapy with Telehealth Method |
(Mollaoğlu |
Türkiye |
60 Patient. |
The intervention group received an education program,
art therapy, and intensive monitoring for 3 months,
while the control group received only usual care. Both
groups were evaluated periodically. |
Age 46- 65 years |
Beck anxiety scores did not differ initially between IG and CG but decreased significantly in IG at the second measurement (P = 0.04), indicating the effectiveness of the intervention in reducing anxiety. |
Beck Anxiety Inventory (BAI) |
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6 |
Progressive Muscle Relaxation |
(Kusnanto |
Indonesia |
105 Patient. |
Group 1: Performing Progressive Muscle Relaxation
(PMR) twice a week for 1 month. Group 2: Performing PMR once a week for the same
duration. Control Group: No PMR intervention. |
> 18 years |
Mann- Whitney U test showed a significant effect on anxiety (p = 0.004). PMR intervention is effective in reducing anxiety in hemodialysis patients. |
Covi Anxiety Scale. |
7 |
Echinacea (EP107TM) |
(Haller 2025) |
Hungary |
24 Patient. |
The intervention group received Echinacea EP107™
tablets (40 mg/day) for 6 weeks, while the control group received a
placebo. Evaluations were performed at the end of treatment
(day 42) and follow- up (day 49). |
Age 43.3 ± 1.9 years. |
This study showed that Echinacea was effective in reducing anxiety more quickly than placebo. HADS-A scores decreased significantly on days 16 and 28, with severe anxiety disappearing at the end of the intervention. HAM-A scores were also reduced in both groups, but anxiety improved more quickly in the Echinacea group. |
Hospital Anxiety and Depression Scale– anxiety subscale HADS-A and HAM-A |
8 |
Inhaled Lavender |
(Ozen 2023) |
Türkiye |
24 Patient. |
The intervention group received aromatherapy
inhalation (3 drops of a mixture of lavender and almond
oil in a ratio of 1:10) dripped onto sterile gauze. The control group received |
Average control 63 years and intervent ion 56.77 years. | Lavender aromatherapy reduced anxiety in the intervention group (P < .05), while the control group showed no significant changes. |
Visual Analogue Scale (VAS) dan STAI |
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no intervention during the study but will be given
similar aromatherapy after the survey is completed for
one week and evaluated 4. |
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9 |
Guided Imagery |
(Beizaee 2018) |
Iran |
80 Patient. |
Hemodialysis patients were given Guided Imagery
therapy 3x/week for a month, compared to a control group
that only received regular care. |
The mean age of participa nts was 47.21 ± 8.34 years. |
After the intervention, the levels of anxiety and depression in the intervention group were significantly lower than in the control group (p = 0.030; p = 0.001). |
HADS |
10 |
Movie Watching |
(Morais, Moreira and Winkelmann, 2020) |
Brazil |
61 Patient. |
The experimental group watched comedy films 2x/week
for 6 weeks (2 hours/session) during hemodialysis, while
the control group received only standard care. |
Mean age 61.7 ± 13.9 years. |
The intervention group experienced a significant decrease in anxiety (p < 0.001), while the control group showed no significant change (p = 0.016). |
Hamilton Anxiety Scale |
11 |
Acupressure |
(Hmwe 2015) |
Malaysia |
108 Patient. |
The experimental group received acupressure therapy
3x/week for 4 weeks (15 minutes/session ) at specific points (Yin Tang, Shenmen, Taixi),
while the control group only received standard care. |
The mean age of participa nts was 58.08 ± 11.4 years. |
The intervention group (acupressure) experienced a significant decrease in anxiety/insom nia (p < 0.001), while the control group did not experience any significant changes (p = 0.133). Acupressure is effective in reducing anxiety in patients. |
DASS-21 |
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| 12 |
Lavender Aromatherapy |
(Şahin, Tokgöz and Demir, 2021) |
Turki |
74 Patient. |
The experimental group received lavender steam
inhalation (5 drops in 200 cc of hot water) for 5
minutes per session, performed 3 times a week with a
standard protocol (eyes closed, deep breathing, and
covered with a cloth). The control group underwent an
identical procedure using olive oil as a placebo. |
Intervent ion group: 50.75 ± 18.02 years. Placebo group: 53.62 ± 11.03 years. |
