Individual Psychotherapy

To investigate the effectiveness of psychotherapy for treating depression in incurable cancer patients and to evaluate the effectiveness of psychotherapy on anxiety, general psychological distress, control of cancer symptoms, quality of life, and coping measures

Databases used, in September 2005, were Cochrane Pain, Palliative and Supportive Care Group Register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and PsycINFO. Investigators looked for additional studies in the  SciSearch database and contacted the authors of significant studies to identify trials for inclusion. Search keywords were psychotherapy, aromatherapy, art therapy, autogenic training, behavior adjustment therapy, biofeedback, implosive therapy, relaxation, yoga, hypnotherapy, imagery and psychotherapy, counseling, group therapy, socio-environmental therapy, depression, depressed, depressive, neoplasm, tumor, cancer, and carcinoma or malignancy. Authors provide extensive detailed lists of the search strategies and terms used with each database.

To be included in the analysis, studies had to 

• Involve psychotherapy of any kind, including interventions such as music therapy
• Include at least one validated measure of the severity of depression, either by self-report or rating by an observer
• Include only participants 18 years old or older who had a primary diagnosis of incurable cancer
• Be randomized controlled trials

Excluded from the analysis were interventions that were not considered forms of psychotherapy, such as aromatherapy and therapeutic touch.

The initial search identified 176 studies for possible inclusion. Of these, two independent raters identified 16 studies as potentially suitable. Six of these were eliminated because they involved interventions such as aromatherapy or structured nursing assessment. The final set of literature included 10 studies. None met risk-of-bias criteria for “good” study quality.

• The final sample of 10 studies included a total of 780 participants. Sample size per study was 20–235.
• Subjects for meta-analysis were obtained from three main groups: patients with metastatic breast cancer (five studies), patients receiving palliative care (three studies), and various patients with advanced cancer (two studies).

Of the 10 studies analyzed

• Five studies used, for the most part, supportive psychotherapy
• Three studies investigated, mosly, behavioral therapies, including relaxation techniques
• Some used cognitive behavioral and problem-solving therapies
• One study involved group therapy sessions

The duration of interventions, across studies, was 3–5 sessions.

Six studies had data that could be used in the meta-analysis of the effects of psychotherapy on depression. All used the Profile of Mood States (POMS) scale. Four involved supportive psychotherapy, one involved cognitive behavioral therapy, and one used problem-solving therapy.

• Combined data involved 292 participants in the psychotherapy arm and 225 in the control arm.
• Combined data showed that psychotherapy had a significant effect on depression among participants (SMD = –0.44, 95% CI –0.08 through –0.80).
• Statistically significant heterogeneity was observed among the six studies (p = 0.004).

Five studies could be used in the meta-analysis of the effect of psychotherapy on anxiety and general psychological distress. The five studies included 242 participants in the psychology arm and 169 in the control.

• Psychotherapy had a borderline effect on anxiety (SMD = –0.68, 95% CI 0.01 through –1.37).
• Statistically significant heterogeneity was observed (p < 0.00001).
• Four studies provided data on general psychological distress by using the POMS total mood disturbance score. Analysis included 237 participants in the psychotherapy arm and 166 in the control.
• Psychotherapy had a significant effect on distress (SMD = –.94, 95% CI = –0.01 through –1.87).
• Heterogeneity was statistically significant (p < 0.00001).

Other findings follow.

• Too few studies provided data to evaluate symptom control, quality of life, coping measures, or severity of physical symptoms.
• Subgroup analysis was done using studies of patients with metastatic breast cancer. Findings were similar and significant for depression, anxiety, and general distress.

Findings suggest that the depression that patients with advanced cancer experience can be effectively ameliorated by psychotherapeutic intervention. However, questions remain concerning duration of effectiveness and timing of interventions. Most studies included in the meta-analysis investigated the impact just after or during continuous cancer treatment and included a limited number of sessions. Effectiveness is further in question because studies did not show that patients were clinically depressed or suffered from depressive disorders. Authors noted that the effects of psychotherapy, as revealed in the meta-analysis, were almost comparable to those observed with antidepressant pharmacotherapy.

Although the analysis discovered significant findings regarding the use of psychotherapeutic interventions for depression, anxiety, and psychological distress, the quality of individual studies was not high and studies involved significant heterogeneity. Subjects’ physical status was not clearly defined. Some studies involved patients during active treatment, so it is unclear if findings are applicable to patients with end-stage disease. The cost associated with psychotherapeutic interventions requiring trained mental health professionals could not be evaluated. Providing such  interventions for many patients may be impossible, from the financial standpoint. Not enough studies met the criteria for meta-analysis to allow the authors to determine the impact of demographic and cultural differences on findings. These differences may influence involvement in and response to psychotherapy. Similarly, differences between types of therapy employed could not be evaluated.

