Effectiveness Not Established

Group Psychotherapy

for Anxiety

Psychotherapy involves a variety of approaches to structured therapeutic interaction between a trained professional and a client addressing problems that are psychological in nature. Group psychotherapy involves providing this therapy in a setting that includes a group of patients.

Research Evidence Summaries

Arch, J.J., & Mitchell, J.L. (2016). An Acceptance and Commitment Therapy (ACT) group intervention for cancer survivors experiencing anxiety at re-entry. Psycho-Oncology, 25, 610–615.

Study Purpose

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

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • 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.

Setting

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

Phase of Care and Clinical Applications

PHASE OF CARE: Transition phase after active treatment

Study Design

Quasiexperimental

Measurement Instruments/Methods

  • 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

Results

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).

Conclusions

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

Limitations

  • 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.

Nursing Implications

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.

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Breitbart, W., Rosenfeld, B., Pessin, H., Applebaum, A., Kulikowski, J., & Lichtenthal, W.G. (2015). Meaning-centered group psychotherapy: An effective intervention for improving psychological well-being in patients with advanced cancer. Journal of Clinical Oncology, 33, 749–754. 

Study Purpose

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

Intervention Characteristics/Basic Study Process

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

Sample Characteristics

  • 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.

Setting

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

Phase of Care and Clinical Applications

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

Study Design

  • Randomized parallel group trial

Measurement Instruments/Methods

  • 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

Results

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).

Conclusions

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.

Limitations

  • 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.

Nursing Implications

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.

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Krebber, A.M., Jansen, F., Witte, B.I., Cuijpers, P., de Bree, R., Becker-Commissaris, A., . . . Verdonck-de Leeuw, I.M. (2016). Stepped care targeting psychological distress in head and neck cancer and lung cancer patients: A randomized controlled trial. Annals of Oncology, 27, 1754–1760. 

Study Purpose

To evaluate the effects of a stepped psychotherapeutic intervention on patients with baseline anxiety

Intervention Characteristics/Basic Study Process

Patients who had completed curative therapy, were referred for follow-up, found to have relevant levels of distress, and consented to participation had a telephone interview at baseline. After the interview, they were randomized to usual care or the stepped program, which included watchful waiting, guided self-help via the Internet or a booklet, face-to-face problem-solving therapy, and psychological interventions and/or medications. Time frames for data collection varied depending upon the duration of the stepped program. General measures were obtained at 3, 6, 9, and 12 months after study entry. Usual care consisted of no psychosocial care in 64% of the group.

Sample Characteristics

  • N = 156, 106 at 12-month follow-up   
  • MEAN AGE = 62 years (SD = 9.4 years)
  • MALES: 60.9%, FEMALES: 39.1%
  • CURRENT TREATMENT: Not applicable
  • KEY DISEASE CHARACTERISTICS: Patients with head and neck or lung cancer in various stages
  • OTHER KEY SAMPLE CHARACTERISTICS: Of the patients, 77.6% had anxiety or a depressive disorder.

Setting

  • SITE: Single site   
  • SETTING TYPE: Multiple settings    
  • LOCATION: Netherlands

Phase of Care and Clinical Applications

PHASE OF CARE: Transition phase after active treatment

Study Design

Single-blind, randomized, controlled trial

Measurement Instruments/Methods

  • Hospital Anxiety and Depression Scale (HADS)
  • European Organization for Research and Treatment of Cancer Core Quality of Life (EORTC QLC-C30)
  • EORTC IN-PATSAT32 for inpatient satisfaction with care 
  • Composite International Diagnostic Interview (CIDI) for the presence of depression or an anxiety disorder

Results

The course of anxiety (p = 0.046) and depression (p = 0.007) was better for the intervention group than for the controls. When corrected for baseline anxiety and depression, depression was better for the intervention group over time (p < 0.001), but anxiety was not significantly different (p = 0.061). The stepped program had more influence over the course of symptoms among patients with a depression or anxiety disorder compared to those without a psychiatric disorder (p = 0.001). Among those without a psychiatric disorder, no differences in anxiety or depression scores were observed after a six-month measurement.

Conclusions

The stepped psychological intervention approach was shown to be effective to reduce anxiety and depression in the short-term, and had particular effectiveness for individuals with psychiatric disorders.

Limitations

  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • Subject withdrawals ≥ 10% 
  • About 40% were lost to follow-up at six months.
  • Patients were not blinded.  
  • No information was provided regarding medication use, etc.
  • More patients in the intervention group used alcohol.
  • Although all patients had clinically relevant anxiety at study entry, the majority of patients in the usual care group had no interventions.
  • Patients had completed initial treatment at highly varied time points prior to the study.

Nursing Implications

Psychiatric and stepped psychological interventions resulted in relatively short-term improvement in anxiety and depression among patients with cancer and anxiety. Interventions were most helpful for individuals with anxiety or depressive disorders over a longer period of time as well.

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Guideline / Expert Opinion

National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology: Distress management [v.2.2016]. Retrieved from

Purpose & Patient Population

PURPOSE: To provide guidance in the assessment and management of distress
 
TYPES OF PATIENTS ADDRESSED: Adult patients

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Consensus-based guideline

PROCESS OF DEVELOPMENT: Details provided on NCCN website
 
DATABASES USED: PubMed
 
INCLUSION CRITERIA: Clinical trials, practice guidelines, meta-analyses, systematic reviews, and validation studies
 
EXCLUSION CRITERIA: Not specified

Phase of Care and Clinical Applications

PHASE OF CARE: Not specified or not relevant

Results Provided in the Reference

From 2014–2015, 235 citations were retrieved.

Guidelines & Recommendations

  • 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

Limitations

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

Nursing Implications

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.

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