Recommended for Practice

Psychoeducation/Psychoeducational Interventions

for Depression

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.

 

Systematic Review/Meta-Analysis

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. 

Purpose

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

Search Strategy

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

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 4,929

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane Collaboration’s risk of bias tool 

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 20 
  • TOTAL PATIENTS INCLUDED IN REVIEW = 3,654
  • SAMPLE RANGE ACROSS STUDIES: 25–571 patients 
  • KEY SAMPLE CHARACTERISTICS: Patients with cancer, access to telehealth, and smart phones; English-speaking; high-income countries; most were studies of patients with breast cancer

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Pediatrics, elder care, and palliative care

Results

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.

Conclusions

This review showed mixed results for the effects of technology-based interventions on pain and depression among patients with cancer.

Limitations

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.

Nursing Implications

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.

Print

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.

Search Strategy

Databases: CINAHL, MEDLINE, PsycLIT, and CANCERLIT

Literature Evaluated

The study evaluated 36 randomized clinical trials (RCTs), seven quasi-experimental trials, five  descriptions, six reviews, and one practice guideline published 1980–2000.

Results

In 22 of 36 RCTS, psychoeducational interventions benefited patients with symptoms of depression.

Conclusions

The evidence dervied from this review supports the benefit of psychoeducational interventions for depression in patients with cancer.

Print

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. 

Purpose

STUDY PURPOSE: To evaluate the effectiveness of educational interventions for managing fatigue in adults with cancer

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED: CENTRAL, MEDLINE, ENBASE, CINAHL, ERIC, PEDro, PsycINFO, OT seeker, clinicaltrials.gov, and Australian New Zealand Clinical Trials Registry
 
INCLUSION CRITERIA: Randomized, controlled trials and adults with cancer. At least one study group received an educational intervention aimed at fatigue management.
 
EXCLUSION CRITERIA: Not specified

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 2,489
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane Risk of Bias tool. All the studies had lack of blinding for outcome assessment, which was not included in the final determination of study quality. All studies had high or unclear risk of bias related to sample size. The GRADE approach was used for study quality.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 14 studies  
  • TOTAL PATIENTS INCLUDED IN REVIEW = 2,213
  • SAMPLE RANGE ACROSS STUDIES: 30–396
  • KEY SAMPLE CHARACTERISTICS: Multiple different types of cancer at various phases of care. Most had mild to moderate fatigue at baseline.

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Results

  • For general fatigue: SMD = –0.27 (95% confidence interval [CI] [–0.51, –0.04]), showing a positive effect of education. These studies were of low quality.
  • For fatigue intensity: SMD = –0.28 (95% CI [–0.51, –0.04]) effect of education. These studies were of moderate quality.
  • For fatigue interference: SMD = –0.35 (95% CI [–0.54, –0.16]), showing benefit of education. Studies were of moderate quality.
  • For anxiety (three studies): SMD = –1.37 (95% [CI –2.76, –0.18]). Studies were of low quality.
  • For depression (four studies of very low quality), no impact on depression was found.
  • Insufficient evidence existed to analyze the results according to stage of disease, phase of care, and method of education delivery. Education was delivered individually, face-to-face, in group settings, or with self-use of video or print material. Most interventions included counseling and patient training components.

Conclusions

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.

Limitations

  • High heterogeneity

Nursing Implications

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.

Print

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.

Purpose

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

Search Strategy

Databases searched were PubMed, CINAHL, PsycINFO, Cochrane Collaboration, and two Chinese databases.

A study was included in the review if it

  • Was a randomized controlled trial
  • Reported on patients with prostate cancer at any disease stage
  • Compared psychosocial strategies to usual or standard care
  • Measured anxiety and depression.

A study was excluded if it focused on disease other than prostate cancer and lacked intergroup comparison.

Literature Evaluated

  • A total of 8,144 references were retrieved.
  • Researchers evaluated the quality of studies by using the Jadad scale.

Sample Characteristics

  • After evaluation, 14 studies, relating to a total of 1,484 patients, were included in the review.
  • Sample range across studies/total patients included in the review was 36–400 patients.
  • Patient age range was 60–76 years.
  • In all but four studies, patients were newly diagnosed.

Phase of Care and Clinical Applications

Patients were undergoing multiple phases of care.

Results

  • Interventions included education (n = 8), cognitive behavioral strategies (n = 6), counseling or psychotherapy (n = 1), and social support (n = 1).
  • Analysis showed that psychosocial strategies did not have a significant immediate effect on reducing anxiety. After three months, there was a significant overall effect on reducing anxiety from two studies included in meta-analysis (SMD = –1.13, 95% CI –1.64, –0.63, p < 0.0001).
  • Eight studies resulted in an overall positive effect on depression in the short term (SMD = –0.43, 95% CI –0.68, –0.18, p < 0.001). Three studies resulted in no significant effect at one-month follow-up. Across two studies, analysis showed a positive effect at three months (SMD = –0.78, 95% CI –1.54, –0.02, p = 0.04) in regard to reducing depression. There were no longer-term significant effects.
  • All types of psychosocial interventions were analyzed together, with no separate analysis based on the type of intervention. Only 35.7% of studies were considered to be of high quality.

Conclusions

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.

Limitations

  • In studies examining effect on depression, depression levels were low, causing one to question the clinical relevance of statistically significant findings.
  • No study required patients to have levels of depression that were clinically meaningful.
  • Authors noted that the majority of studies were of low quality and with small sample size. These factors limit the confidence one can have in the findings.
  • The analysis considered all types of very different interventions to be the same. This methodology did not allow researchers to determine the specific types of interventions that are truly most effective.
  • Studies involved very different intervention types, different timing and frequency of intervention or follow-up, and multiple types of patient care settings. These factors make interpreting overall effectiveness difficult.

Nursing Implications

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.

Print

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. 

Purpose

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

Search Strategy

DATABASES USED: Cochrane Library, PubMed, EMBASE, CINAHL, PsycInfo, SPORTDiscus. MeSH search terms included the examples of behavioral techniques named above, including physical exercise (PhysEx) terms and outcome measures, combined with the population terms breast cancer and breast neoplasm.
 
INCLUSION CRITERIA: Randomized, controlled trials of how any of the named behavioral techniques or PhysEx affected the outcomes of interest (fatigue, depression, anxiety, body image, stress) or healthcare quality of life. Reference lists were reviewed to identify additional potential articles. 
 
EXCLUSION CRITERIA: Articles were excluded if calculating the effect size or standard error was not possible with the available information.

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 171 retrieved, 115 excluded because they were not randomized, controlled trials; they did not have enough quantitative data; the outcomes were not related to the current study; or their interventions were not related to the current study.
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No evaluation of study quality was reported, although the authors reported evaluation of publication bias.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED =  56 studies: 39 studies of behavioral techniques; 14 studies of physical exercise; 3 studies of both 
  • TOTAL PATIENTS INCLUDED IN REVIEW = Not reported. This meta-analysis reported the number of patients by each randomized, controlled trial: 5,462 (behavioral intervention patients), 1,457 (PhysEx patients), 6,919 (total)
  • SAMPLE RANGE ACROSS STUDIES: 28–558 (behavioral intervention), 22–242 (PhysEx)
  • KEY SAMPLE CHARACTERISTICS: 33 studies of patients with nonmetastatic cancer, 4 studies of patients with metastatic cancer, 5 studies with a mix of patients

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Elder care, palliative care

Results

The effect of these interventions on stress and anxiety were not consistently significant. In addition, publication bias on the outcome of behavioral techniques on depression and anxiety existed. Behavioral techniques showed positive (improvement) summary ejection fraction (EF) effect sizes on fatigue (14 studies: EF = –0.158,  p < 0.001), depression (23 studies: EF = –0.336, p < 0.001), anxiety (23 studies: EF = –0.346, p < 0.001), and stress (p = 0.038) scores, but not on body image scores (p = 0.051). Behavioral techniques had a small, insignificant effect on health-related quality of life (ES = 0.045, p = 0.322). PhysEx had a positive effect on fatigue (11 studies: EF = –0.315, p = 0.004), depression (6 studies: EF =  –0.262, p = 0.016) and body image (p = 0.007) but not on anxiety. PhysEx had a positive effect on health-related quality of life (ES = 0.298, p = 0.001). The effect size of PhysEx on stress could not be calculated. Publication bias was found for behavioral techniques on depression and anxiety. No publication bias was found for the effect of behavioral techniques on fatigue, body image, or stress. Publication bias was found for PhysEx on fatigue and health-related quality of life, but no publication bias was found for PhysEx on depression, anxiety, or body image.

Conclusions

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.

Limitations

  • No quality evaluation
  • High heterogeneity
  • The variety of behavioral interventions made it challenging to select which was more effective than others (e.g., telephone counseling, telephone support, education, body-mind social support self-help, therapeutic groups by telephone, nurse self-efficacy).
  • Studies were included only through 2008—more recent evidence has shown some different findings.
  • High heterogeneity in behavioral technique analysis
  • The studies used a wide range of different measurements and interventions.

Nursing Implications

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).

Print

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.

Purpose

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

Search Strategy

  • This study did not involve database searches; authors analyzed three randomized trials. Search keywords were not provided.
  • Authors selected trials with similar designs (i.e., similar intervention and measurements).
  • The study provided no information about trial exclusion. One can note, however, that each of the three trials excluded participants for these factors: acute suicidality, high alcohol use scores, recent use of lithium or antipsychotic medications, life expectancy of fewer than six months, and significant cognitive impairment.
     

Literature Evaluated

  • Evaluation involved a no-scoring system applied to three clinical trials. Authors examined reanalyzed pooled data from the trials. The outcome measures were
    • Treatment responses (where a 50% reduction in the Patient Health Questionnaire-9 (PHQ-9) score from baseline was considered a clinically meaningful improvement in symptoms of depression).
    • Major depression (PHQ-9 ≥ 10).
    • Composite scores of quality-of-life subscales (the Short-Form Health Survey).
    • Health care utilization.
  • The three studies employed similar collaborative care as an intervention. The intervention included antidepressant medication, problem-solving therapy, and by-telephone symptom monitoring and relapse prevention by telephone over 12 months. The intervention incorporated personalized multidiscipline collaborative care based on the structured algorithm for stepped care. For example, a clinical specialist in depression communicated with an antidepressant prescriber in regard to a patient’s medication.
  • The control group in all three studies received enhanced usual care. The usual care included standard health system care, patient- and family-focused educational pamphlets on depression, and community resources. However, usual care in the studies differed slightly as the result of differences in setting.
  • In all three studies, data were collected at baseline, 6 or 8 months, and 12 months.
     

Sample Characteristics

  • Samples from the three randomized controlled trials consisted of 1,081 patients with major depressive symptoms and comorbid illness. When combining data, authors excluded patients with dysthymia alone or patients with no depression.
  • Sample range across studies:
    • Study 1: cancer trial, n = 472, age 18 and older
    • Study 2: diabetes trial, n = 387, age 18 and older
    • Study 3: homecare trial, n = 311, age 65 and older.
  • Key sample characteristics:
    • Total sample: age 60 and older, n = 440; age 18–59, n = 641.       
    • Patients had diverse multiple diseases (cancer, diabetes, hypertension, heart disease, kidney disease, etc.).
    • Sites were oncology and primary care safety-net clinics and diverse home healthcare programs.