Future research in this area should clarify the cost-effectiveness of psychotherapy. This area could benefit from research studies of higher quality, which would clarify effectiveness. Investigators noted that experts often recommend specific types of therapy, particularly cognitive behavioral therapy. However, this systematic review points to the need for more well-designed clinical trials to clarify the actual effect of each therapy on depression as well as on other patient outcomes.

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 determine the efficacy of short-term psychodynamic psychotherapy among women with breast cancer diagnosed with depression

Patients were randomized to study intervention or usual care groups. The usual care group received information about local counseling centers, and psychological diagnostic information was provided to their general practitioners. Physicians could refer for further treatment. Those in the experimental group received up to 5 pretreatment and 20 additional weekly psychotherapy sessions provided by psychotherapists who were trained in specific techniques for the study and a treatment manual. To ensure treatment fidelity, psychotherapists presented each patient in group supervision three times during the study. Study assessments were done at baseline, 6 months, and 12 months.

• N = 106  
• MEAN AGE = 51.8 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer; all had depression at baseline as determined by Structured Clinical Interview for DSM (SCID) and Hospital Anxiety and Depression Scale (HADS) score of at least 8.
• OTHER KEY SAMPLE CHARACTERISTICS: 55.8% were married, 32.7% had previous psychotherapy, and 56% were employed full-time or part-time.

• SITE: Multi-site
• SETTING TYPE: Outpatient 
• LOCATION: Germany

Randomized clinical trial

Remission at follow-up determined by SCID–I interview and HADS

By intention-to-treat (ITT) analysis (p = .007) and per protocol analysis (p = .02), remission rate was higher in the STPP group by HADs analysis. There was no difference in rates of remission by SCID criterion. Variables that were predictive of remission were study group, higher depression level at baseline, and time until post-treatment measure. STPP patients received an average of 18 sessions compared to an average of 2.4 sessions among controls. There was a trend for more use of antidepressant medication in the STPP group (p = .09).

Individual psychotherapy was shown to improve depression among depressed patients with breast cancer.

• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Level of depression by HADs was higher at baseline in the experimental group. There was a > 30% drop-out rate.

Individual psychotherapy can be beneficial for patients with cancer experiencing clinical depression. Screening for depression can identify those patients who may benefit from interventions.

To examine the influence of psycho-oncologic intervention on the psychological condition of patients with cancer

Patients, who had self-assessed regarding anxiety and depression levels, were placed in high- or low-risk groups. Participants were then randomized to either a psycho-oncologic support group or a control group. Support involved talks with a certified psychologist, who addressed development of a therapeutic relationship, supported the patient’s personal autonomy and defense mechanisms, worked to increase hopefulness and confidence, and facilitated communication between patients and providers. Patients were randomized at the time of surgery. Study measures were obtained at hospital discharge and 12 months later. The number of support sessions varied according to the length of inpatient care. High-risk groups averaged four sessions lasting an average of 41 minutes each. Low-risk patients had two or three sessions lasting an average of 40 minutes each.

• The sample was composed of 131 participants.
• Mean patient age was 57.2 years, with a range of 27–79 years.
• The sample was 36.6% male and 63.4% female.
• All cancer types were represented.

• Single site
• Inpatient setting
• Berlin, Germany

Active treatment

Randomized controlled trial

Hospital Anxiety and Depression Scale (HADS), German version

The study showed statistically significant reduction of anxiety and depression in high-risk patients who had undergone psycho-oncologic intervention at the end of inpatient care (p = 0.001). At 12 months, anxiety and depression scores increased in all patients. Depression scores increased in all low-risk patients at the time of discharge.

Patients with cancer who have anxiety may benefit from psycho-oncologic support.

• The study sample had a higher percentage of women than men, and patients had different cancer diagnoses.
• At 12 months, only 49 patients had completed the HADS tool.

Postsurgical patients with cancer who are anxious may benefit from psycho-oncologic support services. In the study, the effect of the intervention was significant in only those patients who had high anxiety scores at baseline. Study findings are similar to those produced by other research. This fact may suggest that interventions for anxiety are most beneficial for individuals who have meaningful levels of anxiety to begin with. Psycho-oncologic support did not appear to affect depression scores; however, these scores were not high at baseline.

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

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.

• 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.

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

PHASE OF CARE: Transition phase after active treatment

Single-blind, randomized, controlled trial

• 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

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.

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.

• 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.

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.

This study describes an integrated approach that includes a qualified psychotherapist as an active part of the oncology team. The first consultation with the patient included a PhD-level specialist. The oncologist asked the patient for both medical and psychological treatment consent. The psychologist performed psychological evaluations; conducted structured interviews; and measured, observed, and supported patients. One aim of the study was to evaluate feasibility of this integrated approach.

