Psychoeducation or psychoeducational interventions encompass a broad range of activities that combine education and other activities such as counseling and supportive interventions. Psychoeducational interventions may be delivered individually or in groups, and may be tailored or standardized. This type of intervention generally includes providing patients with information about treatments, symptoms, resources and services, training to provide care and respond to disease-related problems, and problem-solving strategies for coping with cancer. Interventions may include use of booklets, videos, audiotapes, and computers, and formats may be interactive between healthcare professionals and patients and caregivers, self-directed via use of CDs and other materials, online, or delivered telephonically. Studies using psychoeducational interventions tend to vary substantially in specific content, format, frequency, and timing of the interventions. For this reason, there is limited ability to currently examine the relative effectiveness of different formats and delivery methods. Highly specific content approaches, such as mindfulness-based stress reduction and cognitive behavioral approaches, are identified in these resources as separate interventions, rather than incorporated into overall psychoeducation.
Agboola, S.O., Ju, W., Elfiky, A., Kvedar, J.C., & Jethwani, K. (2015). The effect of technology-based interventions on pain, depression, and quality of life in patients with cancer: A systematic review of randomized controlled trials. Journal of Medical Internet Research, 17, e65.
STUDY PURPOSE: To review randomized, controlled trials evaluating the effect of telehealth interventions on pain, depression, and health-related quality of life outcomes in cancer care
TYPE OF STUDY: Systematic review
DATABASES USED: PubMed, EMBASE, Google Scholar, CINAHL, and PsychINFO
KEYWORDS: Neoplasms, cancer remote consultation, mHealth, connected health, text messaging, telemedicine, telehealth, ehealth, telephone therapy, teleconsultation, mobile technology, telecare, internet, digital health, mobile phone, smartphone, apps, and mobile application
INCLUSION CRITERIA: Reported the effect of telehealth on pain, depression, or quality of life in patients with cancer; randomized, controlled trials
EXCLUSION CRITERIA: Not stated
TOTAL REFERENCES RETRIEVED: 4,929
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane Collaboration’s risk of bias tool
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Pediatrics, elder care, and palliative care
Many of the included studies were telephone-based interventions with the interventions provided by professionals or peer counselors. Five studies used a web-based delivery of the intervention. The duration of the interventions ranged from one week to 12 months with a median of 12 weeks. Three studies examined the effect on pain; two of these showed a significant positive effect of the intervention, and one showed no difference between the groups. Nine studies examined the intervention effect on depression; four of these showed positive effect on depression while five showed no significant effect. Eight studies examined quality of life, and one measured well-being.
This review showed mixed results for the effects of technology-based interventions on pain and depression among patients with cancer.
There were few included studies, and most of them were done in high-income populations that were tech-savvy. There was high heterogeneity in the outcomes. Many of the studies had a high or unclear risk of bias.
It may be worthwhile to use telehealth applications with tech-savvy, high-income patients. These types of interventions are worthy of additional study to fully determine the efficacy of these interventions for symptom management.
Barsevick, A.M., Sweeney, C., Haney, E., & Chung, E. (2002). A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncology Nursing Forum, 29, 73–84.
Databases: CINAHL, MEDLINE, PsycLIT, and CANCERLIT
The study evaluated 36 randomized clinical trials (RCTs), seven quasi-experimental trials, five descriptions, six reviews, and one practice guideline published 1980–2000.
In 22 of 36 RCTS, psychoeducational interventions benefited patients with symptoms of depression.
The evidence dervied from this review supports the benefit of psychoeducational interventions for depression in patients with cancer.
Bennett, S., Pigott, A., Beller, E.M., Haines, T., Meredith, P., & Delaney, C. (2016). Educational interventions for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, 11, CD008144.
STUDY PURPOSE: To evaluate the effectiveness of educational interventions for managing fatigue in adults with cancer
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
Educational interventions appear to play some role in reducing overall fatigue, fatigue intensity, and fatigue interference, and might provide some benefit for anxiety. No effect on depression was found in this study, but baseline levels of depression were not generally clinically relevant.
The incorporation of educational interventions as part of care to manage fatigue is reasonable but may not be sufficient to have a clinically meaningful impact.
Chien, C.H., Liu, K.L., Chien, H.T., & Liu, H.E. (2013). The effects of psychosocial strategies on anxiety and depression of patients diagnosed with prostate cancer: A systematic review. International Journal of Nursing Studies.
To evaluate, by means of meta-analysis and systematic review, evidence regarding the effectiveness of psychosocial interventions for anxiety and depression in patients with prostate cancer
Databases searched were PubMed, CINAHL, PsycINFO, Cochrane Collaboration, and two Chinese databases.
A study was included in the review if it
A study was excluded if it focused on disease other than prostate cancer and lacked intergroup comparison.
Patients were undergoing multiple phases of care.
Findings suggest that psychosocial interventions can be helpful in reducing anxiety and depression, at various time points in the cancer trajectory, for men who are newly diagnosed with prostate cancer. Positive effects were generally short-term only.
Findings of this analysis suggest that various types of psychosocial interventions can help reduce anxiety and depression in men with prostate cancer. Effects shown tended to be short-lived. Nurses can help reduce anxiety and depression among patients with prostate cancer by using psychosocial types of strategies. Information about ways to sustain this effect is limited, and the analysis does not identify the types of approaches that are the most helpful. Further exploration of longer-term sustainable effects and associated dosage and intervention frequency is needed. Given the relatively low level of quality of research in this area, more well-designed studies are needed.
Duijts, S.F., Faber, M.M., Oldenburg, H.S., van Beurden, M., & Aaronson, N.K. (2011). Effectiveness of behavioral techniques and physical exercise on psychosocial functioning and health-related quality of life in breast cancer patients and survivors—A meta-analysis. Psycho-Oncology, 20, 115–126.
STUDY PURPOSE: To examine the effects of behavioral techniques (e.g., behavioral therapy, cognitive therapy, mind-body and relaxation techniques, counseling, social support, hypnosis, biofeedback, exercise, physical exercise (PhysEx), aerobic exercise, physical activity, motor activity) on psychosocial functioning outcome measures, such as fatigue, depression, anxiety, body image, and stress, and on health-related quality of life
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Elder care, palliative care
Behavioral techniques affect specific aspects of psychosocial functioning but have a minor, insignificant effect on health-related quality of life. PhysEx has a positive effect on health-related quality of life. Behavioral techniques demonstrated a moderately significant effect on anxiety and depression and showed a significant but small effect on fatigue. PhysEx was effective for fatigue and showed a positive effect for depression.
A range of behavioral techniques may be effective for patients with breast cancer and fatigue, depression, and depressed body image. PhysEx was shown to improve health-related quality of life, fatigue, anxiety, and depression. Recognizing the symptoms of patients with breast cancer was emphasized as having positive effects (e.g., feeling relieved, hearing helpful strategies addressing quality of life and psychosocial problems).
Ell, K., Aranda, M.P., Xie, B., Lee, P.J., & Chou, C.P. (2010). Collaborative depression treatment in older and younger adults with physical illness: Pooled comparative analysis of three randomized clinical trials. American Journal of Geriatric Psychiatry, 18(6), 520–530.
To perform intent-to-treat meta-analyses on pooled data, to compare the effect of collaborative multidisciplinary care on depression in older adults to that received by younger adults
Study findings indicate that collaborative depression care in individuals with diverse comorbid illness is as effective in reducing depression in older patients as it is in younger patients, including those in low-income, minority classifications.
Galway, K., Black, A., Cantwell, M., Cardwell, C.R., Mills, M., & Donnelly, M. (2012). Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients. Cochrane Database of Systematic Reviews, 11, CD007064.
To assess the effects of psychosocial interventions on quality of life and mood symptoms in patients diagnosed with cancer within the past 12 months
Multiple phases of care
Findings suggest that psychosocial interventions have a positive impact on quality of life among newly diagnosed patients with cancer. Psychoeducational interventions and nurse-delivered interventions demonstrate a small significant effect across combined trials. Overall evidence does not indicate that individual psychosocial interventions are effective at improving the mood- and quality-of-life–related symptoms of patients newly diagnosed with cancer.
A small number of studies in meta-analysis related to mood changes. Effect sizes in mood changes were small, and study samples comprised high heterogeneity, demonstrating that findings should be interpreted with some caution in terms of clinical relevance.
The fact that nurse-delivered psychosocial interventions demonstrated a positive and statistically significant effect is promising, although the effect size was small. This finding provides some support for interventions delivered by nurses rather than by other healthcare professionals. Other studies have reported this finding. Nurses may be uniquely positioned to provide such interventions: Their knowledge base includes both physiologic and psychosocial components of the cancer experience, and individual interventions can simultaneously and effectively address physical and psychosocial symptom management. The findings of this study provide general support for the effectiveness of psychoeducational interventions.
Hoon, L.S., Chi Sally, C.W., & Hong-Gu, H. (2013). Effect of psychosocial interventions on outcomes of patients with colorectal cancer: A review of the literature. European Journal of Oncology, 17, 883–891.
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Pediatrics, elder care, palliative care
Various psychosocial interventions, including educational interventions, cognitive behavioral therapy, relaxation training, and supportive group therapy, were found to reduce the length of patients’ hospital stays, decrease the number of days to proficiency in self-care for stoma, decrease levels hospital anxiety and depression, and increase quality of life.
Various forms of psychosocial interventions were used to improve outcomes, but no clear winner was found. All forms seemed to improve patient outcomes.
Howell, D., Harth, T., Brown, J., Bennett, C., & Boyko, S. (2017). Self-management education interventions for patients with cancer: A systematic review. Supportive Care in Cancer, 25, 1323–1355.
STUDY PURPOSE: To identify core components of self-management education interventions and assess effectiveness
TYPE OF STUDY: Systematic review
DATABASES USED: Ovid, MEDLINE, EMBASE, Cochrane collaboration, CINAHL, PsycINFO
INCLUSION CRITERIA: Adults, use of any type of teaching strategy, addressed any single core element of self-management interventions as defined by the authors, group based or individual structure
EXCLUSION CRITERIA: Psychotherapy or support groups, use of only information such as leaflets or videos, focus on family members, focus on decision making by patients, gray literature, interventions related to diet and exercise
TOTAL REFERENCES RETRIEVED: 4,579
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane risk of bias tool to evaluate study quality. All were at high risk of bias related to lack of blinding
FINAL NUMBER STUDIES INCLUDED: 43
TOTAL PATIENTS INCLUDED IN REVIEW: 6,795
SAMPLE RANGE ACROSS STUDIES: 22 to 483
PHASE OF CARE: Multiple phases of care
Authors attempted to correlate core elements of interventions with outcomes. Overall, there were very few studies that had any common combinations of core elements, so this analysis could not be done. Overall, studies suggested that psychoeducational interventions may be beneficial for relieving symptoms of anxiety and depression. The content, elements, structure duration and frequency of interventions across studies were varied. Many interventions labeled as self-management education did not include components related to self management.
Psychoeducational interventions appear to be beneficial for symptoms of anxiety and depression. It is not possible to determine the specific components of these types of interventions that are most helpful.
Psychoeducational interventions of various types can be beneficial in reducing patients’ anxiety and depressive symptoms.