The intervention group showed a significant decrease in STAI anxiety scores at the second follow- up (p < 0.05). In contrast, the difference with the placebo group at the first follow-up was not significant (p > 0.05). Lavender inhalation has the potential to be a safe and effective method to reduce anxiety in hemodialysis patients. |
STAI |
| 13 |
Lavender Aromatherapy |
(Meneklİ and Durmaz, 2021) |
Turki |
80 Patient. |
The experimental group received lavender aromatherapy
through massage and inhalation for 6 weeks. The massage
was performed on the pruritic area every HD session for
7–15 minutes, while inhalation used lavender- scented
cotton before bedtime. The control group only underwent
routine care without additional therapy. Effectiveness was assessed after 6 weeks. |
Age 41– 55 years |
Anxiety score (AI) in the intervention group decreased significantly after intervention (p=0.003) and was substantially different from the control group (p=0.003). Lavender aromatherapy is effective in reducing anxiety in hemodialysis patients. |
State Anxiety Inventory (SAI) |
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| 14 |
Lavender Oil Application Via Inhalation |
(Şentürk and Kartin, 2018) |
Turki |
34 Patient. |
The intervention group received lavender aromatherapy
by inhalation for 1 week. The control group was not
given any intervention. |
The intervent ion group was predomi nantly aged 42– 52 years, while the control group was predomi nantly aged 53– 65 years. |
The total and subdimension scores of the Hamilton Anxiety Scale differed significantly between the intervention and control groups (P<0.001). Lavender inhalation was shown to be effective in reducing anxiety. |
Hamilton Anxiety Assessment Scale |
| 15 |
Music Therapy |
(Gulcek and Aylaz, 2022) |
Turki |
120 Patient. |
The intervention group received music therapy of
maqam “Rast” and “Ussak” for 3 weeks, three times a
week, 30 minutes each during hemodialysis. The control group only underwent routine care without
music therapy. |
Average age 25-64 years | Music therapy significantly decreased situational anxiety in hemodialysis patients compared to the control group. | State and trait anxiety scale |
| 16 |
Acupressure |
(Suandika 2021) |
Indonesia |
96 Patient. |
The intervention group received acupressure at the
original acupuncture points (K1, ST36, SP6) for 4 weeks, three times a week, during the first 2 hours
of hemodialysis. The control group received acupressure at the sham
points without therapeutic effect by the same method. |
Age >18 years | Acupressure was shown to significantly reduce anxiety in hemodialysis patients compared to the control group (HADS: 7.653 vs 14.968; p = 0.000). |
HADS |
| 17 |
Music |
(Haghi, Zadeh and Vafayee, 2019) |
Iran |
25 Patient. |
The intervention group received classical and |
Average age 31-60 years |
The average anxiety score of patients |
Beck anxiety inventory (BAI) |
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modern music therapy for 4 weeks, three times a week,
30 minutes each during hemodialysis. The control group only received routine care without
music therapy. Evaluation after 12 sessions |
before the intervention reached 19.6% and decreased to 14.48% after the intervention, with a statistically significant decrease (P < 0.05). | |||||||
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Lavender Oil Inhalation versus Acupressure |
(El-abdeen |
Egypt |
66 Patient. |
Intervention group A received lavender oil inhalation
for 4 weeks, three times a week, for 20 minutes after 1
hour of hemodialysis. Intervention group B received
acupressure at three specific points for 15 minutes per
session. The control group received only routine care
without additional intervention. Anxiety after 4 weeks |
average age 69.4 ± 9.8. |
Elderly anxiety scores decreased significantly after intervention, with lavender aromatherapy being more effective than acupressure (p = 0.001). |
Geriatric Anxiety Scale |
| 19 | Aromatherapy |
(Setyawan, Syahruramdha ni and Setyaningrum,
2022) |
Indonesia |
32 Patient. |
The intervention group received lavender aromatherapy
for 15 minutes in each hemodialysis session for three
sessions. Lavender- scented cotton was placed under the
patient's nose to be inhaled commonly. The control
group only underwent |
Average age 46-59 years. | The parametric t- test showed a significant decrease in pre-post values in the intervention group (p = 0.001). The delta difference between the control and intervention groups was also important (p = 0.001). |
Zung-Self Rating Anxiety Scale (ZSRAS) |
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hemodialysis without additional intervention.
