Group Psychotherapy

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.

To test the hypothesis that an Acceptance and Commitment Therapy (ACT) group intervention would reduce anxiety and increase positive outcomes among cancer survivors at the re-entry phase

Groups were facilitated by a trained clinical psychologist and oncology social worker and provided in seven weekly two-hour sessions. Participants were assisted in cultivating awareness and acceptance of thoughts and emotions about cancer, disentangling from rigid thoughts and beliefs, clarifying personal values, and committing to pursue activities aligned with those values through experiential exercises, metaphors, discussion, and homework. Study outcomes were measured at 3.5, 2, and 0.5 weeks baseline prior to the intervention, midintervention, one week following the last session, and three months after the last session.

• N = 42   
• MEAN AGE = 53.52 years
• AGE RANGE = 20–70 years
• MALES: 7.1%, FEMALES: 92.9%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Varied cancers; 59.5% had breast cancer. All had completed initial treatment within the past 12 months.
• OTHER KEY SAMPLE CHARACTERISTICS: Ninety-seven percent were Caucasian with an average of a bachelor’s degree and a median income of $41,000–$60,000. All patients demonstrated anxiety on screening tools, and 52% had both anxiety and depression upon study entry.

• SITE: Multi-site   
• SETTING TYPE: Other    
• LOCATION: A community center in Colorado

PHASE OF CARE: Transition phase after active treatment

Quasiexperimental

• State-Trait Anxiety Inventory (STAI)  
• Center for Epidemiological Studies Depression Scale (CESD)
• Short Form 36 Health Survey (SF-36)
• Concerns about recurrence scale
• Revised Impact of Event Scale (IES)
• Orientation to Life Questionnaire
• Participant rating of the value of each session

Anxiety declined following the intervention at immediate postmeasurement (p < 0.001) and three-month follow-up (p < 0.001). Depression symptoms also declined after the intervention (p < 0.001) and at three-month follow-up (p < 0.001). Fear of cancer recurrence decreased (p < 0.05) and at follow-up (p = 0.001).

The findings suggest that the group ACT intervention can help reduce anxiety and depression at healthcare re-entry among cancer survivors.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement validity/reliability questionable
• Intervention expensive, impractical, or training needs
• Used a large battery of tests repeatedly over a short period of time—testing effect could be a threat to validity.

The group psychotherapy approach used here may be helpful to patients who are suffering from anxiety and/or depression after completion of initial treatment for cancer. Further research is needed.

To explore the effectiveness of psycho-oncologic interventions for patients and partners on anxiety, depression, psychopathology, and distress

Patients and partners who had been referred for psycho-oncologic service were recruited. Common interventions were psychoeducation, cognitive restructuring, behavior control techniques, guided imagery, relaxation, couples communication training, and other types of counseling in an individualized, nonstandard fashion. Patients and partners were grouped according to propensity scores calculated from variables shown to be significant in regression analysis for outcomes of interest, including gender, age, cancer site, stage of disease, baseline anxiety, and depression. Propensity matched control patients, and partners who did not receive the intervention were identified and used as control comparisons. Analysis was done in groupings according to the level of distress with propensity scores as low-, moderate-, or high-distress.

• N = 66 patients and 45 partners in ITT analysis; 43 patients and 27 partners completed the study  
• MEAN AGE = 57.8 years (SD = 14.2 years) for patients, 56 years (SD = 14.4 years) for partners in the intervention
• MALES: 60.6% for patients, 26.1% for partners; FEMALES: 39.4% for patients, 73.9% for partners
• KEY DISEASE CHARACTERISTICS: Multiple tumor types—hematologic, head and neck, and gastrointestinal most common; 63.6% of patients had stage 3 or 4 disease; 69.5% of partners were involved with stage 3–4 disease
• OTHER KEY SAMPLE CHARACTERISTICS: In most areas, patients in the control group did not have significant differences from those in the treatment groups. However, the majority of patients in the control group were highly educated, with 24% at the university level. Educational characteristics of patients and partners in the intervention group were not reported. Note: Sample characteristics are those who were moderately distressed. All characteristics of the full sample across all groups are not clearly provided.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Germany