Phase of Care and Clinical Applications

  • Phase of care: long-term follow-up
  • Clinical applications: late effects and survivorship, eldercare

Results

  • Comparing patients ≥ 60 years to patients 18–59 years revealed no significant differences with respect to reducing depression symptoms (p = 0.18–0.58) or improving quality of life (t = 1.86, df = 669, p = 0.07 for physical functioning at 12 months, and p = 0.23–0.99 for all others).
  • At six months in both age groups, intervention patients had significantly higher rates of a 50% reduction of the PHQ-9 score (older patients: Wald chi [df = 1] = 4.82, p = 0.03; younger patients: Wald chi [df = 1] = 6.47, p = 0.02) and  a greater reduction in major depression rates (older patients: Wald chi [df = 1] = 7.72, p = 0.01; younger patients: Wald chi [df = 1] = 4.0, p = 0.05) than did patients receiving enhanced usual care.
  • There was no significant age-group differences in treatment type or intensity.

Conclusions

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.

Print

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.

Purpose

To assess the effects of psychosocial interventions on quality of life and mood symptoms in patients diagnosed with cancer within the past 12 months

Search Strategy

  • Databases searched, up to January 2011, were Cochrane Central Register, MEDLINE EMBASE, CINAHL, and PsycINFO.
  • Authors provided an extensive listing of keywords and specific search strategies.
  • To be included, studies had to
    • Be randomized controlled trials (RCTs) or quasi-RCTs involving interpersonal dialog between a trained helper and individual newly diagnosed patients with cancer.
    • Measure quality of life and general psychological distress.
    • Include control groups that received standard care only.
  • Authors excluded trials involving a combination of psychosocial and pharmacologic interventions, as well as group- and couples-based interventions.

Literature Evaluated

  • A total of 3,272 references were retrieved.
  • Quality evaluation used criteria specified in the review for random allocation and allocation concealment, blinding, loss to follow-up, and assessment of reporting bias.

Sample Characteristics

  • Authors chose 30 trials to include, with 20 included in the meta-analysis.
  • The sample range across studies was 17–558, with a total sample across studies of 5,155.
  • All studies involved patients diagnosed within the past 12 months only.
  • Disease types included breast, colon, gastric, skin, prostate, and testicular cancers as well as, in some mixed trials, a few others.
  • All participants were adult patients.

Phase of Care and Clinical Applications

Multiple phases of care

Results

  • Anxiety outcomes were evaluated in four studies, depression outcomes were evaluated in six studies, and mood measures were evaluated in eight studies.
  • Analysis of studies involving mood measures resulted in a standard mean difference (SMD) of –0.81 (95% CI, 1.44, –0.18, p = 0.01) in favor of the intervention.
  • Analysis of quality-of-life outcomes showed mixed results with cognitive behavioral therapy, positive findings in favor of psychoeducational interventions (SMD = 0.29, 95% CI, 0.05, 0.54, p = 0.02), and no significant effects of counseling. Nurse-delivered interventions showed a significant positive effect (SMD = 0.23, 95% CI, 0.04, 0.43, p = 0.02) for quality of life. Interventions provided by a psychologist; general practitioner; and combined nurse, social worker, or others did not demonstrate significant effects.
  • No meta-analysis addressed the outcomes of anxiety or depression only.
  • Many studies were of relatively low quality, and the studies included substantial heterogeneity.

Conclusions

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.

Limitations

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.

Nursing Implications

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.

Print

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. 

Purpose

STUDY PURPOSE: To explore the effects of preoperative psychosocial interventions on the outcomes of patients with colorectal cancer, including measurements of physical, psychological, and social functioning, as well as quality of life
 
TYPE OF STUDY: Systematic review

Search Strategy

DATABASES USED: MEDLINE, CINAHL, Scopus, PsycINFO, Mednar, and Proquest
 
KEYWORDS: Psychosocial interventions for patients with colorectal cancer
 
INCLUSION CRITERIA: Research articles in peer-reviewed journals relevant to colorectal cancer with or without stoma formation in the adult population; articles related to any form of psychosocial intervention provided by healthcare professionals
 
EXCLUSION CRITERIA: Studies including pediatric patients and studies that involved patients with other forms of cancer

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 413
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Seventeen papers were deemed potentially relevant based on an assessment of titles and abstracts. Seven studies were excluded because they included participants with forms of cancer other than colorectal.

Sample Characteristics

FINAL NUMBER STUDIES INCLUDED = 11 
 
TOTAL PATIENTS INCLUDED IN REVIEW = About 300
 
KEY SAMPLE CHARACTERISTICS: Colorectal cancer, psychosocial intervention

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Pediatrics, elder care, palliative care

Results

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.

Conclusions

Various forms of psychosocial interventions were used to improve outcomes, but no clear winner was found. All forms seemed to improve patient outcomes.

Limitations

  • A limited number of studies met the inclusion criteria.

Nursing Implications

Any type of psychosocial intervention seems to be worthwhile as none of the studies described in this analysis hurt a patient. Nurses can therefore safely recommend a psychosocial intervention to patients with colorectal cancer. Identifying areas of nursing research going forward is important.
Print

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.

Purpose

STUDY PURPOSE: To identify core components of self-management education interventions and assess effectiveness

TYPE OF STUDY: Systematic review

Search Strategy

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

Literature Evaluated

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

Sample Characteristics

FINAL NUMBER STUDIES INCLUDED: 43 

TOTAL PATIENTS INCLUDED IN REVIEW: 6,795

SAMPLE RANGE ACROSS STUDIES: 22 to 483

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Results

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.

Conclusions

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.

Limitations

  • Mostly low quality/high risk of bias studies
  • High heterogeneity
  • Wide variation of the components, etc., of these types of interventions

Nursing Implications

Psychoeducational interventions of various types can be beneficial in reducing patients’ anxiety and depressive symptoms.

Print

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.

Purpose

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

Search Strategy

DATABASES USED: MEDLINE and PsycINFO
 
INCLUSION CRITERIA: Existing systematic reviews and meta-analyses of the effects of psychosocial interventions on anxiety and depression in adults with cancer; clinical practice guidelines relevant to distress and psychosocial care of adults with cancer
 
EXCLUSION CRITERIA: Not listed

Literature Evaluated

TOTAL REFERENCES RETRIEVED: Initially, 14 systematic reviews and meta-analyses; randomized and nonrandomized studies of patients with cancer included
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: This literature was summarized in terms of the number of randomized controlled trials that demonstrated efficacy in managing anxiety or depression based on intervention type and patient disease or treatment status. Intervention recommendations with significant effects (p < 0.05) relative to control were presented. The NCCN Guidelines for Distress Management, and the National Breast Cancer Center and the National Cancer Control Initiative in Australia’s Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer (2003) were also reviewed.

Sample Characteristics

  • FINAL NUMBER OF STUDIES INCLUDED = 13
  • TOTAL PATIENTS INCLUDED IN REVIEW = Not stated
  • SAMPLE RANGE ACROSS STUDIES: Not described
  • KEY SAMPLE CHARACTERISTICS: Not described

Phase of Care and Clinical Applications

PHASE OF CARE: Active treatment

APPLICATIONS: Late effects and survivorship

Results

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.

The authors provide examples of psychosocial interventions found to be effective using three considerations as guides. First, the interventions had to have been found superior to a control condition in a published randomized controlled trial. Second, the interventions must show good potential for dissemination (acceptable to patients, easy to implement, 12 sessions or less, and requiring no more than one mental health professional). Third, interventions that addressed common indications for preventing or managing anxiety or depression were sought. Five interventions were illustrated: 
  1. Psychoeducation for new patients with cancer reported significantly less anxiety and depressive symptoms (p < 0.001) as well as greater satisfaction with their care than usual care (p < 0.01).
  2. Patients randomized to problem-solving therapy demonstrated significantly less depression (p < 0.05), and results were maintained through a one-year follow-up period.
  3. Stress-management techniques of paced abdominal breathing, progressive muscle relaxation with guided imagery, and the use of coping self-statements were briefly taught and provided to patients via print and audiovisual materials prior to beginning chemotherapy. Significantly less anxiety and depression (p < 0.05) was found versus usual care.
  4. Cognitive therapy evaluated against a wait-list control in women with breast cancer who had clinically significant depressive symptoms demonstrated significantly less depression postintervention (p < 0.01), with even a further reduction occurring during the six-month follow-up period.
  5. Group cognitive-behavioral therapy was offered to early-stage breast cancer survivors post treatment; the efficacy of this intervention in an randomized controlled trial compared with no-intervention controls indicated that the intervention group reported significantly (p < 0.05) less depression immediately postintervention and at two-year follow-up.

Limitations

In “summarizing the summaries,” limitations include review differences in scope, methods used to summarize findings, and the manner in which recommendations were reached. 
 
Weaknesses found in nearly all the studies include:
  • Gaps regarding benefits of psychosocial interventions for diverse demographic, disease, and treatment characteristics. Men and ethnic and racial minorities were underrepresented, and most studies were based on several different types of cancer, usually early stage. 
  • Inconsistency in the evaluation of interventions, the number and timing of outcome assessments, and outcome measures used
  • Inadequate reporting of study methodology 
  • Lack of research on patients experiencing clinically significant anxiety or depression (most patients studied were experiencing low levels when recruited)

Nursing Implications

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.

Print

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. 

Purpose

PURPOSE: To analyze the effects of nonpharmacologic interventions for depression in patients with cancer
 
TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED: Medline, PsycINFO, and Cochrane Collaboration
 
KEYWORDS: Prostatic neoplasms and depression or depressive disorder and adaptation; psychological; additional specific Medline terms were provided
 
INCLUSION CRITERIA: Randomized, controlled trials comparing any intervention to no treatment or placebo; patients with any stage of prostate cancer or studies in which a subgroup analysis of prostate cancer patients was done; reported statistical measures of depression outcomes
 
EXCLUSION CRITERIA: None identified

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 471
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Study quality was evaluated using components of methods of the Drug Effectiveness Review Project. The majority of studies were of poor or fair quality.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 10 for qualitative review (nine in meta-analysis)
  • TOTAL PATIENTS INCLUDED IN REVIEW = 1,131
  • SAMPLE RANGE ACROSS STUDIES: 21–389 patients
  • KEY SAMPLE CHARACTERISTICS: All patients had prostate cancer.  

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Results

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.

Conclusions

The findings of this study suggest that psychosocial interventions can be effective in reducing depressive symptoms among patients with prostate cancer.

Limitations

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.

Nursing Implications

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.

Print

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.

Search Strategy

The study involved searches of the MEDLINE, Healthplan, PsychLIT, and Allied and Complementary Medicine databases. The articles included were published prior to December 1998.

Literature Evaluated

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.

Limitations

Despite increased use of RCT designs, the methodological quality was generally suboptimal.

Nursing Implications

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.

Print

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.

Purpose

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

Search Strategy

The study involved searching MEDLINE, PsycINFO, and the Cochrane Database for the period 1993–2004.

Literature Evaluated

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.

Sample Characteristics

The sample size was 1,492.

Conclusions

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.

Print

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.

Purpose

To produce an evidence-based report that reviews empirical literature about depression in patients with cancer and focuses on occurrence, assessment, and treatment

Search Strategy

Authors examined literature published January 1966–September 2000. Authors found literature by searching PubMed, PsycINFO, CINAHL, and BiOSIS Citation Index.

Literature Evaluated

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).

 

Sample Characteristics

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.

Conclusions

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.)

Limitations

RCTs of alternative or complementary interventions were not found.

Print

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.

Purpose

To evaluate the efficacy of pharmacologic and nonpharmacologic treatments for depression in patients with cancer

Search Strategy

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.