Evaluation at the third session. |
Lavender aromatherapy is effective in reducing anxiety. | |||||||
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Dhikr |
(Anggun 2021) |
Indonesia |
32 Patient. |
The intervention group underwent dhikr therapy before
and after hemodialysis with a specific dhikr sequence,
done verbally or silently. The control group only
underwent hemodialysis procedures without dhikr. |
Average age 46-55 years. | The results showed that dhikr therapy significantly reduced anxiety levels in hemodialysis patients (p < 0.05). The decrease in anxiety in the experimental group was more significant than in the control group. |
Hospital Anxiety and Depression Scale |
| 21 |
Benson Relaxation Technique |
(Otaghi 2016) |
Iran |
70 Patient. |
The intervention group received Benson’s Relaxation
Therapy for 15 minutes twice daily for 4 weeks, with one
session in the hospital and one independent session at
home. The control group received only routine care
without relaxation therapy. |
The average age was 62.29 ± 8.51 years. |
Benson relaxation is effective in reducing anxiety in hemodialysis patients (p < 0.05). | Depression Anxiety Stress Scale (DASS) 21 |
| 22 |
Comparing the Effect of Acupressure and Foot
Reflexology |
(Dehghanmehr |
Iran |
60 Patient. |
The intervention group underwent acupressure therapy
at the P6 point (8 minutes) or reflexology at the solar
plexus point (10 minutes per foot) three times a week
for 4 weeks. The |
Reflexolo gy (42.75 ± 8.8 years), acupress ure (39.20 ± 11.32 years), and control (40.85 ± 6.15 years). |
The experimental group showed a significant decrease in anxiety after the intervention (P < 0.001), while the control group did not experience any significant changes. |
State-Trait anxiety inventory (STAI) |
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control group received only routine care. |
Acupressure and reflexology are effective in reducing anxiety in hemodialysis patients. |
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| 23 |
Eye Movement Desensitization And Reprocessing |
(Rahimi 2019) |
Iran |
90 Patient. |
The intervention group underwent EMDR therapy during
hemodialysis three times a week for 2 weeks over 4 weeks. Sessions lasted 30–45 minutes
according to Shapiro's protocol. The control group
received routine care only. |
Mean age was 51.52 ± 11.134 years. |
Before the intervention, the mean anxiety scores did not differ significantly between groups (P = 0.10). After the intervention, the anxiety scores decreased substantially in the intervention group (P = 0.001), indicating the effectiveness of EMDR in reducing anxiety. |
Hospital anxiety and depression scale |
| 24 |
Benson’s Relaxation |
(Kiani, Zadeh and Shahrakipour, 2017) |
Iran |
105 Patient. |
The intervention group received Benson relaxation
technique training in three group sessions (60 minutes)
and individual instruction in the first week. Patients practiced twice daily for 4 weeks, with
monitoring via checklists and phone calls. The control
group received routine care only. |
Rata-rata usia peserta adalah 42,73 ± 12,16 tahun. |
Benson relaxation was effective in reducing anxiety in hemodialysis patients (P = 0.001), while there was no significant change in the control group. | Spielburger anxiety evaluation questionnair e |
| 25 |
Humor |
(Borzoee 2022) |
Iran |
63 Patient. |
The intervention group underwent humor therapy for
one month with six sessions |
The mean age of participa nts in the intervent |
After the intervention, state anxiety scores decreased significantly in |
State-Trait Anxiety Inventory (STAI) |
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(120 minutes per session) in the group. The sessions
included funny video screenings, competitions with
prizes, and interactive humor sharing. The control group
received only routine care. Anxiety evaluation was
conducted after 3 weeks. |
ion and control groups was 61.85 ± 7.93 and 54.61 ± 5.89 years, respectiv ely. |
the intervention group (P < 0.001), while in the control group it increased (P = 0.227). Humor therapy is effective in reducing state anxiety in hemodialysis patients. | ||||||
