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.

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.

• 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.

• 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.

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

• 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.

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

• 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

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.

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.

• 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.

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.