Literature Evaluated

Authors identified seven pharmacologic randomized control trials and four nonpharmacologic trials.

Results

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.

Limitations

The evidence of treatment effectiveness for depressive disorders in patients with cancer is limited and of modest quality.

Nursing Implications

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.

Print

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

PURPOSE: To synthesize evidence regarding effects of eHealth in patients with cancer and informal caregivers from systematic reviews

TYPE OF STUDY: Systematic review

Search Strategy

DATABASES USED: PubMed, EMBASE, CINAHL, PsycINFO, and the Cochrane Collaboration
 
KEYWORDS: Multiple terms for eHealth, cancer, systematic review, and meta analysis
 
INCLUSION CRITERIA: Systematic reviews reporting the effects of eHealth were included. EHealth was defined as the provision of information and/or support for patients or caregivers. Only minor or minimal flaws existed in the review.
 
EXCLUSION CRITERIA: Studies including patients without cancer were only included if the results for cancer were reported separately.

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 8,157
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Quality assessment checklist for reviews; studies were only included if scores were at least of moderate quality

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 10
  • TOTAL PATIENTS INCLUDED IN REVIEW = Not reported
  • SAMPLE RANGE ACROSS STUDIES: Not reported
  • KEY SAMPLE CHARACTERISTICS: Varied tumor types; mostly breast, prostate, and head and neck cancers

Results

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.

Conclusions

EHealth applications have been shown to have a positive effect on knowledge. Its effects on other aspects of the patient experience are inconsistent.

Limitations

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.

Nursing Implications

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.

Print

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. 

Purpose

STUDY PURPOSE: To summarize and analyze the results of controlled studies published in China to assess the effects of psycho-oncologic interventions on distress in patients with cancer 
 
TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED: China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Database, PubMed
 
KEYWORDS: Chinese terms for psychology, distress, anxiety, depression, and terms related to cancer and interventions including training, group therapy, meditation, and music therapy
 
INCLUSION CRITERIA: Randomized, controlled trials and nonrandomized, controlled studies; patients greater than 18 years old

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 1,398
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The Jadad Scale for Reporting Randomized Controlled Trials was used to determine the risk of bias. Only those studies scoring > 2 on the Jadad scale were included in this meta analysis.

Sample Characteristics

FINAL NUMBER STUDIES INCLUDED = 207 (qualitative synthesis), 31 (meta-analysis)
 
TOTAL PATIENTS INCLUDED IN REVIEW = 3,007 
 
SAMPLE RANGE ACROSS STUDIES: The median sample size was 48 patients.
 
KEY SAMPLE CHARACTERISTICS: Multiple tumor types were included and the median age was 50.85 years. The majority of studies were conducted in women diagnosed with breast cancer.

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Results

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.

Conclusions

The findings of this study support the effectiveness of psychoeducational interventions to reduce anxiety and depression in patients with cancer in China.

Limitations

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.

Nursing Implications

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.

Print

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.

Purpose

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

Search Strategy

  • Authors consulted these databases: MEDLINE (1948–Oct. 1, 2011), EMBASE Classic and EMBASE (1947–week 41, 2011), PsycINFO (1806–week 2, 2011), CINAHL Plus (1937–October 2011), and the Cochrane Central Register of Controlled Trials. Search keywords were depression, lung cancer, treatment, and systematic review.
  • In this randomized controlled trial, adults were 18 years old or older and had received a definite diagnosis of lung cancer.
  • The trial evaluated the efficacy or effectiveness of a pharmacologic or nonpharmacologic intervention intended to improve patients’ symptoms or quality of life. Depression outcomes were assessed using a standardized measure.
  • Excluded from the analysis were nonprimary publications for which the full paper could not be obtained for data extraction.

Literature Evaluated

The total number of references retrieved was 143. The evaluation method consisted of the review, by two independent researchers, of full articles.

Sample Characteristics

  • The final number of studies included was six.
  • The sample range, across studies, was 64–549.
  • Patients in the largest sample were newly diagnosed or new to the clinic; those in the smallest sample had a prognosis of 3–12 months. Most were from ambulatory clinics. Some patients had early-stage disease and some had metastatic disease.
     

Phase of Care and Clinical Applications

  • Phase of care: multiple
  • Application: eldercare

Results

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.

Conclusions

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.

Limitations

  • The review was not limited to interventions designed specifically to treat depression.
  • Participants were not necessarily depressed at the time of trial enrollment.
  • Reviewers found that reports of the procedures for participant recruitment and the collection of outcome data frequently lacked detail.

Nursing Implications

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.

Print

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.

Purpose

To perform a systematic review of studies regarding the efficacy of psychotherapeutic and antidepressant interventions for cancer patients with depression or symptoms of depression

Search Strategy

  • Authors searched these databases: PubMed, CINAHL, Database of Abstracts and Reviews of Effects (DARE), Cochrane Database of Systematic Reviews (CDSR), Cochrane Controlled Trials Register (CCTR), PsycARTICLES, and manual searches of items from reference lists. Searched keywords consisted of multiple terms relevant to depression and cancer; the terms were from articles relevant to the review and U.S. National Library of Medicine medical subject headings (MeSH). Intervention terms included antidepressant agents, SSRI, fluoxetine, and cognitive therapy.
  • Studies included related to randomized controlled trials (RCTs), reported in English, that involved pharmacologic and psychotherapeutic interventions for depression in adult patients with cancer.
  • Excluded studies were those that used combined pharmacologic and psychotherapeutic interventions, complementary or alternative treatment for cancer, or informational or educational strategies.
     

Literature Evaluated

The total number of references retrieved was 164. Authors conducted analysis according to the methodological-quality instrument developed Bo, Cho, and Bero.
 

Sample Characteristics

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.
 

Results

  • Authors analyzed reports of six pharmacologic trials, 18 psychotherapeutic interventions, and two studies of computer-based assessment and care planning. Most studies did not control for cointerventions. Most aimed at treatment of depression.
  • The majority of psychotherapeutic trials involved use of cognitive behavioral therapy. Other interventions were social support, counseling, support and education, and psychotherapy.
  • None of the trials using antidepressants reported avoidance or monitoring of cointerventions.
  • One trial found paroxetine to be effective in cases of major depression. One found paroxetine to be effective in reducing symptoms of depression. 
  • One trial reported that fluoxetine was ineffective in patients who presented with major depressive disorder. Response was not significantly higher than that of patients using placebo.
  • Two trials were reported to show effectiveness in reducing symptoms of depression.
  • Symptoms were measured at various time points with various instruments. 
  • Of all studies analyzed, 42% demonstrated significant improvement in depression as measured.
     

Conclusions

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.

Limitations

  • Almost no trials monitored, avoided, or reported co-interventions that could affect symptoms of depression. 
  • Most psychotherapeutic trials were single-center trials, a fact that limits generalizability.
  • In many studies, recruited patients did not have significant psychological morbidity.
  • Few pharmacologic studies reported tolerability data.
  • The analysis included few studies of the use of antidepressants by the included patients.
  • No studies described patients receiving palliative care.

Nursing Implications

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.

Print

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. 

Purpose

STUDY PURPOSE: To assess the effects of psychological interventions on depression and anxiety in Chinese adults with cancer 
 
TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED: China National Knowledge Infrastructure, Wangfang database, Vip, Chinese Biomedical Literature, PubMed, and Web of science
 
KEYWORDS: Psychotherapy MeSH terms, cancer terms, depression, and anxiety
 
INCLUSION CRITERIA: Subjects aged 16 years and over; randomized, controlled trials with samples of at least 30; depression and anxiety measured with validated tools; subjects from mainland China
 
EXCLUSION CRITERIA: Subjects in Hong Kong, Taiwan, or Macao; unclear descriptions of the interventions; studies with insufficient data to calculate effect sizes; use of nonpsychological interventions including medicine; patients in hospice or terminal home care

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 2,134
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The authors modified the Jadad scale for study quality assessment, eliminating the evaluation of blinding and adverse effects.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 143
  • TOTAL PATIENTS INCLUDED IN REVIEW = 14,039
  • SAMPLE RANGE ACROSS STUDIES: 30–326 patients
  • KEY SAMPLE CHARACTERISTICS: Most studies included patients with various types of cancer.

Results

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.

Conclusions

The findings of this review suggest that various psychological interventions can benefit patients with cancer dealing with symptoms of anxiety and depression.

Limitations

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.

Nursing Implications

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.

Print

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.

Purpose

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

Search Strategy

  • Databases searched were PsycINFO, PSYNDEX, MEDLINE (1980–October 2004). Search keywords were cancer, neoplasm, carcinoma, oncology, breast cancer, psychological therapy, psychotherapy, intervention, counseling, group support, peer support, relaxation, imagery, coping skills training, cognitive therapy and psychological support. Investigators also did some manual searching, using references from retrieved articles.
  • In cases in which the literature reported incomplete outcomes, investigators communicated with the authors of the studies to get the data. Some authors provided the necessary data.
  • Literature included in the meta-analysis reported, in English or German, on randomized controlled trials (RCTs) and provided complete documentation of outcome measures.
  • Literature excluded from the meta-analysis did not report on an RCT or did not include complete data, including the sample sizes of the treatment and control groups; group means; standard deviations or values of t tests, F tests, and chi-square tests.

 

Literature Evaluated

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.

Sample Characteristics

  • The final number of studies included in the meta-analysis was 56. Sample range was 19–638.
  • Meta-analysis, across studies, included a total of 6,419 patients. Mean patient age was 52.4 years (SD = ±4.7 years), and the age range was 40–65 years. The majority of study participants  (89%) were female.
  • Studies in the meta-analysis were conducted in the United States or in multiple European countries. Thirty-four studies involved a homogeneous group of patients with breast cancer, and 22 studies involved mixed diagnoses.

Results

  • Across all studies, effect size (ES) d = –0.47–2.66; overall average, ES d = 0.56.
  • Types of interventions were as follows. Some studies involved more than one treatment group.
    • Psychoeducational (EDU): 8 studies (ES/d = 0.53).
    • Cognitive behavioral therapy (CBT): 24 studies (ES/d = 0.19).
    • Supportive therapy (SUP): 15 studies (ES/d = 0.13).
    • Relaxation (REL): 12 studies.
  • Moderator effects were as follows.
    • The majority of studies were led by psychologists (n = 21) or nurses (n = 11). Psychologist-led interventions had a higher ES (d = 0.30) than did those led by nurses (d = 0.15) (p < 0.001).
    • Nature of the control group in studies was identified as active if active interventions of some type were delivered. The control group was identified as passive if controls received usual care or were wait-listed. Passive control groups had higher ES (d = 0.34) than did those with active controls (d = 0.11) (p < 0.001).
    • Formats of the intervention were individual, group, couple, self-help, and patient with family-member. Comparison between group and individual formats showed higher ES for individual interventions (d = 0.30) than for group interventions (d = 0.19) (p < 0.001).
    • Timing of the intervention was reported in 82% of studies. Timing options were directly after diagnosis or surgery, during or following chemotherapy or radiation therapy, and months or years after initial diagnosis. Interventions conducted directly after diagnosis or surgery (d = 0.33) had higher ES than did those during treatment (d = 0.18) or those conducted months or years after diagnosis (d = 0.16) (p < 0.001).
    • Patients with early-stage (I–III) disease had higher ES (d = 0.32) than those with advanced disease (d = 0.13) (p < 0.01).
    • For EDU, moderate ES (d = 0.73) resulted if the intervention had been conducted by nursing or medical staff rather than by psychologists. Psychologist-delivered ED resulted in small ES (d = 0.27).
    • CBT resulted in moderate ES (d = 0.40) if conducted by psychologists. CBT resulted in no effects if nurses or social workers delivered the intervention.
    • Authors found no difference in the results of interventions delivered by different SUP interventionists.

