Alexisomia, Depression, and Adherence in Kidney Transplantation: A Cross-Sectional Preliminary Investigation

Alexisomia, Depression, and Adherence in Kidney Transplantation: A Cross-Sectional Preliminary Investigation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Alexisomia, Depression, and Adherence in Kidney Transplantation: A Cross-Sectional Preliminary Investigation Taha Enes Cetin, Omer Faruk Akcay, Zilan Ayhan, Asil Demirezen, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8369597/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Adherence to immunosuppressive therapy (IT) is essential for long-term graft survival in kidney transplant recipients (KTRs). While depression and anxiety have been widely studied as determinants of nonadherence, the influence of emotional awareness and bodily perception constructs remain unclear. This study aimed to evaluate the associations of alexithymia, alexisomia, and affective symptoms with medication adherence among KTRs. Methods This cross-sectional study included 82 KTRs followed at a tertiary nephrology outpatient clinic. Participants completed validated psychometric instruments, including the Toronto Alexithymia Scale (TAS), Shitsu-taikan-sho Scale for alexisomia, Hospital Anxiety and Depression Scale (HADS), and the Immunosuppressant Therapy Adherence Scale (ITAS). Correlation analyses and stepwise linear regression were used to identify psychological predictors of adherence. Results The mean ITAS score was 10.49 ± 1.82. Medication adherence showed significant mild negative correlations with alexisomia (r = –0.267, p = 0.015), alexithymia (r = –0.327, p = 0.003), and depressive symptoms (r = –0.380, p < 0.001), while anxiety was not significantly associated with adherence (r = –0.189, p = 0.089). In the regression model, depressive symptoms were the only independent predictor of adherence (β = –0.380, p < 0.001), explaining 14.5% of the variance. To our knowledge, this is the first study to identify an association between alexisomia and IT adherence in KTRs. Conclusion Alexithymia, alexisomia, and depressive symptoms are significant psychological correlates of reduced IT adherence among KTRs. The novel finding regarding alexisomia suggests that impaired recognition and interpretation of internal bodily and emotional states may hinder consistent self-management after transplantation. Early psychosocial screening and targeted psychological interventions may improve adherence and reduce rejection risk in this population. Alexisomia Alexithymia Medication adherence Kidney transplantation Immunosuppressive therapy Depression INTRODUCTION Kidney transplantation (KT) is the preferred treatment modality for patients with end-stage renal disease (ESRD), offering superior survival and quality of life compared with hemodialysis (HD) or peritoneal dialysis (PD) [ 1 ]. However, long-term graft survival depends substantially on consistent adherence to immunosuppressive therapy (IT). Medication nonadherence has been reported to account for approximately 20% of acute rejection episodes and one-third of late graft losses, representing a major modifiable risk factor in transplant medicine. [ 2 ]. Psychological and behavioral factors are increasingly recognized as key determinants of medication adherence in kidney transplant recipients (KTRs) [ 3 ]. Depression, anxiety, and emotional regulation difficulties are frequently observed in KTRs and have been associated with reduced adherence to IT [ 4 ]. Alexithymia, defined as difficulty identifying and expressing emotions, has been associated with maladaptive coping behaviors and poor treatment adherence in chronic illnesses [ 5 ]. Alexisomia is conceptualized as a somatic expression of emotional distress, whereby individuals perceive psychological discomfort as bodily symptoms rather than recognizing it as an emotional state [ 6 ]. Although alexisomia is theoretically thought to negatively affect disease perception and treatment participation, its impact on medication adherence in the transplant population has not yet been investigated. Although numerous studies have investigated the effects of depression and anxiety on treatment adherence, the role of cognitive-emotional constructs related to emotion recognition and the perception of bodily sensations in this process has not been sufficiently elucidated [ 7 ]. Alexithymia and alexisomia, which impair the recognition and expression of internal emotional and somatic experiences, may affect both illness perception and treatment-related behaviors. We therefore examined whether alexithymia, alexisomia, and affective symptoms are associated with poorer immunosuppressive therapy adherence in KTRs. These findings may help identify psychological factors that contribute to nonadherence and inform the design of supportive interventions in this population. MATERIALS AND METHODS Participants This cross-sectional study was conducted at the Nephrology Outpatient Clinic of Gazi University Faculty of Medicine between February and April 2025. A total of 141 KTRs were invited to participate. Among those approached during routine clinic visits, 94 patients agreed to participate in the survey; however, due to incomplete data in 12 individuals, the final analysis was performed on 82 patients. Inclusion criteria were as follows: age ≥18 years, being under follow-up as a KTRs for at least 6 months, and having sufficient cognitive capacity to fully understand and complete the Hospital Anxiety and Depression Scale (HADS), Toronto Alexithymia Scale (TAS), Shitsu-taikan-sho Scale for alexisomia (STSS), and Immunosuppressant Therapy Adherence Scale (ITAS). Exclusion criteria included KTRs under 18 years of age, those who declined informed consent, patients with psychotic disorders that would interfere with questionnaire completion, and individuals with a history of psychotropic medication use. Sample size was based on available population; post-hoc power analysis showed adequate power. Data Collection Demographic and clinical characteristics were collected using both patient interviews and electronic medical records. Variables included age, sex, marital status, education levels, post-transplantation duration (years), donor type (living and deceased), smoking status, and alcohol use. Psychiatric history, family history of psychiatric disorders, and explanatory notes regarding previous or current illnesses were documented where applicable. Participants completed validated psychometric instruments, including the HADS, TAS, STSS, and ITAS. Complete data were available for all variables. All questionnaires were self-administered by the participants and completed during face-to-face interviews under the supervision of the research team. Assessment of Immunosuppressive Therapy Adherence Immunosuppressive medication adherence was measured using the ITAS, developed by Chisholm et al. for kidney transplant populations [8]. The scale consists of four items addressing medication-taking patterns over the past three months, with responses categorized as 0%, 1–20%, 21–50%, or >50% adherence. Scores range from 0 to 12, with higher scores representing better adherence. The Turkish adaptation has been validated by Madran et al. [9]. Although Chisholm's original framework considered only a score of 12 as indicating full adherence, alternative cutoff criteria have since been proposed [10]. categorizing scores as follows: 12 (perfect adherence), 10–11 (acceptable adherence), and ≤9 (poor adherence). We adopted this three-tier system, as minor adherence deviations are common in transplant recipients and do not necessarily compromise graft survival [11]. Moreover, the binary classification tends to overestimate nonadherence rates, whereas this stratified approach has been shown by Promraj et