Expressive Writing/Emotional Disclosure/Journaling

To examine the effects of an expressive writing intervention on cancer-related distress, symptoms of depression, and mood in women with early-stage breast cancer

Women were randomized to an expressive writing group or a control group. Both groups were instructed to write for 20 minutes once a week over a three-week period. On each writing day, patients were contacted by telephone to initiate the writing session and contacted again after 20 minutes to terminate writing. Patients in the expressive writing group were instructed to write about a distressing event and to explore their deepest emotions and feelings about the experience. Control group patients were asked to write about their daily activities in a detailed and objective manner. Study questionnaires were completed at baseline and at three and nine months postintervention.

• The study reported on a sample of 437 female patients.
• Mean patient age was 53.6 years.
• All patients had breast cancer (stage I or II) and were contacted regarding study participation within three weeks of initial breast surgery.
• The majority (80%) of patients were married or partnered, and 64.5% were retired or unemployed.

• Multisite
• Home setting
• Denmark

Single-blind, randomized controlled trial with an active control group

• Impact of Event Scale
• Beck Depression Inventory
• Profile of Mood States
• Social Constraints Scale
• Toronto Alexithymia Scale

The expressive writing group showed significant changes in negative and positive mood immediately after the writing sessions (d = 0.84–1.04, p < 0.001). When age and baseline measures were included in analysis as covariates, there were no significant effects or group-by-time interactions.

Investigators could not confirm the hypothesis that, compared to patients in an active control group, patients in an expressive writing group experience less cancer-related distress.

• Fifteen percent of the sample initially randomized dropped out or was lost to follow-up.
• Investigators did not report whether patients were actively receiving treatment during the study.
• Baseline outcome data were not reported.

This study does not provide evidence to support expressive writing as an intervention to reduce anxiety and symptoms of depression in women with breast cancer.

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.