Conclusions

  • Psychosocial interventions of various types can have a positive effect on patients with cancer.
  • Psychoeducational interventions appear to have the greatest effect, and this effect is higher when the education is delivered by professionals with medical expertise than when delivered by others.
  • Interventions appear to be most effective in cases of early-stage disease and when delivered early in the phase of care.
  • Individualized interventions appear to have an effect that is greater than interventions delivered in groups.

Limitations

  • The quality of individual studies included was highly variable.
  • Some studies provided actual data on significant findings only, although the studies had measured several outcomes. As a result, the ES reported in this meta-analysis may be somewhat overestimated.
  • Long-term effects of intervention types are still unclear because most studies did not include long-term follow-up.

Nursing Implications

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.

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Research Evidence Summaries

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.

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 100
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Stage 0, I, or II breast cancer

Setting

  • SITE: Multi-site
  • LOCATION: Several hospitals and medical practices in Miami, FL

Measurement Instruments/Methods

  • Outcomes measured: Distress (mood disturbance, depressive symptoms, and thought intrusion and avoidance), perceptions of benefit from having breast cancer, and general optimism regarding the future
  • Scales: Profile of Mood States (POMS), Center for Epidemiological Studies-Depression (CES-D), Impact of Events Scale (IES), Life Orientation Test-Revised (LOT-R), and a 17-item measure of perceived benefits

Results

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.

Conclusions

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.

Limitations

Although this is a well-designed RCT, several flaws exist.

  • The sample is made up of volunteers who were relatively educated, affluent, and motivated. Only 26% identified themselves as an ethnic minority.
  • The participants had non-metastatic cancers and were free from physical and mental health comorbidities at the time of recruitment, so generalizability is constrained.
  • The measure of benefit finding is new; more information is needed regarding its validity.
  • Levels of distress reported in this sample were generally low.
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Ashing, K., & Rosales, M. (2014). A telephonic-based trial to reduce depressive symptoms among Latina breast cancer survivors. Psycho-Oncology, 23(5), 507–515.

Study Purpose

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 Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 199 (intervention = 99 [English language preferred = 45, Spanish language preferred = 54]; control = 100 [English language preferred = 39, Spanish language preferred = 61])
  • MEAN AGE = 52.9 years (SD = 10.5 years)
  • MALES: NA, FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer survivors
  • OTHER KEY SAMPLE CHARACTERISTICS: Latino

Setting

  • SITE: Multi-site  
  • SETTING TYPE: Other  
  • LOCATION: California cancer registry, hospital cancer registries, and breast cancer survivor support groups

Phase of Care and Clinical Applications

PHASE OF CARE: Late effects and survivorship

Study Design

Randomized, controlled trial

Measurement Instruments/Methods

Center for Epidemiological Studies Depression Scale (CESD) to assess depressive symptoms in addition to demographic and clinical characteristics

Results

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.

Conclusions

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.

Limitations

  • Findings not generalizable
  • Greater than 10% were lost to follow-up; lots of steps taken to assure treatment fidelity

Nursing Implications

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.

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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.

Study Purpose

To test the effectiveness of two telephone-delivered psychosocial interventions for maintaining and improving quality of life

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The sample included 71 men (survivors) and 70 partners.  
  • Mean age of survivors was 66.99 years and mean age of partners was 61.13 years.
  • Of the survivors, 100% were male. Of the partners, 5.7% were male and 92.9% were female.
  • All survivors had been diagnosed with prostate cancer.

Setting

  • Single site
  • Home setting

Phase of Care and Clinical Applications

  • Phase of care: long-term follow-up
  • Clinical applications: late effects and survivorship, eldercare

Study Design

Repeated-measures experimental design

Measurement Instruments/Methods

  • Center for Epidemiological Studies Depression Scale   
  • Positive and Negative Affect Schedule
  • UCLA Prostate Cancer Index
  • Multidimensional Fatigue Inventory
  • Social Well-Being Scale
  • Perceived Social Support from Family Scale
  • Spiritual Well-Being subscale of Quality of Life Instrument–breast cancer version

Results

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.

Conclusions

Both interventions in this study were effective in improving multiple dimensions of quality of life for men with prostate cancer and their partners.

Limitations

  • The study had a small sample size (fewer than 100 participants).
  • Length of time since diagnosis was highly varied in the sample and needs can be expected to differ based on this.
  • Predominantly Caucasian sample
  • Baseline QOL was high.

Nursing Implications

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.

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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.

Study Purpose

To evaluate the effectiveness of a psychoeducational program on cancer-related fatigue

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 129   
  • AGE: Mean = 55.9 years
  • MALES: 15.6%  
  • FEMALES: 84.4%
  • CURRENT TREATMENT: Not applicable
  • KEY DISEASE CHARACTERISTICS: Multiple tumor types–over 60% were breast cancer cases. Average of slightly less than one month since diagnosis.
  • OTHER KEY SAMPLE CHARACTERISTICS: Mean baseline fatigue was 5 in both groups.

Setting

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

Study Design

RCT

Measurement Instruments/Methods

  • Numeric rating scale for fatigue intensity
  • FACT-Fatigue
  • Piper Fatigue Scale
  • EORTC-QLQ-C30
  • Hospital Anxiety and Depression Scale

Results

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.

Conclusions

The educational program tested here did not demonstrate an effect on fatigue, anxiety, or depression.

Limitations

  • Risk of bias (no appropriate attentional control condition)
  • Questionable protocol fidelity
  • Subject withdrawals ≥ 10%
  • Other limitations/explanation: Authors questioned the possibility of study group contamination since all patients were treated at the same clinical centers. No observations to check program fidelity were described. Phase of care is not clear in this report. Question of author bias–authors attribute lack of apparent effect to the need for better fatigue measures.

Nursing Implications

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.

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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. 

Study Purpose

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.

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 141
  • MEDIAN AGE = 58 years
  • MALES: 33%, FEMALES: 67%
  • KEY DISEASE CHARACTERISTICS: Diagnosis of advanced cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: Four or above on the ESAS, normal score on the Mini Mental State Examination (MMSE), no severe comorbid conditions including severe anxiety, major depression, substance abuse, or erythropoietin use

Setting

  • SITE: Multi-site  
  • SETTING TYPE: Outpatient  
  • LOCATION: Outpatient palliative care and oncology clinics at MD Anderson Cancer Center and at Lyndon B. Johnson General Hospital, both in Houston, TX

Phase of Care and Clinical Applications

  • PHASE OF CARE: Mutliple phases of care
  • APPLICATIONS: Pediatrics, elder care, palliative care

Study Design

Randomized, controlled trial; placebo controlled

Measurement Instruments/Methods

  • Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F)
  • ESAS
  • MMSE
  • Hospital Anxiety and Depression Scale (HADS)
  • Pittsburgh Sleep Quality Index (PSQI)

Results

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).

Conclusions

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.

Limitations

  • Risk of bias (no blinding)
  • No statistical control for multiple comparisons, which could lead to a type one error
  • Limited duration of two weeks  
  • Content of CTI not described

Nursing Implications

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.

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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.

Study Purpose

To test the feasibility of the implementation of a psychoeducational intervention program for patients with gynecologic cancer

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 26  
  • MEAN AGE = 54.5 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Cervical cancer, uterine cancer, and ovarian cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: Preoperative for surgical resection of disease

Setting

  • SITE: Single-site    
  • SETTING TYPE: Inpatient    
  • LOCATION: Hong Kong

Phase of Care and Clinical Applications

  • PHASE OF CARE: Diagnostic
  • APPLICATIONS: Elder care, palliative care 

Study Design

Single-blinded, randomized trial with a mixed-methods design

Measurement Instruments/Methods

  • Baseline data on outcome variables were measured at the initial intervention for both groups. Both groups were reassessed following surgery, during inpatient stay, and eight weeks after surgery. A Sexual Function-Vaginal Changes Questionnaire (SVQ) was given during the third interview. Interviews were recorded.
  • The Traditional Chinese Functional Assessment of Cancer Therapy–General (FACT-G) was used to measure quality of life. 
  • Mishel’s Uncertainty in Illness Scale (MUIS) was used to measure perceived uncertainty.
  • The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression.
  • The Medical Outcomes Study Support Survey (MOS-SS) was used to measure perceived social supports.
  • Nonparametric inferential statistical methods were used in the analysis of quantitative data, including the Mann-Whitney U test and the Kruskal-Wallis test. Qualitative data were analyzed by content analysis based on transcriptions of the recordings.

Results

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.

Conclusions

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.

Limitations

  • Small sample (< 30)
  • Risk of bias (sample characteristics)
  • Unintended interventions or applicable interventions not described that would influence results 
  • Findings not generalizable
  • Questionable protocol fidelity
  • Other limitations/explanation: Three interventions took place during a relatively short period of time, and one took place two months later. The implementation period was six months long.

Nursing Implications

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.

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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.

Study Purpose

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

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 210 (patients who completed 24-month assessment, 44% of initial study).
  • Mean patient age was 48.7 years (SD = 12.9 years).
  • Males, 11%; females, 89%.
  • Of all patients in the study, 93% were Hispanic; 75% had been in the United States for more than 10 years.
  • Baseline data: 64% of cancers were gynecologic or breast cancers; 28%, stage III or IV recurrent cancer.
  • Mean depression score at baseline was 12.52 (SD = 3.36).
  • Included patients had received a cancer diagnosis at least 90 days prior to baseline and met criteria for having symptoms of depression as stated in eligibility.
  • Patients were excluded if they had suicidal ideation, had a life expectancy of fewer than six months, reported scores greater than or equal to 8 on the Alcohol Use Disorders Identification Test, had recently used lithium or antipsychotic medication, had a score of equal to or less than 2 on the Karnofsky Performance Status Score, or were unable to speak English or Spanish. 

Setting

  • Multisite
  • Outpatient
  • California and southern Florida

Phase of Care and Clinical Applications

  • Phase of care: long-term follow-up
  • Applications: late effects and survivorship
     

Study Design

Randomized control trial, longitudinal 

Measurement Instruments/Methods

  • Patient Health Questionnaire-9 (PHQ-9)
  • Functional Assessment of Cancer Therapy Scale
     

Results

  • The number of reports of receiving treatment for depression declined over time; however, reports of treatment were more numerous in the intervention group. At 12 months, researchers found significant differences (p < 0.001) between groups in regard to use of antidepressant medication, with the intervention group reporting greater use of antidepressant medications.
  • The intervention group reported greater use of counseling at 12 months (p < 0.001) and 18 months (p = 0.001), than did the other group.
  • The number of reports of having had any depression treatment was significantly different in the intervention group at 12 months (p < 0.001) and 18 months (p = 0.001).
  • The intervention group had a 46% decrease in PHQ-9 scores; the usual-care group had a 32% decrease, which was a significant decrease (p = 0.02). The intervention group was significantly more likely to have decreased its PHQ-9 score by 5 points since baseline at 12, 18, and 24 months (p = 0.01, p =0.03, p = 0.02, respectively).

Conclusions

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.

Limitations

  • The study had no appropriate attentional control condition.
  • The control group had no attention control, a fact that limits interpretation of between-group differences. 
  • This was a complex and multifaceted intervention; therefore, knowing which component of the intervention had the greatest influence is difficult.
     