Jacobsen, P.B., & Jim, H.S. (2008). Psychosocial interventions for anxiety and depression in adult cancer patients: Achievements and challenges. CA: A Cancer Journal for Clinicians, 58, 214–230.
STUDY PURPOSE: To describe an evidence-based approach to the use of psychosocial interventions to manage anxiety and depression in adults with cancer
TYPE OF STUDY: Combined systematic review and meta-analysis
PHASE OF CARE: Active treatment
APPLICATIONS: Late effects and survivorship
Nine of the 13 publications reached positive conclusions about the efficacy of psychosocial interventions for depression in patients with cancer. Positive supporting evidence yielded recommendations for behavioral therapy, counseling/psychotherapy, and either of these approaches combined with education, relaxation training for patients not undergoing surgery, and cognitive-behavioral therapy.
Six of eight publications reached positive conclusions about the efficacy of psychosocial interventions for anxiety. Recommended are behavioral interventions for patients undergoing treatment, relaxation training for patients not undergoing surgery, and cognitive-behavioral therapy in the post-treatment period.
Future research is needed, particularly focusing on men, minorities, patients with advanced disease, and patients who have completed treatment. Studies must include patients experiencing significant depression and/or anxiety prior to intervention. Combinations of interventions should also be studied. Last, timing for screening and intervening is important, but current data specify only “vulnerable times” rather than evidence to guide practice.
Newby, T.A., Graff, J.N., Ganzini, L.K., & McDonagh, M.S. (2015). Interventions that may reduce depressive symptoms among prostate cancer patients: A systematic review and meta-analysis. Psycho-Oncology. Advance online publication.
PHASE OF CARE: Multiple phases of care
The meta-analysis across all studies with all types of interventions showed a positive effect of intervention (p = 0.002). In four studies using exercise, there was no significant effect. Across three studies of psychosocial interventions, including psychotherapy and peer support, the was an overall significant effect (point estimate –0.961, p = 0.003). In two studies of educational interventions, there was no statistically significant effect.
The findings of this study suggest that psychosocial interventions can be effective in reducing depressive symptoms among patients with prostate cancer.
The majority of studies included were of low quality. The authors stated that in multiple-arm studies, outcomes were only used in certain selected study arms. For each subanalysis, there were few individual studies. There were some discrepancies in the report regarding the number of studies included. Samples were mixed in terms of inclusion of patients who did or did not have clinically relevant depressive symptoms. Most studies were brief, and the long-term benefits of the interventions were not clear.
Although this analysis provides relatively limited evidence regarding the effectiveness of individual types of interventions, its findings do suggest that some intervention is more effective than doing nothing. Nurses need to identify patients with symptoms of depression and those at risk for depression and take action.
Newell, S.A., Sanson-Fisher, R.W., & Savolainen, N.J. (2002). Systematic review of psychological therapies for cancer patients: Overview and recommendations for future research. Journal of the National Cancer Institute, 94, 558–584.
The study involved searches of the MEDLINE, Healthplan, PsychLIT, and Allied and Complementary Medicine databases. The articles included were published prior to December 1998.
The study consisted of a critical review of psychological therapies used by patients with cancer. Authors identified 627 relevant articles reporting 329 intervention trials. Authors identified 11 papers discussing 15 trials of fair quality and exploring interventions aimed at reducing depression.
Despite increased use of RCT designs, the methodological quality was generally suboptimal.
No intervention can be recommended for depression reduction, but interventions involving group therapy, education, structured counseling, cognitive-behavioral therapy (CBT), communication-skills training, and self-esteem building warrant further exploration before recommendations can be made.
Osborn, R.L., Demoncada, A.C., & Feuerstein, M. (2006). Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: Meta-analyses. International Journal of Psychiatry in Medicine, 36, 13–34.
To investigate the effects of cognitive behavioral therapy (CBT) and patient education on depression, anxiety, pain, physical functioning, and quality of life (QOL) in adult cancer survivors
The study involved searching MEDLINE, PsycINFO, and the Cochrane Database for the period 1993–2004.
The literature evaluated included 15 randomized controlled trials (RCTs), five of which measured depression and all of which had been published 1993–2004. Authors assessed quality of the RCTs by means of the Jadad scale.
The sample size was 1,492.
CBT is related to short-term effects on depression; individual interventions were more effective than group interventions. Neither CBT nor patient education produced significant long-term effects on depression.
Pirl, W.F. (2004). Evidence report on the occurrence, assessment, and treatment of depression in cancer patients. Journal of the National Cancer Institute Monographs, 32, 32–39.
To produce an evidence-based report that reviews empirical literature about depression in patients with cancer and focuses on occurrence, assessment, and treatment
Authors examined literature published January 1966–September 2000. Authors found literature by searching PubMed, PsycINFO, CINAHL, and BiOSIS Citation Index.
The most common intervention for depression is behavioral/cognitive counseling. Because hundreds of articles exist on this topic, the review was limited to several meta-analyses of psychosocial interventions; some measured emotional adjustment or distress rather than depression. All studies cited were conducted prior to 1998. Tools for measuring depression included the Hamilton Rating Scale for Depression, Clinical Global Impression, Hospital Anxiety and Depression Scale, and Montgomery-Asberg Depression Rating Scale. Descriptive reports were found on complementary treatments but no randomized controlled trials (RCTs).
Authors identified 11 RCTs of medication treatment for depression in patients with cancer. The RCTs included data about 755 patients, an average of 58 patients per study.
Some data support the efficacy of psychosocial and pharmacologic treatments for depression in people with cancer. Studies, using antidepressant medications, that conformed to usual practices for antidepressant trials did demonstrate benefit. (The studies that lasted for fewer than five weeks tended to show less benefit than did longer studies.)
RCTs of alternative or complementary interventions were not found.
Rodin, G., Lloyd, N., Katz, M., Green, E., Mackay, J.A., & Wong, R.K.S. (2007). The treatment of depression in cancer patients: A systematic review. Supportive Care in Cancer, 15, 123–136.
To evaluate the efficacy of pharmacologic and nonpharmacologic treatments for depression in patients with cancer
Literature review of works, published through June 2005, conducted by the Supportive Care Guidelines Group (Ontario). Databases searched were MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Database.
Authors identified seven pharmacologic randomized control trials and four nonpharmacologic trials.
Pharmacologic trials: Three trials detected significant differences (symptom improvement) among treatment groups on a measure of depression. Two compared the antidepressant mianserin to placebo. The third, which compared use of alprazolam to muscle relaxation, found reduction in symptoms of depression with the use of alprazolam. Two studies compared active treatments—fluoxetine versus desipramine and paroxetine versus amitriptyline. They found improvement of symptoms of depression in all groups, with no differences in treatment efficacy. The remaining two trials found no significant differences among patients randomized to fluoxetine versus placebo; however, only low-dose fluoxetine was evaluated in one of the studies, and both studies were for a short duration, only five weeks.
Nonpharmacologic trials: Two of the four studies reported greater improvement in symptoms of depression in the intervention groups rather than in groups with usual care. Interventions included an orientation program with educational information and a multicomponent intervention. One of the remaining studies found that adjuvant psychotherapy did not significantly affect patients’ Hospital Anxiety and Depression Scale (HADS) subscores for depression. The final study found no significant difference among patients receiving cognitive-existential group therapy plus relaxation and those receiving relaxation therapies alone.
The evidence of treatment effectiveness for depressive disorders in patients with cancer is limited and of modest quality.
At present, treatment guidelines must be based on limited evidence and on data derived from the general population, other medically ill populations, and on expert opinions.
Slev, V.N., Mistiaen, P., Pasman, H.R., Verdonck-de Leeuw, I.M., Uden-Kraan, C.F., & Francke, A.L. (2016). Effects of eHealth for patients and informal caregivers confronted with cancer: A meta-review. International Journal of Medical Informatics, 87, 54–67.
PURPOSE: To synthesize evidence regarding effects of eHealth in patients with cancer and informal caregivers from systematic reviews
Evidence was found for positive effects of eHealth on knowledge and perceived support. The findings regarding effects on decision-making were inconsistent. Interventions had some positive effects on patient involvement in healthcare. The findings regarding the effects of Internet support groups on anxiety and depression were mixed. Most interventions were Internet-based and had multiple components of education, support, chat groups, and communications with providers. One study used smart phone applications.
EHealth applications have been shown to have a positive effect on knowledge. Its effects on other aspects of the patient experience are inconsistent.
All but one study were of moderate quality. Studies of low quality were excluded. Types of programs and components varied greatly, making the synthesis of effects for discrete interventions difficult.
eHealth applications may be a useful and practical way to provide patient and caregiver education. Its effectiveness as an intervention for psychological well-being and other outcomes was not clear given the mixed evidence. Ongoing research is needed to determine the full range of potential effects, program components that are most helpful, and needed duration of use for positive effects.
Tao, W.W., Jiang, P., Liu, Y., Aungsuroch, Y., & Tao, X.M. (2014). Psycho-oncologic interventions to reduce distress in cancer patients: A meta-analysis of controlled clinical studies published in People's Republic of China. Psycho-Oncology, 24, 269–278.
PHASE OF CARE: Multiple phases of care
Intervention types that were included in the meta-analysis were educational, psychological support, cognitive behavioral therapy, relaxation training, music therapy, coping skills training, and communication skills training. The majority of studies incorporated two or more interventions together. Fifteen studies showed overall significant effects on anxiety (d = -8.71, p < .001). The combination of education and psychological support (d = -8.17, p = .04) or education combined with relaxation training (d = -12.95, p < .001) were effective in reducing anxiety. Large combined effects were seen on depression (d = -8.12, p < .001). No analysis of effects for specific intervention types was possible. In greater than 69% of studies, the interventions were performed by nurses.
The findings of this study support the effectiveness of psychoeducational interventions to reduce anxiety and depression in patients with cancer in China.
The studies included in this analysis had numerous flaws. The meta-analysis was primarily done across all types of interventions. Because most of the studies used combined interventions, the effectiveness of individual components could not be determined. The authors noted that the trials were carried out in Chinese regions where almost no negative studies are reported, so publication bias cannot be ruled out.
The findings of these studies support the effectiveness of psychoeducational interventions for anxiety and depression in patients with cancer. Although these findings were only in Chinese patients, they are in agreement with the bulk of overall evidence in this area. These results suggest that psychoeducational interventions are likely to have similar levels of effectiveness in various cultural groups.
Walker, J., Sawhney, A., Hansen, C.H., Symeonides, S., Martin, P., Murray, G., & Sharpe, M. (2013). Treatment of depression in people with lung cancer: A systematic review. Lung Cancer (Amsterdam, Netherlands), 79(1), 46–53.
To determine, by using a systematic review, which, if any, treatments have been found to be effective in reducing depression in patients with lung cancer
The total number of references retrieved was 143. The evaluation method consisted of the review, by two independent researchers, of full articles.
No trials aimed to evaluate the effectiveness of treatments for depression in people with lung cancer. The six trials in the sample discussed interventions intended to improve symptoms related to quality of life, and each trial included a measure of depression as a secondary measure. The interventions, depression measures, and time of measurement varied. The interventions included breathlessness advice and discussion, education about self-referral for local psychosocial resources, counseling, coping skills training (including progressive muscle relaxation and symptom management strategies), early introduction of palliative care, and supportive psychotherapy. Studies indicated that enhanced care was more effective in reducing depression symptoms than was standard care.
