Progressive Muscle Relaxation (PMR)

To test the effectiveness of progressive muscle relaxation (PMR) and guided imagery as stress-reducing interventions

Patients randomized to usual care had weekly meetings with psychologists. Those randomized to PMR and guided imagery had four supervised sessions and daily self-practice for three weeks. To stimulate imagery, the guided imagery component included auditory, tactile, and olfactory images. The imagery script was accompanied by music. The intervention was tested and measured with biofeedback prior to study use.  Both groups were assessed at baseline and at the end of three weeks. Daily text message reminders were sent to the intervention group to remind them to practice PMR.

• N = 208  
• AGE RANGE: 40-60 years
• MALES: 50%, FEMALES: 50%
• KEY DISEASE CHARACTERISTICS: Breast and prostate cancer
• OTHER KEY SAMPLE CHARACTERISTICS: 49% had university education; 71% were married

• SITE: Multi-site  
• SETTING TYPE: Home    
• LOCATION: Cyprus

• PHASE OF CARE: Active antitumor treatment

• Single, blind. randomized, controlled trial

• Zung self-rating anxiety scale
• Beck Depression Inventory
• Salivary a-amylase and cortisol levels

The group had a decrease in mean anxiety score whereas the control group had an increase in anxiety at three weeks compared to baseline. The difference between groups of this change was significant (p < 0.001).  The same pattern of change between groups was shown for depression (p < 0.001). Salivary amylase and cortisol levels were directly related to anxiety and depression scores (p < 0.001).

PMR and guided imagery were associated with reduced anxiety and depression among patients with breast and prostate cancer during chemotherapy.

• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: No information was provided regarding patient adherence to daily PMR practice. No information was provided regarding any medications for anxiety or depression or chemotherapy regimens involved. Very limited demographic information is provided. The manner in which the imagery scenarios and music were provided were not described.

Findings here showed that progressive muscle relaxation and guided imagery were effective in reducing anxiety and depression during chemotherapy treatment. These are very low-risk interventions that can be helpful and can be readily incorporated into standard patient care.

To study the effects of two different interventions on anxiety and depression postoperatively

The interventions that were studied included a single educational session and a single session of progressive muscle relaxation delivered between the third and sixth postoperative day to women who had surgery for gynecologic cancers. Women randomly were assigned to intervention groups. Study measures were obtained preoperatively prior to hospital discharge.

• N = 35  
• MEAN AGE = 49.4 years (range = 23–79 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Varied tumor types (ovarian and cervical were most common); most had grade-2 disease

• SITE: Single-site    
• SETTING TYPE: Inpatient    
• LOCATION: Germany

• PHASE OF CARE: Active antitumor treatment

Randomized, noncontrolled trial

• Hospital Anxiety and Depression Scale (HADS)
• Perceived-stress questionnaire
• NeXus 1 (device for measuring physiological measures, respiratory rate, heart rate, skin conductance, etc.)

Anxiety scores declined significantly in both groups (p < .005), and depression declined significantly in those receiving the educational intervention (p < .001). There were no differences between groups in self-reported stress, and there were no significant changes in physiologic measures.

The findings of this study demonstrate that the interventions tested here may have some benefit; however, the strength of the results is low due to study limitations

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: It could be expected that anxiety levels would decline between preoperative and postoperative states without any intervention. The types of surgery were not described. It could be expected that outcomes at discharge could vary according to the type of surgical procedure performed and expected prognosis. Almost one fourth of participants dropped out of the study.

This study does not provide strong evidence in support of educational and muscle relaxation interventions for the reduction of anxiety or depression.

To examine effects of music therapy and progressive muscle relaxation (PMR) training on depression and anxiety in Chinese patients with breast cancer 

Patients randomly were assigned to the intervention group (which received the music and PMR intervention) or a usual care group after a radical mastectomy. To avoid contamination, intervention and control patients were placed in different inpatient areas. Music therapy involved listening to music via headphones connected to an MP3 player for 30 minutes twice per day. This began within 48 hours after surgery. Patients selected their preferred music. PMR training was conducted on the second postoperative day. Training was conducted twice per day for 30 minutes until discharge. Patients were encouraged to do PMR and music listening exercises together. Patients in the control group received the usual postoperative nursing care only. Study measures were obtained the day before surgery and the day before hospital discharge. Data collectors were blinded to group assignment.

• N = 170  
• MEAN AGE = 47.01 years (SD = 9.5 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Most had modified radical mastectomy and 89% had chemotherapy immediately after surgery

• SITE: Single-site    
• SETTING TYPE: Inpatient    
• LOCATION: China

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled, single-blinded trial

• Zung Self-Rating Depression Scale (SDS)
• State-Trait Anxiety Inventory (STAI)

Analysis showed that there was a significant reduction in anxiety and depression over time alone (p < .001) as well as by group (p < .001), and there was a significant interaction between group and time (p = .0009). Depression scores declined an average of 7.2 points in the intervention group and 4.6 points in the control group. Anxiety scores declined an average of 16 points in the intervention group and 11 points in the control group. Hospital stay time was significantly lower in the intervention group (p < .001). Hospital stay length was shorter in the intervention group.

The findings of this study suggest that the combination of PMR and listening to music was helpful in reducing anxiety and depression in women after mastectomies.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Findings not generalizable
• Other limitations/explanation: No information was provided regarding other potential confounders such as postoperative complications, pain levels, etc. that could influence reported outcomes. Data collection was conducted via face-to-face interview, and although it was stated that data collectors were blinded, it is not clear where the data collection took place. If it took place in the hospital, data collectors could deduce group assignment because of the different locations in the hospital. This study was of Chinese women, so applicability to other groups is not known. It is not clear in the report whether all sessions of the intervention were guided by the investigators or done by the patients on their own. It is not clear how, if supervised by investigators, the patient could listen to the PMR training if they also were listening to music via headphones.

Listening to music and using progressive muscle relaxation may have a positive impact on anxiety and depression in patients postoperatively. These are low-risk, low-cost interventions that may be beneficial. The findings of this study showed that those who had the intervention also had shorter hospital stays. There is insufficient evidence to determine the real impact of this intervention on duration of hospitalization; however, these findings suggest that this area deserves further exploration.

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.