Nursing Implications

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.

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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.

Study Purpose

To determine the effectiveness of Alleviating Depression Among Patients with Cancer (ADAPt-C) collaborative care management for major depression or dysthymia

Intervention Characteristics/Basic Study Process

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. 

Sample Characteristics

  • N = 472 participants (242 in the intervention group  and 230 in the control group).
  • Of participants, 49.4% was age 50 or older.
  • Female: 84.5%; male: 15.5%.
  • Participants had diverse cancer types at a variety of stages. Most participants (42.6%) had gynecologic cancer.
  • Adult patients showed evidence of depression or dysthymia after cancer diagnosis.
  • Of all participants, 87.9% were Hispanic.
  • Intervention and control groups differed at baseline in regard to emotional well-being and quality of life. Researchers noted lower well-being in the intervention group.
  • The two groups differed in regard to percentage of foreign-born participants. The greater percentage was in the intervention group (p = 0.04).

Setting

  • Single site
  • Outpatient
  • Southern California

Phase of Care and Clinical Applications

Active treatment and transition

Study Design

Prospective, randomized, controlled trial with simple blinding

Measurement Instruments/Methods

  • Patient Health Questionnaire-9 (PHQ-9) for the diagnosis of major depression and depression severity level
  • Functional Assessment of Cancer Therapy-General (FACT-G)
  • Medical Outcome Study 12-item Short-Form Health Survey (SF-12) for quality of life
  • Brief Pain Inventory (Short Form)

Results

  • From baseline to the 12-month follow-up, 63.2% of intervention patients had a 50% or greater reduction in depression symptoms as assessed by the PHQ-9 depression scale. In comparison, 50% of patients in the EUC group had a 50% or greater reduction (p = 0.01).
  • Researchers noted five-point reduction in the PHQ-9 score: 72.2% of intervention patients versus 59.7% of EUC (p = 0.02).
  • Intervention patients had significantly better quality-of-life outcomes (p < 0.05).
  • At the six-month follow-up, researchers found no difference between groups in regard to depression severity.
  • Intervention patients experienced greater rates of depression treatment (p < 0.0001).

Conclusions

ADAPt-C collaborative care may be a feasible and effective means of reducing symptoms of depression in some cancer patients.

Limitations

  • The study may have had risks of bias due to large attrition (214 participants, or 45% of participants), lack of control over the type of cancer treatments, and the range of time lapses since treatment.
  • The baseline differences in the emotional well-being subscale scores of the FACT-G and SF-12 mental component summary were not adjusted for the main analyses.
  • Cost will be involved in training the team members (e.g., a clinical specialist) and in hiring these personnel.

Nursing Implications

ADAPt-C is a time- and personnel-intensive intervention that requires significant commitment on the part of the patient.

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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. 

Study Purpose

To determine whether a therapist-led psychoeducational intervention is effective in reducing anxiety, depression, and radiation therapy-related patient concerns

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 102
  • MEAN AGE = 54.6 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All participants were diagnosed with breast cancer and were receiving radiation therapy. About 73% of participants were receiving concomitant chemotherapy.
  • OTHER KEY SAMPLE CHARACTERISTICS: Slightly greater than half of participants were employed part- or full-time, 25% had some college-level education, and one third had less than 10 years of formal education. The majority of participants were married.

Setting

  • SITE: Single-site  
  • SETTING TYPE: Outpatient  
  • LOCATION: Australia

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment

Study Design

Randomized, controlled trial

Measurement Instruments/Methods

  • Hospital Anxiety and Depression Scale (HADS)
  • Concerns about radiotherapy scale (reliability = .91)
  • Knowledge of radiotherapy scale (reliability = .86)
  • Patient preparedness and understanding index: Single-item Visual Analog Scale (VAS) 

Results

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).

Conclusions

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.

Limitations

  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Other limitations/explanation: Baseline HADS scores were not provided, so it is not clear whether any patients had clinically-relevant anxiety or depression or if there was a floor effect in measurement.  Usual care was not well-described, so it is not clear how much or what type of information usual care patients received.

Nursing Implications

The provision of this type of education and supportive intervention may reduce anxiety and improve patient knowledge prior to beginning radiation therapy.

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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.

Study Purpose

To examine the feasibility and effectiveness of problem-solving therapy for psychological distress among patients with early-stage breast cancer

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • Mean patient age was 50.21 years (SD = 11.09 years).
  • The sample was 100% female.
  • The majority of participants had stage II disease. All had had prior surgery; 89% were on hormone therapy.
  • Of all participants, 43% were employed full- or part-time, 79% were married, and 21% had a college education.

Setting

  • Single site
  • Outpatient setting
  • Japan

Phase of Care and Clinical Applications

Patients were undergoing active antitumor treatment.

Study Design

A pre/post-test design was used.

Measurement Instruments/Methods

  • Two-item 11-point Likert-type distress scale
  • Hospital Anxiety and Depression Scale (HADS), Japanese version
  • Scale that measured self-efficacy of patients with advanced cancer
  • Brief Cancer-Related Worry Inventory
  • European Organization for Research and Treatment Cancer Core Quality-of-Life Questionnaire (QLC-C30), Japanese version

Results

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.

Conclusions

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.

Limitations

  • The study had a small sample size, with fewer than 30 participants.
  • The study had risks of bias due to the lack of a control group, blinding, and random assignment.

Nursing Implications

Study results are insufficient to allow evaluation of the acceptability and efficacy of the problem-solving intervention.

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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.

Study Purpose

To test the efficacy of behavioral activation for depression therapy (BADT) compared to problem-solving therapy (PST) in depressed breast cancer patients

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The sample was composed of 65 patients with breast cancer (100% female).
  • Mean patient age was 55.4 years (SD = ±11.9 years).
  • Average time since diagnosis was 3.1 years.
  • Most patients had stage 0–II disease; 95% had had surgery, 74% had had chemotherapy, and 64% had had radiation therapy; 52% were currently taking antidepressants.
  • Approximately 42% were working either full- or part-time.
  • All patients had to meet screening criteria that demonstrate a diagnosis of major depression of at least moderate severity.

Setting

  • Outpatient settings, specific sites unstated or unknown 
  • Tennessee and Maryland

Phase of Care and Clinical Applications

Late effects and survivorship

Study Design

Randomized controlled trial design

Measurement Instruments/Methods

  • Beck Depression Inventory (BDI)
  • Environmental Reward Observation Scale (EROS)
  • Beck Anxiety Inventory (BAI)
  • Quality of Life Inventory (QOLI)
  • 36-item Short-Form Health Survey (SF-36)
  • Multidimensional Scale of Perceived Social Support (MSPSS)
  • Hamilton Rating Scale for Depression (HRSD)

Results

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.

Conclusions

Findings demonstrate that both the BADT and PST interventions were effective in reducing depression in the groups of patients studied.

Limitations

  • The study had a small sample size, with fewer than 100 participants.
  • The study had risk of bias due to no blinding.
  • Of all participants, 19% dropped out. Authors had determined sample size to accommodate this, given previous research.
  • Findings relate to patients with major depression and may not relate to patients with symptoms of depression that is less severe than major depression.

Nursing Implications

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.

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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.

Study Purpose

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.  

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The sample was composed of 26 patients. In the group with sudden gains, mean age was 54.5 years. Mean age in the group without sudden gains was 51.2 years.
  • Males: 8%; females: 92%.
  • Of the 26 participants, 10 had coexistent diagnoses of generalized anxiety disorder, social phobia, panic disorder, post-traumatic stress disorder, or specific phobia. Cancer types were breast, lung, stomach, colon, prostate, and pancreatic. Average time since diagnosis was two years.

 

Setting

  • Single site
  • Outpatient
  • University of Tennessee Medical Center Cancer Institute medical clinics
     

Phase of Care and Clinical Applications

  • Phase of care: active treatment
  • Clinical applications: late effects and survivorship

 

Study Design

Pre/post-test time-series measurements

Measurement Instruments/Methods

  • Anxiety Disorders Interview Schedule (ADIS-IV)    
  • Beck Depression Inventory-II (BDI-II)
  • Hamilton Rating Scale for Depression-24 (HRSD)
  • Beck Anxiety Inventory-II (BAI-II)
  • Medical Outcomes Study 36-item Short-Form 36 Health Survey (SF-36)
  • Multidimensional Scale of Perceived Social Support (MSPSS)
     

Results

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.

Conclusions

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.

Limitations

  • The study had a small sample size, with fewer than 30 participants.
  • The study included no ethnic diversity, and participants consisted primarily of breast cancer patients. These factors may affect generalizability.

 

Nursing Implications

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.

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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.

Study Purpose

To investigate the effects of inoculation training on stress, anxiety, and depression

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 40  
  • AGE RANGE: 28-65 years
  • MALES: 31.73%,FEMALES: 68.27%
  • KEY DISEASE CHARACTERISTICS: Patients had non-hematologic cancers and were in the third course of chemotherapy. None were receiving radiation therapy.

Setting

  • SITE: Single site  
  • SETTING TYPE: Not specified    
  • LOCATION: Iran

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment

Study Design

  • Randomized, controlled trial

Measurement Instruments/Methods

  • Depression Anxiety and Stress Scale (DASS)

Results

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).

Conclusions

The psychoeducational intervention tested here was associated with significantly less anxiety and depression compared to patients who did not receive this intervention.

Limitations

  • Small sample (less than 100)
  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • Measurement/methods not well described
  • Other limitations/explanation: No information is provided about the types of cancer, stage of disease, type of chemotherapy provided, other associated symptoms, or use of medication that may affect anxiety or depression–all of which could be expected to influence outcomes. The specific timing of postintervention measurement is not stated.

Nursing Implications

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.

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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.

Study Purpose

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

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The study reported on a sample of 108 patients.
  • Mean patient age was 59.8 years.
  • The sample was 67.6% male and 32.4% female.
  • The sample included patients with stage IV solid tumors (breast, gastrointestinal, genitourinary, lung, head and neck, and other).
  • Most patients had been prescribed opioid analgesics.

Setting

  • Single site
  • Outpatient
  • Seoul, Republic of Korea

Phase of Care and Clinical Applications

  • Patients were undergoing the end-of-life phase of care.
  • The study has clinical applicability for elder care and palliative care.

Study Design

A randomized controlled trial design was used.

Measurement Instruments/Methods

  • Brief Pain Inventory (BPI)
  • Hospital Anxiety and Depression Scale (HADS)
  • Distress Thermometer
  • European Organization for Research and Treatment of Cancer quality of life questionnaire
  • Karnofsky Performance Status score

Results

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.

Conclusions

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.

Limitations

  • The study had risk of bias due to the lack of an appropriate attentional control condition.
  • A one-week study may be too short to show significant improvement in pain outcomes.
  • To extend this study, researchers should conduct a baseline screening with multiple variable assessments in addition to the Karnofsky score.

Nursing Implications

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.

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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.

Study Purpose

Evaluate the effects of a self-help program on depression and anxiety in women with breast cancer receiving chemotherapy

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 65      
  • MEAN AGE: Intervention = 47.7 years (SD = 8 years), control = 49.5 years (SD = 10.9 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All had breast cancer at stages 1–3. All had previous surgery.
  • OTHER KEY SAMPLE CHARACTERISTICS: Most had breast-conserving surgery. The majority had less than a bachelor’s degree education level.