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Resilience Training |
(Amirkhani |
Iran |
57 Patient. |
The intervention group underwent 12 resilience
training sessions through workshops guided by clinical
psychologists using lecture, discussion, role- playing,
and peer training methods. The control group did not
receive training during the study but received a
workshop after the survey was completed. The evaluation
was conducted one week after the intervention. |
Average age 40–70 years. | Patient anxiety scores decreased significantly in the intervention group (P < 0.001) but did not change significantly in the control group (P > 0.05). Resilience training is practical as a non- pharmacologic al method to reduce anxiety in hemodialysis patients. |
Depression Anxiety Stress Scale (DASS) 21 |
| 27 |
Listening to Music |
(Midilli, Ergin and Yilmaz, 2017) |
Türkiye |
46 Patient. |
The experimental group listened to music for 30
minutes during hemodialysis using earphones, with the
music of Maqam Hicaz and Nihavend from the |
The mean age of patients in this study was 59.00 ± 16.09 years. |
There was a significant difference in anxiety scores between the two groups (p<0.05). In the intervention group, anxiety scores decreased |
State Trait Anxiety Inventory (STAI) |
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TÜMATA group. The control group only underwent hemodialysis
procedures without music, with anxiety and vital signs
measured at the same time. |
significantly at 30 minutes of dialysis (z=- 3.821, p=0.000). The results showed that music is effective in reducing anxiety in hemodialysis patients. |
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| 28 |
Differences Between the Effects of The Benson
Relaxation Technique and Deep Breath |
(Krismiadi, Wihastuti and Ismail, 2023) |
Indonesia |
52 Patient. |
The intervention group received Benson relaxation
therapy and deep breathing for 4 weeks. Benson relaxation was performed twice daily for 15–20
minutes, both during hemodialysis and at home, with
audio and written guidance. Training was provided in three group sessions in the
first week. The control group received standard care only. |
The Benson relaxatio n group had more participa nts in the 45–59 age category, while the deep breathing relaxatio n group had more participa nts in the 60–74 age category. | Benson relaxation is more effective than deep breathing relaxation in reducing anxiety in hemodialysis patients (p = 0.000 < 0.05). | Hamitton Rating Scale For Anxiety |
| 29 |
Aromatherapy Using the Damask Rose Essential Oil |
(Dehkordi |
Iran |
60 Patient. |
The intervention group received aromatherapy with
Damascus rose oil for one month, performed at every
hemodialysis session. The control group received only
standard care. |
The mean age of the control group was 58.2 ± 12.6 years, and the mean age of the intervent ion group was 58.9 ± 13.4 years. |
After intervention, anxiety decreased significantly in the damask rose aromatherapy group (P ≤ 0.05) but not in the control group. Conclusion: Damask rose inhalation aromatherapy is effective in reducing anxiety in |
Depression Anxiety Stress Scale (DASS) 21 |
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hemodialysis patients. |
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| 30 |
Live Music |
(Soliva 2024) |
Spanish |
90 Patient. |
The intervention group received live music therapy
for four weeks, with twice-weekly sessions of 30– 45 minutes in the hemodialysis room. The music played
covered a variety of genres, including classical,
popular, and spiritual. The control group received only
standard care. |
In the intervent ion group (IG), the average age in the first Monday, Wednesd ay, and Friday sessions was 70.41 years, while in the second Tuesday, Thursday , and Saturday sessions, it was higher, at 77.75 years. Meanwhi le, in the control group (CG), the average age in the second Monday, Wednesd ay, and Friday sessions was recorded at 73.12 years, and in the first Tuesday, Thursday , and Saturday sessions, it was the highest, at 79.21 years. |
