Group Psychotherapy

Group Psychotherapy

PEP Topic 
Depression
Description 

Psychotherapy involves a variety of approaches to structured therapeutic interaction between a trained professional and a client addressing problems that are psychological in nature. Group psychotherapy involves providing this therapy in a setting that includes a group of patients.

Effectiveness Not Established

Guideline/Expert Opinion

Andersen, B.L., DeRubeis, R.J., Berman, B.S., Gruman, J., Champion, V.L., Massie, M.J., . . . American Society of Clinical Oncology. (2014). Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: An American Society of Clinical Oncology guideline adaptation. Journal of Clinical Oncology, 32, 1605–1619. 

PROFESSIONAL GROUP: American Society of Clinical Oncology

doi: 10.1200/JCO.2013.52.4611
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Purpose & Patient Population:

PURPOSE: To screen, assess, and care for anxiety and depression symptoms at various points across the trajectory of care 
 
TYPES OF PATIENTS ADDRESSED: All adult patients with cancer 

Type of Resource/Evidence-Based Process:

RESOURCE TYPE: Evidence-based guideline  
 
PROCESS OF DEVELOPMENT: Used the ADAPTE methodology using existing guidelines from another organization; included two parts, a methodologic review and a content review; used the Rigour of Development Domain of the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument
 
DATABASES USED: MEDLINE, EMBASE, CINAHL, and Cochrane library (recent to December 2009); clinical practice guideline databases; guideline developer websites; published literature  
 
KEYWORDS: Not mentioned specifically, but included state documents that addressed screening, assessment, or treatment of psychosocial distress in adults with cancer
 
INCLUSION CRITERIA: Clinical practice guidelines, systematic reviews, and other guidance documents
 
EXCLUSION CRITERIA: Not mentioned

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Pediatrics, elder care, palliative care 

Results Provided in the Reference:

The guideline provides an algorithm for the screening and assessment of anxiety, a care map for anxiety in adults with cancer, an algorithm for the screening and assessment of depression, a care map for depression in adults with cancer, the Patient Health Questionnaire (PHQ 9) symptom depression scale and generalized anxiety disorder (GAD) items, and selected measures for depression and anxiety (modified).

Guidelines & Recommendations:

  • Before the implementation of guidelines, referral systems and resources should be identified and available in each institution.
  • The guidelines are designed for healthcare providers, patients, family members, and caregivers to guide in the screening, assessment, and treatment approaches of adult patients with cancer who have anxiety and depression at any stage of the cancer continuum, regardless of cancer type, disease stage, or treatment modality. 
  • All patients with cancer and cancer survivors should be evaluated for the symptoms of anxiety and depression with validated instruments at periodic times during the cancer care. Treatment recommendations are based on the levels of symptoms. Follow-up care and reassessment are important in this setting to monitor for follow-through, compliance with referrals, and pharmacologic management. If compliance is poor, develop a plan. After eight weeks of treatment, if symptoms are not improved or poor compliance is noted, alter the treatment course and add a psychological or pharmacologic intervention. The guidelines recommend that individual psychological interventions be delivered by a licensed mental health professional, which may include cognitive and behavioral strategies, education and relaxation strategies, group psychosocial interventions, and physician-prescribed antidepressants. 

Limitations:

  • A guideline that has been adapted from another country often can't lend itself to different policies or cultural influences.
  • Some of the recommendations were removed from the original guideline because of references to the Edmonton Symptom Assessment Scale screening measure, which is not widely used in the United States.

Nursing Implications:

Nurses play a vital role in the early screening, assessment, and treatment of patients who may have significant symptoms of anxiety and depression. By screening and making appropriate referrals, we can impact the emotional, interpersonal, and financial costs for patients and reduce the economic impact for providers and the healthcare system.

National Comprehensive Cancer Network. (2012). NCCN clinical practice guidelines in oncology: Distress management [v.2.2013]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf

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Purpose & Patient Population:

To provide clinical practice guidelines for the evaluation and treatment of distress — a normal feeling of vulnerability to a feeling that leads to disabling problems, such as depression and anxiety — in adult patients with cancer

Type of Resource/Evidence-Based Process:

  • Evidence-based guidelines    
  • Consensus development involving a panel composed of physicians, psychiatrists, psychologists, and social workers

Phase of Care and Clinical Applications:

  • Phases of care: multiple phases 
  • Clinical application: palliative care

Results Provided in the Reference:

Results were not stated.