Setting

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Japan

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment

Study Design

Non-random, two-group comparison, quasi-experimental—historical control approach

Measurement Instruments/Methods

  • Center for Epidemiological Studies Depression Scale (CESD)
  • State-Trait Anxiety Inventory (STAI)
  • SF-36
  • National Cancer Institute-Common Toxicity Criteria version 2.0

Results

No significant differences were found in outcomes between study groups. Study measures improved over time in all patients.

Conclusions

This study did not find that the intervention tested here had an effect on depression or anxiety.

Limitations

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Risk of bias (no appropriate attentional control condition)
  • Questionable protocol fidelity
  • No information is provided about patient compliance with diaries and symptoms experienced. No method was used for determining intervention fidelity. No information is provided as to patients' actual attendance at support group sessions. If patients in both groups were being treated in the same location, whether group contamination could have occurred is unclear. The control comparison used was actually a historic control. How the program was designed is unclear, and no apparent theoretical foundation of the program design exists. Although not statistically significant, baseline anxiety and depression scores were lower in the control group, which may have affected the ability to detect differences. Analysis was the comparison of average scores at each study time point, but changes in these scores were not analyzed. Changes in anxiety and depression scores appeared to be greater in the intervention group—analysis of differences in the size of the improvement may have shown different significance. Data reporting is questionable—confidence intervals reported with F values do not appear to be actually related to those values.

Nursing Implications

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.

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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. 

Study Purpose

To examine the benefits of a single-session psychoeducational intervention using a tablet PC during chemotherapy

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 19 (intervention), 17 (control)  
  • AVERAGE AGE = 57.5 years
  • MALES: 45%, FEMALES: 55%
  • KEY DISEASE CHARACTERISTICS: Patients with cancer undergoing chemotherapy
  • OTHER KEY SAMPLE CHARACTERISTICS: The majority of participants were married and were diagnosed with stage IV cancer with an Eastern Cooperative Oncology Group score of 1. All participants scored 11 or more on anxiety and depression scales.

Setting

  • SITE: Single-site    
  • SETTING TYPE: Outpatient    
  • LOCATION: Seoul, South Korea

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS: Elder care, palliative care 

Study Design

Two-group trial

Measurement Instruments/Methods

  • Hospital Anxiety and Depression Scale (HADS)
  • Short Form-8 Health Survey (SF-8)
  • Insomnia Severity Index (ISI)
  • Impact of Event Scale–Revised (IES-R)

Results

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.

Conclusions

A tablet-based, 20-minute psychoeducational intervention could be an effective intervention for managing depression, sleep disturbance, and quality of life.

Limitations

  • Small sample (< 100) 
  • Risk of bias (no random assignment)
  • Risk of bias (sample characteristics)
  • Key sample group differences that could influence results
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: Patients needed to understand how to use a tablet PC. Patients had to be able to hear and understand the tablet PC. Patients had to be undergoing chemotherapy. Tablet PCs are expensive. There was a high refusal rate to participate in the study.

Nursing Implications

This was not a well-made study and had low numbers. Feasibly, nurses could hand their patients a tablet and not interact with them.
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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.

Study Purpose

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  

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The sample was composed of 41 participants.
  • The range of mean patient age was 56–69 years.
  • Males: 0 %; females: 100%.
  • Participants were patients with breast cancer.
  • Most patients were receiving chemotherapy and radiation therapy.
     

Setting

  • Single site
  • Outpatient
  • Vasteras Hospital, Sweden
     

Phase of Care and Clinical Applications

Phase of care: transition phase after initial treatment

Study Design

Randomized controlled trial

Measurement Instruments/Methods

  • Hospital Anxiety and Depression Scale    
  • Norwegian Fatigue Questionnaire
  • Immune analysis
     

Results

  • Results revealed no significant immune effect from support intervention.
  • More patients in the support group had higher anxiety scores at the start of the intervention than did patients in the nonsupport group.
  • The mean value of anxiety in the support group was higher than that in the nonsupport group, and the value improved significantly over time.
  • Patients in both groups had low levels of depression, with no significant difference in depression scores.
  • Patients in both groups had no significant difference in fatigue. The measure of fatigue decreased over time for all patients.
  • No significant differences in study measures existed between groups.
     

Conclusions

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.

Limitations

  • The  study had a small sample size, with fewer than 100 participants.
  • Participants had low depression scores at baseline.
  • Authors did not specify how the intervention was provided—individually, in groups, in the home, or in some other setting. 
  • The study had a risk of bias due to no blinding.

Nursing Implications

Findings do not support effectiveness of the intervention tested here. Results show that levels of depression, anxiety, and fatigue reduced significantly over time.

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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.

Study Purpose

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

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 63
  • AGE = Older than 21 years
  • MEDIAN AGE = 51–60 years
  • MALES: 35%, FEMALES: 65%
  • CURRENT TREATMENT: Chemotherapy

Setting

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: National Cancer Institute-Singapore Medical Oncology Clinic

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment

Study Design

  • Quasiexperimental study

Measurement Instruments/Methods

  • Distress Thermometer (DT)
  • Hospital Anxiety and Depression Scale (HADS)
  • EuroQol EQ-5D
  • Data were analyzed using SPSS, version 22.

Results

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.

Conclusions

A six-month intervention of psychoeducation, counseling, and behavior technique teaching improved participants’ distress, quality of life, anxiety, and depression.

Limitations

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Questionable protocol fidelity
  • Subject withdrawals ≥ 10%

Nursing Implications

Program inclusion of patients helped to individualize nurse-led interventions and enhanced screening tools to capture a larger participation group and encourage completion. This showed that the psychoeducational intervention used here reduced anxiety and depression among the newly diagnosed patients. The low recruitment rate and dropout rate, however, suggest that the program may not have been practical or of interest to many patients. Greater individualization of content may be important for patient participation in this type of intervention. This program is likely to be most beneficial to individuals with higher anxiety and depression symptoms at baseline.
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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.

Study Purpose

To compare the efficacy of two psychological interventions to the efficacy of usual care

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

The study included 353 women with primary gynecologic cancer who were in active treatment.

Setting

  • Two comprehensive cancer centers and eight hospitals
  • Three states in the United States

Measurement Instruments/Methods

  • Beck Depression Inventory
  • Impact of Event Scale
  • Emotional Expressiveness Questionnaire
  • Cancer Rehabilitation Evaluation System subscale
  • Modified Expectancy Rating Form
  • A version of Borkovec and Nau’s evaluation of treatment credibility

Conclusions

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.

Limitations

  • The RCT was poorly designed, with a high rate of refusal and lack of survey completion.
  • The sample was primarily Caucasian, young, and had ovarian cancer; this lack of diversity limits generalizability.
  • Participants were paid $25 for each survey or session, a relatively high compensation.
  • Different therapists were used for SC and CCI.
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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.

Study Purpose

To evaluate the effects of group therapy on anxiety and depression

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N= 30
  • MEAN AGE = 47.2 years (range = 29-59)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All had breast cancer, but stages varied.  Standard therapy was completed.

Setting

  • SITE: Single site  
  • SETTING TYPE: Not specified  
  • LOCATION: Iran

Phase of Care and Clinical Applications

  • PHASE OF CARE: Transition phase after active treatment

Study Design

Randomized, controlled trial

Measurement Instruments/Methods

  • Beck Depression Inventory
  • Beck Anxiety Scale

Results

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).

Conclusions

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.

Limitations

  • Small sample (less than 100)
  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Other limitations/explanation: There is no description of the control condition, and apparently no attentional control. Baseline anxiety and depression scores were higher in the experimental group, and other studies have shown that interventions can have a greater effect for those with higher anxiety and depression initially.

Nursing Implications

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.

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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.

Study Purpose

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.

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N: 102 
  • MEAN AGE: 55.86 years
  • MALES: 40%  
  • FEMALES: 60%
  • CURRENT TREATMENT: Chemotherapy
  • KEY DISEASE CHARACTERISTICS: Gastrointestinal, breast, lung, hepatic, and hematologic malignancies

Setting

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Hanoi, Vietnam

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active anti-tumor treatment
  • APPLICATIONS: Elder care, palliative care

Study Design

Single-blind, pilot, quasi-experimental trial with pre-/post-test follow up.

Measurement Instruments/Methods

  • Numerical Analogue Scales (NAS)
  • Brief Fatigue Inventory (BFI)
  • Brief Pain Inventory (BPI)
  • Hospital Anxiety and Depression Scale
  • EuroQol-5D-5L
  • Intervention Rating Profile-15
  • Symptom self-management diary

Results

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.

Conclusions

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.

Limitations

  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • Findings not generalizable
  • Other limitations/explanation: Non-strict patient randomization, potential for placebo or social desirability effects.

Nursing Implications

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.

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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.

Study Purpose

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.

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 347   
  • AGE: Treatment group, mean = 52.9 years; waitlist control group, mean = 53.1 years; all combined, mean = 53.1 years
  • MALES: 21%; n = 73
  • FEMALES: 79%; n = 274
  • CURRENT TREATMENT: Other
  • KEY DISEASE CHARACTERISTICS: Multiple tumors: Most common were breast cancer (n = 161, 46.4%) followed by prostate cancer (n = 43, 12.4%)
  • OTHER KEY SAMPLE CHARACTERISTICS: Participants with multiple cancers and participants with female reproductive cancers were at 6.1% each (n = 21)

Setting

  • SITE: Multi-site (tumor registry, outreach to websites, and cancer forums)
  • SETTING TYPE: Other (online)
  • LOCATION: Online

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Study Design

Randomized controlled clinical trial

Measurement Instruments/Methods

  • Primary outcomes: distress measured by Distress Thermometer, psychological functioning by Outcomes questionnaire-45, depression by Center for Epidemiologic Studies Depression scale, and trauma-related anxiety by Impact of Event Scale-revised 
  • Secondary outcomes: Fatigue and vigor by the subscales from Profile of Mood States (POM-SF) 
  • Engagement on outcomes: Time spent online with the intervention  
  • Outcomes measured at baseline and 12 weeks.

Results

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.

Conclusions

Health space social networking did not improve the cancer-related distress outcomes.

Limitations

  • Unintended interventions or applicable interventions not described that would influence results
  • Questionable protocol fidelity
  • Subject withdrawals ≥ 10%  
  • Other limitations/explanation: Attrition

Nursing Implications

Online interventions could be suggested to patients as it is associated with strong engagement.

Print

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.

Study Purpose

Determine the effectiveness of group psycho-education on well-being and depression among breast cancer survivors in Malaysia

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 34    
  • AGE = Older than 18 years; 47% older than 50 years; 26.5% for both 30–49 years and younger than 30 years
  • MALES: 0%, FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer on appropriate medications
  • OTHER KEY SAMPLE CHARACTERISTICS: 70.6% were married; 47% completed secondary level of education, 32.3% completed primary level of education, and 20.6% completed college level of education; 29.4% were employed; comorbid conditions: 55.6% had hypertension, 44.4% had diabetes, and 22.2% had both

Setting

  • SITE: Single site 
  • SETTING TYPE: Outpatient 
  • LOCATION: Melaka, Malaysia

Phase of Care and Clinical Applications

PHASE OF CARE: Active antitumor treatment

Study Design

Cluster, non-randomized trial

Measurement Instruments/Methods

  • Pre-test questionnaire for socio-demographic profile
  • World Health Organization (Five) Well-being Index (WHO-5 Well-being Index)

Results

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.

Conclusions

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.

Limitations

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Risk of bias (no appropriate attentional control condition)  
  • Risk of bias(sample characteristics)
  • Measurement/methods not well described
  • Measurement validity/reliability questionable
  • Findings not generalizable
  • Only women included; findings not generalizable because of small size
  • Measurement of well-being not clearly reflective of anxiety or depression

Nursing Implications

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.

