Portugal faces a significant burden of mental health disorders, with an estimated prevalence rate of 22.9% for any mental disorder, according to the Analysis of the World Mental Health Survey (WMHS) Initiative^.1 Despite this, data on the prevalence of mental health issues among Portuguese hemodialysis patients are notably absent. This includes the prevalence of depression or anxiety disorders, which are the most frequently observed.

Studies indicate that the prevalence of depression in hemodialysis patients ranges from 20% to 75%.^2,3Depression can manifest with diverse mental and physical symptoms, varying from mild sadness to suicidal ideation. Nevertheless, it is frequently overlooked and underdiagnosed. Depression substantially impairs quality of life² and increases the risk of cardiovascular disease, malnutrition, and inflammation, thereby contributing to poorer outcomes in hemodialysis patients.⁴

In Portugal, the healthcare system is heavily oriented towards acute care, often neglecting chronic conditions and rehabilitation. Mental health issues exemplify this systemic gap. Our country has one of the highest prevalences of patients on hemodialysis globally.⁵ The high quality of care provided for the physical aspects of health undoubtedly contributes to these numbers. Nephrologists and dialysis nurses are highly skilled and competent, and most outpatient hemodialysis clinics include dieticians or social workers to enhance care quality. However, few employ psychologists, leading to a significant, yet often unaddressed, psychological burden. Renal Psychology, a specialized field addressing the behavioral, cognitive, emotional, social, and existential challenges faced by individuals with kidney diseases and their caregivers, is undeniably essential. Despite compelling evidence linking mental health issues to poorer treatment adherence, increased complications, higher healthcare utilization, and premature mortality in this vulnerable population,⁶ the global presence of dedicated Renal Psychologists in nephrology centers remains critically insufficient.

The approval of Portugal’s ‘National Strategy for the Promotion of Kidney Health and Integrated Care in Chronic Kidney Disease 2023-2026’ and the establishment of the ‘Implementation Commission of the National Strategy for Chronic Kidney Disease’ (CIMEN‑DRC) signal a pivotal shift towards genuinely multidisciplinary healthcare through the recommended inclusion of psychologists. This forward‑thinking initiative acknowledges the multifaceted needs of kidney disease patients and their families, moving beyond a purely biomedical focus.

The project “Together We Stand” outlines a stepwise approach to psychological care for hemodialysis patients. Firstly, significant efforts were dedicated to designing evidence‑informed psychological interventions tailored specifically for this population. The project comprehensively evaluated the perceptions of patients, caregivers, and dialysis providers. This process identified critical areas for intervention, including communication skills, emotional management, psychological flexibility to cope with uncertainty, and adaptive strategies for treatment‑related challenges like neurocognitive changes, sexual dysfunction, needle distress, and caregiver burden. Crucially, recognizing barriers to face-to-face sessions, such as geographic distance and treatment burden, led to the development of alternative, Internet‑mediated modalities, underscoring a commitment to accessibility.

Secondly, the team addressed the pressing need for streamlined psychological assessment. Acknowledging the limitations of generic tools, they developed and validated two specific, easy‑to‑complete instruments: the Hemodialysis Distress Thermometer for Patients (HD‑DT) and for Caregivers (HD-DT-C). These tools serve as invaluable starting points for identifying distress sources and facilitating essential communication between healthcare providers and families, guiding referrals to appropriate support services. The validation of this pragmatic approach was a cornerstone for effective intervention.^7,8

Finally, the culmination of this structured effort is the ‘Connected We St@nd’ (CwS) program. This innovative, interdisciplinary online psychoeducational group initiative combines asynchronous health education with synchronous psychological support from clinical health psychologists. Its adaptable format, catering to patients, caregivers, or dyads, makes it uniquely responsive to individual preferences and needs. Early evidence of the CwS program’s feasibility, acceptability, and likely effectiveness in improving psychological health is highly encouraging, paving the way for large‑scale trials and, hopefully, integration into routine nephrology practices. The Portuguese experience powerfully demonstrates the indispensable role of Renal Psychologists in improving both physical and mental health outcomes for individuals with kidney failure and their families. The demonstrated willingness of patients and caregivers to engage in structured psychological assessments and flexible disease management programs underscores the high acceptability and potential clinical utility of such initiatives. To truly advance Renal Psychology practices in Portugal and, by extension, globally, it is imperative to: