Expressive Writing/Emotional Disclosure/Journaling

Expressive Writing/Emotional Disclosure/Journaling

PEP Topic 
Depression
Description 

Expressive writing/journaling is the art of putting thoughts and feelings on paper. Writing about negative emotional experiences may improve physical and psychological health, and writing about deep feeling regarding personal stressors can enhance well-being and health. Expressive writing as a form of emotional disclosure has been examined in fatigue and depression and may have relevance for pain, sleep-wake disturbances, anxiety, and caregiver strain and burden. Individuals may be counseled to write specifically about thoughts and feelings, or some other aspect of their experience.  

Effectiveness Unlikely

Research Evidence Summaries

Jensen-Johansen, M.B., Christensen, S., Valdimarsdottir, H., Zakowski, S., Jensen, A.B., Bovbjerg, D.H., & Zachariae, R. (2012). Effects of an expressive writing intervention on cancer-related distress in Danish breast cancer survivors—Results from a nationwide randomized clinical trial. Psycho-Oncology, 22, 1492–1500.

doi: 10.1002/pon.3193
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Study Purpose:

To examine the effects of an expressive writing intervention on cancer-related distress, symptoms of depression, and mood in women with early-stage breast cancer

Intervention Characteristics/Basic Study Process:

Women were randomized to an expressive writing group or a control group. Both groups were instructed to write for 20 minutes once a week over a three-week period. On each writing day, patients were contacted by telephone to initiate the writing session and contacted again after 20 minutes to terminate writing. Patients in the expressive writing group were instructed to write about a distressing event and to explore their deepest emotions and feelings about the experience. Control group patients were asked to write about their daily activities in a detailed and objective manner. Study questionnaires were completed at baseline and at three and nine months postintervention.

Sample Characteristics:

  • The study reported on a sample of 437 female patients.
  • Mean patient age was 53.6 years.
  • All patients had breast cancer (stage I or II) and were contacted regarding study participation within three weeks of initial breast surgery.
  • The majority (80%) of patients were married or partnered, and 64.5% were retired or unemployed.

Setting:

  • Multisite
  • Home setting
  • Denmark

Study Design:

Single-blind, randomized controlled trial with an active control group

Measurement Instruments/Methods:

  • Impact of Event Scale
  • Beck Depression Inventory
  • Profile of Mood States
  • Social Constraints Scale
  • Toronto Alexithymia Scale

Results:

The expressive writing group showed significant changes in negative and positive mood immediately after the writing sessions (d = 0.84–1.04, p < 0.001). When age and baseline measures were included in analysis as covariates, there were no significant effects or group-by-time interactions.

Conclusions:

Investigators could not confirm the hypothesis that, compared to patients in an active control group, patients in an expressive writing group experience less cancer-related distress.

Limitations:

  • Fifteen percent of the sample initially randomized dropped out or was lost to follow-up.
  • Investigators did not report whether patients were actively receiving treatment during the study.
  • Baseline outcome data were not reported.

Nursing Implications:

This study does not provide evidence to support expressive writing as an intervention to reduce anxiety and symptoms of depression in women with breast cancer.

Low, C.A., Stanton, A.L., Bower, J.E., & Gyllenhammer, L. (2010). A randomized controlled trial of emotionally expressive writing for women with metastatic breast cancer. Health Psychology, 29(4), 460–466.

doi:10.1037/a0020153
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Study Purpose:

To test the effects of emotionally expressive writing versus disease-related writing on patients with metastatic breast cancer; to determine whether the effects of expressive writing vary as a function of perceived social support or time since diagnosis of metastasis   

Intervention Characteristics/Basic Study Process:

Investigators used three sources of recruitment: a larger study, flyers, and advertising on a website and Listserv. All contact with patients was via telephone, postal mail, or email. Participants completed baseline assessments, which gathered data about demographics and emotional support. Investigators collected saliva samples. Patients were randomized to either the emotional or control writing condition, and patients received information about the exercises. Patients were scheduled to participate in four 20-minute sessions that occurred at patients' convenience within a three-week interval. A research assistant monitored compliance. After each session, a patient mailed her writing to the research office. At study entry and three months after the final writing session, a by-mail questionnaire measured outcomes according to stated instruments.