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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.

Study Purpose

To develop a brief, cost-effective, self-administered psychological intervention to improve well-being by using positive psychology and mindfulness meditation

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The sample was composed of 27 participants with metastatic breast or prostate cancer.
  • Mean age of women was 60.8 years; mean age of men was 72.4 years.
  • Of female participants, 13 were in the analysis phase; of males, 14 were in the analysis phase.
  • A stable life expectancy greater than 6 months was a condition of inclusion. Patients with a psychiatric diagnosis were included if the condition was diagnosed as stable.

 

Setting

  • Single site
  • Outpatient
  • Cambridge, Cambridgeshire, England

Phase of Care and Clinical Applications

Active treatment and transition

Study Design

Randomized controlled trial

Measurement Instruments/Methods

  • World Health Organization Quality of Life Instrument-BREF (WHOQOL-BREF)
  • Hospital Anxiety and Depression Scale (HADS)
  • Social and Occupational Functioning Assessment Scale (SOFAS)
  • Life Orientation Test, Revised (LOT-R)
  • Ten Item Personality Inventory (TIPI)

Results

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.

Conclusions

The intervention was associated with some improvement in quality-of life-measures, but there was no effect on depression or anxiety.

Limitations

  • The study had a small sample size, with fewer than 30 participants and a high attrition rate.
  • The study had risk of bias due to no blinding.
  • Measures of internal consistency reliability for the instruments were not reported.
  • Follow-up occurred by different methods: in the clinic, at home, via telephone, or by means of a mailed survey.
  • Patients complained of repetitiveness in the diary-writing aspect of the intervention. They study did not include analysis of patient adherence to or actual use of the approach.

Nursing Implications

Findings do not indicate that mindfulness-based intervention, as used in this study, had an impact on well-being.

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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.

Study Purpose

To evaluate the effectiveness of a residential rehabilitation course for patients with cancer in decreasing psychological distress

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The study reported on a sample of 394 patients.
  • Mean patient age was 61 years (range = 39–82 years).
  • The sample was 64.4% female and 32.2% male.
  • Patients had diagnoses of breast, prostate, or colon cancer.
  • Average time since diagnosis was 15 months (range = 2.5–28.1 months).
  • Of the sample, 48% were employed, 47.5% had higher than youth education, and 72% were married or cohabiting.

Setting

  • Single site
  • Other setting
  • Denmark

Phase of Care and Clinical Applications

Transition phase of care after initial treatment

Study Design

Randomized controlled trial

Measurement Instruments/Methods

  • Profile of Mood States Short Form
  • EORT QLC-C30

Results

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).

Conclusions

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.

Limitations

  • The study had a risk of bias due to no blinding and no appropriate attentional control condition.
  • This type of residential program or intervention would require training and be expensive and impractical for many individuals. It is not clear if participants incurred any costs to participate.
  • Usual care was not described.
  • Measurement for cognition was one item on a subjective measure.
  • There was 13% attrition at time of six-month follow-up testing.

Nursing Implications

 This study suggests that an intensive residential program for cancer survivors, as examined, was of no benefit.

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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. 

Study Purpose

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

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 165 included in analysis of primary outcome   
  • MEAN AGE = 67.2 years (intervention), 67.6 years (usual care group)
  • MALES: 100%  
  • CURRENT TREATMENT: Radiation
  • KEY DISEASE CHARACTERISTICS: Low risk prostate cancer for both groups (about 11%), intermediate risk (prostate cancer control group) (42.3%), prostate cancer risk intervention group (41.1%), high risk prostate cancer (about 47% for both groups) 
  • OTHER KEY SAMPLE CHARACTERISTICS: A little less than 80% were married, 82% were from urban areas, about 78% had previous treatment (e.g., prostatectomy, ADT). Included patients aged 18 years or older with prostate cancer

Setting

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

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS: Elder care

Study Design

Phase-III, two-arm cluster, randomized, controlled trial

Measurement Instruments/Methods

  • Hospital Depression and Anxiety Scale (HADS)
  • Cancer Treatment Scale (CaTS)
  • The Short-Form Supportive Care Needs survey questionnaire (SCNS-SF34-R)
  • Expanded Prostate Cancer Index Composite (EPIC-26)

Results

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.

Conclusions

Nurse-led group consultations may help address patient education, particularly among men who are experiencing depression.

Limitations

  • Findings not generalizable
  • Participants had a baseline high level of baseline functioning.

Nursing Implications

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.

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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. 

Study Purpose

To investigate which approach, psychoeducation or support, provides the greatest benefit to patients with early-stage breast cancer

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 367  
  • MEAN AGE = 54.75 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All had breast cancer.  Most were stage T1 or T2.  More than 70% had radiotherapy, 50% had chemotherapy, and 60% had endocrine therapy. All had surgery.
  • OTHER KEY SAMPLE CHARACTERISTICS: 67% were married, 38% were employed, and slightly more than 50% had more than a high school education.

Setting

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

Phase of Care and Clinical Applications

  • PHASE OF CARE: Transition phase after active treatment

Study Design

  • Randomized, controlled trial with active control

Measurement Instruments/Methods

  • Hospital Anxiety and Depression Scale
  • Mini Mental Adjustment to Cancer scale
  • Life Orientation Test, revised (measuring optimism and pessimism)

Results

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.

Conclusions

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.

Limitations

  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Other limitations/explanation: Unclear if repeated measures could have created a testing effect. Content in both groups was similar, raising the question of whether these two interventions were substantially different from each other. Groups received a different number of sessions, which could have accounted for the few differences seen. 

Nursing Implications

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.

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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. 

Study Purpose

To report on health-related quality of life (HRQOL) and depressive outcomes from an earlier trial using nurse counseling after intervention (NUCAI)

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 179  
  • MEAN AGE = 60.1 years (intervention), 60.7 years (control)
  • MALES: 70%, FEMALES: 30%
  • KEY DISEASE CHARACTERISTICS: Intervention type of cancer: 23% larynx, 47% oral cavity, 18% OP, and 13% hypopharynx; control type of cancer: 24% larynx, 19% oral cavity, 48% OP, and 8% hypopharynx; intervention tumor stage: I–II 58% and III–IV 42%; control tumor stage: I–II 59% and III–IV 40% 
  • OTHER KEY SAMPLE CHARACTERISTICS: Working status intervention: employed 35%, unemployed 33%, retired 22%, and unknown 10%; working status control: employed 37%, unemployed 37%, retired 23%, and unknown 2%

Setting

  • SITE: Single site    
  • SETTING TYPE: Not specified    
  • LOCATION: Utrecht, Netherlands

Phase of Care and Clinical Applications

  • PHASE OF CARE: Transition phase after active treatment

Study Design

Single, blinded, randomized, controlled trial

Measurement Instruments/Methods

  • Questionnaires were completed at baseline before cancer treatment and at three, six, nine, 12, 18, and 24 months after treatment completion.
  • European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck (EORTC QLQ-C30 H&N 35)
  • Center for Epidemiologic Studies Depression Scale (CES-D)
  • Demographic and medical information collection

Results

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.

Conclusions

The NUCAI showed significant improvements for patients with head and neck cancer 24 months after completing treatment.

Limitations

  • Risk of bias (no blinding)
  • Intervention expensive, impractical, or training needs
  • Subject withdrawals ≥ 10% 
  • Other limitations/explanation: High attrition rate because of disease state; several analyses of data; fatigue measured as one aspect of multicomponent quality of life

Nursing Implications

As a nurse-led intervention, this is a feasible option for patients with head and neck cancer desiring a problem-focused intervention for symptoms.

Print

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.

Study Purpose

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.

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • The initial sample was composed of 205 participants with HNC. The final analysis included 150 participants.
  • Mean patient age in the intervention group was 60.1 years; in the usual-care group, 60.7 years.
  • The intervention group comprised 70.5% males and 29.5% females. The control (usual-care) group comprised 70.3% males and 29.7% females.
  • The majority of patients in both groups were married. Cancer of the oral cavity was the most common cancer diagnosis among the patients.

Setting

  • Single site
  • Outpatient
  • The Netherlands

Phase of Care and Clinical Applications

Transition phase after active treatment

Study Design

Randomized controlled trial

Measurement Instruments/Methods

  • Self-report questionnaires for age, gender, education level, and social status
  • Medical records review for treatment, tumor type, and stage
  • Center for Epidemiological Studies Depression Scale (CESD) (primary outcome)
  • European Organization for Research and Treatment questionnaire for quality of life of cancer patients (EORTC QLC) for physical symptoms (secondary outcome)

Results

  • In the intervention group, 11.7% of patients did not attend sessions.
  • Treatment fidelity is documented by using trained, experienced oncology nurses to conduct the intervention.
  • One year after HNC treatment, levels of symptoms of depression were significantly lower in the intervention group than in the control group ( p < 0.05, –5.2 change with intervention). Overall physical symptoms decreased more in the intervention group than in the control group, with a significant decrease in pain and symptoms related to swallowing and opening the mouth.

Conclusions

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).

Limitations

  • The study had a risk of bias due to no appropriate attentional control condition.
  • Protocol fidelity was questionable.
  • Subject withdrawals ≥ 10%.
  • At 12 months, 55 patients were lost to follow-up. In terms of age and education, findings showed a significant difference between patients who were lost to follow-up and patients who completed the study through 12 months. Patients who were lost to follow-up were older and more educated and had an advanced stage of tumor. Of all participants, 27% were lost to follow-up.
  • Because all sessions occurred at clinic follow-up appointments, the potential for contamination or other relevant threats to validity is unknown.

Nursing Implications

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.

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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.

Study Purpose

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

Intervention Characteristics/Basic Study Process

  • Three different delivery means were available, and participants chose the means they preferred. Delivery means were small-group format, one-to-one format, and home format.
  • Outcomes were quality of life and symptoms of depression. Outcomes were evaluated at baseline and at three to four months after baseline.
  • A control group received no intervention.
  • The Nucare psychoeducational program provided a workbook describing effective coping, ways of thinking, communication, uses of social support, problem-solving techniques, and goal setting; healthful lifestyle; and relaxation training.

Sample Characteristics

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.

Setting

  • Outpatient clinic
  • One hospital
  • Montreal, Quebec, Canada

Study Design

Feasibility study using a prospective, nonrandomized design

Measurement Instruments/Methods

  • European Organization for Research and Treatment of Cancer Core Quality of Life (EORTC QLQ-C30)
  • Hospital Anxiety and Depression Scale (HADS)

 

Results

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.

Conclusions

Intervention delivery is feasible.

Limitations

  • The study used a prospective, quasiexperimental design without randomization.
  • The study employed a convenience sample, and many patients refused to participate. These factors reduce generalizability.
  • Authors did not compare the three delivery formats.
  • At baseline, the characteristics of the test and control groups were significantly different. Therefore, outcomes may not have been the result of the intervention.
Print

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. 

Study Purpose

To study the effects of psychosocial telephone counseling on anxiety, quality-of-life domains, and biomarkers

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 168 at 4 months, 151 at 9 months  
  • MEAN AGE = 44.75 years
  • FEMALES: 00%
  • KEY DISEASE CHARACTERISTICS: All had cervical cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: More than half had some college education. About 40% were Hispanic.