The intervention group listening to music experienced a significant decrease in anxiety (-5.35; p < 0.001), while the control group experienced an increase in anxiety over time. |
Hospital Anxiety and Depression Scale (HAD) |
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| 31 |
Lavender Aromatherapy |
(Setyaningrum and Setyawan, 2023) |
Indonesia |
32 Patient. |
Intervention Group: Received lavender aromatherapy
through inhalation by dropping essential oil on cotton
buds. Control Group: Did not receive aromatherapy. |
Average age 46-59 | The study findings showed a significant decrease in pre-post scores in the intervention group (p = 0.001). The difference in delta scores between the control and intervention groups was also important (p = 0.001). Lavender aromatherapy has been shown to be effective in reducing anxiety. |
Zung-Self Rating Anxiety Scale (ZSAS) |
| 32 |
Transcranial Direct Current Stimulation (tDCS) |
(Ebrahimi and Azizi, 2022) |
Iran |
30 Patient. |
Patients in the experimental group received two mA
transcranial direct current stimulation (tDCS)
electrical stimulation for 10 20-minute sessions per
week. The control group received no intervention. |
- | The anxiety score after the intervention was also significantly lower than before the intervention in the experimental group (p < 0.001), while in the control group, there was no significant difference (p > 0.05). Electrical brain stimulation has been shown to be effective in reducing anxiety and stress in hemodialysis patients. |
Anxiety and Stress Questionnair e (DASS-21) |
Anxiety is one of the most common psychological problems
experienced by hemodialysis (HD) patients, which can worsen physical
conditions and overall quality of life (Delgado-Domínguez
holistic nursing encourages the use of complementary therapies
based on bio- psycho-socio-spiritual as a safe and effective
non-drug alternative to reduce anxiety (Wijaya
Breathing relaxation techniques aim to enhance alveolar
ventilation, support effective gas exchange, prevent pulmonary
atelectasis, and improve cough efficiency. These techniques also
help alleviate both physical and emotional stress by reducing pain
levels and anxiety. Additionally, they contribute to lowering
systolic and diastolic blood pressure and promoting better sleep
quality in dialysis patients (Muhith
Krismiadi et al., (2023) also found that Benson Relaxation was more effective than deep breathing techniques. In addition, Eltafianti et al., (2022) supported the evidence of the effect of Benson relaxation on reducing anxiety in hemodialysis patients. Meanwhile, progressive muscle relaxation performed twice a week for one month, as studied by Kusnanto et al., (2019), was shown to reduce anxiety significantly. After progressive muscle relaxation, the parasympathetic nervous system is activated and releases acetylcholine in the ganglion. Acetylcholine then binds to nicotinic receptors on the muscle membrane in the postsynaptic area, which stimulates muscarinic receptors. This helps reduce anxiety and makes muscles and mental conditions more relaxed and comfortable (Carisa and Wahyuni, 2022).
Therefore, relaxation and breathing techniques such as Benson Relaxation, progressive muscle relaxation, and deep breathing can be effective non- pharmacological intervention alternatives to reduce anxiety, increase calmness, and support mental well-being in hemodialysis patients.
Aromatherapy, particularly with lavender oil, has been proven effective in alleviating anxiety among hemodialysis (HD) patients. Research by Ozen et al., (2023) demonstrated that inhaling lavender oil over 12 sessions significantly reduced anxiety and enhanced patient comfort. Similarly, other studies (Setyawan, Syahruramdhani and Setyaningrum, 2022; Setyaningrum and Setyawan, 2023) found that applying three drops of lavender oil on a cotton bud
and placing it 1 cm below the nose for 15 minutes, followed by a 10-minute break, effectively decreased anxiety levels in HD patients. Additionally, Salsabila et al., (2025) reported similar findings, showing that inhaling lavender oil through a diffuser for 30 minutes was beneficial in reducing anxiety.