al. to better represent real-world adherence behaviors [12]. Assessment of Anxiety and Depression Anxiety and depression levels were assessed using the HADS, originally developed by Zigmond and Snaith in 1983 [13]. This instrument consists of 14 self-report items divided into two subscales, each comprising seven items: anxiety (HADS-A) and depression (HADS-D). Each item is rated on a 4-point Likert scale ranging from 0 to 3. Accordingly, each subscale yields a total score between 0 and 21, with higher scores indicating greater symptom severity. The Turkish adaptation of HADS has been reported to demonstrate satisfactory psychometric properties [14]. Assessment of Alexithymia Alexithymia was assessed using the 20-item TAS-20, originally developed by Bagby et al. in 1994 [15]. The Turkish version of TAS-20 has demonstrated satisfactory reliability and construct validity in previous validation studies by Güleç et al., confirming its suitability for use in Turkish clinical and non-clinical populations [16]. Written permission for the use of the Toronto Alexithymia Scale-20 (TAS-20) in this study was obtained from one of the original authors and copyright holders (R. Michael Bagby, PhD). Assessment of Alexisomia Alexisomia was assessed using the STSS, which originates conceptually from the psychophysiological framework first proposed by Ikemi in 1979 as a phenomenon where emotional tension manifests through bodily sensations rather than being cognitively recognized as an affective state [17]. The construct was later operationalized by Nakao as a measurable psychological trait and standardized in the form of the STSS, a 10-item self-report instrument rated on a 5-point Likert scale (1–5), with higher scores indicating greater levels of alexisomia [18]. Aksu et al. validated the Turkish version of the STSS, reporting adequate psychometric properties and factorial structure for use in Turkish clinical settings [19]. Statistical Analysis All statistical analyses were performed using IBM SPSS Statistics version 26.0. Variables with non-normal distribution, including serum creatinine and estimated glomerular filtration rate (eGFR), were presented as median (interquartile range). The relationships between ITAS total score and psychological measures (alexisomia, alexithymia, HADS-anxiety, HADS-depression) were evaluated using Pearson correlation analysis. To identify independent psychological predictors of medication adherence, variables that showed significant correlations in univariate analyses were entered into a stepwise linear regression model, with ITAS total score as the dependent variable. A two-tailed p value <0.05 was considered statistically significant. Ethical Considerations Ethical approval for this study was obtained from the Ethics Committee of Gazi University on 31 January 2025 (Approval No: 2025-147). The study was conducted in accordance with the Declaration of Helsinki. All transplanted organs were obtained through standard clinical transplantation procedures at the Department of Nephrology, Faculty of Medicine, Gazi University, Ankara, Türkiye. No organs or tissues were obtained from prisoners or other vulnerable populations. RESULTS A total of 82 KTRs were included in the final analysis. The mean age of the participants was 45.06 ± 12.32 years, and 63.4% were male. The mean duration since transplantation was 9.71 ± 6.79 years. Most participants were married (74.4%), nonsmokers (80.5%), and reported no history of psychiatric illness (93.9%). Sociodemographic and clinical characteristics are summarized in Table 1. The psychological scale scores and ITAS adherence scores are presented in Table 2. The mean ITAS total score was 10.49 ± 1.82, indicating generally high adherence with variability among individuals. Correlation analysis demonstrated significant negative relationships between ITAS total score and alexisomia (r = –0.267, p = 0.015), alexithymia (r = –0.327, p = 0.003), and depressive symptoms (r = –0.380, p < 0.001). Anxiety symptoms showed a nonsignificant trend toward lower adherence (r = –0.189, p = 0.089) (Table 3). A stepwise linear regression analysis was conducted to identify independent psychological predictors of immunosuppressive medication adherence. Among the candidate variables, only HADS-Depression remained in the final model. The model was statistically significant (R = 0.380, R² = 0.145, adjusted R² = 0.134, F(1,80) = 13.540, p < 0.001), accounting for 14.5% of the variance in ITAS total scores. In the final model, HADS-Depression demonstrated a significant association with ITAS total score (β = –0.380, B = –0.182, SE = 0.049, t = –3.680, p < 0.001) (Table 4). DISCUSSION This cross-sectional study examined 82 KTRs with a mean age of 45 years and a median follow-up period of approximately ten years after transplantation. Psychological factors related to emotional awareness and emotion processing were found to be closely associated with compliance with IT. Although the overall compliance level in the cohort was high, both alexithymia and alexisomia ITAS scores showed significant inverse relationships; this suggests that impairments in recognizing or interpreting emotional or physical states may negatively affect daily medication-taking behaviors. Depressive symptoms also showed a moderate negative relationship with adherence and emerged as the only significant independent predictor in the multivariate model, explaining 14.5% of the variance. Taken together, these findings suggest that beyond mere affective symptoms, deeper emotional processing characteristics may significantly influence treatment adherence in clinically stable KTRs. The magnitude of these relationships is consistent with previous studies showing that mood and emotional processing disorders have serious effects on post-transplant outcomes. Novak and colleagues followed 527 KTRs and reported that depressive symptoms nearly doubled the risk of mortality [ 20 ]. Similarly, Zelle and colleagues demonstrated in prospective cohort studies that depression increased the risk of graft loss by 51% and all-cause mortality by 67% [ 21 ]. These strong clinical effects parallel the fact that depressive symptoms explained a significant portion of the variance in adjustment in our study, suggesting that mood disorders, even at a subclinical level, can have measurable effects on behavioral outcomes. The relationship between alexithymia and lower treatment compliance is consistent with previous cross-sectional data reporting clinically high levels of alexithymia in approximately 40% of KTRs [ 22 ]. High levels of alexithymia have been shown to be associated with poorer perceived health status, lower treatment adherence, and weaker kidney function. Calia and colleagues reported that KTRs with high alexithymia had significantly lower treatment adherence and approximately 11 mL/min lower eGFR compared to individuals with better emotional awareness [ 23 ]. These findings support the moderate negative relationship between alexithymia and compliance in our study and suggest that emotional awareness deficits may have clinically significant effects. One of the original contributions of this study is that it is the first to show a significant relationship between alexisomia and immunosuppressive treatment compliance, as this relationship has not been previously investigated in the transplantation literature. Alexisomia, as defined in the Eastern psychosomatic medicine approach by Ikemi and colleagues, is characterized by misinterpreting emotional distress as physical symptoms and an excessive focus on bodily sensations [ 24 , 25 ]. Previous studies in psychosomatic populations have shown that individuals with high levels of alexisomia experience unexplained physical symptoms 2–3 times more frequently than