Patients with lung cancer tend to be older adults with medical comorbidities, and these patients tend to suffer severe physical deterioration. Although standard depression treatments may be a reasonable course for treating depressed people with lung cancer, no randomized controlled trials (RCTs) guide clinicians in treating this population.
No evidence guides clinicians who are caring for this specific population; well-conducted RCTs are urgently needed. Analysis indicates that clinicians may consider, as tools to reduce depression, depression treatments effective in older adults in the general population and those with medical comorbidities.
Williams, S., & Dale, J. (2006). The effectiveness of treatment for depression/depressive symptoms in adults with cancer: A systematic review. British Journal of Cancer, 94, 372–390.
To perform a systematic review of studies regarding the efficacy of psychotherapeutic and antidepressant interventions for cancer patients with depression or symptoms of depression
The total number of references retrieved was 164. Authors conducted analysis according to the methodological-quality instrument developed Bo, Cho, and Bero.
The final number of included studies was 24. The sample range across studies of pharmacologic intervention was 892 (range = 40–549); of psychotherapeutic intervention, 2,518 (range = 36–450). Studies related to multiple disease sites.
Some evidence indicates that antidepressants are effective in reducing symptoms of depression in patients with cancer. Overall tolerability of antidepressants appeared to be good. Cognitive behavioral therapy was effective in reducing symptoms of depression. Another intervention that might be effective is the use of social support groups.
Findings suggest that antidepressants, cognitive behavioral interventions, and support-group interventions can have a positive impact on symptoms of depression in patients with cancer. Variability in findings suggests that these interventions are likely to be of most benefit to patients who actually have clinically meaningful symptoms of depression. Further research regarding the efficacy of antidepressants in the included patients is needed. Studies should include data about co-interventions for depression.
Yang, Y.L., Sui, G.Y., Liu, G.C., Huang, D.S., Wang, S.M., & Wang, L. (2014). The effects of psychological interventions on depression and anxiety among Chinese adults with cancer: A meta-analysis of randomized controlled studies. BMC Cancer, 14, 956-2407-14-956.
The meta-analysis was completed using all studies in a single analysis. The interventions were highly varied, including patient education, relaxation, cognitive behavioral therapy, etc. An analysis showed an overall effect size of SMD = 1.199 (95% CI 1.095 – 1.303, p < 0.001) for depression in 122 studies and an overall effect size SMD = 1.298 (95% CI 1.187-1.408, p < 0.001) for anxiety in 131 studies. There was high heterogeneity in the analysis. An analysis showed a significant publication bias for both depression and anxiety. A subgroup analysis showed significant effects of cancer type, patient selection, intervention format, and the method of measurement used in moderating results. The findings of this analysis suggested that interventions appeared to be more useful for patients with increased levels of psychological distress.
The findings of this review suggest that various psychological interventions can benefit patients with cancer dealing with symptoms of anxiety and depression.
The major limitation of this analysis was that the meta-analysis was done considering all studies together. This is questionable because it is difficult to see interventions such as cognitive behavioral therapy as equivalent to general patient education or relaxation techniques. The analysis showed high heterogeneity, which is not surprising given the range of interventions considered together and the variety of types of patients. The high risk of publication bias also limits the potential validity of these findings. Reports were restricted to studies involving patients from mainland China, so it is unclear if the findings would be applicable to other cultural groups. Databases outside of China were limited.
This meta-analysis did not provide substantial or useful support for various types of interventions aimed at managing the symptoms of depression and anxiety. To determine which interventions are most effective as supported by evidence, the interventions that are very similar if not exactly the same must be grouped for analysis. This was a major limitation of this report, and it is reflected in its high heterogeneity. Its findings need to be viewed with some caution given the limitations of this study.
Zimmermann, T., Heinrichs, N., & Baucom, D.H. (2007). “Does one size fit all?” Moderators in psychosocial interventions for breast cancer patients: A meta-analysis. Annals of Behavioral Medicine, 34, 225–239.
To illuminate the moderators of the effect of psychosocial interventions and better understand the variability of these effects in patients with cancer; to test the hypothesis that cancer type, intervention type, and interventionist can moderate intervention effect
Initially, investigators retrieved 127 articles, of which 46 were eliminated because they did not report on RCTs. Four of the 127 articles were unavailable. Of the remaining 77 reports of RCTs, the data in 26 were incomplete. Communication with the authors of studies with incomplete data resulted in obtaining complete data for five studies.
Nurses are particularly suited to providing psychoeducational and educational interventions for patients, and these types of nurse-led interventions can have a positive effect on patient outcomes. Psychologist-delivered CBT interventions seem to be more effective than nurse-delivered CBT interventions. This finding suggests that, if nurses are to provide CBT, the nurses must develop significant expertise.This finding may also suggest the importance of interdisciplinary approaches to providing psychosocial interventions. This meta-analysis demonstrated that moderators have a significant effect on intervention effectiveness; therefore, future studies should provide information about potential moderators.
Antoni, M.H., Lehman, J.M., Kilbourn, K.M., Boyers, A.E., Culver, J.L., Alferi, S.M., . . . Carver, C.S. (2001). Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychology, 20, 20–32.
Participants were randomly assigned to the intervention or control group. The intervention one was a closed, structured group that met weekly for 10 two-hour sessions. It included didactic material, experiential exercises, and homework assignments (practicing relaxation exercises) and focused on learning to cope better. The control group participants received a condensed version of the intervention during a five- to six-hour seminar; it provided information but lacked the therapeutic group environment and support. Participants were assessed initially, post-treatment, at three months, and at nine months. The study was advertised by letters and posters, and participants phoned for eligibility screening.
The intervention group showed reduced prevalence of moderate depression per the CES-D. The intervention also influenced two measures of positive well-being—increasing reports of experiencing benefit from having had breast cancer and increasing general optimism about the future.
An implication here is that it is important to collect information on positive experiences as well as negative. Responding to adversity presents an opportunity to experience growth and positive change.
Although this is a well-designed RCT, several flaws exist.
Ashing, K., & Rosales, M. (2014). A telephonic-based trial to reduce depressive symptoms among Latina breast cancer survivors. Psycho-Oncology, 23(5), 507–515.
Test the effectiveness of a paraprofessionally delivered, telephonic-based, psycho-educational intervention (telephone sessions plus survivorship booklet) to reduce depressive symptoms compared with the control condition (survivorship booklet only)
Intervention was based on the contextual model of health-related quality of life and the cognitive behavioral framework. Participants allocated to the intervention condition received eight 40–50-minute, biweekly, psychoeducational telephone services. Telephonic sessions involved seven domains: basic breast cancer information; managing medical and physical issues, follow-up care, and cancer resources; coping skills and problem-solving training; balancing emotions and stress management; family and social concerns; sexual health concerns; and financial issues and employment concerns. A booster and debriefing session took place one month after completion of telephone sessions.
PHASE OF CARE: Late effects and survivorship
Randomized, controlled trial
Center for Epidemiological Studies Depression Scale (CESD) to assess depressive symptoms in addition to demographic and clinical characteristics
A statistically significant decrease in depressive symptoms was seen among Latina patients with breast cancer in the intervention condition compared with Latina patients with breast cancer in the control condition, after controlling for depressive symptoms at T1 and language (p < 0.05). English-language-preferred and Spanish-language-preferred Latina patients with breast cancer in the intervention condition showed an eight-point decrease in depressive symptoms from baseline to follow-up, whereas those in the control condition showed no significant change.
These findings support the success of psycho-educational telephonic intervention in significantly reducing depressive symptoms among Latina patients with breast cancer, regardless of language. This is a great way to address distress among the ethnically diverse population of patients with cancer.
This study represents a novel psycho-educational trial implemented by paraprofessionals. This could be a cost effective approach that would improve distress symptoms in a minority population with cancer. With proper training, nurses and social workers may implement this intervention, which will contribute to better patient outcomes.
Badger, T.A., Segrin, C., Figueredo, A.J., Harrington, J., Sheppard, K., Passalacqua, S., . . . Bishop, M. (2011). Psychosocial interventions to improve quality of life in prostate cancer survivors and their intimate or family partners. Quality of Life Research, 20, 833–844.
To test the effectiveness of two telephone-delivered psychosocial interventions for maintaining and improving quality of life
The first intervention was by-telephone interpersonal counseling (TIP-C) delivered weekly for eight weeks to prostate cancer survivors and every other week for eight weeks to partners. The second intervention involved eight weekly health education attention condition (HEAC) sessions delivered by telephone.
Repeated-measures experimental design
Improvements in depression, negative affect, stress, fatigue, and spiritual well-being were significantly greater for survivors receiving the HEAC intervention than for those receiving the TIP-C intervention.Compared to partners in the TIP-C intervention, partners in the HEAC group showed significantly greater improvements in depression, fatigue, perceived social support from family members, social well-being, and spiritual well-being.
Both interventions in this study were effective in improving multiple dimensions of quality of life for men with prostate cancer and their partners.
Both interventions were effective, but additional research is needed. Health education may be just as effective or more effective in helping patients and caregivers than individualized counseling.
Bourmaud, A., Anota, A., Moncharmont, C., Tinquaut, F., Oriol, M., Trillet-Lenoir, V., . . . Chauvin, F. (2017). Cancer-related fatigue management: Evaluation of a patient education program with a large-scale randomised controlled trial, the PEPs fatigue study. British Journal of Cancer, 116, 849–858.
To evaluate the effectiveness of a psychoeducational program on cancer-related fatigue
Patients were randomly assigned to the study intervention or usual care. Patients in the intervention group (PEPs) received written information explaining cancer-related fatigue and difference approaches for management. Patients in this group were also encouraged to participate in five group educational sessions of two hours each over a six-week period. The PEPs content was designed to incorporate NCI and CPEN guidelines. Content included information about the disease, fatigue, self expression of attitude, coping strategies, and skill development for managing fatigue. Educational teams received a two-day intensive training to standardize program content. Patients in the control group received the written documentation as described. After the study, patients in the control group were offered participation in the program.
RCT
There were no differences between groups in fatigue scores after the intervention, and no differences in the trajectory of fatigue. Fatigue declined overall in all patients. There were no differences between groups in anxiety or depression.
The educational program tested here did not demonstrate an effect on fatigue, anxiety, or depression.
Psychoeducation is an intervention that has shown mixed results for impact on cancer-related fatigue and other symptoms. The specific program tested here did not demonstrate an effect. Fatigue in particular is a complex multifaceted symptom. Various psychoeducational and supportive approaches have also been complex in terms of design, content, timing, dose, etc. The effectiveness of psychoeducational-type interventions may relate to all of these aspects of both content and delivery.
Bruera, E., Yennurajalingam, S., Palmer, J.L., Perez-Cruz, P.E., Frisbee-Hume, S., Allo, J.A., . . . Cohen, M.Z. (2013). Methylphenidate and/or a nursing telephone intervention for fatigue in patients with advanced cancer: A randomized, placebo-controlled, phase II trial. Journal of Clinical Oncology, 31(19), 2421–2427.