Guidelines & Recommendations:

Recommended standards of care include

  • Screening all patients for distress, at initial visits and appropriate intervals
  • Distress management according to guidelines
  • Having committees to implement standards, provide relevant education and training to healthcare professionals
  • Having mental health professionals and certified chaplains available
  • Providing a distress-thermometer screening tool
  • Identifying at-risk patients and periods of increased vulnerability, to define appropriate screening intervals

Evaluation should include measures relating to level of distress, behavior symptoms, psychiatric history and medications, pain and symptom control, body image and sexuality issues, impaired capacity, safety, potential medical causes, and psychological disorders.

Management algorithms should be provided for dementia, delirium, mood disorder, psychotic disorder, adjustment disorder, anxiety disorder, personality disorder, and substance-related disorder.

Treatments identified for use include psychotherapy, anxiolytics, antidepressants, psychoeducation, cognitive behavioral therapy, social work and counseling interventions, spiritual counseling and ethics, and palliative care consultation according to algorithms.

Limitations:

  • The evidence is mainly "lower level," and recommendations are primarily consensus-based. 
  • The panel did not include a nursing member.
  • Many recommendations tend to focus on approaches to care for patients with significant mental disorders or for those referred to a mental health team. 
  • The guidelines provide limited suggestions regarding low-level distress associated with physical symptoms.

Nursing Implications:

The guidelines provide recommended pathways regarding assessment and management of distress. They do not provide a nursing perspective or identify a role for nursing in patient management.

Research Evidence Summaries

Barth, J., Delfino, S., & Kunzler, A. (2013). Naturalistic study on the effectiveness of psycho-oncological interventions in cancer patients and their partners. Supportive Care in Cancer, 21, 1587–1595.

doi: 10.1007/s00520-012-1700-8
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Study Purpose:

To explore the effectiveness of psycho-oncologic interventions for patients and partners on anxiety, depression, psychopathology, and distress

Intervention Characteristics/Basic Study Process:

Patients and partners who had been referred for psycho-oncologic service were recruited. Common interventions were psychoeducation, cognitive restructuring, behavior control techniques, guided imagery, relaxation, couples communication training, and other types of counseling in an individualized, nonstandard fashion. Patients and partners were grouped according to propensity scores calculated from variables shown to be significant in regression analysis for outcomes of interest, including gender, age, cancer site, stage of disease, baseline anxiety, and depression. Propensity matched control patients, and partners who did not receive the intervention were identified and used as control comparisons. Analysis was done in groupings according to the level of distress with propensity scores as low-, moderate-, or high-distress.

Sample Characteristics:

  • N = 66 patients and 45 partners in ITT analysis; 43 patients and 27 partners completed the study  
  • MEAN AGE = 57.8 years (SD = 14.2 years) for patients, 56 years (SD = 14.4 years) for partners in the intervention
  • MALES: 60.6% for patients, 26.1% for partners; FEMALES: 39.4% for patients, 73.9% for partners
  • KEY DISEASE CHARACTERISTICS: Multiple tumor types—hematologic, head and neck, and gastrointestinal most common; 63.6% of patients had stage 3 or 4 disease; 69.5% of partners were involved with stage 3–4 disease
  • OTHER KEY SAMPLE CHARACTERISTICS: In most areas, patients in the control group did not have significant differences from those in the treatment groups. However, the majority of patients in the control group were highly educated, with 24% at the university level. Educational characteristics of patients and partners in the intervention group were not reported. Note: Sample characteristics are those who were moderately distressed. All characteristics of the full sample across all groups are not clearly provided.

Setting:

  • SITE: Single site  
  • SETTING TYPE: Outpatient  
  • LOCATION: Germany

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Palliative care 

Study Design:

  • Naturalistic design
    • Quasi-experimental with matched control comparison

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Symptom checklist (nine psychological symptoms)
  • Global Severity Index for overall psychopathology

Results:

Time effects within patient groups showed significant decreases over time in depression and distress (p ≤ .05), but not for anxiety and psychopathology. No group effects were seen on outcomes over time. Among partners, no changes were seen over time and no significant effects of the intervention were seen on outcomes. The same pattern was seen in completer and intent to treat analysis. Pre- and post-intervention data showed that patients had significant declines in anxiety (effect size Cohen’s d = 0.32, p = .01), distress (d = .46, p = .001), and depression (d = 0.52, p = .001) at 12 months, and partners had significant declines in anxiety (d = 0.45, p = .01) and distress (d = .42, p = .02) within the highly distressed group. No significant differences were seen in the less distressed group over time.

Conclusions:

Findings suggest that psychotherapeutic interventions can reduce anxiety, distress, and depression among patients and partners who are highly distressed. Little benefit may exist for individuals who are less anxious or distressed at baseline.

