Akechi, T., Okuyama, T., Onishi, J., Morita, T., & Furukawa, T.A. (2009). Psychotherapy for depression among incurable cancer patients. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD005537.

To investigate the effectiveness of psychotherapy for treating depression in incurable cancer patients and to evaluate the effectiveness of psychotherapy on anxiety, general psychological distress, control of cancer symptoms, quality of life, and coping measures

Databases used, in September 2005, were Cochrane Pain, Palliative and Supportive Care Group Register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and PsycINFO. Investigators looked for additional studies in the  SciSearch database and contacted the authors of significant studies to identify trials for inclusion. Search keywords were psychotherapy, aromatherapy, art therapy, autogenic training, behavior adjustment therapy, biofeedback, implosive therapy, relaxation, yoga, hypnotherapy, imagery and psychotherapy, counseling, group therapy, socio-environmental therapy, depression, depressed, depressive, neoplasm, tumor, cancer, and carcinoma or malignancy. Authors provide extensive detailed lists of the search strategies and terms used with each database.

To be included in the analysis, studies had to 

• Involve psychotherapy of any kind, including interventions such as music therapy
• Include at least one validated measure of the severity of depression, either by self-report or rating by an observer
• Include only participants 18 years old or older who had a primary diagnosis of incurable cancer
• Be randomized controlled trials

Excluded from the analysis were interventions that were not considered forms of psychotherapy, such as aromatherapy and therapeutic touch.

The initial search identified 176 studies for possible inclusion. Of these, two independent raters identified 16 studies as potentially suitable. Six of these were eliminated because they involved interventions such as aromatherapy or structured nursing assessment. The final set of literature included 10 studies. None met risk-of-bias criteria for “good” study quality.

• The final sample of 10 studies included a total of 780 participants. Sample size per study was 20–235.
• Subjects for meta-analysis were obtained from three main groups: patients with metastatic breast cancer (five studies), patients receiving palliative care (three studies), and various patients with advanced cancer (two studies).

Of the 10 studies analyzed

• Five studies used, for the most part, supportive psychotherapy
• Three studies investigated, mosly, behavioral therapies, including relaxation techniques
• Some used cognitive behavioral and problem-solving therapies
• One study involved group therapy sessions

The duration of interventions, across studies, was 3–5 sessions.

Six studies had data that could be used in the meta-analysis of the effects of psychotherapy on depression. All used the Profile of Mood States (POMS) scale. Four involved supportive psychotherapy, one involved cognitive behavioral therapy, and one used problem-solving therapy.

• Combined data involved 292 participants in the psychotherapy arm and 225 in the control arm.
• Combined data showed that psychotherapy had a significant effect on depression among participants (SMD = –0.44, 95% CI –0.08 through –0.80).
• Statistically significant heterogeneity was observed among the six studies (p = 0.004).

Five studies could be used in the meta-analysis of the effect of psychotherapy on anxiety and general psychological distress. The five studies included 242 participants in the psychology arm and 169 in the control.

• Psychotherapy had a borderline effect on anxiety (SMD = –0.68, 95% CI 0.01 through –1.37).
• Statistically significant heterogeneity was observed (p < 0.00001).
• Four studies provided data on general psychological distress by using the POMS total mood disturbance score. Analysis included 237 participants in the psychotherapy arm and 166 in the control.
• Psychotherapy had a significant effect on distress (SMD = –.94, 95% CI = –0.01 through –1.87).
• Heterogeneity was statistically significant (p < 0.00001).

Other findings follow.

• Too few studies provided data to evaluate symptom control, quality of life, coping measures, or severity of physical symptoms.
• Subgroup analysis was done using studies of patients with metastatic breast cancer. Findings were similar and significant for depression, anxiety, and general distress.

Findings suggest that the depression that patients with advanced cancer experience can be effectively ameliorated by psychotherapeutic intervention. However, questions remain concerning duration of effectiveness and timing of interventions. Most studies included in the meta-analysis investigated the impact just after or during continuous cancer treatment and included a limited number of sessions. Effectiveness is further in question because studies did not show that patients were clinically depressed or suffered from depressive disorders. Authors noted that the effects of psychotherapy, as revealed in the meta-analysis, were almost comparable to those observed with antidepressant pharmacotherapy.

Although the analysis discovered significant findings regarding the use of psychotherapeutic interventions for depression, anxiety, and psychological distress, the quality of individual studies was not high and studies involved significant heterogeneity. Subjects’ physical status was not clearly defined. Some studies involved patients during active treatment, so it is unclear if findings are applicable to patients with end-stage disease. The cost associated with psychotherapeutic interventions requiring trained mental health professionals could not be evaluated. Providing such  interventions for many patients may be impossible, from the financial standpoint. Not enough studies met the criteria for meta-analysis to allow the authors to determine the impact of demographic and cultural differences on findings. These differences may influence involvement in and response to psychotherapy. Similarly, differences between types of therapy employed could not be evaluated.

Future research in this area should clarify the cost-effectiveness of psychotherapy. This area could benefit from research studies of higher quality, which would clarify effectiveness. Investigators noted that experts often recommend specific types of therapy, particularly cognitive behavioral therapy. However, this systematic review points to the need for more well-designed clinical trials to clarify the actual effect of each therapy on depression as well as on other patient outcomes.