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.

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

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.

• 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 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.

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.

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.

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.