Hopko, D.R., Robertson, S.M., & Carvalho, J.P. (2009). Sudden gains in depressed cancer patients treated with behavioral activation therapy. Behavior Therapy, 40(4), 346–356.

The overall purpose of the study was to examine sudden improvements in the symptoms of depressed patients with cancer who were receiving brief (nine-session) behavioral activation therapy (BAT). Specificially, the study examined the the frequency of sudden gains, the relation of sudden gains to the intervention components, the association of sudden gains to clinical and demographic variables, and the relation of sudden gains to treatment response and maintenance at three-month follow-up.  

Authors recruited study participants by means of medical clinic screenings at the University of Tennessee Medical Center Cancer Institute. Participants provided informed consent and were included if they scored 9 or higher on the Harvard Department of Psychiatry National Depression Screening (HANDS) scale and met inclusion criteria following completion of a pretreatment diagnostic assessment battery (see instruments below). Inclusion criteria consisted of being diagnosed with cancer at age 18 or older, having a primary diagnosis of major depression with moderate to severe symptoms, and not being psychotic or cognitively impaired. After developing rapport with each particpant, the therapy provider assessed the function of depressed behavior and introduced the treatment rationale. Rationale included to reduce reinforcement of depressed behavior, increase healthy behavior, or increase exposure to reinforcement of healthy behavior. Provider and patient discussed a behavioral checklist form each week, in the one-hour psychoeducation session. The provider presented the treatment rationale and facilitated activity and goal selection and behavioral activation. Examples of activities and goals included engaging in weekly self-monitoring of daily activities, providing baseline measurement, and identifying potential activities to target during BAT. Patients prioritized activities and values, and they set goals from easy to difficult, with the aim of working upward in this hierarchy: family, peer, intimate relationships, education, employment, career, hobbies, recreation, volunteer work, charity, physical, health issues, and spirituality.

• The sample was composed of 26 patients. In the group with sudden gains, mean age was 54.5 years. Mean age in the group without sudden gains was 51.2 years.
• Males: 8%; females: 92%.
• Of the 26 participants, 10 had coexistent diagnoses of generalized anxiety disorder, social phobia, panic disorder, post-traumatic stress disorder, or specific phobia. Cancer types were breast, lung, stomach, colon, prostate, and pancreatic. Average time since diagnosis was two years.

• Single site
• Outpatient
• University of Tennessee Medical Center Cancer Institute medical clinics
   

• Phase of care: active treatment
• Clinical applications: late effects and survivorship

Pre/post-test time-series measurements

• Anxiety Disorders Interview Schedule (ADIS-IV)    
• Beck Depression Inventory-II (BDI-II)
• Hamilton Rating Scale for Depression-24 (HRSD)
• Beck Anxiety Inventory-II (BAI-II)
• Medical Outcomes Study 36-item Short-Form 36 Health Survey (SF-36)
• Multidimensional Scale of Perceived Social Support (MSPSS)
   

During the treatment 50% of participants experienced sudden gains as measured by an average of 11.8 BDI-II points. None experienced more than one sudden gain. Four participants exhibited reversals following sudden gains; all four returned to within 50% of their sudden gain in the post-treatment assessment. The initial scores of participants who experienced sudden gains had less-severe depression as measured by the pretreatment ADIS-IV. Those who made sudden gains in measures related to emotional problems, as measured by the SF-36 subscales, reported greater physical functioning, less bodily pain, and fewer problems with work and daily activities. Authors found no between-group differences regarding demographic and cancer-related variables. Compared to those without sudden gains, patients with sudden gains had significantly lower HRSD post-treatment scores. However, “as a follow-up to the finding that decreased depression severity was associated with sudden gains, the relationship of depression severity and sudden gains in treatment responders was evaluated. ... [D]epression severity did not differ as a function of sudden gain status at post-treatment but was marginally significant at 3-month follow-up . . . with those experiencing sudden gains exhibiting a trend for lower pre-treatment depression severity ratings relative” to responders who did not report sudden gains.

Authors noted that 50% of depressed patients with cancer who had received BAT experienced a sudden gain. Findings suggest that, in regard to depression treatment in patients with cancer, a streamlined and parsimonious behavioral activation approach is as adequate as a more comprehensive cognitive-behavioral approach.

• The study had a small sample size, with fewer than 30 participants.
• The study included no ethnic diversity, and participants consisted primarily of breast cancer patients. These factors may affect generalizability.

Nurses treating depressed patients with cancer are advised to consider the role of increased pain and physical functioning in preventing sudden gains and other desirable treatment responses.  Nurses who assimilate this knowledge into treatment plans may provide better care to depressed patients with cancer than do nurses who do not.