Effectiveness Not Established

Psychotherapy

for Fatigue

Psychotherapy involves a variety of approaches for structured therapeutic interaction between a trained professional and the client addressing problems that are psychological in nature.

Research Evidence Summaries

Boesen, E. H., Ross, L., Frederiksen, K., Thomsen, B. L., Dahlstrøm, K., Schmidt, G., . . . Johansen, C. (2005). Psychoeducational intervention for patients with cutaneous malignant melanoma: a replication study. Journal of Clinical Oncology, 23, 1270–1277.

Intervention Characteristics/Basic Study Process

A psychoeducational intervention was offered between three weeks and four months postsurgery for malignant melanoma to groups of 8 to 10 patients. The intervention was organized into six sessions lasting approximately 2.5 hours each and was performed over a six-week period. The intervention consisted of health education about malignant melanoma and follow-up routines, the importance of limiting sun exposure, stress awareness, and stress management (relaxation and guided imagery). Patients were given a workbook and a CD with relaxation and imagery exercises. Psychological support was provided via the presence of a group therapist throughout all sessions and through peer support in the group setting.

Sample Characteristics

  • In total, 262 patients with T1-4, N1a-2a, M0 malignant melanoma were recruited between 3 and 12 weeks postsurgery.
  • No follow-up data on these patients were available.
  • There were no significant differences between the treatment and control groups relative to any demographic or medical variables.
  • The majority of the patients in both groups were married and between ages 40 and 60 years.

Setting

  • Multisite
  • Outpatient oncology clinics in eastern Denmark

Phase of Care and Clinical Applications

Patients were undergoing the long-term follow-up phase of care.

Study Design

The study was a randomized, controlled trial with a usual care control group. Fatigue was evaluated at baseline prior to the intervention and at 6 and 12 months postintervention.

Measurement Instruments/Methods

Profile of Mood States (POMS)

Results

Controlling for baseline levels of fatigue, there was a statistically significant effect of the intervention on fatigue six months postintervention. This effect was not sustained at 12-month follow-up. Sixteen patients dropped out of the intervention before it started or after one session. All patients who dropped out cited that they dropped out due to the time or the distance involved or that they felt no need for support.

Limitations

  • The study lacked an attentional control group.
  • Sixteen patients dropped out of the intervention.
  • The direction of the bias on the intervention effect on fatigue (i.e., overestimation of the effect versus underestimation of the effect) created by these drop-outs was not examined/reported.
  • Professional training was required to deliver the intervention.

Nursing Implications

Efficiencies of treatment were achieved through the group intervention modality.

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Courneya, K. S., Friedenreich, C. M., Sela, R. A., Quinney, H. A., Rhodes, R. E., & Handman, M. (2003). The group psychotherapy and home-based physical exercise (group-hope) trial in cancer survivors: physical fitness and quality of life outcomes. Psycho-Oncology, 12, 357–374.

Intervention Characteristics/Basic Study Process

Patients were randomized to receive either 10 weeks of group psychotherapy and exercise (home-based, moderate intensity, 20 to 30 minutes, three to five times per week, and tailored across the intervention to promote progression toward the goal of achieving a heart rate during exercise of 65% to 75% of the estimated heart rate maximum) or group psychotherapy only. The group psychotherapy intervention consisted of stress management and relaxation training or expressive supportive therapy. Both group psychotherapy interventions had a psychoeducational focus. Patients in the group psychotherapy only arm received a personalized exercise plan after study completion. To control for possible contamination between the experimental conditions, groups of patients who had registered for a group psychotherapy program at a large cancer center, rather than individual patients, were randomized.

Sample Characteristics

  • The study included 96 patients (group psychotherapy and exercise group, n = 51; group psychotherapy only, n = 45).
  • Mean age was 51.55 years (range 25–74).
  • Of the patients, 84% were female, 50% had stage I or II disease, and 50% had stage III or IV disease.
  • Most patients were Caucasian and had an annual income of $40,000 per year.
  • All patients were screened for participation restrictions for a moderate exercise program using the revised Physical Activity Readiness Questionnaire (PAR-Q) and a submaximal fitness assessment.
  • Diagnoses included breast cancer (40.9%), colon cancer (9.4%), lymphoma (6.2%), ovarian cancer (5.2%), gastric cancer (4.2%), melanoma, and mixed solid tumors (21.8%).

Setting

  • Single site
  • Outpatient comprehensive cancer center

Phase of Care and Clinical Applications

Patients were undergoing the active treatment and long-term follow-up phases of care.

Study Design

This was a randomized, controlled trial with a crossover for the control group receiving group psychotherapy alone.

Measurement Instruments/Methods

Functional Assessment of Cancer Therapy–Fatigue (FACT-F)

Results

No difference existed between expressive supportive therapy and stress management and relaxation therapy in group psychotherapy effect in either group. Group psychotherapy and exercise improved quality of life beyond group psychotherapy only in cancer survivors (active treatment and long-term follow-up). The group psychotherapy intervention did not significantly reduce fatigue; however, the addition of moderate-intensity exercise resulted in a statistically significant improvement in fatigue.

Limitations

  • The group was relatively homogeneous with regard to race (most were Caucasian), educational level (59% had completed university), and socioeconomic status (67% had a median annual family income greater than $40,000).
  • The exercise program was only 10 weeks in length and provided no long-term follow-up because of the control group crossover design.
  • Some exercise, adherence, and contamination problems were noted; about 20% of the patients in the exercise condition did not meet the minimum cut point of 60 minutes per week of moderate or strenuous exercise, and 20% of patients in the control group met this cut point.
  • Contamination may have resulted from having the control condition monitor patients and report their exercise on a weekly basis or because previous exercisers were allowed to participate.
  • All patients were selected from among patients who declared themselves interested in a group psychotherapy intervention; thus, the results are generalizable to patients who voluntarily join group psychotherapy classes.
  • The authors did not differentiate outcomes achieved by patients who were receiving active treatment and those on long-term follow-up.
  • Nontolerance of exercise and safety parameters for exercise in the group psychotherapy and exercise groups was not described.
  • For group psychotherapy, a therapist experienced in stress management, relaxation therapy, and expressive-supportive therapy is required. A certified fitness appraiser must appraise and design each individual program.
  • Skills and equipment for performing a submaximal cardiovascular treadmill test are needed to evaluate the fitness level of patients prior to having them commence an exercise program.
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