Setting

  • SITE: Single site  
  • SETTING TYPE: Home  
  • LOCATION: California

Phase of Care and Clinical Applications

  • PHASE OF CARE: Late effects and survivorship

Study Design

Randomized, controlled trial

Measurement Instruments/Methods

  • PROMIS depression short form
  • Brief Symptom Inventory (BSI)
  • Gynecologic Problems Checklist
  • FACT (cervical and general questionnaires)
  • Plasma cytokine measurement

Results

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.

Conclusions

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.

Limitations

  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Participant withdrawals of 10% or greater

Nursing Implications

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.

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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. 

Study Purpose

To present the short-term effects of a web-based computer-tailored intervention on quality of life, anxiety, depression, and fatigue in cancer survivors

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 419   
  • AGE = 18 years or older
  • MALES: 19%, FEMALES: 81%
  • CURRENT TREATMENT: Not applicable
  • KEY DISEASE CHARACTERISTICS: Any cancer survivor
  • OTHER KEY SAMPLE CHARACTERISTICS: Off treatment for at least four weeks but no longer than 56 weeks; no recurrence; no serious psychiatric, medical, or cognitive impairment

Setting

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

Phase of Care and Clinical Applications

  • PHASE OF CARE: Late effects and survivorship
  • APPLICATIONS: Elder care

Study Design

Randomized, controlled trial comparing the KNW intervention with a waiting list control group

Measurement Instruments/Methods

  • Global health status scale
  • European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
  • Hospital Anxiety and Depression Scale (HADS)
  • Checklist Individual Strength

Results

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.

Conclusions

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.

Limitations

  • Baseline sample/group differences of import
  • Risk of bias (no appropriate attentional control condition)  
  • Risk of bias (sample characteristics)
  • Unintended interventions or applicable interventions not described that would influence results
  • Key sample group differences that could influence results 
  • Measurement/methods not well described
 

 

Nursing Implications

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.

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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.

Study Purpose

To evaluate a web-based cognitive behavioral (CB) stress reduction program

Intervention Characteristics/Basic Study Process

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.

Sample Characteristics

  • N = 61   
  • MEAN AGE = 68.84 (SD = 9.23)
  • MALES: 100%  
  • CURRENT TREATMENT: Radiation, other
  • KEY DISEASE CHARACTERISTICS: Advanced prostate cancer (APC), stage 3 or 4 at diagnosis
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients aged 50 years of age or older, treatment with androgen-deprivation therapy alone or in combination with radiation within the past six months, no history of surgery or chemotherapy in the past six months, no prior inpatient psychiatric treatment, a score 20 or greater on the Mini-Mental State Examination (MMSE)

Setting

  • SITE: Multi-site   
  • SETTING TYPE: Home    
  • LOCATION: Participants were recruited at Robert H. Lurie Comprehensive Cancer Center of Northwestern University and Jesse Brown VA Medical Center in Chicago; however, group interventions occurred over the Internet with participants accessing them from their homes.

Phase of Care and Clinical Applications

PHASE OF CARE: Transition phase after active treatment

Study Design

Parallel, two-group trial

Measurement Instruments/Methods

  • Feasibility/acceptability assessed through recruitment, retention, and group attendance rates
  • Efficacy evaluated using the Impact of Event Scale-Revised (IES-R) for cancer-related distress, the Patient-Reported Outcomes Measurement Information System (PROMIS) for depressive symptoms, and the Functional Assessment of Cancer Therapy-General (FACT-G) for health-related quality of life outcomes

Results

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.

Conclusions

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.

Limitations

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Findings not generalizable
  • Subject withdrawals ≥ 10%  
  • The sample size was underpowered, which limits the detection of significant results. Participants were provided with a tablet and/or Internet as needed to complete intervention, which was not feasible for all patients, limiting its generalizability.

Nursing Implications

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.

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Guideline / Expert Opinion

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. 

Purpose & Patient Population

PURPOSE: To provide a clinical pathway for anxiety and depression in adult patients with cancer to guide best practice
 
TYPES OF PATIENTS ADDRESSED: Adult patients at any phase of care and type of cancer

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Consensus-based guideline
 
PROCESS OF DEVELOPMENT: A review of existing guidelines and systematic reviews relevant to the purpose of the guideline was conducted. Structured interviews with 12 multidisciplinary staff from varied institutions were done, followed by an online Delphi process with 87 stakeholders representing multiple disciplines. Additional input was obtained from a multidisciplinary advisory panel.
 
DATABASES USED: Cochrane, Google, PubMed, Medline, PsycInfo, and CINAHL
 
KEYWORDS: not stated

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Results Provided in the Reference

No information is provided regarding literature retrieved, quality of evidence, or how the evidence was used to develop the guidelines provided.

Guidelines & Recommendations

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.

Limitations

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.

Nursing Implications

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.

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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. 

Purpose & Patient Population

PURPOSE: This is an update of a previously published guideline that provided recommendations for the management of depression in adult patients with cancer.
 
TYPES OF PATIENTS ADDRESSED: Patients with cancer at various stages of treatment with suspected or diagnosed major depressive disorder

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Evidence-based guideline

PROCESS OF DEVELOPMENT: A working group that involved experts in nursing, health research methodology, psychiatry, and psychology conducted the review. The project methodologist extracted data, and the project research assistant verified the data. The draft recommendations were reviewed by a panel of internal reviewers and external reviewers. Targeted peer review and professional consultation were also obtained, and the results were incorporated into the final guideline.
 
SEARCH STRATEGY: Search terms related to depression and cancer were used.
 
DATABASES USED: Websites of guideline developers, relevant cancer agencies, MEDLINE, and EMBASE
 
INCLUSION CRITERIA: Systematic reviews of randomized, controlled trials (RCTs) or single RCTs in the English language
 
EXCLUSION CRITERIA: Not mentioned

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Results Provided in the Reference

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.

Guidelines & Recommendations

Evidence synthesis resulted in eight recommendations for the management of depression: 
  • Screening of patients with cancer for depression is very important to guide treatment.
  • Psychoeducation and providing information about the nature of depression and its impact in cancer outcomes are important. Optimizing cancer-related symptom management
  • Pharmacologic or psychosocial interventions either alone or in combination have beneficial effects.
  • A stepped care model that suggests low intensity interventions (i.e., physical activity programs, group-based peer support, and self-help programs) for mild -to-moderate depression and high-intensity interventions (i.e., group cognitive behavioral therapy, behavioral couples’ therapy, and individual or group supportive-expressive psychotherapies) for severe depression were recommended.
  • Collaborative care (active collaboration between the oncologist or primary care provider and a patient care manager nurse, social worker, or psychologist) should be considered.
  • Referral to psychosocial specialist when needed
  • Selection of psychological therapy should be based on patient factors and local resource availability. This recommendation is based in consensus. 
  • Antidepressants should be considered for severe depression, not for mild depression related to high risk–benefit ratio.

Limitations

Some recommendations were consensus-based.

Nursing Implications

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.

Print

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

Purpose & Patient Population

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

Type of Resource/Evidence-Based Process

  • Evidence-based guidelines    
  • Consensus development involving a panel composed of physicians, psychiatrists, psychologists, and social workers

Phase of Care and Clinical Applications

  • Phases of care: multiple phases 
  • Clinical application: palliative care

Results Provided in the Reference

Results were not stated.

Guidelines & Recommendations

Recommended standards of care include

  • Screening all patients for distress, at initial visits and appropriate intervals
  • Distress management according to guidelines
  • Having committees to implement standards, provide relevant education and training to healthcare professionals
  • Having mental health professionals and certified chaplains available
  • Providing a distress-thermometer screening tool
  • Identifying at-risk patients and periods of increased vulnerability, to define appropriate screening intervals

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.

Limitations

  • The evidence is mainly \"lower level,\" and recommendations are primarily consensus-based. 
  • The panel did not include a nursing member.
  • Many recommendations tend to focus on approaches to care for patients with significant mental disorders or for those referred to a mental health team. 
  • The guidelines provide limited suggestions regarding low-level distress associated with physical symptoms.

Nursing Implications

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.

Print

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

Purpose & Patient Population

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.

Type of Resource/Evidence-Based Process

Evidence was presented using levels I, II, III-1, III-2, III-3, and IV rating system with level I representing the gold standard.

Guidelines & Recommendations

 Clinically relevant recommendations supported by level I and II evidence about depression include the following.

  • Referring high-risk patients to specialized psychological services to minimize the likelihood of developing significant distress (level I)
  • Using a range of psychoeducational interventions to decrease distress (level I)
  • Managing depression by incorporating a combination of supportive psychotherapy, cognitive and behavioral techniques, and pharmacotherapy (levels I, II)
  • There is no evidence that any particular antidepressant is superior to another in the management of depression in people with cancer (level I).
  • Other therapies that may improve depression are art, music, painting, reading, poetry, wellness programs, meditation, hypnosis, acupuncture, relaxation, exercise, prayer, and laughter. (levels I, II, III-3, IV).

Nursing Implications

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.

  • The sedating properties of tricyclics may be beneficial to some patients, as may their potentiation and enhancement of opioid analgesia in those with pain.
  • Their anticholinergic side effects may aggravate stomatitis, exacerbate constipation, and affect cardiac rhythm.
  • Patients with cancer may respond to a lower dose of tricyclic antidepressants.
  • Selective serotonin reuptake inhibitors have been demonstrated to be effective in treating depression in patients with cancer.
  • The long half-life of fluoxetine makes it less desirable in patients with hepatic or renal dysfunction where sertraline or paroxetine is preferable.
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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.

Purpose & Patient Population

Objectives were to

  • Present evidence that will contribute to the improvement of palliative care at the end of life.
  • Answer questions regarding critical elements.
  • Identify patients who could benefit from palliative approaches.
  • Identify treatment strategies that work for pain, dyspnea, and depression.
  • Identify elements important in advance care planning, collaboration and consultation, and assessment and support aspects helpful to caregivers.

Included were patients with any disabling or symptomatic condition at the end of life.

Type of Resource/Evidence-Based Process

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.

Results Provided in the Reference

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:

  • Pain
    • Evidence is strong in support of the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain, with bisphosphonates used for bone pain specifically.
    • Insufficient evidence exists to evaluate the usefulness of acupuncture or exercise for pain control.
    • Palliative care teams may be moderately beneficial in providing pain management.
  • Dyspnea
    • Evidence shows a valuable effect of morphine.
    • Nebulized opioids show no additional benefit over oral opioids.
    • Evidence regarding the use of oxygen is equivocal.
    • Studies that evaluated facilitated communication or palliative care consultation showed no effect.
  • Depression
    • Evidence suggests that long-term use of tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions are beneficial for patients with cancer who are depressed.
    • Evidence is mixed regarding the benefit of guided imagery and exercise in the defined patient population.
    • Evidence showed that care coordination had no effect.

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.

Guidelines & Recommendations

The following were graded as strong recommendations with moderate quality of evidence.

  • Patients with serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.
  • For patients with cancer, clinicians should use therapies with proven effectiveness to manage pain. These therapies include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
  • Clinicians should use therapies with proven effectiveness to manage dypsnea. These therapies include opioids (for unrelieved dyspnea) and oxygen (for the relief of short-term hypoxemia).
  • Clinicians should use therapies with proven effectiveness to manage depression in patients with cancer. These therapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions.
  • Clinicians should ensure that advance care planning occurs for all patients with serious illness. Such planning includes the preparation of advance directives.

Limitations

  • Several authors had grants from the Agency for Healthcare Research and Quality or pharmaceutical companies.
  • Financial support for this guideline was entirely from the American College of Physicians.

Nursing Implications

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.

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