Limitations:

  • Small sample (less than 100)
  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Measurement/methods not well described
  • Questionable protocol fidelity
  • Other limitations/explanation: Distress measurement and definition are not described. The matched controls were not completely described but were highly educated; the education level of the comparison group is unknown. The intervention was not standardized or reviewed for content, so one cannot determine the similarities or dissimilarities of intervention sessions.

Nursing Implications:

Psychotherapeutic interventions may be beneficial for patients and caregivers who are highly distressed. Nurses need to be aware of the overall level of patient and caregiver distress and identify those who are likely to benefit from referral for therapy.

Herschbach, P., Berg, P., Waadt, S., Duran, G., Engst-Hastreiter, U., Henrich, G., … Dinkel, A. (2010). Group psychotherapy of dysfunctional fear of progression in patients with chronic arthritis or cancer. Psychotherapy and Psychosomatics, 79, 31–38.

doi:10.1159/000254903
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Study Purpose:

To examine the effects of generic psychotherapeutic interventions on dysfunctional fear of progression (FoP)

Intervention Characteristics/Basic Study Process:

Randomization was stratified by diagnosis, and participants were blinded with regard to group assignment. The intervention group received four sessions of group psychotherapy, each 90 minutes. The first group received cognitive behavioral group therapy (CBT) and a manual that was structured with content, topics, and interventions. The supportive experiential group therapy (SET) had a manual with regard to structure, but it was less prescriptive in content than was the CBT manual. The groups were led by psychotherapists who had had three years or more of clinical experience or were in the final phase of training. Sessions were recorded, to monitor integrity. Measures were taken at the initial session, before discharge, at three months, at 12 months, and after discharge. The control group provided data at the initial, before-discharge, and after-discharge points only. The intervention groups received booster telephone calls at six and nine months after discharge. The control group was sampled in the same clinics as were other patients and at one year after the completion of the intervention, using the same eligibility criteria.

Sample Characteristics:

  • The sample was composed of 872 participants total; 174 had chronic arthritis (CA)  and 174 had cancer.
  • All participants were at least 18 years old.
  • Mean age of CA patients was 46.7 years (SD = 9.5 years); mean age patients with cancer, 53.7 years (SD = 10.2 years).
  • The number of female patients in the CA group was 194; in the cancer group, 220. The number of male patients in the CA group was 64; in the cancer group, 45.
  • Of participants with cancer, 58.8% had breast cancer, 8% had colon cancer, 9.5% had bladder or prostate cancer, 9.1% had gynecologic cancer, and 14.4% had some other kind of cancer.

Setting:

  • Multisite.
  • Inpatient.
  • Patients with chronic arthritis were from one rehabilitation clinic. Patients with cancer were from two rehabilitation clinics.

Phase of Care and Clinical Applications:

Active treatment and transition phase

Study Design:

Single-blind partially longitudinal randomized controlled study

Measurement Instruments/Methods:

  • Fear of Progression Questionnaire (FoP-Q), consisting of 43 items relating to five dimensions
  • German version of the Hospital Anxiety and Depression Scale (HADS)
  • German version of the SF-12
  • Questions on Life Satisfaction Modules (FLZM)

Results:

Both interventions were associated with a decrease in FoP over time, but only among cancer patients. The two interventions did not differ in reducing FoP. A significant interaction between time and illness group emerged for anxiety, depression, and the mental component of health-related quality of life, indicating an improvement in cancer patients. The intervention had no effect  on any of the secondary outcomes.

Conclusions:

Dysfunctional FoP can be identified and targeted with brief group interactions. These interventions may reduce FoP, especially in populations with cancer. The intervention used here did not appear to have a long term benefit related to symptoms of depression.

Limitations:

  • Randomization was incomplete.
  • Participants in the rehabilitation setting may have had issues other than CA or cancer, and these issues may have affected outcomes.
  • Authors did not specify the stage of disease. Stage would affect a patient’s perception of progression.
  • Because of the settings involved, results may not be generalizable.

Nursing Implications:

Dealing with FoP is important in the care of cancer survivors. Findings of this study suggest that dysfunctional fear can be identified and that interventions can be appropriately targeted. While the intervention in this study did not show a lasting benefit related to depression, the study does provide potential approaches to identifying patients who may benefit from interventions to address fear.