Sample Characteristics:

  • The sample was composed of 62 participants, 31 were in the expressive writing group and 31 were in the control group.
  • Mean patient age was 53.8 years (SD = 10.3 years). The age range was 29–78 years.
  • All participants were female.
  • All patients had stage IV metastatic breast cancer.
  • Participants were eligible for the study if they could complete the writing exercises and assessments in English and if they were undergoing any medical treatment for cancer.
  • Of all participants, 74% were college-educated, 71% were married or partnered, 87% were white, and 78% were not working outside the home. On average, participants had been diagnosed with breast cancer 7.9 years ago. Most had received the diagnosis of stage IV cancer 3.3 years ago. The cancer of most participants had metastasized to the bone.
  • Of all participants, 72% had had experience with support groups, 63% were working on cancer-related issues with a mental health professional, and 63% had journaled about their cancer experience.
     

Setting:

  • Multisite.
  • Home.
  • California (October 2006–April 2009); however, information was posted online and on a Listserv.

Phase of Care and Clinical Applications:

  • Phases of care: multiple phases of care
  • Clinical applications: supportive care (end-of-life and palliative care), late effects and survivorship
     

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

  • Center for Epidemiologic Studies Depression Scale (CESD), a 20-item scale to assess the frequency of depression symptoms in the past week.
  • Seven-item intrusions subscale of the Impact of Event Scale (IES), to measure the extent of distress caused by cancer-related intrusive thoughts over the past week.
  • Instrument, developed by Pennebaker (1982), to measure negative somatic symptoms. The instrument, shown to be responsive to the expressive writing intervention, asks respondents to report the number of days in the past month on which they experienced each of nine somatic symptoms.
  • Pittsburgh Sleep Quality Index (PSQI), to assess sleep quality over the past month and yield a total sleep disturbance score. Scores of 5 and above indicate clinically significant sleep disruptions. This scale has been used as an outcome measure in previous trials of expressive writing as practiced by patients with advanced cancer.
  • Items adapted from a tool by Alferi et al. (2001), to measure perceived emotional support.
  • Questionnaire, to gather demographic data.
     

Results:

  • Investigators observed no significant main effects of the experimental condition, with respect to demographic or cancer-related variables or experience with cancer, support groups, psychotherapy, or journaling. 
  • Investigators reported no significant group differences, at study entry, regarding symptoms of depression, intrusive thoughts, sleep disturbance, somatic symptoms, or perceived emotional support.
  • A significant condition, correlated with social support interaction, emerged regarding intrusive thoughts: Expressive writing was associated with reduced intrusive thoughts in women reporting low emotional support. The significant condition correlated with time, because investigators also observed an interaction between the measure of metastatic diagnosis and the measures of somatic symptoms and sleep disturbance. Relative to the control, participants in the intervention who were more recently diagnosed had fewer somatic symptoms. Intervention participants with longer diagnosis duration exhibited increases in sleep disturbance.
  • Among outcome variables, only scores reflecting depression symptoms correlated significantly with intrusive thoughts (r = 0.56, p < 0.001), sleep disturbance (r = 0.30, p = 0.019), and somatic symptoms (r = 0.53, p < 0.001). None of the correlations between the other three outcome variables was significant.

Conclusions:

Expressive writing did not produce reduction in psychological distress or improvement in physical health. The intervention may be beneficial for a subset of patients with metastasis and contraindicated for other patients.

Limitations:

  • The study had a small sample size, with fewer than 100 participants.
  • Participants were predominantly white and well educated.
  • Outcome measures related to physical health relied on self-reporting.
  • The study was underpowered in regard to detection of main effects. Study design should have included alternative writing topics or a control topic unrelated to cancer.
     

Nursing Implications:

Expressive writing may be of benefit to a certain subset of patients. The intervention is cost-effective and an activity that patients with low levels of social support can do. Future study should apply the expressive-writing approach to vulnerable, underserved, and understudied populations and offer broader topics for expressive writing (e.g., benefits of the cancer experience, a topic unrelated to cancer). Investigators should provide writing supplies. Future research should consider privacy protections (possibly from family members), especially in cultures that place great value on the privacy of written material.

Mosher, C. E., Duhamel, K. N., Lam, J., Dickler, M., Li, Y., Massie, M. J., & Norton, L. (2012). Randomised trial of expressive writing for distressed metastatic breast cancer patients. Psychology and Health, 27, 88–100.

doi: 10.1080/08870446.2010.551212
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Study Purpose:

To examine the health effects—on existential and psychological well-being, fatigue, and sleep—of writing about the deepest cancer-related thoughts and feelings in patients with advanced breast cancer.