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care 

• Naturalistic design
  • Quasi-experimental with matched control comparison

• Hospital Anxiety and Depression Scale (HADS)
• Symptom checklist (nine psychological symptoms)
• Global Severity Index for overall psychopathology

Time effects within patient groups showed significant decreases over time in depression and distress (p ≤ .05), but not for anxiety and psychopathology. No group effects were seen on outcomes over time. Among partners, no changes were seen over time and no significant effects of the intervention were seen on outcomes. The same pattern was seen in completer and intent to treat analysis. Pre- and post-intervention data showed that patients had significant declines in anxiety (effect size Cohen’s d = 0.32, p = .01), distress (d = .46, p = .001), and depression (d = 0.52, p = .001) at 12 months, and partners had significant declines in anxiety (d = 0.45, p = .01) and distress (d = .42, p = .02) within the highly distressed group. No significant differences were seen in the less distressed group over time.

Findings suggest that psychotherapeutic interventions can reduce anxiety, distress, and depression among patients and partners who are highly distressed. Little benefit may exist for individuals who are less anxious or distressed at baseline.

• Small sample (less than 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement/methods not well described
• Questionable protocol fidelity
• Other limitations/explanation: Distress measurement and definition are not described. The matched controls were not completely described but were highly educated; the education level of the comparison group is unknown. The intervention was not standardized or reviewed for content, so one cannot determine the similarities or dissimilarities of intervention sessions.

Psychotherapeutic interventions may be beneficial for patients and caregivers who are highly distressed. Nurses need to be aware of the overall level of patient and caregiver distress and identify those who are likely to benefit from referral for therapy.

To test the efficacy of group psychotherapy to reduce distress and improve spiritual well being among patients with advanced or terminal cancer

Groups of 8-10 patients were formed and then randomized to either meaning-centered group psychotherapy (MCGP) or supportive group psychotherapy (SGP) as an active control. Questionnaires were completed at baseline, after eight weeks of therapy, and two months after completion of the intervention. MCGP focused on helping people develop or increase meaning. SGP focused on coping by encouraging patients to share concerns, describe experiences and emotions, and offer support and advice to each other. Groups met weekly, and all were facilitated by a social worker or clinical psychologist and doctoral student. Facilitators only conducted one type of session, clinical supervision was done weekly, and group sessions were audiotaped for random review for fidelity of the intervention

• N = 127
• MEAN AGE = 58.3 years (range = 27 -91)
• MALES: 30%, FEMALES: 70%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types.
• OTHER KEY SAMPLE CHARACTERISTICS: Predominantly Caucasian ethnicity, but did include African Americans and Hispanics, overall average years of education was 15.9.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: New York

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

• Randomized parallel group trial

• Functional Assessment of Chronic Illness Therapy Spiritual Well Being Scale
• McGill QOL questionnaire
• Beck Depression Inventory
• Hospital Anxiety and Depression Scale
• Hopelessness Assessment in Illness Questionnaire
• Memorial Symptom Assessment Scale
• Mini Mental State Exam
• Functional Social Support Questionnaire

Depression declined over time in all participants, but showed a significant decline among those in the meaning centered psychotherapy group, for those who completed at least three sessions (p < 0.05). The number of those completing three sessions is not provided.  All other measures, except anxiety, also improved over time and improved more in the meaning-centered group. Within group change scores showed moderate effects in both MCGP (d = 0.54) and SGP (d = 0.39).