Further studies (Şentürk and Kartin, 2018; Meneklİ and Durmaz,
2021; Şahin, Tokgöz and Demir, 2021), support the effectiveness of
lavender aromatherapy in lowering anxiety and improving sleep
quality, whether administered through inhalation or massage. Apart
from lavender, damask rose oil has also been found to have
anxiolytic effects, as reported by Dehkordi
Music therapy aims to reduce negative emotions and physical
symptoms and improve psychological well-being. Music can calm,
inspire, energize, and reduce anxiety by relaxing the mind and
minimizing stress (Ji
Another study by Yulianto et al., (2024) supports the effectiveness of education in the form of explanations about the patient's condition and humor therapy (Javanese jokes) in reducing family anxiety levels in the Emergency Room (IGD). In addition (Midilli, Ergin and Yilmaz, 2017; Haghi, Zadeh and Vafayee, 2019) reported that listening to music during the hemodialysis process also had a positive impact on reducing anxiety. Another study by Soliva et al., (2024) found that live music played by professional musicians significantly reduced patient anxiety. Similar findings were reported by Gulcek & (Aylaz, 2022) who revealed that music therapy with traditional melodies was effective in reducing anxiety. In conclusion, music therapy, either through recordings or live performances, as well as humor, is a valuable and enjoyable approach to help HD patients manage anxiety.
Acupressure is a non-invasive, safe, and cost-effective therapy
that can be self-administered after proper training. Specific
acupressure points have been identified to help alleviate anxiety,
promote relaxation, and influence pathological mechanisms associated
with depression (Novianti and Safitri Muchtar, 2021). This therapy
has been shown to effectively reduce symptoms of depression,
anxiety, and stress in both elderly individuals and hemodialysis
(HD) patients (Komariah
Guided imagery therapy allows patients to create and receive suggestions from themselves through the subconscious threshold or relaxed state by following finger movements as instructed. This therapy is a verbal communication art designed to enter suggestions independently, helping patients reduce their anxiety (Safitri and Tresya, 2023). A study by Afshar et al., (2018) showed that conducting guided imagery six times a week for four weeks can significantly reduce anxiety. Beizaee et al., (2018) also found that a frequency of three times a week for four weeks had a similar effect in reducing anxiety. These findings indicate that mental relaxation techniques such as guided imagery can be a helpful strategy in managing anxiety in HD patients.
Spiritual therapy is an alternative treatment that uses prayer and dhikr to increase self-confidence and optimism, as well as reduce the psychological impact of stress and anxiety. This helps patients adapt to physical conditions during hemodialysis that can be psychologically stressful (Faizal and Putri, 2021; Kurniasih, Kurnia and Istiqomah, 2021). Research by Babamohamadi et al., (2015) reported that listening to the recitation of the Qur'an is effective in reducing anxiety in patients. found that dhikr also has a significant effect in reducing anxiety.
In addition, research by (Durmuş and Ekinci, 2022) showed that spiritual care carried out for 16 sessions provided effective results in reducing anxiety levels. These results are supported by research (Nurrohmah and Rinaldi, 2022) that spiritual therapy can reduce anxiety in the elderly. These findings emphasize
the importance of a spiritual approach in anxiety management in hemodialysis (HD) patients.
Technology-based interventions, such as Virtual Reality (VR) and Transcranial Direct Current Stimulation (tDCS), have shown promising potential in reducing anxiety in hemodialysis (HD) patients. Research by Turoń- Skrzypińska et al., (2023) found that VR training using the NefroVR system for 20 minutes was effective in reducing anxiety in HD patients. The effect of VR on anxiety can be explained through two mechanisms, namely exposure and distraction (Yulianti and Mulyono, 2021). In addition, Ebrahimi & Azizi, (2022) reported that tDCS, which involves giving mild electrical stimulation to the brain, was able to reduce anxiety significantly.