Intervention Characteristics/Basic Study Process:

  • By telephone, one week after the screening assessment, investigators conducted a baseline interview of patients who met the criteria. Investigators obtained consents.
  • At random, a computer assigned patients to the expressive writing or neutral writing group. Patients were stratified by ethnicity and age.
  • Patients received four sets of writing instructions, lined paper, forms for rating the essays, and envelopes for returning the materials by postal mail.
  • Study design called for each patient to complete four writing sessions over a period of four to seven weeks, with instructions for each session provided by telephone by the study staff. Intervention and control groups were to begin writing immediately after the instruction telephone call. All patients were to write for 20 minutes continuously. At the 20-minute mark, a telephone call from staff collected patients' assessments of the quality of the writing time; adjustments were made for interruptions. Staff told patients to rate their essays on a scale of one to seven and asked patients to mail their essays to the investigators.

Sample Characteristics:

  • The study reported a sample of 86 females with stage IV breast cancer.
  • Mean age was 57.4 years (standard deviation [SD] = 12.5 years) in the expressive writing group and 58.5 years (SD = 11.7 years) in  the neutral writing group.
  • Patients were included if they had clinically elevated distress, as indicated by scores greater than four on the Distress Thermometer, were fluent in English, and were 18 years or older.
  • Patients were excluded from the study if they had severe cognitive impairment, as assessed by the Short Portable Mental Status Questionnaire, or if they were already engaged in expressive writing on a daily basis.
  • Average range of time since diagnosis was 4.2 to 4.7 years in the expressive writing group and 3 to 3.5 years in the neutral writing group. Most patients had received chemotherapy or hormone therapy.
  • Of the patients in the expressive writing group, 40.9% were using mental health services at baseline.

Setting:

  • Single site
  • Outpatient setting
  • Comprehensive cancer center in New York City

Phase of Care and Clinical Applications:

  • Patients were undergoing the active treatment phase of care.
  • The study has clinical applicability for late effects and survivorship and end-of-life and palliative care.

Study Design:

The study was a randomized trial, with interviewers blinded in regard to the group they were interviewing.

Measurement Instruments/Methods:

  • Meaning/Peace subscale of the Functional Assessment of Chronic Illness Therapy (FACIT)–Spiritual Well-Being Scale, to assess existential well-being. This measure reflected patients’ degree of purpose in life and inner peace.
  • A measure of demoralization, or existential despair and distress
  • Distress Thermometer, to measure psychological well-being and general distress
  • Center for Epidemiologic Studies Depression (CESD) Scale, to assess symptoms of depression
  • Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS), to measure anxiety
  • Pittsburgh Sleep Quality Index (PSQI), to measure habitual sleep disturbance and fatigue over one month. This study used the total global sleep-quality score.
  • Fatigue subscale of the FACIT, to measure fatigue during the past seven days 
  • Australia-modified Karnofsky Performance Status (KPS) Score, to measure sociodemographic and medical variables and functional impairment at baseline. Trained interviewers administered this instrument.
  • Manipulation check and essay ratings, gathered by an independent rater blinded to the group assignment, to assess the writing instructions for each essay
  • Seven-point scale, used by each patient, to rate how personal the patient's essays were and how much essays revealed of emotions
  • Linguistic Inquiry and Word Count, a computerized text-analysis program, to report the percentage of position and negative-emotion words in each essay

Results:

In this sample, expressive writing—compared to neutral writing—did not result in better existential and psychological well-being, reduced fatigue, or enhanced sleep quality. Although both writing groups showed little change in their distress over time, during the study, patients in the expressive writing group reported more than double the rate of mental health service use than did patients in the neutral writing group.

Conclusions:

Expressive writing may have increased patients’ awareness of their distress and challenging circumstances, prompting the patients to seek mental health services. Further research is needed.

Limitations:

  • The study had a small sample size, with less than 100 patients.
  • Patients who were younger and closer to diagnosis were more likely to participate; however, these response biases were relatively small.
  • Whether results are generalizable to men and patients with diverse ethnic and socioeconomic backgrounds are points that warrant examination.
  • The study relied on self-reported outcome measures administered at one follow-up assessment.

Nursing Implications:

Expressive writing may increase use of psychological support services by distressed patients, without increasing symptom severity. Expressive writing may help keep patients in touch with their emotions, whether negative or positive. When patients are in touch with their emotions, they may be more likely to reach out for help, if they recognize negative emotions that they are not resolving on their own. However, this intervention did not result in differences in patient symptoms or outcomes.