Compare the effects of methylphenidate (MP) (psychostimulant) with those of a placebo (PL) on cancer-related fatigue. The effect of a combined intervention including MP plus a nursing telephone intervention (NTI) also was assessed.
Patients with a fatigue score of greater than or equal to 4 out of 10 on the Edmonton Symptom Assessment Scale (ESAS) randomly were assigned to one of the following four groups: MP plus NTI, PL plus NTI, MP plus control telephone intervention (CTI), and PL plus CTI.
Randomized, controlled trial; placebo controlled
The groups MP alone, NTI alone, or MP plus NTI proved not significantly better than PL for cancer-related fatigue. Anxiety improved with the telephone intervention (p = .01), as did sleep (p < .001).
MP, used alone or in combination with NTI, was not superior to the control group or the PL for fatigue or depression. NTI was associated with improvement in anxiety and sleep.
Although the use of MP did not prove to be effective for cancer-related fatigue, several cancer-related symptoms significantly were improved with NTI. Further research in this area would be ideal, but NTIs remain potentially effective for patient support and education and can have a positive effect on patient experience.
Chow, K.M., Chan, C.W., Chan, J.C., Choi, K.K., & Siu, K.Y. (2014). A feasibility study of a psychoeducational intervention program for gynecological cancer patients. European Journal of Oncology Nursing, 18, 385–392.
To test the feasibility of the implementation of a psychoeducational intervention program for patients with gynecologic cancer
This study consisted of a series of interventions consisting of multiple components based on a thematic counseling model for patients with newly diagnosed gynecologic cancers. Blinding was performed at randomization. Quantitative data on sexual functioning, uncertainty, quality of life, anxiety, depression, and support systems were collected at recruitment, following surgery, during hospitalization, and eight weeks following surgery. Both quantitative and qualitative methods were used in the data analysis. The intervention consisted of four psychoeducational sessions. An individual format was used for the first three sessions and a group format was used for the last session. All intervention sessions were conducted by the researcher. The researcher also met with the control group on four occasions during the same period: at recruitment, after surgery, once in-hospital, and once via telephone four weeks following surgery during which participants were invited to attend a support group. The researcher was a registered nurse experienced in gynecologic cancer care.
Single-blinded, randomized trial with a mixed-methods design
Thirteen patients were in the intervention group and 13 were in the control group. There were no statistical differences between the populations of the two groups. The compliance rate was 69.2% in the intervention group with the greatest lack of compliance occurring during the final session. The compliance rate for the control group was 46.2%. Statistic significance regarding trends of change in the outcome variables was not obtained. There was no statistic significance in the comparison of baseline outcome variables of the two groups. There was no statistic significance of intervention effects between the two groups, except in the area of uncertainty. The inconsistency subscale showed a statistic significance between the two groups with the intervention group receiving less inconsistent information regarding their illnesses. The intervention group demonstrated better trends for improvement than the control group in all categories although there were contradictory results in the scales measuring quality of life, perceived social support, anxiety, and depression.
This patient population has healthcare needs that currently are not being met. This particular study did not show statistically significant results regarding anxiety, depression, quality of life, and sexual functioning in patients with gynecologic cancer. Further research is indicated.
Further research is indicated regarding anxiety, depression, quality of life, and sexual functioning in patients with gynecologic cancer, particularly during the postoperative period. This study showed trends for overall improvement, indicating the importance of nursing in this population. Understanding the implications of cultural differences regarding the effects of gynecologic therapies is an important nursing responsibility.
Ell, K., Xie, B., Kapetanovic, S., Quinn, D.I., Lee, P.J., Wells, A., & Chou, C.P. (2011). One-year follow-up of collaborative depression care for low-income, predominantly Hispanic patients with cancer. Psychiatric Services (Washington, D.C.), 62(2), 162–170.
To examine 18- and 24-month outcomes for patients who participated in the Alleviating Depression Among Patients with Cancer (ADAPt-C) clinical trial, whose aim was to improve access to culturally adapted depression care among low-income, predominantly Hispanic women with cancer
The usual-care group received standard oncology care for patients with depression. Oncologists were free to prescribe antidepressants or mental health care to both groups, and patients were free to use community mental health services. The intervention is adapted from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) intervention, which provided collaborative intervention focused on problem solving, health navigation, personalized treatment and monitoring, assessment, and follow-up and education by a specialist. Follow-up occurred by telephone monthly.
Randomized control trial, longitudinal
The effectiveness of the psychoeducational components of the intervention is unclear because patients in the experimental group also used antidepressants to a greater degree and received more counseling than did patients in the other group. Evidence does support the conclusion that, in the intervention group, management of depression improved.
Collaborative supportive care with symptom monitoring, support, and follow-up can help patients with depression improve their outcomes. Ongoing monitoring and involvement to address depression in patients appears to result in more treatment of depression. Future work is needed to understand which component of this intervention is most effective.
Ell, K., Xie, B., Quon, B., Quinn, D.I., Dwight-Johnson, M., & Lee, P.J. (2008). Randomized controlled trial of collaborative care management of depression among low-income patients with cancer. Journal of Clinical Oncology, 26, 4488–4496.
To determine the effectiveness of Alleviating Depression Among Patients with Cancer (ADAPt-C) collaborative care management for major depression or dysthymia
ADAPt-C is collaborative care management developed for low-income and minority patients. The control group received enhanced usual care (EUC). Data collection occurred at baseline, 6 months, and 12 months. The intervention involved semistructured assessment and patient and family education, navigation assistance, behavioral therapy components in weekly sessions, and patient homework. After treatment initiation, patients received monthly telephone contact for up to 12 months, for maintenance and relapse prevention. Medication was used as clinically indicated for psychiatric symptoms. Overall management was based on guidelines, from the National Comprehensive Cancer Care Network, for treatment of depression in cancer patients.
Active treatment and transition
Prospective, randomized, controlled trial with simple blinding
ADAPt-C collaborative care may be a feasible and effective means of reducing symptoms of depression in some cancer patients.
ADAPt-C is a time- and personnel-intensive intervention that requires significant commitment on the part of the patient.
Halkett, G.K., O'Connor, M., Aranda, S., Jefford, M., Shaw, T., York, D., . . . Schofield, P. (2013). Pilot randomised controlled trial of a radiation therapist-led educational intervention for breast cancer patients prior to commencing radiotherapy. Supportive Care in Cancer, 21, 1725–1733.
To determine whether a therapist-led psychoeducational intervention is effective in reducing anxiety, depression, and radiation therapy-related patient concerns
Patients in the control group received usual care. The intervention group received two face-to-face therapist consultations, one prior to radiation planning and one prior to treatment. Therapists received training in how to prepare patients for radiotherapy planning and treatment, focusing on procedure and sensory and side effect information, as well as training in eliciting and responding to emotional cues. Study measures were obtained at baseline and after each intervention time point. Intervention delivery was recorded, and content analysis was completed to determine intervention fidelity by two reviewers from a randomly selected set of 40 recorded sessions.
Randomized, controlled trial
Analysis showed statistically significant intervention effects for anxiety after the first intervention, (p = .0009) but a small size of effect (beta coefficient = –.145). There was no significant effect seen after the second intervention session. There was no effect on depression scores. Knowledge scores increased more on average for the intervention group between baseline and the first intervention session (p < .05) and related concerns dropped more in the intervention group over the same time period (p < .01).
The provision of a psychoeducational intervention was effective in increasing patients’ knowledge, reducing radiation therapy-related concerns, and reducing anxiety in women receiving radiation therapy for breast cancer.
The provision of this type of education and supportive intervention may reduce anxiety and improve patient knowledge prior to beginning radiation therapy.
Hirai, K., Motooka, H., Ito, N., Wada, N., Yoshizaki, A., Shiozaki, M., . . . Akechi, T. (2012). Problem-solving therapy for psychological distress in Japanese early-stage breast cancer patients. Japanese Journal of Clinical Oncology, 42, 1168–1174.
To examine the feasibility and effectiveness of problem-solving therapy for psychological distress among patients with early-stage breast cancer
The problem-solving therapy involved five weekly sessions aimed at assessing problems, setting goals, generating solutions, choosing a solution, and implementing the solution and evaluating results. The therapy included a manual and worksheet for patients to use. Authors collected self-report data prior to the intervention, after the final sessions, and three months after the final sessions.
Patients were undergoing active antitumor treatment.
A pre/post-test design was used.
Four patients dropped out of the study after starting treatment. Analysis showed a significant effect of time on anxiety and depression scores (p < 0.01). Over time scores for global health status, physical functioning, emotional functioning, and role functioning improved significantly.
The study shows that symptoms of anxiety and depression and some aspects of quality of life improved over time. The effect of the intervention cannot be evaluated from these study results. Though authors state that the intervention was feasible, the fact that 17% of the initial sample did not complete the study suggests that the intervention was not of interest to a substantial proportion of the patients.
Study results are insufficient to allow evaluation of the acceptability and efficacy of the problem-solving intervention.
Hopko, D.R., Armento, M.E., Robertson, S.M., Ryba, M.M., Carvalho, J.P., Colman, L.K., . . . Lejuez, C.W. (2011). Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: Randomized trial. Journal of Consulting and Clinical Psychology, 79, 834–849.
To test the efficacy of behavioral activation for depression therapy (BADT) compared to problem-solving therapy (PST) in depressed breast cancer patients
Patients were randomly assigned to either BADT or PST. Each therapy was delivered in individual sessions over eight weeks. In the BADT group, patients engaged in self-monitoring exercises and identified the level of reward or pleasure for behaviors and activities. Then researchers emphasized identifying values and goals within multiple life areas and targeting behaviors for attention. The patient and therapist collaboratively set goals and activities each week, and patients progressed through activities, from easiest to hardest, aimed at reducing aversive experiences. Sessions included muscle relaxation, assertiveness training, and graduated exposure to anxiety-producing stimuli. PST involved therapy to increase patients' understanding of the connection between current depression and anxiety symptoms with everyday problems, to help patients define current problems, and to teach patients a specific problem-solving method. Therapists were experienced in providing the intervention they delivered. Sessions were recorded, and a 15% sample was independently evaluated to assess fidelity of the intervention. The principal investigator supervised all therapists weekly and individually.
Late effects and survivorship
Randomized controlled trial design
BDI and HRSD sales demonstrated significant improvement in depression (p = 0.04). Mental health and general health scales on the SF-36 also improved (p = 0.02). Results revealed no significant difference between groups, and both interventions demonstrated a strong effect size.
Findings demonstrate that both the BADT and PST interventions were effective in reducing depression in the groups of patients studied.
Findings show that both of the interventions were effective in reducing the level of depression among patients with breast cancer with major depression. The drop-out rate over the eight-week study period suggests that participating in the target intervention may be difficult or impractical for many patients.
Hopko, D.R., Robertson, S.M., & Carvalho, J.P. (2009). Sudden gains in depressed cancer patients treated with behavioral activation therapy. Behavior Therapy, 40(4), 346–356.
The overall purpose of the study was to examine sudden improvements in the symptoms of depressed patients with cancer who were receiving brief (nine-session) behavioral activation therapy (BAT). Specificially, the study examined the the frequency of sudden gains, the relation of sudden gains to the intervention components, the association of sudden gains to clinical and demographic variables, and the relation of sudden gains to treatment response and maintenance at three-month follow-up.