individuals with better emotional awareness [ 25 ]. The significant negative relationship between alexisomia and treatment compliance in our study, along with the strong positive relationships between alexisomia and alexithymia and depression, suggests that alexisomia may be an overlooked psychological mechanism that could influence treatment behaviors in KTRs. These findings suggest that somatic-emotional misinterpretation may reduce insight into treatment, increase misattribution of side effects, and weaken confidence in IT. Behavioral research also supports these findings. Frazier and colleagues showed that emotional dysregulation and poor coping skills approximately doubled the likelihood of IT noncompliance [ 26 ]. A meta-analysis by Dew and colleagues also revealed that depression and anxiety are significant risk factors for morbidity and mortality in solid organ transplantation [ 27 ]. These data support that emotional processing disorders, beyond traditional mood symptoms, significantly shape treatment adherence. From a clinical perspective, our findings emphasize the importance of routine psychological screening in post-transplant follow-up. Standardized tools such as the HADS, TAS-20, and STSS can aid in the early identification of patients at risk of non-compliance due to emotional processing disorders. Integrating these assessments into comprehensive psychosocial screening systems, such as the Stanford Integrated Psychosocial Transplantation Assessment (SIPAT), may improve risk stratification and guide personalized interventions [ 28 ]. Psychotherapeutic approaches aimed at increasing emotional awareness, interpreting internal bodily sensations more accurately, or managing depressive symptoms have the potential to improve compliance and enhance long-term graft outcomes. This study has several strengths. It is the first to investigate alexisomia in the kidney transplant setting, and it uses multiple validated psychometric instruments specifically adapted for Turkish populations. The sample also reflects a real-world outpatient cohort with long-term post-transplant follow-up, enhancing the clinical relevance of the findings. Despite these advantages, the study also has some limitations. First, the cross-sectional design precludes establishing a causal relationship between psychological characteristics and medication adherence. Prospective studies are needed to assess whether alexithymia or alexisomia predict future nonadherence. Second, medication adherence was assessed using self-report, which may be susceptible to recall bias or social desirability effects. Future studies could strengthen the results by using objective adherence indicators such as blood level monitoring or electronic monitoring. Third, the study was single-center and may have limited generalizability to KTRs in different sociocultural or clinical settings. Finally, while the sample size was sufficient, a larger patient group would allow for the construction of more robust statistical models, according to post-hoc power analysis. CONCLUSION In conclusion, alexithymia, alexisomia, and depressive symptoms were significantly associated with reduced immunosuppressive adherence in KTRs, with depression emerging as the strongest predictor. The novel finding that alexisomia correlates with nonadherence suggests this construct represents an underrecognized but clinically relevant factor in post-transplant self-management. Early psychosocial screening incorporating assessment of emotional awareness may improve adherence and long-term graft outcomes in this population. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Gazi University Ethics Committee (Approval date: 14 January 2025, Approval number: 2025-147). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to inclusion in the study. Consent for publication Not applicable. Availability of data and materials Data supporting this study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no conflicts of interest relevant to this work. Funding The authors received no specific funding for this study. Authors’ contributions TEC conceptualized and designed the study, performed the statistical analysis, interpreted the data, and drafted the manuscript. OFA contributed to data acquisition, data interpretation, and critically revised the manuscript for important intellectual content. ZA contributed to data collection and interpretation and assisted in manuscript revision. AD contributed to data acquisition and critically revised the manuscript. VBT contributed to data interpretation and critically revised the manuscript. GG contributed to data acquisition and manuscript revision. MHA contributed to data collection and data interpretation. OH supervised the study, contributed to study design and data interpretation, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank all participants for their contribution to the study. 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Sociodemographic and Clinical Characteristics of the Study Population Variable n (%), Mean ± SD or Median (IQR) Age (years) 45.06 ± 12.32 Sex Female Male 30 (36.6) 52 (63.4) Serum creatinine (mg/dL) 1.40 (1.06–1.95) eGFR (mL/min/1.73 m²) 58.0 (39.0–74.5) Post-transplant duration (years) 9.71 ± 6.80 Marial Status Single Married 21 (25.6) 61 (74.4) Educational level Illiterate/Primary education High school or lower University 10 (12.2) 41 (50) 31 (37.8) Type of donor Living Deceased 56 (68.3) 26 (31.7) Smoking Status Non-smoker Smoker 66 (80.5) 16 (19.5) Alcohol use Non-user User 72 (87.8) 10 (12.2) History of psychiatric illness Absent Present 77 (93.9) 5 (6.1) Family history of psychiatric illness Absent Present 80 (97.6) 2 (2.4) eGFR= estimated glomerular filtration rate; SD= Standard deviation; IQR=Interquartile range. Table 2. Psychological Scala Scores of the Study Population Variable Min-Max Mean ± SD HADS- Anxiety 0-17 6.72 ± 4.08 HADS- Depression 0-18 6.65 ± 3.81 Alexisomia Total Score 20-68 40.28 ± 10.5 Alexithymia Total Score 28-79 51.57 ± 10.66 ITAS Total Score 3-12 10.49 ± 1.82 HADS= Hospital Anxiety and Depression Scale; ITAS= Immunosuppressant Therapy Adherence Scale; Min= Minimum; Max=Maximum; SD= Standard deviation. Table 3. Correlation Analysis Between Psychological Variables and Medication Adherence Variable ITAS Total Alexisomia Alexithymia HADS- Depression HADS- Anxiety ITAS Total - Alexisomia -0.267* - Alexithymia -0.327** 0.402** - HADS- Depression -0.380** 0.484** 0.508** - HADS- Anxiety -0.189 0.482** 0.476** 0.534** - HADS= Hospital Anxiety and Depression Scale; ITAS=Immunosuppressant Therapy Adherence Scale; * p<0.05; ** p<0.01. Table 4. Linear Regression Analysis for Predicting ITAS Total Score Variable B SE β t p Constant 11.696 0.378 - 30.955 <0.001 HADS-Depression -0.182 0.049 -0.380 -3.680 <0.001 Model statistics: R = 0.380; R² = 0.145; Adjusted R² = 0.134; SEE = 1.694; F(1,80) = 13.540; p < 0.001. B = unstandardized coefficient; SE = standard error; β = standardized coefficient; HADS = Hospital Anxiety and Depression Scale, ITAS = Immunosuppressant Therapy Adherence Scale. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 27 Jan, 2026 Editor assigned by journal 22 Jan, 2026 Editor invited by journal 30 Dec, 2025 Submission checks completed at journal 29 Dec, 2025 First submitted to journal 29 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8369597","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581376374,"identity":"8cd4ea05-20f6-4108-800f-8b2a4a96007a","order_by":0,"name":"Taha Enes Cetin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYFACHgjFz998AEhJyBChAapFcsaxBJAWHuK1GBzIMUCyFA+wZz978MPHHTb2DAfOfH51o8aCh4H98NENeG3hyUuWnHkmLbGxuXebdc4xoMN40tJu4HdYjoE0b9vhBGaGs9uMc9iAWiR4zPBr4X9j/Ptv2397NoacZ8Y5/4jRIpFjJs3YdoCxhyGH+XFuGzFabrwxs+xtS06cIXHMjDm3T4KHjZBf2PtzjG/8bLOztz/f/Phzzrc6OX72w8fwakEGbBJgkljlIMD8gRTVo2AUjIJRMHIAAJZIRWRWIya+AAAAAElFTkSuQmCC","orcid":"","institution":"Gazi University","correspondingAuthor":true,"prefix":"","firstName":"Taha","middleName":"Enes","lastName":"Cetin","suffix":""},{"id":581376376,"identity":"9b9d4c9c-29fb-48c8-870c-bcae892bb46a","order_by":1,"name":"Omer Faruk Akcay","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Omer","middleName":"Faruk","lastName":"Akcay","suffix":""},{"id":581376378,"identity":"0beb471f-8a55-45b9-946b-039ad78b99d8","order_by":2,"name":"Zilan Ayhan","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Zilan","middleName":"","lastName":"Ayhan","suffix":""},{"id":581376381,"identity":"da6a0809-56ed-47f0-98f2-6a43a7740a51","order_by":3,"name":"Asil Demirezen","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Asil","middleName":"","lastName":"Demirezen","suffix":""},{"id":581376384,"identity":"f6587cd7-b073-4c95-b684-82194e744f65","order_by":4,"name":"Veysel Baran Tomar","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Veysel","middleName":"Baran","lastName":"Tomar","suffix":""},{"id":581376387,"identity":"4dc429be-33ad-45de-9158-889b20ebd809","order_by":5,"name":"Galip Guz","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Galip","middleName":"","lastName":"Guz","suffix":""},{"id":581376390,"identity":"85cfc765-11ee-4e7b-a8fa-5dd45149d30b","order_by":6,"name":"Muhammed Hakan Aksu","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Muhammed","middleName":"Hakan","lastName":"Aksu","suffix":""},{"id":581376395,"identity":"defa8749-ffb4-4d05-82f9-9cc1819b101f","order_by":7,"name":"Ozant Helvaci","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Ozant","middleName":"","lastName":"Helvaci","suffix":""}],"badges":[],"createdAt":"2025-12-15 19:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8369597/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8369597/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101398590,"identity":"bed7a0b8-34f0-43b5-b5cc-b797be139f9d","added_by":"auto","created_at":"2026-01-29 09:42:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":753920,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8369597/v1/d0b7eedb-0496-4c2c-88da-bbae77c6f207.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Alexisomia, Depression, and Adherence in Kidney Transplantation: A Cross-Sectional Preliminary Investigation","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eKidney transplantation (KT) is the preferred treatment modality for patients with end-stage renal disease (ESRD), offering superior survival and quality of life compared with hemodialysis (HD) or peritoneal dialysis (PD) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, long-term graft survival depends substantially on consistent adherence to immunosuppressive therapy (IT). Medication nonadherence has been reported to account for approximately 20% of acute rejection episodes and one-third of late graft losses, representing a major modifiable risk factor in transplant medicine. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological and behavioral factors are increasingly recognized as key determinants of medication adherence in kidney transplant recipients (KTRs) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Depression, anxiety, and emotional regulation difficulties are frequently observed in KTRs and have been associated with reduced adherence to IT [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Alexithymia, defined as difficulty identifying and expressing emotions, has been associated with maladaptive coping behaviors and poor treatment adherence in chronic illnesses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Alexisomia is conceptualized as a somatic expression of emotional distress, whereby individuals perceive psychological discomfort as bodily symptoms rather than recognizing it as an emotional state [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although alexisomia is theoretically thought to negatively affect disease perception and treatment participation, its impact on medication adherence in the transplant population has not yet been investigated.\u003c/p\u003e \u003cp\u003eAlthough numerous studies have investigated the effects of depression and anxiety on treatment adherence, the role of cognitive-emotional constructs related to emotion recognition and the perception of bodily sensations in this process has not been sufficiently elucidated [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Alexithymia and alexisomia, which impair the recognition and expression of internal emotional and somatic experiences, may affect both illness perception and treatment-related behaviors. We therefore examined whether alexithymia, alexisomia, and affective symptoms are associated with poorer immunosuppressive therapy adherence in KTRs. These findings may help identify psychological factors that contribute to nonadherence and inform the design of supportive interventions in this population.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted at the Nephrology Outpatient Clinic of Gazi University Faculty of Medicine between February and April 2025. A total of 141 KTRs were invited to participate. Among those approached during routine clinic visits, 94 patients agreed to participate in the survey; however, due to incomplete data in 12 individuals, the final analysis was performed on 82 patients.\u003c/p\u003e\n\u003cp\u003eInclusion criteria were as follows: age ≥18 years, being under follow-up as a KTRs for at least 6 months, and having sufficient cognitive capacity to fully understand and complete the Hospital Anxiety and Depression Scale (HADS), Toronto Alexithymia Scale (TAS), Shitsu-taikan-sho Scale for alexisomia (STSS), and Immunosuppressant Therapy Adherence Scale (ITAS). Exclusion criteria included KTRs under 18 years of age, those who declined informed consent, patients with psychotic disorders that would interfere with questionnaire completion, and individuals with a history of psychotropic medication use. Sample size was based on available population; post-hoc power analysis showed adequate power.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and clinical characteristics were collected using both patient interviews and electronic medical records. Variables included age, sex, marital status, education levels, post-transplantation duration (years), donor type (living and deceased), smoking status, and alcohol use. Psychiatric history, family history of psychiatric disorders, and explanatory notes regarding previous or current illnesses were documented where applicable. Participants completed validated psychometric instruments, including the HADS, TAS, STSS, and ITAS. Complete data were available for all variables. All questionnaires were self-administered by the participants and completed during face-to-face interviews under the supervision of the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Immunosuppressive Therapy Adherence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImmunosuppressive medication adherence was measured using the ITAS, developed by Chisholm et al. for kidney transplant populations [8]. The scale consists of four items addressing medication-taking patterns over the past three months, with responses categorized as 0%, 1–20%, 21–50%, or \u0026gt;50% adherence. Scores range from 0 to 12, with higher scores representing better adherence. The Turkish adaptation has been validated by Madran et al. [9]. Although Chisholm's original framework considered only a score of 12 as indicating full adherence, alternative cutoff criteria have since been proposed [10]. categorizing scores as follows: 12 (perfect adherence), 10–11 (acceptable adherence), and ≤9 (poor adherence). We adopted this three-tier system, as minor adherence deviations are common in transplant recipients and do not necessarily compromise graft survival [11]. Moreover, the binary classification tends to overestimate nonadherence rates, whereas this stratified approach has been shown by Promraj et al. to better represent real-world adherence behaviors [12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Anxiety and Depression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnxiety and depression levels were assessed using the HADS, originally developed by Zigmond and Snaith in 1983 [13]. This instrument consists of 14 self-report items divided into two subscales, each comprising seven items: anxiety (HADS-A) and depression (HADS-D). Each item is rated on a 4-point Likert scale ranging from 0 to 3. Accordingly, each subscale yields a total score between 0 and 21, with higher scores indicating greater symptom severity. The Turkish adaptation of HADS has been reported to demonstrate satisfactory psychometric properties [14].