Both types of group therapy used here were associated with improvement in depression and quality of life measures. Results were somewhat stronger for the meaning-centered therapy group.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement validity/reliability questionable
• Subject withdrawals at 10% or greater 
• Other limitations/explanation: There was no complete control group, and the active control intervention used here could also have positive effects on outcomes measured. Patients completed a battery of repeated measures which could have resulted in fatigue and testing effects. Only 65%-70% completed at least one session. Sample included those without clinically relevant depression or anxiety, so there was limited opportunity for improvement. Medications used that could have affected outcomes are not stated. Those in the MCGP had higher distress at baseline.

Group psychotherapy can be helpful to patients with advanced cancer for depression and quality-of-life issues, and both meaning-centered and supportive interventions may be of benefit. There are a number of study limitations here which mitigate the strength of these findings. Nurses can consider and advocate for these types of interventions for appropriate patients.

To examine the effects of generic psychotherapeutic interventions on dysfunctional fear of progression (FoP)

Randomization was stratified by diagnosis, and participants were blinded with regard to group assignment. The intervention group received four sessions of group psychotherapy, each 90 minutes. The first group received cognitive behavioral group therapy (CBT) and a manual that was structured with content, topics, and interventions. The supportive experiential group therapy (SET) had a manual with regard to structure, but it was less prescriptive in content than was the CBT manual. The groups were led by psychotherapists who had had three years or more of clinical experience or were in the final phase of training. Sessions were recorded, to monitor integrity. Measures were taken at the initial session, before discharge, at three months, at 12 months, and after discharge. The control group provided data at the initial, before-discharge, and after-discharge points only. The intervention groups received booster telephone calls at six and nine months after discharge. The control group was sampled in the same clinics as were other patients and at one year after the completion of the intervention, using the same eligibility criteria.

• The sample was composed of 872 participants total; 174 had chronic arthritis (CA)  and 174 had cancer.
• All participants were at least 18 years old.
• Mean age of CA patients was 46.7 years (SD = 9.5 years); mean age patients with cancer, 53.7 years (SD = 10.2 years).
• The number of female patients in the CA group was 194; in the cancer group, 220. The number of male patients in the CA group was 64; in the cancer group, 45.
• Of participants with cancer, 58.8% had breast cancer, 8% had colon cancer, 9.5% had bladder or prostate cancer, 9.1% had gynecologic cancer, and 14.4% had some other kind of cancer.

• Multisite.
• Inpatient.
• Patients with chronic arthritis were from one rehabilitation clinic. Patients with cancer were from two rehabilitation clinics.

Active treatment and transition phase

Single-blind partially longitudinal randomized controlled study

• Fear of Progression Questionnaire (FoP-Q), consisting of 43 items relating to five dimensions
• German version of the Hospital Anxiety and Depression Scale (HADS)
• German version of the SF-12
• Questions on Life Satisfaction Modules (FLZM)

Both interventions were associated with a decrease in FoP over time, but only among cancer patients. The two interventions did not differ in reducing FoP. A significant interaction between time and illness group emerged for anxiety, depression, and the mental component of health-related quality of life, indicating an improvement in cancer patients. The intervention had no effect  on any of the secondary outcomes.

Dysfunctional FoP can be identified and targeted with brief group interactions. These interventions may reduce FoP, especially in populations with cancer. The intervention used here did not appear to have a long term benefit related to symptoms of depression.

• Randomization was incomplete.
• Participants in the rehabilitation setting may have had issues other than CA or cancer, and these issues may have affected outcomes.
• Authors did not specify the stage of disease. Stage would affect a patient’s perception of progression.
• Because of the settings involved, results may not be generalizable.

Dealing with FoP is important in the care of cancer survivors. Findings of this study suggest that dysfunctional fear can be identified and that interventions can be appropriately targeted. While the intervention in this study did not show a lasting benefit related to depression, the study does provide potential approaches to identifying patients who may benefit from interventions to address fear.

To examine efficacy of eight weeks of behavioral activation and problem-solving therapies toward reducing depression and suicidal ideation

Patients who had breast cancer and met the Harvard National Depression scale criteria for symptoms of major depression were randomized to behavioral activation or problem-solving psychotherapy interventions. Sessions were provided by clinical psychology doctoral students who were skilled in both interventions. All sessions were one on one and audiotaped, and 15% of tapes were randomly selected for review of competence and adherence by an independent therapist.