Vos, P.J., Visser, A.P., Garssen, B., Duivenvoorden, H.J., & de Haes, H. (2007). Effectiveness of group psychotherapy compared to social support groups in patients with primary, non-metastatic breast cancer. Journal of Psychosocial Oncology, 25(4), 37–60.

doi: 0.1300/J077v25n04_03
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Study Purpose:

To compare the effectiveness, for women with a primary breast cancer, of experiential-existential group psychotherapy (incorporating cancer into one’s life) with that of a social-support group in regard to psychosocial adjustment (including psychological, psychosexual, and social adjustment); to examine the effect of age, type of surgery, and stage of disease on psychosocial adjustment indicators at the end of the intervention and at one year after the intervention

 

Intervention Characteristics/Basic Study Process:

After the participants provided informed consent, they were randomly assigned to treatment groups: one group that received group psychotherapy; one group,  social support. Data were collected at baseline (T0), then the intervention groups were conducted for three months. Data were collected after the intervention (T1) and at 12 months after completion of the intervention (T2). The interventions consisted of 12 weekly sessions of 2.5 hours each, including a 30-minute coffee break. The two follow-up sessions were at one and two months after the close of the intervention groups. The two follow-up sessions involved only 6–10 women and were conducted by trained leaders. Two trained therapists led the experiential-existential groups, and two trained leaders led the social-support groups. The study method required at least one of the therapists or leaders in each group to be a woman. Each group psychotherapy session, except the 1st and the 12th, followed a specific structure: opening, discussion of a specific topic, choosing the topic for the following week, and closing the session. The first session focused on introduction of the procedures and getting to know others. The 12th session was used to evaluate the group, to discuss what was learned or missed, to suggest improvements, and to say goodbye. Participants were allowed to choose the topics of the two follow-up sessions.

Sample Characteristics:

  • The sample was composed of 67 participants.
  • Mean age of participants in each group was 49 years.
  • All participants were female.
  • Participants had breast cancer with no distant metastasis. No participant had a diagnosed psychiatric illness. In the psychotherapy group, 12 participants had had breast-conserving surgery; in the social-support group, 10. In the psychotherapy group, 21 had had mastectomy;  in the social-support group, 24.
  • No significant demographic differences existed between intervention groups.
     

Setting:

  • Multisite
  • Outpatient
  • Several hospitals in Rotterdam, The Netherlands
     

Phase of Care and Clinical Applications:

  • Phase of care: transition phase after initial treatment
  • Clinical applications: late effects and survivorship
     

Study Design:

A time-series randomized clinical trial

Measurement Instruments/Methods:

  • Emotional adjustment: Dutch version of the Profile of Mood States (POMS) scale   
  • Psychosexual functioning: Sexual Functioning subscale of the European Organization for Research and Treatment quality of life questionnaire (EORTC QLQ-C30)
  • Psychosexual functioning: Body Image subscale of the the EORTC QLQ-C30
  • Social adjustment: Social Interaction subscale of the Sickness Impact Profile (SIP)
  • Social adjustment: Recreation subscale of the SIP
  • Demographic questionnaire
     

Results:

In regard to distress, vitality, sexual functioning, and social intentions, the psychotherapy group did not benefit more from the intervention than did the social-support group. At the end of the sessions, participants reported positive changes in regard to body image and recreation; the disease had less impact on recreational activities than on body image. Type of surgery was related to body image: Participants who had had breast-conserving surgery reported a more positive body image than did participants who had not.

 

Conclusions:

Psychologically well-adjusted women diagnosed with breast cancer do not benefit from the interventions described in this study: experiential-existential group psychotherapy and social-support groups.

Limitations:

  • The study has a small sample size, with fewer than 100 participants.
  • The details of the therapies limit generalizability and raise questions regarding study replication.
  • Decrease in the impact of disease on recreation could be a function of time.
  • The drop-out rate seemed higher among participants who had had mastectomy than among those who had had breast-conserving surgery.
  • Participants were psychosocially well adjusted at the beginning of the study, which may account for the minimal improvements shown.
  • Only 27.5% of the women asked to participate in the study agreed to participate; 23% who began the study dropped out.
     

Nursing Implications:

Results do not make clear whether support groups or group psychotherapy are beneficial for women who do not have substantial distress. In clinical practice, screening patients for psychological distress makes sense, as does providing therapy and the specified support interventions only to those patients who have distress and who may benefit.

Systematic Review/Meta-Analysis

Naaman, S.C., Radwan, K., Fergusson, D., & Johnson, S. (2009). Status of psychological trials in breast cancer patients: A report of three meta-analyses. Psychiatry, 72, 50–69.

doi: 10.1521/psyc.2009.72.1.50
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Purpose:

To determine the overall efficacy of psychological interventions, in patients with breast cancer, in regard to the outcome variables of anxiety, depression, and quality of life; to examine the moderating effects of disease stage, treatment type, duration, and orientation on overall treatment efficacy

Search Strategy:

Databases searched were MEDLINE (1966–January 2004), EMBASE (1980–2004), Cochrane Controlled Trials Register (1985–February 2004), PsycLIT (1973–2004), Biological Abstracts (1990–December 2003), CANCERLIT (1975–October 2002), CINAHL (1982–December 2003), and Health Start (1975–January 2004).