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Alexithymia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlexithymia was assessed using the 20-item TAS-20, originally developed by Bagby et al. in 1994 [15]. The Turkish version of TAS-20 has demonstrated satisfactory reliability and construct validity in previous validation studies by Güleç et al., confirming its suitability for use in Turkish clinical and non-clinical populations [16]. Written permission for the use of the Toronto Alexithymia Scale-20 (TAS-20) in this study was obtained from one of the original authors and copyright holders (R. Michael Bagby, PhD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Alexisomia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlexisomia was assessed using the STSS, which originates conceptually from the psychophysiological framework first proposed by Ikemi in 1979 as a phenomenon where emotional tension manifests through bodily sensations rather than being cognitively recognized as an affective state [17]. The construct was later operationalized by Nakao as a measurable psychological trait and standardized in the form of the STSS, a 10-item self-report instrument rated on a 5-point Likert scale (1–5), with higher scores indicating greater levels of alexisomia [18]. Aksu et al. validated the Turkish version of the STSS, reporting adequate psychometric properties and factorial structure for use in Turkish clinical settings [19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics version 26.0. Variables with non-normal distribution, including serum creatinine and estimated glomerular filtration rate (eGFR), were presented as median (interquartile range). The relationships between ITAS total score and psychological measures (alexisomia, alexithymia, HADS-anxiety, HADS-depression) were evaluated using Pearson correlation analysis. To identify independent psychological predictors of medication adherence, variables that showed significant correlations in univariate analyses were entered into a stepwise linear regression model, with ITAS total score as the dependent variable. A two-tailed p value \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Ethics Committee of Gazi University on 31 January 2025 (Approval No: 2025-147). The study was conducted in accordance with the Declaration of Helsinki. All transplanted organs were obtained through standard clinical transplantation procedures at the Department of Nephrology, Faculty of Medicine, Gazi University, Ankara, Türkiye. No organs or tissues were obtained from prisoners or other vulnerable populations.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 82 KTRs were included in the final analysis. The mean age of the participants was 45.06 ± 12.32 years, and 63.4% were male. The mean duration since transplantation was 9.71 ± 6.79 years. Most participants were married (74.4%), nonsmokers (80.5%), and reported no history of psychiatric illness (93.9%). Sociodemographic and clinical characteristics are summarized in Table 1.\u003c/p\u003e\n\u003cp\u003eThe psychological scale scores and ITAS adherence scores are presented in Table 2. The mean ITAS total score was 10.49 ± 1.82, indicating generally high adherence with variability among individuals.\u003c/p\u003e\n\u003cp\u003eCorrelation analysis demonstrated significant negative relationships between ITAS total score and alexisomia (r = –0.267, p = 0.015), alexithymia (r = –0.327, p = 0.003), and depressive symptoms (r = –0.380, p \u0026lt; 0.001). Anxiety symptoms showed a nonsignificant trend toward lower adherence (r = –0.189, p = 0.089) (Table 3).\u003c/p\u003e\n\u003cp\u003eA stepwise linear regression analysis was conducted to identify independent psychological predictors of immunosuppressive medication adherence. Among the candidate variables, only HADS-Depression remained in the final model. The model was statistically significant (R = 0.380, R² = 0.145, adjusted R² = 0.134, F(1,80) = 13.540, p \u0026lt; 0.001), accounting for 14.5% of the variance in ITAS total scores. In the final model, HADS-Depression demonstrated a significant association with ITAS total score (β = –0.380, B = –0.182, SE = 0.049, t = –3.680, p \u0026lt; 0.001) (Table 4).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis cross-sectional study examined 82 KTRs with a mean age of 45 years and a median follow-up period of approximately ten years after transplantation. Psychological factors related to emotional awareness and emotion processing were found to be closely associated with compliance with IT. Although the overall compliance level in the cohort was high, both alexithymia and alexisomia ITAS scores showed significant inverse relationships; this suggests that impairments in recognizing or interpreting emotional or physical states may negatively affect daily medication-taking behaviors. Depressive symptoms also showed a moderate negative relationship with adherence and emerged as the only significant independent predictor in the multivariate model, explaining 14.5% of the variance. Taken together, these findings suggest that beyond mere affective symptoms, deeper emotional processing characteristics may significantly influence treatment adherence in clinically stable KTRs.\u003c/p\u003e \u003cp\u003eThe magnitude of these relationships is consistent with previous studies showing that mood and emotional processing disorders have serious effects on post-transplant outcomes. Novak and colleagues followed 527 KTRs and reported that depressive symptoms nearly doubled the risk of mortality [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Similarly, Zelle and colleagues demonstrated in prospective cohort studies that depression increased the risk of graft loss by 51% and all-cause mortality by 67% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These strong clinical effects parallel the fact that depressive symptoms explained a significant portion of the variance in adjustment in our study, suggesting that mood disorders, even at a subclinical level, can have measurable effects on behavioral outcomes.\u003c/p\u003e \u003cp\u003eThe relationship between alexithymia and lower treatment compliance is consistent with previous cross-sectional data reporting clinically high levels of alexithymia in approximately 40% of KTRs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. High levels of alexithymia have been shown to be associated with poorer perceived health status, lower treatment adherence, and weaker kidney function. Calia and colleagues reported that KTRs with high alexithymia had significantly lower treatment adherence and approximately 11 mL/min lower eGFR compared to individuals with better emotional awareness [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These findings support the moderate negative relationship between alexithymia and compliance in our study and suggest that emotional awareness deficits may have clinically significant effects.