Background: There is a lack of understanding about recruiting hard-to-reach research participants. We explored this issue by describing the various challenges, strategies, and social determinants of health (SDOH) associated with recruitment of participants into our study of people receiving dialysis for remotely delivered therapist-guided cognitive behavioral therapy (CBT). Methods: Our study used data from ‘Re: CBT Dialysis’ project. Patients were invited through indirect recruitment strategies at 25 dialysis sites in Alberta and British Columbia (e.g., letters/posters), through Canadian kidney organizations, and via a previous project. Recruitment challenges were discussed with Community Advisors and site managers; strategies were co-developed. Due to low enrollment, patients were subsequently recruited in-person from 12 (of 25) sites. In-person recruitment challenges and reasons for not participating were recorded; conventional content analysis was used to categorize these notes. A Chi-square test was used to compare SDOH of those eligible to receive CBT but did not participate and those who participated. Results: Initially, indirect recruitment resulted in 58 participants. Subsequently, 2,015 patients were approached in-person. Of these, 1771 were unsuccessfully recruited: 335 were ineligible, 62 incomplete recruitment, 462 other reasons, and 912 declined to join. Top 4 reasons for not joining included: no interest (652), unknown reasons (63), already participating in research (63), too busy (58). To boost recruitment, the inclusion criteria were expanded to include all people receiving dialysis and phone surveys were introduced. Consequently, 168 people joined through in-person recruitment and 162 people joined through indirect recruitment. Of the 221 participants invited to receive CBT, 48 participated. Several SDOH (religion, disabilities, housing, finances, medication access, income, and social supports) were significantly associated with final participation in CBT (p < 0.05). Conclusion: There is a great need for additional strategies to improve equitable people-centred recruitment of hard-to-reach research participants, including people receiving dialysis and experiencing depressive symptoms.