Authors recruited study participants by means of medical clinic screenings at the University of Tennessee Medical Center Cancer Institute. Participants provided informed consent and were included if they scored 9 or higher on the Harvard Department of Psychiatry National Depression Screening (HANDS) scale and met inclusion criteria following completion of a pretreatment diagnostic assessment battery (see instruments below). Inclusion criteria consisted of being diagnosed with cancer at age 18 or older, having a primary diagnosis of major depression with moderate to severe symptoms, and not being psychotic or cognitively impaired. After developing rapport with each particpant, the therapy provider assessed the function of depressed behavior and introduced the treatment rationale. Rationale included to reduce reinforcement of depressed behavior, increase healthy behavior, or increase exposure to reinforcement of healthy behavior. Provider and patient discussed a behavioral checklist form each week, in the one-hour psychoeducation session. The provider presented the treatment rationale and facilitated activity and goal selection and behavioral activation. Examples of activities and goals included engaging in weekly self-monitoring of daily activities, providing baseline measurement, and identifying potential activities to target during BAT. Patients prioritized activities and values, and they set goals from easy to difficult, with the aim of working upward in this hierarchy: family, peer, intimate relationships, education, employment, career, hobbies, recreation, volunteer work, charity, physical, health issues, and spirituality.
Pre/post-test time-series measurements
During the treatment 50% of participants experienced sudden gains as measured by an average of 11.8 BDI-II points. None experienced more than one sudden gain. Four participants exhibited reversals following sudden gains; all four returned to within 50% of their sudden gain in the post-treatment assessment. The initial scores of participants who experienced sudden gains had less-severe depression as measured by the pretreatment ADIS-IV. Those who made sudden gains in measures related to emotional problems, as measured by the SF-36 subscales, reported greater physical functioning, less bodily pain, and fewer problems with work and daily activities. Authors found no between-group differences regarding demographic and cancer-related variables. Compared to those without sudden gains, patients with sudden gains had significantly lower HRSD post-treatment scores. However, “as a follow-up to the finding that decreased depression severity was associated with sudden gains, the relationship of depression severity and sudden gains in treatment responders was evaluated. ... [D]epression severity did not differ as a function of sudden gain status at post-treatment but was marginally significant at 3-month follow-up . . . with those experiencing sudden gains exhibiting a trend for lower pre-treatment depression severity ratings relative” to responders who did not report sudden gains.
Authors noted that 50% of depressed patients with cancer who had received BAT experienced a sudden gain. Findings suggest that, in regard to depression treatment in patients with cancer, a streamlined and parsimonious behavioral activation approach is as adequate as a more comprehensive cognitive-behavioral approach.
Nurses treating depressed patients with cancer are advised to consider the role of increased pain and physical functioning in preventing sudden gains and other desirable treatment responses. Nurses who assimilate this knowledge into treatment plans may provide better care to depressed patients with cancer than do nurses who do not.
Kashani, F., Kashani, P., Moghimian, M., & Shakour, M. (2015). Effect of stress inoculation training on the levels of stress, anxiety, and depression in cancer patients. Iranian Journal of Nursing and Midwifery Research, 20, 359–364.
To investigate the effects of inoculation training on stress, anxiety, and depression
Forty patients were randomly selected and randomly assigned to study and control groups. Study group patients had weekly group education sessions for eight weeks. Sessions were aimed at understanding stress, relaxation, education, concepts of cognition, feelings and behaviors, role of negative self-talk, concentration and distraction techniques, and problem solving skills. Data were obtained before and after the intervention period.
Anxiety and depression declined after the intervention, but did not decline in the control group. After eight weeks, anxiety was significantly lower in the intervention group (p = 0.00) and depression was significantly lower than controls (p = 0.04). Stress increased in the control group, but declined in the intervention group (p = 0.01).
The psychoeducational intervention tested here was associated with significantly less anxiety and depression compared to patients who did not receive this intervention.
Findings suggest that the type of psychoeducational intervention provided here was helpful to manage anxiety and depression. Study design limitations affect the strength of evidence from this particular study; however, findings are in general concert with the body of evidence regarding effectiveness of psychoeducational interventions. Various psychoeducational interventions have been shown to be effective for anxiety and depression. These interventions can be incorporated into usual nursing practice.
Kim, H.S., Shin, S.J., Kim, S.C., An, S., Rha, S.Y., Ahn, J.B., . . . Lee, S. (2013). Randomized controlled trial of standardized education and telemonitoring for pain in outpatients with advanced solid tumors. Supportive Care in Cancer, 21, 1751–1759.
To evaluate whether standardized educational tools, with or without telemonitoring, can improve the pain levels, pain interference, anxiety, depression, distress, performance, and quality of life of outpatients with cancer who have advanced tumors
Patients were randomized to receive either standard pain education plus telemonitoring or standard education alone. A nurse practitioner (NP) performed telemonitoring of pain every day for one week. The NP telephoned the patients and asked for average visual analog scale (VAS) pain score and worst VAS pain score in the last 24 hours. This provided patients with the opportunity to assess the severity of pain themselves. Using the National Comprehensive Cancer Care Network (NCCN) guidelines for pain management, the NP advised patients whether to increase or decrease medication. The NP was trained in pain management but had no specific training for other psychosocial interventions. Standard education included a video and booklet with individual coaching, to correct misconceptions, and an outline of decision making for pain control. Outcomes were measured at one week, and average pain was measured at two months.
A randomized controlled trial design was used.
Pain intensity, for all patients, had significantly improved at one week, including worst pain (7.3–5.7, p < 0.01) and average pain (4.6–3.8, p < 0.01). Additionally, anxiety (HADS score ≥ 11, 75%–56%, p < 0.01), depression (HADS score ≥ 11, 73%–51%, p < 0.01), quality of life (fatigue and insomnia), and Karnofsky score (32–66, p < 0.01) were significantly improved at one week. However, the level of distress did not improve. The study revealed no significant differences between groups in these areas.
Standardized pain education delivered by a nursing specialist is an efficient means of improving not only pain but also anxiety, depression, performance, and quality of life. This study did not show that the addition of telemonitoring substantially improved pain management in the outpatient setting.
Findings show that comprehensive pain education was associated with short-term reduction in pain, anxiety, and depression scores. The addition of telemonitoring follow-up for pain management did not result in a significant difference in these scores; however, the follow-up period was only one week. Longer-term studies of the effects of monitoring via telephone and other technologies, for the purpose of improved symptom management, may be helpful in identifying effective methods of improving symptom control in outpatient settings.
Komatsu, H., Hayashi, N., Suzuki, K., Yagasaki, K., Iioka, Y., Neumann, J., . . . & Ueno, N.T. (2012). Guided self-help for prevention of depression and anxiety in women with breast cancer. ISRN Nursing, 716367.
Evaluate the effects of a self-help program on depression and anxiety in women with breast cancer receiving chemotherapy
Patients were assigned to intervention or treatment groups by authors (not random assignment). The intervention was a self-learning package aimed at rehearsing the chemotherapy procedure, improving beliefs in managing side effects, and helping build problem-solving skills. This group also was given a professional-led support group that met two to three times during the study. The control group received usual care including a chemotherapy education leaflet. Nurses monitored patient progress from review of patient diaries in the intervention group that documented side effects and self management performed at the beginning of each cycle of chemotherapy. Nurses involved with the intervention were educated and demonstrated increased knowledge regarding improving coping processes in daily living. Data were collected at baseline, one week, three months, and six months.
PHASE OF CARE: Active antitumor treatment
Non-random, two-group comparison, quasi-experimental—historical control approach
No significant differences were found in outcomes between study groups. Study measures improved over time in all patients.
This study did not find that the intervention tested here had an effect on depression or anxiety.
This particular study did not demonstrate effectiveness of the intervention tested here. The study had several limitations. Anxiety and depression improved in all patients, suggesting that usual nursing education provided was just as effective as the expanded approach used here. Several study results have suggested that interventions aimed at improving anxiety and depression are most effective for patients who have clinically relevant anxiety and depression.
Lee, J.Y., Park, H.Y., Jung, D., Moon, M., Keam, B., & Hahm, B.J. (2014). Effect of brief psychoeducation using a tablet PC on distress and quality of life in cancer patients undergoing chemotherapy: A pilot study. Psycho‐Oncology, 23, 928–935.
To examine the benefits of a single-session psychoeducational intervention using a tablet PC during chemotherapy
Patients were assigned to intervention or control groups according to their dates of informed consent rather than strict randomization. Study measures were obtained at baseline and two to four weeks later. The study group was given a single-session psychoeducational intervention using a tablet PC to administer the education.
Two-group trial
Compared to the control group, the intervention group showed a positive score change on the HADS scale. The mental component summary score of the SF-8, the IES-R avoidance subscale, the ISI, and the total score of the HADS scale were the following. HADS (p = .0002), SF-8 (p = .011), ISI (p = .021), and IES-R (p = .036) declined from baseline more in the intervention group. Scores did decline in both groups.
A tablet-based, 20-minute psychoeducational intervention could be an effective intervention for managing depression, sleep disturbance, and quality of life.
Lindemalm, C., Mozaffari, F., Choudhury, A., Granstam-Björneklett, H., Lekander, M., Nilsson, B., . . . Mellstedt, H. (2008). Immune response, depression and fatigue in relation to support intervention in mammary cancer patients. Supportive Care in Cancer, 16(1), 57-65.
To examine the effect of a support intervention on immune function and levels of depression, anxiety, and fatigue in breast cancer patients after completion of surgery and adjuvant treatment
Authors chose 41 women from an ongoing prospective randomized study. The first patients in each stratum of treatment were chosen for the current study. Of the 41 women, 21 received adjuvant combined radiochemotherapy (CT-RT) and 20 women received radiotherapy (RT). Eleven women (CT-RT) were randomized to the support group, and 10 women (RT) were randomized to the support group. Ten CT-RT and 10 RT patients served as controls. The support intervention consisted of educational lectures about cancer etiology risk factors, treatment, psychological and physical effects, and coping. Exercise, relaxation training, qigong, and art therapy were also included. The intervention was provided for one week and, two months later, for another four days. Study measures were obtained at baseline, 2 months, 6 months, and 12 months.
Phase of care: transition phase after initial treatment
Randomized controlled trial
The support intervention had no effect on depression or immune parameters. The intervention did not appear to cause any difference in improvement of anxiety and fatigue over time.
Findings do not support effectiveness of the intervention tested here. Results show that levels of depression, anxiety, and fatigue reduced significantly over time.
Mahendran, R., Lim, H.A., Tan, J.Y., Chua, J., Lim, S.E., Ang, E.N., & Kua, E.H. (2015). Efficacy of a brief nurse-led pilot psychosocial intervention for newly diagnosed Asian cancer patients. Supportive Care in Cancer, 23, 2203–2206.