• N = 80 in ITT analysis, 65 completed treatment  
• MEAN AGE: 55.4 years (SD = 11.9 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer; average time since diagnosis was 3.2 years
• OTHER KEY SAMPLE CHARACTERISTICS: 43% had prior psychotherapy and, on average, had moderate level depression and mild to moderate suicidal ideation at baseline; 93% were Caucasian; and research included people taking antidepressants, but the number of those on antidepressants was not reported.

• SITE: Single site  
• SETTING TYPE: Not specified  
• LOCATION: New York, NY

PHASE OF CARE: Transition phase after active treatment

• Randomized trial

• Hamilton Rating Scale for Depression (HRSD) 
• Beck Depression Inventory (BDI)
• Center for Epidemiological Studies Depression scale (CES-D)

For all measures, there was a significant main effect for time (p < 0.05), showing decline in depression; but there were no differences between groups. There was a significant linear reduction in suicidal ideation and an increase in hopefulness at post-treatment and at the 12-month follow-up.

Both types of psychotherapy examined here were associated with reduced depression and suicidal ideation.

• Small sample (less than 100)
• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• Subject withdrawals of 10% or greater 
• Proportion of the sample on antidepressants is not described, and there is no subgroup analysis of outcomes between those on or not on antidepressants

Psychotherapy can be helpful for patients with cancer who also suffer from depression and may have suicidal ideation. This study adds to the body of evidence on efficacy of psychotherapy for these patients. Psychotherapy should be considered as part of treatment options for individuals who have clinically relevant depression or a major depressive disorder.

To compare the effectiveness, for women with a primary breast cancer, of experiential-existential group psychotherapy (incorporating cancer into one’s life) with that of a social-support group in regard to psychosocial adjustment (including psychological, psychosexual, and social adjustment); to examine the effect of age, type of surgery, and stage of disease on psychosocial adjustment indicators at the end of the intervention and at one year after the intervention

After the participants provided informed consent, they were randomly assigned to treatment groups: one group that received group psychotherapy; one group,  social support. Data were collected at baseline (T0), then the intervention groups were conducted for three months. Data were collected after the intervention (T1) and at 12 months after completion of the intervention (T2). The interventions consisted of 12 weekly sessions of 2.5 hours each, including a 30-minute coffee break. The two follow-up sessions were at one and two months after the close of the intervention groups. The two follow-up sessions involved only 6–10 women and were conducted by trained leaders. Two trained therapists led the experiential-existential groups, and two trained leaders led the social-support groups. The study method required at least one of the therapists or leaders in each group to be a woman. Each group psychotherapy session, except the 1st and the 12th, followed a specific structure: opening, discussion of a specific topic, choosing the topic for the following week, and closing the session. The first session focused on introduction of the procedures and getting to know others. The 12th session was used to evaluate the group, to discuss what was learned or missed, to suggest improvements, and to say goodbye. Participants were allowed to choose the topics of the two follow-up sessions.

• The sample was composed of 67 participants.
• Mean age of participants in each group was 49 years.
• All participants were female.
• Participants had breast cancer with no distant metastasis. No participant had a diagnosed psychiatric illness. In the psychotherapy group, 12 participants had had breast-conserving surgery; in the social-support group, 10. In the psychotherapy group, 21 had had mastectomy;  in the social-support group, 24.
• No significant demographic differences existed between intervention groups.
   