\u003c/p\u003e \u003cp\u003eOne of the original contributions of this study is that it is the first to show a significant relationship between alexisomia and immunosuppressive treatment compliance, as this relationship has not been previously investigated in the transplantation literature. Alexisomia, as defined in the Eastern psychosomatic medicine approach by Ikemi and colleagues, is characterized by misinterpreting emotional distress as physical symptoms and an excessive focus on bodily sensations [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Previous studies in psychosomatic populations have shown that individuals with high levels of alexisomia experience unexplained physical symptoms 2\u0026ndash;3 times more frequently than individuals with better emotional awareness [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The significant negative relationship between alexisomia and treatment compliance in our study, along with the strong positive relationships between alexisomia and alexithymia and depression, suggests that alexisomia may be an overlooked psychological mechanism that could influence treatment behaviors in KTRs. These findings suggest that somatic-emotional misinterpretation may reduce insight into treatment, increase misattribution of side effects, and weaken confidence in IT. Behavioral research also supports these findings. Frazier and colleagues showed that emotional dysregulation and poor coping skills approximately doubled the likelihood of IT noncompliance [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A meta-analysis by Dew and colleagues also revealed that depression and anxiety are significant risk factors for morbidity and mortality in solid organ transplantation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These data support that emotional processing disorders, beyond traditional mood symptoms, significantly shape treatment adherence.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, our findings emphasize the importance of routine psychological screening in post-transplant follow-up. Standardized tools such as the HADS, TAS-20, and STSS can aid in the early identification of patients at risk of non-compliance due to emotional processing disorders. Integrating these assessments into comprehensive psychosocial screening systems, such as the Stanford Integrated Psychosocial Transplantation Assessment (SIPAT), may improve risk stratification and guide personalized interventions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Psychotherapeutic approaches aimed at increasing emotional awareness, interpreting internal bodily sensations more accurately, or managing depressive symptoms have the potential to improve compliance and enhance long-term graft outcomes.\u003c/p\u003e \u003cp\u003eThis study has several strengths. It is the first to investigate alexisomia in the kidney transplant setting, and it uses multiple validated psychometric instruments specifically adapted for Turkish populations. The sample also reflects a real-world outpatient cohort with long-term post-transplant follow-up, enhancing the clinical relevance of the findings. Despite these advantages, the study also has some limitations. First, the cross-sectional design precludes establishing a causal relationship between psychological characteristics and medication adherence. Prospective studies are needed to assess whether alexithymia or alexisomia predict future nonadherence. Second, medication adherence was assessed using self-report, which may be susceptible to recall bias or social desirability effects. Future studies could strengthen the results by using objective adherence indicators such as blood level monitoring or electronic monitoring. Third, the study was single-center and may have limited generalizability to KTRs in different sociocultural or clinical settings. Finally, while the sample size was sufficient, a larger patient group would allow for the construction of more robust statistical models, according to post-hoc power analysis.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, alexithymia, alexisomia, and depressive symptoms were significantly associated with reduced immunosuppressive adherence in KTRs, with depression emerging as the strongest predictor. The novel finding that alexisomia correlates with nonadherence suggests this construct represents an underrecognized but clinically relevant factor in post-transplant self-management. Early psychosocial screening incorporating assessment of emotional awareness may improve adherence and long-term graft outcomes in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Gazi University Ethics Committee (Approval date: 14 January 2025, Approval number: 2025-147). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest relevant to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTEC conceptualized and designed the study, performed the statistical analysis, interpreted the data, and drafted the manuscript. OFA contributed to data acquisition, data interpretation, and critically revised the manuscript for important intellectual content. ZA contributed to data collection and interpretation and assisted in manuscript revision. AD contributed to data acquisition and critically revised the manuscript. VBT contributed to data interpretation and critically revised the manuscript. GG contributed to data acquisition and manuscript revision. MHA contributed to data collection and data interpretation. OH supervised the study, contributed to study design and data interpretation, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all participants for their contribution to the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTonelli, M., et al., \u003cem\u003eSystematic Review: Kidney Transplantation Compared With Dialysis in Clinically Relevant Outcomes.\u003c/em\u003e American Journal of Transplantation, 2011. \u003cstrong\u003e11\u003c/strong\u003e(10): p. 2093-2109.\u003c/li\u003e\n\u003cli\u003eButler, J.A., et al., \u003cem\u003eFrequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review.\u003c/em\u003e Transplantation, 2004. \u003cstrong\u003e77\u003c/strong\u003e(5).\u003c/li\u003e\n\u003cli\u003eSchweizer, R.T., et al., \u003cem\u003eNoncompliance in organ transplant recipients.\u003c/em\u003e Transplantation, 1990. \u003cstrong\u003e49\u003c/strong\u003e(2): p. 374-7.\u003c/li\u003e\n\u003cli\u003eScheel, J.F., et al., \u003cem\u003ePsychosocial Variables Associated with Immunosuppressive Medication Non-Adherence after Renal Transplantation.\u003c/em\u003e Frontiers in Psychiatry, 2018. \u003cstrong\u003eVolume 9 - 2018\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eTaylor, G.J. and R.M. Bagby, \u003cem\u003eNew trends in alexithymia research.\u003c/em\u003e Psychother Psychosom, 2004. \u003cstrong\u003e73\u003c/strong\u003e(2): p. 68-77.\u003c/li\u003e\n\u003cli\u003eNakao, M. and A.J. Barsky, \u003cem\u003eClinical application of somatosensory amplification in psychosomatic medicine.\u003c/em\u003e BioPsychoSocial Medicine, 2007. \u003cstrong\u003e1\u003c/strong\u003e(1): p. 17.\u003c/li\u003e\n\u003cli\u003eChilcot, J., et al., \u003cem\u003eDepression and Kidney Transplantation.\u003c/em\u003e Transplantation, 2014. \u003cstrong\u003e97\u003c/strong\u003e(7): p. 717-721.\u003c/li\u003e\n\u003cli\u003eChisholm, M.A., et al., \u003cem\u003eDevelopment and validation of the immunosuppressant therapy adherence instrument (ITAS).\u003c/em\u003e Patient Educ Couns, 2005. \u003cstrong\u003e59\u003c/strong\u003e(1): p. 13-20.