Outcomes measured included anxiety and depression, adaptation and awareness, and subjective perception of medical treatment quality. Outcome data were collected before and after 18 weeks of chemotherapy.

The sample was composed of 98 participants with metastatic or locally advanced colorectal cancer.

• Single site
• Cancer institute
• Rome, Italy

Prospective, nonrandomized design

• Hospital Anxiety and Depression Scale (HADS)
• European Organization for Research and Treatment quality of life questionnaire (EORTC QLQ-C30)

Prior to treatment 30% (29 patients) were found to have psychopathologic disorders. With the total of 294 psychodynamic interviews conducted, the McNemar test showed a significant improvement in terms of adaptation and awareness between pretreatment and 18 weeks. The mean HADS score initially was 4.9 ±2.9 for anxiety and 5.5 ±3.4 for depression, showing no abnormal depression or anxiety. After 18 weeks, the scores for anxiety decreased (p < 0.02). No significant change occurred with depression. At the completion of 18 weeks of therapy, there was a significant increase in the number of patients having a positive experience on health-related quality of life (53% versus 70%), anxiety (49% versus 63%), depression (54% versus 69%), interpersonal relationships (61% versus 79%), free time (61% versus 73%), and positive perception of treatment quality.

The results show the feasibility and some evidence of the benefit of the integrated approach to oncology care. Patients seemed to have a positive inner experience regarding the physician-patient relationship.

• The study was prospective and nonrandomized. It did not include a control group and was conducted at one site only.
• The study did not specify the exact actions of the psychologist.

To determine the effectiveness of integrating a depression management program into the care of patients with cancer and major depressive disorder (MDD).

Patients were randomized into the treatment group or the usual care group. The treatment group received up to 10 individual one-to-one 45-minute sessions over a three-month period; some occurred via telephone or in the patients' homes, as needed. The intervention consisted of education about depression and its treatment, problem-solving and coping strategies, and collaboration with each patient’s oncologist and primary care provider. Two repeat sessions were offered to persons whose Patient Health Questionnaire-9 (PHQ-9) scores were increasing. No further intervention occurred after six months, but a progress-monitoring interview was conducted at 12 months.

• The sample was comprised of 200 patients.
• Mean patient age in each group was 56.6 years.
• The usual care group included 71 women and 28 men, and the intervention group included 70 women and 31 men.
• Patients had breast, colorectal, gynecologic, genitourinary, hematologic, lung, and mixed cancers.
• Patients were eligible based on the presence of MDD antidepressant therapy (any dose or therapeutic dose). Symptoms (depression, anxiety, pain, fatigue, and physical functioning) were also identified.

• Home visit or telephone visit, if patients were unable to attend the single site
• Regional cancer treatment center in Scotland, United Kingdom

Patients were undergoing the active treatment and transitional phases of care.

The study was a randomized trial with a control (usual care) group.

• Hospital Anxiety and Depression Scale (HADS)
• Structured Clinical Interview for DSM-IV (SCID-IV), to determine if patients met the criteria for MDD
• PHQ-9, to assess the severity of depression
• Hopkins Symptom Checklist (SCL-20) depression scale, to measure changes in depression
• A 10-item subscale of the Symptom Checklist-90 (SCL-90) questionnaire, to measure anxiety
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• EuroQol EQ-5D questionnaire, to measure quality of life for economic analysis

Measurements revealed no statistically significant differences in the two groups at baseline, including differences in the use of antidepressant medication. However, at three and six months, more patients in the intervention group than in the control group were using a therapeutic level of antidepressants. Depression scores on the SCL-20 decreased between baseline and three months in both groups, but the scores decreased more in the intervention group. More patients in the intervention group had a depression score that decreased by at least 50% from baseline to the three-month follow-up (p = 0.0008). In addition, several patients in the intervention group no longer met the criteria for MDD at three months and had reduced anxiety and fatigue. The study showed no significant changes in pain or physical functioning at three or six months. In addition, at six and 12 months, the study showed a significant improvement in quality of life for patients in the intervention group.

Supplementation of usual care with a nurse-delivered intervention for the management of depression reduced the symptoms of depression, anxiety, and fatigue more than usual care alone. There were no significant improvements in pain or physical functioning. The authors noted the close relationship of anxiety and fatigue to depression as a possible rationale for the cluster of improvements.

• The study had risk of bias due to no attentional control.
• Patient bias may have affected the outcome assessments:  the Hawthorne effect may have applied because patients knew that management of depression was taught.

A cost-effective, patient-acceptable, nurse-delivered intervention can support the management of depression, anxiety, and fatigue in patients with cancer and MDD. At 12 months, the evidence showed a sustained effect of the three-month intervention.

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.