Eye Movement Desensitization and Reprocessing (EMDR) therapy, studied by Rahimi et al., (2019), has also been shown to be effective in reducing anxiety in HD patients by processing adverse events experienced by clients. Saccadic movement in EMDR stimulates the brain to release anxiety into the conscious mind (Renata and Satrianta, 2020). These findings suggest that technology-based interventions can be an innovative alternative to anxiety management.
The use of herbal interventions, such as Echinacea EP107™ extract, has also shown potential in reducing anxiety in hemodialysis (HD) patients. research conducted by Haller et al., (2025) found that Echinacea EP107™ extract was effective in reducing psychological anxiety in hemodialysis patients, although it did not affect somatic symptoms of anxiety. This extract significantly reduced anxiety compared to placebo, supporting the use of herbal therapies to manage anxiety in HD patients by suppressing pro-inflammatory cytokines and oxidative stress. Echinacea works by activating CB1 receptors in the brain, increasing the effects of GABA, decreasing glutamate, and increasing serotonin and stabilizing the autonomic system to create relaxation.
Some additional interventions, such as art therapy and resilience training, have also been shown to be effective in reducing anxiety. Research conducted by Mollaoğlu et al., (2024) showed that art therapy combined with telehealth-based education was effective in reducing anxiety in patients. In addition, Amirkhani et al., (2021) showed that resilience training, which included workshops, role- playing, and group discussions, was effective in reducing anxiety while improving the quality of life of HD patients. These findings enrich the non- pharmacological intervention options for managing anxiety in hemodialysis patients.
Based on the literature review conducted, it can be concluded that various interventions are effective in reducing anxiety in hemodialysis (HD) patients.
Relaxation techniques such as Benson Relaxation and Progressive Muscle Relaxation (PMR) have been shown to be significant in reducing anxiety levels. Aromatherapy, especially with lavender oil, has demonstrated consistency in reducing anxiety and increasing patient comfort. Music therapy, either through recordings or live performances, also has a positive effect in reducing anxiety. In addition, interventions such as acupressure, guided imagery, and spiritual approaches (such as dhikr and reading the Qur'an) also contribute to anxiety management. Technology-based interventions, such as Virtual Reality (VR) and Transcranial Direct Current Stimulation (tDCS), as well as herbal therapies such as Echinacea extract, have shown promising potential. Other interventions, such as art therapy, humor therapy, and resistance training, have also had positive impacts.
Overall, the combination of physical, psychological, spiritual, and technological approaches can be a comprehensive strategy to reduce anxiety in HD patients. The selection of interventions can be tailored to the patient's individual preferences and needs to achieve optimal results. These findings confirm that complementary therapies can be a practical and holistic approach to reduce anxiety in HD patients and improve their quality of life and psychological well-being. However, further studies with stronger designs, larger sample sizes, and longer intervention durations are needed to strengthen the evidence and optimize the application of complementary therapies in clinical practice.
Future studies should aim to strengthen the evidence base for the use of complementary therapies in reducing anxiety among hemodialysis (HD) patients. To achieve this, more high-quality randomized controlled trials (RCTs) are needed to validate the effectiveness of specific interventions and compare different types of therapies, such as spiritual versus technological approaches. Research involving larger and more diverse sample sizes is also essential to ensure the generalizability of findings across various populations and healthcare settings. Additionally, studies should assess the long-term effects of these interventions by extending the duration of therapy and incorporating follow-up periods to evaluate sustained outcomes on anxiety and overall quality of life. Exploring the effectiveness of multimodal interventions—combinations of two or more therapies—could reveal synergistic effects that offer greater benefits than single interventions. It is equally important to consider patient-centered approaches that investigate individual preferences, adherence, and acceptance of complementary therapies to enhance clinical applicability. Moreover, cost-effectiveness analyses are necessary to determine the economic feasibility of integrating these therapies into routine clinical practice. Finally, further research should explore the physiological and psychological mechanisms behind the observed benefits to provide a deeper understanding of how these interventions alleviate anxiety. These directions will help optimize the implementation of complementary therapies and support their role in holistic care for HD patients.