Rodriguez Vega, B., Palao, A., Torres, G., Hospital, A., Benito, G., Perez, E., . . . Bayon, C. (2011). Combined therapy versus usual care for the treatment of depression in oncologic patients: A randomized controlled trial. Psycho-Oncology, 20(9), 943–952.

doi:10.1002/pon.1800
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Study Purpose:

To compare the effects—on quality of life and symptoms of depression—of an intervention consisting of a psychotherapeutic intervention, narrative therapy, plus escitalopram to the effects of usual care plus escitalopram

Intervention Characteristics/Basic Study Process:

The initial sample was composed of 1,026 patients, between March 2006 and June 2008, with a diagnosis of breast, lung, or colorectal nonmetastatic cancer, three months after cancer diagnosis and no later than two years after diagnosis. Investigators used the Hospital and Anxiety Depression Scale (HADS) to screen participants for depression. A total of 150 had depressive disorder according to DSM-IV-TR criteria. The study contained 72 participants, 33 in usual care and 39 in combined care. Escitalopram was administered on a fixed-flexible schedule in both groups, beginning with 10 mg per day and adjusted up to 20 mg per day by week 8. A minimum of six months treatment was established for both groups. The narrative intervention was carried out individually during 12 weekly sessions, each 45 minutes long, and was guided by a treatment manual. Of the sessions, 10% were videotaped to help ensure adherence. Usual care consisted of oncologist-adminstered antidepressant. The oncologist followed a protocol and reported side effects of the medication. The follow-up of patients in the usual-care group was similar to that of patients in the treatment group. Investigators assessed depression-related outcome at weeks 12 and 24.

Sample Characteristics:

  • The sample was composed of 72 participants. At the 12-week assessment, the sample contained 68 participants. At the 24-week assessment, the sample contained 56 participants.
  • Mean patient age was 54.6 years (SD = 10.4 years). The age range was 35–75 years.
  • The sample contained 19.4% males and 80.6% females.
  • Participants had lung, breast, or colorectal nonmetastatic cancer and major depressive disorder, single-episode or major recurrent depressive disorder, or adjustment disorder with depressed mood, or adjustment disorder with mixed anxiety and depressed mood.
  • Participants had a life expectancy longer than one year and a Karnofsky Performance Status Score of 70 or higher. Participants were receiving ambulatory care and had depressive disorder according to DSM-IV-TR criteria.
     

Setting:

  • Multisite
  • Outpatient
  • Madrid, Spain


 

Phase of Care and Clinical Applications:

  • Phases of care: multiple
  • Clinical applications: late effects and survivorship

Study Design:

Two-center randomized controlled trial

Measurement Instruments/Methods:

  • European Organization for Research and Treatment Cancer Core Quality of Life C30 (EORTC QLQ-C30), a self-rating scale that measures quality of life. Thirty items evaluate five functional domains and three scales of symptoms. Five items assess common physical symptoms of cancer. Other items assess global health, global quality of life, and the perceived financial impact of disease and treatment. Scores are 0–100. The EORTC QLQ-C30 has been validated for use by Spanish patients with cancer.    
  • Hospital anxiety and depression scale (HADS). Investigators used this scale at baseline, for screening, and at 12 and 24 weeks. HADS is a 14-item self-rating scale that measures anxiety and depression and is designed specifically for patients with physical illness. A score of 11 or more indicates probable psychological morbidity; a score of 8–10 indicates possible psychological morbidity. The scale has been validated for use by Spanish patients.

Results:

Demographic variables did not differ significantly between the two groups. Gender and age were unbalanced because of cancer types. At 12 and 24 weeks, the combined-therapy group showed significantly greater improvement in all the dimensions of function (p < 0.01), pain scale (p = 0.02), global health (p = 0.02), and global quality of life (p = 0.007). Between groups there were no statistically significant differences in symptoms of depression. From week 12 to 24, study retention was higher in the combined-treatment group (p = 0.01).

Conclusions:

Using combined therapy for major depression in patients with cancer results in significant improvements in quality of life but does not result in a significant reduction in symptoms of depression. Narrative therapy is an integrative intervention designed to address components of critical importance in patients with depression. The therapy may have a positive impact on patient’s fears and worries about medication interactions and side effects.

Limitations:

  • The study had a small sample size, with fewer than 100 participants.
  • Types of cancer were not evenly distributed between groups.
  • The study used interim analysis to estimate statistical power and sample size.
  • A different specialist administered the drug.
     

Nursing Implications:

The interventions proved to be acceptable to patients. The intervention shows good potential for dissemination, is relatively easy to implement, and improved compliance. The intervention may be a low-cost means of improving the quality of life of patients with cancer.

 

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