\u003c/li\u003e\n\u003cli\u003eMadran, B., et al., \u003cem\u003eImmunosuppressant Therapy Adherence Scale for Transplant Recipients: The Study of Validity and Reliability.\u003c/em\u003e Turkiye Klinikleri Journal of Nursing, 2016. \u003cstrong\u003e8\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eWeng, F.L., et al., \u003cem\u003ePrevalence and correlates of medication non-adherence among kidney transplant recipients more than 6 months post-transplant: a cross-sectional study.\u003c/em\u003e BMC Nephrology, 2013. \u003cstrong\u003e14\u003c/strong\u003e(1): p. 261.\u003c/li\u003e\n\u003cli\u003eShemesh, E., B.L. Shneider, and G.V. Mazariegos, \u003cem\u003eWeekend versus weekday adherence: Do we, or do we not, thank God it\u0026apos;s Friday?\u003c/em\u003e Am J Transplant, 2020. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 7-9.\u003c/li\u003e\n\u003cli\u003ePromraj, R., et al., \u003cem\u003eImmunosuppressive Medication Adherence in Liver Transplant Recipients.\u003c/em\u003e Transplant Proc, 2016. \u003cstrong\u003e48\u003c/strong\u003e(4): p. 1198-201.\u003c/li\u003e\n\u003cli\u003eZigmond, A.S. and R.P. Snaith, \u003cem\u003eThe hospital anxiety and depression scale.\u003c/em\u003e Acta Psychiatr Scand, 1983. \u003cstrong\u003e67\u003c/strong\u003e(6): p. 361-70.\u003c/li\u003e\n\u003cli\u003eAydemir, O., et al., \u003cem\u003eHastane Anksiyete ve Depresyon \u0026Ouml;l\u0026ccedil;eği T\u0026uuml;rk\u0026ccedil;e Formunun Ge\u0026ccedil;erlilik ve G\u0026uuml;venilirlik \u0026Ccedil;alışması. Reliability and Validity of the Turkish version of Hospital Anxiety and Depression Scale.\u003c/em\u003e Turk psikiyatri dergisi = Turkish journal of psychiatry, 1997. \u003cstrong\u003e8\u003c/strong\u003e: p. 280-287.\u003c/li\u003e\n\u003cli\u003eBagby, R.M., J.D. Parker, and G.J. Taylor, \u003cem\u003eThe twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure.\u003c/em\u003e J Psychosom Res, 1994. \u003cstrong\u003e38\u003c/strong\u003e(1): p. 23-32.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;le\u0026ccedil;, H., et al., \u003cem\u003eThe Turkish Version of the 20-Item Toronto Alexithymia Scale (TAS-20): Reliability, Validity, and Factorial Structure.\u003c/em\u003e Bulletin of Clinical Psychopharmacology, 2009. \u003cstrong\u003e19\u003c/strong\u003e: p. 214-220.\u003c/li\u003e\n\u003cli\u003eIkemi, Y., \u003cem\u003ePsychophysiology as the starting point of education.\u003c/em\u003e Jpn J Transactional Analysis, 1979. \u003cstrong\u003e4\u003c/strong\u003e: p. 1-10.\u003c/li\u003e\n\u003cli\u003eOka, T., \u003cem\u003eShitsu-taikan-sho (alexisomia): a historical review and its clinical importance.\u003c/em\u003e BioPsychoSocial Medicine, 2020. \u003cstrong\u003e14\u003c/strong\u003e(1): p. 23.\u003c/li\u003e\n\u003cli\u003eAksu, M.H., et al., \u003cem\u003eTurkish Adaptation, Validity, and Reliability Study of Shitsu-Taikan-Sho (Alexisomia) Scale.\u003c/em\u003e Psychiatry Clin Psychopharmacol, 2023. \u003cstrong\u003e33\u003c/strong\u003e(2): p. 134-142.\u003c/li\u003e\n\u003cli\u003eNovak, M., et al., \u003cem\u003eDepressive symptoms and mortality in patients after kidney transplantation: a prospective prevalent cohort study.\u003c/em\u003e Psychosom Med, 2010. \u003cstrong\u003e72\u003c/strong\u003e(6): p. 527-34.\u003c/li\u003e\n\u003cli\u003eZelle, D.M., et al., \u003cem\u003eImpact of depression on long-term outcome after renal transplantation: a prospective cohort study.\u003c/em\u003e Transplantation, 2012. \u003cstrong\u003e94\u003c/strong\u003e(10): p. 1033-40.\u003c/li\u003e\n\u003cli\u003ePistorio, M.L., et al., \u003cem\u003eAlexithymia in Kidney Transplantation Patients.\u003c/em\u003e Transplant Proc, 2017. \u003cstrong\u003e49\u003c/strong\u003e(4): p. 642-645.\u003c/li\u003e\n\u003cli\u003eCalia, R., et al., \u003cem\u003eEmotional self-efficacy and alexithymia may affect compliance, renal function and quality of life in kidney transplant recipients: Results from a preliminary cross-sectional study.\u003c/em\u003e Physiology \u0026amp; Behavior, 2015. \u003cstrong\u003e142\u003c/strong\u003e: p. 152-154.\u003c/li\u003e\n\u003cli\u003eIkemi, Y. and A. Ikemi, \u003cem\u003eAn Oriental Point of View in Psychosomatic Medicine.\u003c/em\u003e Psychotherapy and Psychosomatics, 2010. \u003cstrong\u003e45\u003c/strong\u003e(3): p. 118-126.\u003c/li\u003e\n\u003cli\u003eIkemi, Y. and H. Ishikawa, \u003cem\u003eIntegration of Occidental and Oriental Psychosomatic Treatments.\u003c/em\u003e Psychotherapy and Psychosomatics, 2010. \u003cstrong\u003e31\u003c/strong\u003e(1-4): p. 324-333.\u003c/li\u003e\n\u003cli\u003eFrazier, P.A., S.H. Davis-Ali, and K.E. Dahl, \u003cem\u003eCorrelates of noncompliance among renal transplant recipients.\u003c/em\u003e Clinical Transplantation, 1994. \u003cstrong\u003e8\u003c/strong\u003e(6): p. 550-557.\u003c/li\u003e\n\u003cli\u003eDew, M.A., et al., \u003cem\u003eDepression and Anxiety as Risk Factors for Morbidity and Mortality After Organ Transplantation: A Systematic Review and Meta-Analysis.\u003c/em\u003e Transplantation, 2016. \u003cstrong\u003e100\u003c/strong\u003e(5): p. 988-1003.\u003c/li\u003e\n\u003cli\u003eMaldonado, J.R., et al., \u003cem\u003eThe Stanford Integrated Psychosocial Assessment for Transplantation: A Prospective Study of Medical and Psychosocial Outcomes.\u003c/em\u003e Psychosom Med, 2015. \u003cstrong\u003e77\u003c/strong\u003e(9): p. 1018-30.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eSociodemographic and Clinical Characteristics of the Study Population\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"549\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%), Mean \u0026plusmn; SD or Median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e45.06 \u0026plusmn; 12.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eSex\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Male\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (36.6)\u003c/p\u003e\n \u003cp\u003e52 (63.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSerum creatinine (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.40 (1.06\u0026ndash;1.95)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eeGFR (mL/min/1.73 m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e58.0 (39.0\u0026ndash;74.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003ePost-transplant duration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e9.71 \u0026plusmn; 6.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eMarial Status\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Single\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21 (25.6)\u003c/p\u003e\n \u003cp\u003e61 (74.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eEducational level\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIlliterate/Primary education\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; High school or lower\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; University\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e10 (12.2)\u003c/p\u003e\n \u003cp\u003e41 (50)\u003c/p\u003e\n \u003cp\u003e31 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eType of donor\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Living\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Deceased\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e56 (68.3)\u003c/p\u003e\n \u003cp\u003e26 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eSmoking Status\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-smoker\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66 (80.5)\u003c/p\u003e\n \u003cp\u003e16 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eAlcohol use\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-user\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;User\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72 (87.8)\u003c/p\u003e\n \u003cp\u003e10 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eHistory of psychiatric illness\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e77 (93.9)\u003c/p\u003e\n \u003cp\u003e5 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eFamily history of psychiatric illness\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Absent\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e80 (97.6)\u003c/p\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eeGFR= estimated glomerular filtration rate; SD= Standard deviation; IQR=Interquartile range.