Search keywords were cognitive behavioral therapy, group psychotherapy, relaxation, supportive therapy, visual imagery, anxiety, depression, maladjustment, distress, and quality of life. Authors included no language or publication-status restrictions.

Studies were included if they met all these criteria:

  • Were randomized controlled trials (RCTs) that evaluated the efficacy of a psychological or behavioral intervention and were aimed at alleviating psychiatric or psychological morbidity
  • Included women participants who had
    • A histologically confirmed diagnosis of breast carcinoma of any stage
    • Undergone surgery
  • Included at least two arms: an intervention and a control

Studies examining the efficacy of interventions to assuage surgical distress were ineligible.

Literature Evaluated:

  • Investigators initially reviewed a total of 36 studies.
  • The final number of studies assessed for the analysis was 18: 14 studies assessed anxiety and 14 assessed depression.
  • Two reviewers assessed eligible trials and assigned a methodological grade by using the Jadad scale. Trials were pooled under outcome variables (anxiety, depression, and quality of life) to obtain three overall effect sizes, with negative values suggesting a favorable outcome for the treatment condition.
  • Also included was an academic textbook, Psychosocial Interventions for Cancer, by Baum and Anderson (2001).
  • Eight studies were carried out in facilities in the United States; four, in Canada; one, in England; two, in Australia; and one each in Japan, Italy, and China.
  • Eight studies had a score of 5 or greater on the Jadad scale. Ten had a score of less than 5.  The maximum score earned by an assessed study was 7.

Sample Characteristics:

  • Sample range across studies:
    • Anxiety: 1,278 participants, 692 in treatment group and 586 in control.
    • Depression: 1,324 participants, 713 in treatment group and 611 in control.
  • Participant age range was 25–73 years.
  • Of participants, 70% were married or in a committed relationship, 32% were Caucasian, 23.7% were Asian, 10.2% were African American, and 28.4% were Hispanic. The race of 28.4% was unidentified.

Results:

Depression: Authors reported a clinically moderate-to-strong effect (–1.01, 95% CI –1.48 to –0.54, N = 1,324) and robust finding (95% Cl –0.69 to –0.24) in studies treating patients with high psychological morbidity and methodologically more reliable studies. Short-term interventions compared to long-term interventions (–0.56 versus –0.40) showed a stronger clinical benefit for metastatic patients. Group interventions appeared to be moderately to strongly effective in treating depression in advanced disease (–0.56), compared to early-stage disease (–0.15). Cognitive behavioral interventions (–0.56) may be more effective than supportive expressive therapies (–0.36) for patients with advanced disease.

Anxiety: Most trials were conducted on a prophylactic basis rather than involving highly anxious patients. Findings suggested that a moderate-to-strong clinical impact may be observed in patients with breast cancer who are experiencing clinically significant anxiety. Short-term interventions were associated with clinically moderate effects; longer-term interventions also showed a clinically moderate effect (–0.40) in favor of treatment for patients with metastatic disease but not for those with early-stage breast cancer. Group interventions demonstrated a clinically moderate impact in favor of treatment (–0.40). Patients with more-advanced disease made clinically moderate gains (–0.36) with cognitive behavioral interventions, comparable to the gains made with expressive-supportive therapy (–0.40). Relaxation and guided imagery studies were of lower methodological grade; pure educational interventions failed to show any clinical benefit.

Conclusions:

The process of attempting to pool trials and explore effects is complicated and often misleading. Key findings follow.

  • In general, interventions targeting patients with clinically diagnosable levels of anxiety or depression are more beneficial than are interventions targeting patients with a lower level of anxiety or depression.
  • Group psychotherapy appears to be more effective than individual therapy at treating both anxiety and depression.
  • Within a group format, cognitive behavioral interventions appear to be equally effective as supportive-experiential therapies. Duration of treatment need not exceed 20 hours.

Nursing Implications:

Most trials in this analysis relied solely on self-reported measures of anxiety and depression. Literature in the field of cancer indicates that patients with cancer may under-report these symptoms; therefore, self-reported measures may be unreliable and collateral data are needed. In addition, further investigation of the timing of psychological intervention, to determine when the intervention is best delivered, is needed.


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