To determine if psychosocial interventions, led by nurses instead of mental health professionals, for patients newly diagnosed with cancer in Singapore could help ease distress, minor psychiatric morbidity, and psychosocial worry
This quasiexperimental study researched the benefits of a six-month nurse-led psychosocial intervention program for patients with newly diagnosed with cancer receiving chemotherapy. The program consisted of 20- to 30-minute sessions with a nurse and occurred monthly for two visits and bimonthly for two more visits. Participants were offered this intervention along with their treatment. Training of the oncology RNs at the National Cancer Institute in Singapore included personal training by a psychiatrist and a psychologist on psychoeducation for managing stress, sleep hygiene, anxiety, and depression and included resources, deep breathing exercises, muscle relaxation, and inspirational self-talk. Patients also received counseling, supportive therapy, and printed/audio education to encourage practice at home. The RN training also included simulated one-on-one sessions with feedback on performance. Demographic and medical data were collected. Primary outcomes were measured by questionnaires at baseline and at six months.
PHASE OF CARE: Active antitumor treatment
One hundred twenty-one participants were recruited. Seventy (58%) chose to participate, and the rest received treatment as usual (TAU). Sixty-three (90%) participants completed the four nurse-led sessions and were available at six months for reassessment. No significant demographic difference was reported between the intervention and TAU groups at baseline. No significant demographic difference existed between those followed up with and those lost to follow-up, but those lost to follow-up did have higher anxiety and depression scores at baseline. The intervention group had significantly increased distress, anxiety, and depression scores and lower EQ-5D scores at baseline. The intervention group participants had significantly reduced distress (p = 0.001), anxiety (p < 0.001), and depression (p < 0.001) scores, as well as greatly improved quality of life over time. Participants receiving TAU also showed a decline in anxiety and depression over time, with essentially stable distress scores.
A six-month intervention of psychoeducation, counseling, and behavior technique teaching improved participants’ distress, quality of life, anxiety, and depression.
Manne, S.L., Rubin, S., Edelson, M., Rosenblum, N., Bergman, Hernandez, E., . . . Winkel, G. (2007). Coping and communication-enhancing intervention versus supportive counseling for women diagnosed with gynecological cancers. Journal of Consulting and Clinical Psychology, 75(4), 615–628.
To compare the efficacy of two psychological interventions to the efficacy of usual care
The coping- and communication-enhancing intervention (CCI) involved challenging assumptions and talking about thoughts and feelings with others. Six hour-long individual sessions were supplemented with a final by-telephone booster session. Session content focused on enhancing coping, educating, and practicing skills; home practice assignments were included. Supportive counseling (SC) involved six hour-long sessions and a by-telephone booster. Rather than topic discussion, SC stressed reactions to cancer, support of existing coping behaviors, and autonomy. Usual care included routine social work consultations. Nineteen experienced therapists provided intervention. Participants were randomly assigned to CCI, SC, or usual care and were assessed preintervention and at three, six, and nine months.
The study included 353 women with primary gynecologic cancer who were in active treatment.
For all patients, symptoms of depression decreased at first. For patients in CCI and SC, symptoms of depression remained relatively flat after six months, but in usual care they began to increase. Authors reported no significant difference between the interventions’ effects and no impact of either intervention on cancer-specific distress.
Mohabbat-Bahar, S., Maleki-Rizi, F., Akbari, M.E., & Moradi-Joo, M. (2015). Effectiveness of group training based on acceptance and commitment therapy on anxiety and depression of women with breast cancer. Iranian Journal of Cancer Prevention, 8, 71–76.
To evaluate the effects of group therapy on anxiety and depression
Acceptance and commitment therapy (ACT) is described as a type of “third wave” of cognitive behavioral therapy that focuses on values and goals clarification and acceptance-based behavioral strategies and mindfulness processes. Participants were randomly assigned to experimental and control groups. The experimental group had ACT held in eight sessions of 90 minutes during four consecutive weeks. These were provided in a group setting. Study measures were obtained at baseline and after the intervention.
Randomized, controlled trial
Anxiety and depression scores declined in the experimental group, while increasing in the control group. These differences, however, were not statistically significant (p = 0.000).
Findings suggest that a psychoeducational intervention based on acceptance and commitment therapy can be of benefit in reducing anxiety and depression among women with breast cancer.
This type of psychoeducational intervention may be of benefit to reduce anxiety and depression in women with breast cancer. It is not clear to what extent results here were an effect of the protocol used or the participation in group sessions, which could have been supportive. Psychoeducational interventions are generally low-risk and relatively low-cost approaches that may be of benefit to patients.
Nguyen, L.T., Alexander, K., & Yates, P. (2018). Psychoeducational intervention for symptom management of fatigue, pain and sleep disturbance cluster among cancer patients: A pilot quasi-experimental study. Journal of Pain and Symptom Management, 55, 1459–1472.
To assess the feasibility of conducting a trial of a psycho-educational intervention involving the provision of tailored information and coaching to improve management of a cancer-related symptom cluster (fatigue, pain, and sleep disturbance) and reduce symptom cluster effects on patient health outcomes in the Vietnamese context, and to undertake a preliminary evaluation of the intervention.
A parallel-group, single-blind, pilot, quasiexperimental trial with pre-/post-test follow up was conducted in a cancer department of a general public hospital in Hanoi, Vietnam. Participants in the control group received standard treatment. Patient assigned to the intervention group received the psycho-educational program which consisted of three individualized psychoeducational sessions of up to one hour, tailored to meet patient’s major symptom concerns. Strategies such as energy conservation and restorative activities for fatigue management, sleep hygiene for sleep disturbance, and adherence to prescribed therapy for pain management were explored. A patient self-management booklet was provided at the first session to facilitate education and support.
Single-blind, pilot, quasi-experimental trial with pre-/post-test follow up.
The intervention group demonstrated a significant reduction in symptom cluster severity (p < 0.0001), fatigue severity, fatigue interference (p = 0.03), sleep disturbance (p < 0.0001), depression, and anxiety when compared to the control group. For fatigue severity, while the intervention group witnessed no change in fatigue severity (p = 0.4), the control group observed a significant increase (p = 0.01). Depression (p = 0.004) and anxiety (p < 0.0001) decreased significantly in the intervention group, there was significant increase in depression (p = 0.04) and no change in anxiety (p = 0.08) in the control group. There were no significant differences in pain severity, pain interference, functional status, or health-related quality of life.
Psychoeducational interventions may help to achieve improvement in some symptoms such as fatigue and sleep disturbances, but future RCTs are needed to test the effectiveness of a symptom cluster intervention in Vietnam.
Study provides preliminary evidence to support potential efficacy of a psycho-education intervention in improving symptom cluster severity, fatigue burden, sleep disturbance, and psychological distress.
Owen, J., O'Carroll Bantum, E., Pagano, I., Stanton, A., Owen, J.E., & Pagano, I.S. (2017). Randomized trial of a social networking intervention for cancer-related distress. Annals of Behavioral Medicine, 51, 661–672.
To evaluate the effects of a web-based social networking and coping skills training intervention on cancer-related patient based outcomes: distress, depression, anxiety, and psychological well-being. Secondary outcomes are vigor and fatigue.
Participants initially completed a baseline survey following which they were given access to the online health space intervention or waitlisted for the intervention (waitlist control group) randomly. Intervention included an evidence-based online distress management intervention for a period of 12 weeks, including modules, chats, discussion boards, and web mails.
PHASE OF CARE: Multiple phases of care
Randomized controlled clinical trial
No baseline difference was noted between the intervention and control group in terms of demographic and clinical characteristics. All the five outcomes improved over time, but no significant difference between the treatment and control group for psychological functioning, depression, anxiety, and vigor. Interaction between time and treatment group fatigue (time fatigue declined in the treatment group compared to control group). No significant reduction in distress and depression between the groups, although it reduced within the groups over time, association between intervention and engagement.
Health space social networking did not improve the cancer-related distress outcomes.
Online interventions could be suggested to patients as it is associated with strong engagement.
Ram, S., Narayanasamy, R., & Barua, A. (2013). Effectiveness of group psycho-education on well-being and depression among breast cancer survivors of Melaka, Malaysia. Indian Journal of Palliative Care, 19(1), 34–39.
Determine the effectiveness of group psycho-education on well-being and depression among breast cancer survivors in Malaysia
In this cluster, non-randomized trial conducted over a one-month period, 34 adult women with non-metastatic breast cancer participated in a group psycho-education class on well-being status and depression. The class was designed to inform and discuss cancer and treatment. They were evaluated with a pre/post-test questionnaire, as well as a pretest socio-demographic questionnaire.
PHASE OF CARE: Active antitumor treatment
Cluster, non-randomized trial
The study showed that psycho-education decreased depression and increased the state of well-being among participants. Post-test results significantly improved for three of the five items on the WHO-5 Well-being Index.
Psycho-education may be one way to improve the overall well-being of patients diagnosed with breast cancer. More research is needed with larger numbers and a multi-site setting to validate improved well-being.
Psycho-education may be one way to improve the overall well-being of patients diagnosed with breast cancer, but as nursing professionals, taking a holistic approach to patient care and recognizing and addressing other contributing factors, such as biological and social factors, are important.
Ramachandra, P., Booth, S., Pieters, T., Vrotsou, K., & Huppert, F.A. (2009). A brief self-administered psychological intervention to improve well-being in patients with cancer: Results from a feasibility study. Psycho-Oncology, 18, 1323–1326.
Authors recruited for the study were patients with stable metastatic breast cancer or prostate cancer who had at least a six-month life expectancy. Patients were randomized into an immediate treatment group and a wait-list control. All participants had follow-up at 6, 12, and 18 weeks. The intervention consisted of keeping a well-being diary, using a CD with a 10-minute recording to complete a mindfulness body scan, and planning a pleasurable activity.
Active treatment and transition
Randomized controlled trial
Positive qualitative feedback reflected a statistically significant (p = 0.046) improvement in quality of life. Although HADS scores improved after the intervention, the change was not significant, and SOFAS scores did not change significantly. Adherence to the intervention was 67% for CD listening, 71% for writing in the diary, and 46% for activity planning.
The intervention was associated with some improvement in quality-of life-measures, but there was no effect on depression or anxiety.
Findings do not indicate that mindfulness-based intervention, as used in this study, had an impact on well-being.
Rottmann, N., Dalton, S.O., Bidstrup, P.E., Wurtzen, H., Hoybye, M.T., Ross, L., . . . Johansen, C. (2012). No improvement in distress and quality of life following psychosocial cancer rehabilitation. A randomised trial. Psycho-Oncology, 21, 505–514.
To evaluate the effectiveness of a residential rehabilitation course for patients with cancer in decreasing psychological distress
Patients who had completed cancer treatment were randomly assigned to receive either usual care or a six-day residential psychosocial course. Those in the residential group had weekly rehabilitation courses in groups of 20. Course activities included education, supportive talks, physical activity, relaxation, massage, social activities, peer discussions, and dietary instruction. At the end of the course, individuals created a personal action plan to reinforce what was learned. Data were collected at baseline and at 1, 6, and 12 months after completion of the intervention.
Transition phase of care after initial treatment
Randomized controlled trial
At one-month time point, findings revealed significantly more improvement in anxiety (p = 0.03), total mood disturbance (p = 0.04), emotional role function (p = 0.02), and cognitive functioning (p = 0.0009) in the control group. At the six-month time point, a significantly improved outcome for the control group was also found for depression (p = 0.005) as well as sustained improvement in anxiety (p = 0.003), total mood disturbance (p = 0.02), emotional role function (p = 0.04), and cognitive functioning (p = 0.03).