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Psychological Scala Scores of the Study Population\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin-Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eHADS- Anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e0-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e6.72 \u0026plusmn; 4.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eHADS- Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e0-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e6.65 \u0026plusmn; 3.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eAlexisomia Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e20-68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e40.28 \u0026plusmn; 10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eAlexithymia Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e28-79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e51.57 \u0026plusmn; 10.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eITAS Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e3-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e10.49 \u0026plusmn; 1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHADS= Hospital Anxiety and Depression Scale; ITAS=\u0026nbsp;Immunosuppressant Therapy Adherence Scale; Min= Minimum; Max=Maximum;\u0026nbsp;SD= Standard deviation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eCorrelation Analysis Between Psychological Variables and Medication Adherence\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"654\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eITAS Total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlexisomia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlexithymia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHADS- Depression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHADS- Anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003eITAS Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003eAlexisomia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.267*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003eAlexithymia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.327**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.402**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003eHADS- Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.380**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.484**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.508**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003eHADS- Anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e-0.189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.482**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.476**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.534**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHADS= Hospital Anxiety and Depression Scale; ITAS=Immunosuppressant Therapy Adherence Scale; * p\u0026lt;0.05; ** p\u0026lt;0.01.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eLinear Regression Analysis for Predicting ITAS Total Score\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e11.696\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.378\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e30.955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eHADS-Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-0.380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-3.680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eModel statistics:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR = 0.380; R\u0026sup2; = 0.145; Adjusted R\u0026sup2; = 0.134;\u003c/p\u003e\n\u003cp\u003eSEE = 1.694; F(1,80) = 13.540; p \u0026lt; 0.001.\u003c/p\u003e\n\u003cp\u003eB = unstandardized coefficient; SE = standard error; \u0026beta; = standardized coefficient; HADS = Hospital Anxiety and Depression Scale, ITAS = Immunosuppressant Therapy Adherence Scale.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Alexisomia, Alexithymia, Medication adherence, Kidney transplantation, Immunosuppressive therapy, Depression","lastPublishedDoi":"10.21203/rs.3.rs-8369597/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8369597/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdherence to immunosuppressive therapy (IT) is essential for long-term graft survival in kidney transplant recipients (KTRs). While depression and anxiety have been widely studied as determinants of nonadherence, the influence of emotional awareness and bodily perception constructs remain unclear. This study aimed to evaluate the associations of alexithymia, alexisomia, and affective symptoms with medication adherence among KTRs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study included 82 KTRs followed at a tertiary nephrology outpatient clinic. Participants completed validated psychometric instruments, including the Toronto Alexithymia Scale (TAS), Shitsu-taikan-sho Scale for alexisomia, Hospital Anxiety and Depression Scale (HADS), and the Immunosuppressant Therapy Adherence Scale (ITAS). Correlation analyses and stepwise linear regression were used to identify psychological predictors of adherence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean ITAS score was 10.49 ± 1.82. Medication adherence showed significant mild negative correlations with alexisomia (r = –0.267, p = 0.015), alexithymia (r = –0.327, p = 0.003), and depressive symptoms (r = –0.380, p \u0026lt; 0.001), while anxiety was not significantly associated with adherence (r = –0.189, p = 0.089). In the regression model, depressive symptoms were the only independent predictor of adherence (β = –0.380, p \u0026lt; 0.001), explaining 14.5% of the variance. To our knowledge, this is the first study to identify an association between alexisomia and IT adherence in KTRs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlexithymia, alexisomia, and depressive symptoms are significant psychological correlates of reduced IT adherence among KTRs. The novel finding regarding alexisomia suggests that impaired recognition and interpretation of internal bodily and emotional states may hinder consistent self-management after transplantation. Early psychosocial screening and targeted psychological interventions may improve adherence and reduce rejection risk in this population.\u003c/p\u003e","manuscriptTitle":"Alexisomia, Depression, and Adherence in Kidney Transplantation: A Cross-Sectional Preliminary Investigation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 08:47:21","doi":"10.21203/rs.3.rs-8369597/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-27T10:45:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-22T09:41:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-30T05:30:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-29T05:40:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-12-29T05:34:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"39cdafce-f776-4f90-8214-1323ae326ffa","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-29T08:47:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 08:47:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8369597","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8369597","identity":"rs-8369597","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}