• Multisite
• Outpatient
• Several hospitals in Rotterdam, The Netherlands
   

• Phase of care: transition phase after initial treatment
• Clinical applications: late effects and survivorship
   

A time-series randomized clinical trial

• Emotional adjustment: Dutch version of the Profile of Mood States (POMS) scale   
• Psychosexual functioning: Sexual Functioning subscale of the European Organization for Research and Treatment quality of life questionnaire (EORTC QLQ-C30)
• Psychosexual functioning: Body Image subscale of the the EORTC QLQ-C30
• Social adjustment: Social Interaction subscale of the Sickness Impact Profile (SIP)
• Social adjustment: Recreation subscale of the SIP
• Demographic questionnaire
   

In regard to distress, vitality, sexual functioning, and social intentions, the psychotherapy group did not benefit more from the intervention than did the social-support group. At the end of the sessions, participants reported positive changes in regard to body image and recreation; the disease had less impact on recreational activities than on body image. Type of surgery was related to body image: Participants who had had breast-conserving surgery reported a more positive body image than did participants who had not.

Psychologically well-adjusted women diagnosed with breast cancer do not benefit from the interventions described in this study: experiential-existential group psychotherapy and social-support groups.

• The study has a small sample size, with fewer than 100 participants.
• The details of the therapies limit generalizability and raise questions regarding study replication.
• Decrease in the impact of disease on recreation could be a function of time.
• The drop-out rate seemed higher among participants who had had mastectomy than among those who had had breast-conserving surgery.
• Participants were psychosocially well adjusted at the beginning of the study, which may account for the minimal improvements shown.
• Only 27.5% of the women asked to participate in the study agreed to participate; 23% who began the study dropped out.
   

Results do not make clear whether support groups or group psychotherapy are beneficial for women who do not have substantial distress. In clinical practice, screening patients for psychological distress makes sense, as does providing therapy and the specified support interventions only to those patients who have distress and who may benefit.

The guideline provides an algorithm for the screening and assessment of anxiety, a care map for anxiety in adults with cancer, an algorithm for the screening and assessment of depression, a care map for depression in adults with cancer, the Patient Health Questionnaire (PHQ 9) symptom depression scale and generalized anxiety disorder (GAD) items, and selected measures for depression and anxiety (modified).

• Before the implementation of guidelines, referral systems and resources should be identified and available in each institution.
• The guidelines are designed for healthcare providers, patients, family members, and caregivers to guide in the screening, assessment, and treatment approaches of adult patients with cancer who have anxiety and depression at any stage of the cancer continuum, regardless of cancer type, disease stage, or treatment modality. 
• All patients with cancer and cancer survivors should be evaluated for the symptoms of anxiety and depression with validated instruments at periodic times during the cancer care. Treatment recommendations are based on the levels of symptoms. Follow-up care and reassessment are important in this setting to monitor for follow-through, compliance with referrals, and pharmacologic management. If compliance is poor, develop a plan. After eight weeks of treatment, if symptoms are not improved or poor compliance is noted, alter the treatment course and add a psychological or pharmacologic intervention. The guidelines recommend that individual psychological interventions be delivered by a licensed mental health professional, which may include cognitive and behavioral strategies, education and relaxation strategies, group psychosocial interventions, and physician-prescribed antidepressants. 

• A guideline that has been adapted from another country often can't lend itself to different policies or cultural influences.
• Some of the recommendations were removed from the original guideline because of references to the Edmonton Symptom Assessment Scale screening measure, which is not widely used in the United States.

Nurses play a vital role in the early screening, assessment, and treatment of patients who may have significant symptoms of anxiety and depression. By screening and making appropriate referrals, we can impact the emotional, interpersonal, and financial costs for patients and reduce the economic impact for providers and the healthcare system.

RESOURCE TYPE: Consensus-based guideline

PHASE OF CARE: Not specified or not relevant

• Recommends psychological interventions with or without antianxiety or antidepressants to treat anxiety
• Recommends psychological interventions with or without antidepressants to treat depression
• Provides algorithms for social work counseling and chaplain interventions

Limited information on the quality of evidence was retrieved. All recommendations were mainly consensus based.

This guideline provides very general level treatment algorithms based on the results of an initial distress screening, and recommends further assessment and intervention determination if overall distress is 4 or above on the distress thermometer.