The residential rehabilitation course studied did not have a positive effect on anxiety, depression, or cognitive functioning. In this study, the control group improved more over time than those who received the intervention.
This study suggests that an intensive residential program for cancer survivors, as examined, was of no benefit.
Schofield, P., Gough, K., Lotfi-Jam, K., Bergin, R., Ugalde, A., Dudgeon, P., . . . Aranda, S. (2016). Nurse-led group consultation intervention reduces depressive symptoms in men with localised prostate cancer: A cluster randomised controlled trial. BMC Cancer, 16, 637-016-2687-1.
To investigate the benefits of a group nurse-led intervention on psychological morbidity, unmet needs, treatment-related concerns, and quality of life in men with prostate cancer receiving radiotherapy with curative intent
This phase-III, randomized trial assessed the relative benefits of a tailored, group consultation intervention for men receiving curative intent radiotherapy for prostate cancer compared to the best supportive care. The aim was to communicate information about diagnosis, treatment, and side effects, and coaching in self-management. Content and discussion were based on expressed needs and concerns. It included four group consultation sessions and one individual consultation completed by uro-oncology nurse specialists. Survey assessments occurred before treatment, at the end of treatment, and six months postcompletion of treatment. Sessions were tape recorded, and random selections were used to evaluate intervention fidelity.
Phase-III, two-arm cluster, randomized, controlled trial
A higher consent rate existed at one site, but no other statistically significant differences in patient characteristics existed between the two groups. One hundred thirteen (out of 165) participants attended all sessions in the intervention group (p = 0.02). Mixed models analysis indicated that group consultations were statistically more beneficial on depressive symptoms (p = 0.009) and procedural concerns relating to cancer treatment (p = 0.049). Ninety-two percent completed surveys at all three time points. Descriptive analysis showed a slight reduction in depressive symptoms in the intervention group between baseline and the end of radiotherapy; the control (usual care) group reported an increase in these symptoms during the same time period. The difference between groups persisted six months post radiotherapy, although between groups, differences in mean changes was substantially reduced. No significant difference existed in rate of change in anxiety between the intervention group and the usual care group noted from the HADS. Descriptive analysis indicated a reduction in anxious symptoms in both groups at the follow-up assessments. Differences in mean changes from baseline to six months post-radiation also occurred, as it did with depressive symptoms.
Nurse-led group consultations may help address patient education, particularly among men who are experiencing depression.
Nurses must realize the importance of patient education and their role in counseling patients experiencing depression not only during treatment but following treatment as part of survivorship care.
Schou Bredal, I., Karesen, R., Smeby, N.A., Espe, R., Sorensen, E.M., Amundsen, M., . . . Ekeberg, O. (2014). Effects of a psychoeducational versus a support group intervention in patients with early-stage breast cancer: Results of a randomized controlled trial. Cancer Nursing, 37, 198–207.
To investigate which approach, psychoeducation or support, provides the greatest benefit to patients with early-stage breast cancer
Women who had undergone surgery for breast cancer were randomly assigned to receive either a support group (SG) or psychoeducational group (PEG). The PEG intervention consisted of health education about breast cancer and side effects of treatments, stress management (including training and a DVR in progressive muscle relaxation), enhancing problem solving skills, and psychological support from research staff and other group members. Sessions were two hours weekly for five weeks. The SG intervention was part of routine care, consisted of three weekly two-hour sessions on topics women introduced for discussion. A surgeon, physical therapist, and a breast cancer survivor attended the group for 30 minutes each to provide information in a question and answer format. Study assessments were done at baseline, at 2 months, 6 months, and 12 months.
Ninety-seven percent of patients attended all sessions in both groups. Both groups showed significant decline in anxiety. With adjustment for baseline anxiety level, there were no differences in anxiety levels between groups after the intervention. Depression declined significantly in all patients over time, with no difference between groups. At various time points, there were differences in mental adjustment to cancer between optimists and pessimists, but these differences were not consistent, and there were no significant differences at 12 months. Within the first six months, there was greater decline in anxiety and depression among those in the PEG group.
Women in both groups showed reduced anxiety and depression over time. There were no differences in results between those receiving a support group versus a psychoeducational intervention except in the first 6 months. Psychoeducation may be more helpful in the short term at a time when patients are likely to have more distress.
Findings suggest that both psychoeducational and support group interventions can be beneficial to women dealing with breast cancer. In the short term, findings suggest that psychoeducation may yield some greater benefits, but there were no long-term differences based on the type of intervention provided. It may be beneficial to incorporate more psychoeducational components into routine support group and supportive interventions.
van der Meulen, I.C., May, A.M., de Leeuw, J.R., Koole, R., Oosterom, M., Hordijk, G.J., & Ros, W.J. (2014). Long-term effect of a nurse-led psychosocial intervention on health-related quality of life in patients with head and neck cancer: A randomised controlled trial. British Journal of Cancer, 110, 593–601.
To report on health-related quality of life (HRQOL) and depressive outcomes from an earlier trial using nurse counseling after intervention (NUCAI)
Nurses delivered as many as six 45–60 minutes sessions every two months. The sessions consisted of six components: completing a Hospital Anxiety and Depression Scale before each session to lead a discussion of current mental state, having a discussion of current physical problems, having a discussion of life functioning, providing the AFTER (Adjustment to Fear, Threat, or Expectation of Recurrence) intervention, providing general medical assistance, and referring patients to psychological care. The AFTER intervention had four components: expressing fear of recurrence, identifying beliefs about recurrence, evaluating self-examinations, reducing excessive checking behavior, and relaxation. Usual care was provided twice monthly in sessions about complications and monitoring for recurrence. Patients were referred for psychological aftercare if psychosocial problems were assessed.
Single, blinded, randomized, controlled trial
50% of patients were lost to follow-up, the majority of which were because of death or terminal disease. At 12 months, statistically significant differences in physical functioning, emotional functioning, pain, swallowing, social contact, opening the mouth, coughing, and depressive symptoms were present. At 18 months, statistically significant differences in global quality of life, role functioning, emotional functioning, pain, swallowing, opening mouth, and depressive symptoms were present. At 24 months, statistically significant differences in emotional functioning and fatigue were present. Appointments were difficult to complete at times because of the clinic environment.
The NUCAI showed significant improvements for patients with head and neck cancer 24 months after completing treatment.
As a nurse-led intervention, this is a feasible option for patients with head and neck cancer desiring a problem-focused intervention for symptoms.
van der Meulen, I.C., May, A.M., Ros, W.J., Oosterom, M., Hordijk, G.J., Koole, R., & de Leeuw, J.R. (2013). One-year effect of a nurse-led psychosocial intervention on depressive symptoms in patients with head and neck cancer: A randomized controlled trial. The Oncologist, 18, 336–344.
To investigate the effects of a psychosocial nurse counseling and after intervention (NUCAI) versus usual care on symptoms of depression and physical symptoms related to the head or neck cancer (HNC) of patients one year after the diagnosis of HNC.
The NUCAI consisted of six bimonthly 45-minute counseling sessions. NUCAI is a problem-focused method aimed at helping patients to manage the physical, psychological, and social consequences of HNC and its treatment. The intervention consisted of these components: evaluating current mental status, discussing current problems, systematically asking about physical problems and functioning, and providing the adjustment to the fear, threat or expectation of recurrence (AFTER) intervention. AFTER was nurse led. During one year, six sessions were provided with usual and regular medical follow-up visits. Usual care involved 10-minute appointments every two months, for examination and review. Patients were randomly assigned to the intervention or control group. Data were collected every three months for one year.
Transition phase after active treatment
Randomized controlled trial
Study findings showed significant reduction in depression; therefore, this intervention can be used in clinical settings to improve patient outcomes (e.g., reduction of depression and improvement of physical symptoms).
This study utilized a nurse-led intervention for reduction of symptoms of depression in HNC patients. With proper training nurses can be equipped with the skill of providing psychological counseling to patients. Investigators noted that, compared to the cost of counseling offered by a clinical psychologist or psychiatrist, the nurse-led intervention seems a cost-effective method.
Vilela, L.D., Nicolau, B., Mahmud, S., Edgar, L., Hier, M., Black, M., ... Allison, P.J. (2006). Comparison of psychosocial outcomes in head and neck cancer patients receiving a coping strategies intervention and control subjects receiving no intervention. Journal of Otolaryngology, 35(2), 88–96.
To show the effectiveness of the Nucare program, a short-term psychoeducational intervention for patients with a cancer diagnosis, on the ability of individuals with cancer to cope with their disease
The sample was composed of 101 participants. The sample consisted of a convenience sample of patients with head or neck cancer. Participants had completed cancer treatment. The control group was matched to the internvention group in terms of length of time since diagnosis and stage of cancer.
Feasibility study using a prospective, nonrandomized design
From baseline to follow-up, the test group showed improvement in most quality-of-life scores and statistically significant improvement of depression (1.2 points, p < 0.05). The control group showed deterioration in most of the EORTC QLQ-C30 and HADS scores at follow-up. However, none of the changes was statistically significant at the 5% level.
Intervention delivery is feasible.
Wenzel, L., Osann, K., Hsieh, S., Tucker, J.A., Monk, B.J., & Nelson, E.L. (2015). Psychosocial telephone counseling for survivors of cervical cancer: Results of a randomized biobehavioral trial. Journal of Clinical Oncology, 33, 1171–1179.
To study the effects of psychosocial telephone counseling on anxiety, quality-of-life domains, and biomarkers
Eligible patients were randomly assigned to the telephonic intervention or usual care. Those receiving the intervention received a five-minute pre-call to reintroduce the purpose of the intervention and schedule initial sessions. Patients received four sessions of 20-60 minutes for education and counseling for problem solving, social support, communication skill development, and problem identification based on the transactional model of stress and coping. Follow-up letters with session summary and suggested homework assignments were mailed after each session. Surveys were mailed to participants for completion at baseline, 4 months, and 9 months.
Randomized, controlled trial
Patients assigned to the intervention had significantly better scores for depression (p = 0.041) and cancer-specific concerns at four months (p < 0.05). There was no difference between groups in anxiety at four months. Patients assigned to the intervention demonstrated continued improvement in gynecologic problems at nine months. At nine months, there was no difference between groups in depression or anxiety.
Longitudinal evaluation of a telephonic psychoeducational intervention among survivors of cervical cancer showed benefit for depression and gynecologic problems in the first four months after the intervention. These differences were not maintained over the longer term.
Telephone-delivered psychoeducational intervention was associated with reduced depression and cancer concerns within the first few months of the intervention; however, these benefits did not appear to be maintained over the longer term. It is possible that there is a need for continued intervention in order to benefit patients in the longer term. Findings suggest that a telephone intervention delivery can be effective, and may be a practical way to be able to deliver this type of intervention, particularly for patients in rural areas, or those otherwise unable to travel to healthcare facilities.
Willems, R.A., Bolman, C.A., Mesters, I., Kanera, I.M., Beaulen, A.A., & Lechner, L. (2016). Short-term effectiveness of a web-based tailored intervention for cancer survivors on quality of life, anxiety, depression, and fatigue: Randomized controlled trial. Psycho-Oncology. Advance online publication.
To present the short-term effects of a web-based computer-tailored intervention on quality of life, anxiety, depression, and fatigue in cancer survivors
A stand-alone web-based computer-tailored intervention (Cancer Aftercare Guide: KNW) was applied that aims to increase cancer survivor quality of life by providing personalized information and support on specific topics by promoting lifestyle changes. The eHealth intervention was based on principles of the problem-solving theory (PST) and cognitive behavioral theory (CBT). The KNW consists of eight training modules on topics of return to work, fatigue, anxiety, depression, social relationship and intimacy, physical activity, diet, and smoking cessation. After online registration, the computer randomly assigned participants to the intervention or waiting control group. Both groups had to complete questionnaires at 3, 6, and 12 months from baseline. The 6 and 12 month measures revealed the effectiveness. Participants filled in baseline questionnaires, modules were selected by the program, and the information was tailored to the participant, resulting in a personalized action plan. After 30 days, participants were invited to a second session to evaluate goal attainment and to set new goals.The program was unrestricted so that participants could self-select modules they wished to use and skip assignments.
Randomized, controlled trial comparing the KNW intervention with a waiting list control group
With the exception of treatment type, the intervention and control group were comparable. Participants in the intervention group used an average of 2.22 modules from first login to last use of 10.67 weeks. The authors indicated that the KNW intervention had a significant effect on increasing emotional and social functioning (p = 0.022, p = 0.011) and decreased depressions and fatigue (d = 0.019, p = 0.007, d = 0.020, p = 0.02) six months after baseline. The only effect for fatigue occurred in participants who used the module Fatigue (p = 0.009). No significant differences existed between groups for anxiety. For those who used the therapist face-to-face component, available effect sizes ranged from 0.26 to 0.38.
While the use of the web-based intervention showed statistically significant results, the effect sizes for depression, anxiety, and social functioning were extremely small. The module use and program were not fully automated and offered direct therapist contact. The authors reported substantially higher effect sizes with therapist contact, raising the question of overall effectiveness of the web-based content.
eHealth interventions, such as web-based PST or CBT approaches, may be useful for improving quality of life in cancer survivors. Further research is necessary to target the desired information and to provide support specifically for fatigue, anxiety, and depression in cancer survivors. The findings showed much greater size of effects with direct therapist intervention, suggesting that an eHealth system may be best used as an initial step in a multicomponent intervention with additional steps, in which increasing intervention is provided based upon patient need and response.
Yanez, B., McGinty, H.L., Mohr, D.C., Begale, M.J., Dahn, J.R., Flury, S.C., . . . Penedo, F.J. (2015). Feasibility, acceptability, and preliminary efficacy of a technology-assisted psychosocial intervention for racially diverse men with advanced prostate cancer. Cancer, 121, 4407–4415.
To evaluate a web-based cognitive behavioral (CB) stress reduction program
Participants were assigned to receive either the web-based CB program (CBSM group) or a web-based health information program (HP group). The CB program was delivered by a group facilitator according to a manual for treatment. Group web sessions were used to provide education in relaxation techniques, support management, and stress management. The health information program was provided by a group facilitator according to a manual for the intervention. The sessions provided general wellness education but did not include any of the behavioral techniques. Sessions were recorded and reviewed during weekly clinical supervision to ensure treatment fidelity. All sessions lasted for 10 weeks.
PHASE OF CARE: Transition phase after active treatment
Parallel, two-group trial
Feasibility: 31.3% enrollment rate; many refused because of significant time requirements with participation or lack of interest in the intervention. The retention rate was 85.7% at six months for the CBSM group and 86.1% for the HP group. Both groups completed most sessions (more than 70%); however, the HP group completed significantly more sessions and weekly assessments.
Acceptability: Participants in both groups reported liking the study “quite a bit”; no differences existed between groups.
Efficacy (intent to treat analysis): The CBSM group had fewer depressive symptoms than the HP group at six-month follow-up (p = 0.06) and higher scores for relaxation (p = 0.09); however, the HP group reported better social well-being on the FACT-G (p = 0.07).
Efficacy (study completers only): Significantly (p = 0.03) fewer depressive symptoms were reported in the CBSM group as well as improved relaxation (p < 0.01) at the six-month follow-up.
The results generally support the feasibility, acceptability, and preliminary efficacy of web-based psychosocial intervention for patients with APC. Both the CBSM and HP interventions were rated favorably. Clinically meaningful decreases in depressive symptoms and improvements in relaxation (related to functional well-being) were seen in the CBSM group at six-month follow-up, revealing that the results were evident even months after the intervention was provided.
Web-based psychosocial interventions for men with APC have the potential to reduce symptom burden and improve health-related quality of life, specifically for patients who have computer and Internet access. Additional research is needed regarding these types of interventions in advanced disease (stages 3 and 4). Because both the CBSM and HP groups showed some improvement in this study, the positive benefits of social, group-based interventions should be explored further in this population.
Butow, P., Price, M.A., Shaw, J.M., Turner, J., Clayton, J.M., Grimison, P., . . . Kirsten, L. (2015). Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines. Psycho-Oncology, 24, 987–1001.
PHASE OF CARE: Multiple phases of care
No information is provided regarding literature retrieved, quality of evidence, or how the evidence was used to develop the guidelines provided.
Outlines relevant healthcare provider roles. Identified the following assessment tools for use: Edmonton Symptom Assessment Scale, the NCCN's Distress Thermometer, and the Hospital Anxiety and Depression Scale. Provides a stepped path of interventions based on ongoing monitoring of symptoms and effectiveness of previous interventions. Recommendations for initial intervention are patient education (in-person or online) and brief emotional support. Ongoing interventions for those with cancer-related anxiety and depression include coping skills training, relaxation skills, communication skills, mindfulness, and a variety or psychological therapies.
Despite an extensive review process for guidelines, as well as input from stakeholders, there is little information on the evidence base for the recommendations provided.
This guideline outlines recommended providers, and nurses are not specifically outlined as recommended providers in the written pathway other than as “other appropriately trained staff,” although nurses are identified as having roles in screening, assessment, and educational and counseling types of roles. This guideline provides no new information and does not directly provide the evidence base on which recommendations are based. The guideline suggests more limited roles for nurses than has been demonstrated in relevant research.
Li, M., Kennedy, E.B., Byrne, N., Gerin-Lajoie, C., Katz, M.R., Keshavarz, H., . . . Green, E. (2016). Management of depression in patients with cancer: A clinical practice guideline. Journal of Oncology Practice, 12, 747–756.
RESOURCE TYPE: Evidence-based guideline
PHASE OF CARE: Multiple phases of care
Several clinical practice guidelines and two meta-analyses of 21 RCTs and some integrative reviews were included. Guideline quality was assessed with the AGREE II instrument, and a systematic review quality was assessed with the Assessment of Multiple Systematic Reviews (AMSTAR) tool.
Some recommendations were consensus-based.
A quick reference algorithm for the initial management of depression in patients with cancer and the stepped care model for delivering care interventions depending on the severity of depression are great tools nurses and other healthcare professionals can use in their clinical practice while managing depression.
National Comprehensive Cancer Network. (2012). NCCN clinical practice guidelines in oncology: Distress management [v.2.2013]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf
To provide clinical practice guidelines for the evaluation and treatment of distress — a normal feeling of vulnerability to a feeling that leads to disabling problems, such as depression and anxiety — in adult patients with cancer
Results were not stated.
Recommended standards of care include
Evaluation should include measures relating to level of distress, behavior symptoms, psychiatric history and medications, pain and symptom control, body image and sexuality issues, impaired capacity, safety, potential medical causes, and psychological disorders.
Management algorithms should be provided for dementia, delirium, mood disorder, psychotic disorder, adjustment disorder, anxiety disorder, personality disorder, and substance-related disorder.
Treatments identified for use include psychotherapy, anxiolytics, antidepressants, psychoeducation, cognitive behavioral therapy, social work and counseling interventions, spiritual counseling and ethics, and palliative care consultation according to algorithms.
The guidelines provide recommended pathways regarding assessment and management of distress. They do not provide a nursing perspective or identify a role for nursing in patient management.
National Health and Medical Research Council (Australia). (2003). Clinical practice guidelines for the psychosocial care of adults with cancer. Retrieved from http://www.nhmrc.gov.au/publications/synopses/cp90syn.htm
Comprehensive, evidence-based guidelines were developed to assist healthcare professionals in providing optimal psychosocial care. The guidelines are multidisciplinary in focus, with recommendations applicable to diverse treatment settings.
Evidence was presented using levels I, II, III-1, III-2, III-3, and IV rating system with level I representing the gold standard.
Clinically relevant recommendations supported by level I and II evidence about depression include the following.
The treatment of depression should incorporate psychotherapeutic interventions and the use of medication.
Evidence of the efficacy of antidepressant medication in treating depression in patients with cancer is clear.
No evidence suggests that any particular antidepressant is superior to another.
Qaseem, A., Snow, V., Shekelle, P., Casey, D.E., Jr., Cross, J.T., Jr, Owens, D.K., . . . Shekelle, P. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148, 141–146.
Objectives were to
Included were patients with any disabling or symptomatic condition at the end of life.
The guideline was based on a systematic evidence review, done by others, in an Agency for Healthcare Research and Quality evidence report. The guideline does not address nutritional support, complementary and alternative therapies, or spiritual support because evidence related to these areas does not often appear in the literature. Specific procedures for grading the evidence and recommendations are not described.
The guideline was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Evidence and recommendations were graded using the clinical practice guidelines grading system (GRADE).
Databases searched were MEDLINE and the Database of Abstract Reviews of Effects (January 1990–November 2005); citations from the review by the National Consensus Project for Quality Palliative Care (2003) also were searched.
Search keywords were cancer, congestive heart failure, and dementia. The full description of search terms is published elsewhere.
The guideline outlines the strength of GRADE recommendations and includes a brief description of the supporting evidence for each recommendation.
Critical Elements for End-of-Life Care: Elements identified are preventing and treating pain and other symptoms; supporting families and caregivers; ensuring continuity of care; ensuring respect for patients as people and informed decision making; ensuring well-being, including consideration of existential and spiritual concerns; and supporting function and duration of survival.
Identifying Patients Who Could Benefit From Palliation: No evidence tools have been validated or effectively shown to predict optimal timing. Decisions should be based on each patient's symptoms and preferences.
Treatment Strategies:
Important Elements for Advance Care Planning: Evidence shows that extensive multicomponent interventions, goal-oriented interviews with palliative care providers, and proactive communication involving skilled discussants can reduce unnecessary services, without causing harm, and increase the use of advance directives.
Collaboration and Consultation: Use and patient-centered outcomes improve when multidisciplinary teams include nurses and social services providers, address care coordination, and use facilitated communication.
Supporting Caregivers: Evidence regarding the effects of palliative care teams for caregivers is mixed.
The following were graded as strong recommendations with moderate quality of evidence.
The guideline provides clear guidance in several areas of end-of-life care and symptom management and identifies the relevant evidence and strength of the evidence. The guideline may not apply to all patients and is not intended to override clinical judgment. In addition to recommending medication interventions for depression, the guideline recommends psychosocial interventions.