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.
Bennett, S., Pigott, A., Beller, E.M., Haines, T., Meredith, P., & Delaney, C. (2016). Educational interventions for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, 11, CD008144.
STUDY PURPOSE: To evaluate the effectiveness of educational interventions for managing fatigue in adults with cancer
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
Educational interventions appear to play some role in reducing overall fatigue, fatigue intensity, and fatigue interference, and might provide some benefit for anxiety. No effect on depression was found in this study, but baseline levels of depression were not generally clinically relevant.
The incorporation of educational interventions as part of care to manage fatigue is reasonable but may not be sufficient to have a clinically meaningful impact.
Chien, C.H., Liu, K.L., Chien, H.T., & Liu, H.E. (2013). The effects of psychosocial strategies on anxiety and depression of patients diagnosed with prostate cancer: A systematic review. International Journal of Nursing Studies.
To evaluate, by means of meta-analysis and systematic review, evidence regarding the effectiveness of psychosocial interventions for anxiety and depression in patients with prostate cancer
Databases searched were PubMed, CINAHL, PsycINFO, Cochrane Collaboration, and two Chinese databases.
A study was included in the review if it
A study was excluded if it focused on disease other than prostate cancer and lacked intergroup comparison.
Patients were undergoing multiple phases of care.
Findings suggest that psychosocial interventions can be helpful in reducing anxiety and depression, at various time points in the cancer trajectory, for men who are newly diagnosed with prostate cancer. Positive effects were generally short-term only.
Findings of this analysis suggest that various types of psychosocial interventions can help reduce anxiety and depression in men with prostate cancer. Effects shown tended to be short-lived. Nurses can help reduce anxiety and depression among patients with prostate cancer by using psychosocial types of strategies. Information about ways to sustain this effect is limited, and the analysis does not identify the types of approaches that are the most helpful. Further exploration of longer-term sustainable effects and associated dosage and intervention frequency is needed. Given the relatively low level of quality of research in this area, more well-designed studies are needed.
Duijts, S.F., Faber, M.M., Oldenburg, H.S., van Beurden, M., & Aaronson, N.K. (2011). Effectiveness of behavioral techniques and physical exercise on psychosocial functioning and health-related quality of life in breast cancer patients and survivors—A meta-analysis. Psycho-Oncology, 20, 115–126.
STUDY PURPOSE: To examine the effects of behavioral techniques (e.g., behavioral therapy, cognitive therapy, mind-body and relaxation techniques, counseling, social support, hypnosis, biofeedback, exercise, physical exercise (PhysEx), aerobic exercise, physical activity, motor activity) on psychosocial functioning outcome measures, such as fatigue, depression, anxiety, body image, and stress, and on health-related quality of life
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Elder care, palliative care
Behavioral techniques affect specific aspects of psychosocial functioning but have a minor, insignificant effect on health-related quality of life. PhysEx has a positive effect on health-related quality of life. Behavioral techniques demonstrated a moderately significant effect on anxiety and depression and showed a significant but small effect on fatigue. PhysEx was effective for fatigue and showed a positive effect for depression.
A range of behavioral techniques may be effective for patients with breast cancer and fatigue, depression, and depressed body image. PhysEx was shown to improve health-related quality of life, fatigue, anxiety, and depression. Recognizing the symptoms of patients with breast cancer was emphasized as having positive effects (e.g., feeling relieved, hearing helpful strategies addressing quality of life and psychosocial problems).
Galway, K., Black, A., Cantwell, M., Cardwell, C.R., Mills, M., & Donnelly, M. (2012). Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients. Cochrane Database of Systematic Reviews, 11, CD007064.
To assess the effects of psychosocial interventions on quality of life and mood symptoms in patients diagnosed with cancer within the past 12 months
Multiple phases of care
Findings suggest that psychosocial interventions have a positive impact on quality of life among newly diagnosed patients with cancer. Psychoeducational interventions and nurse-delivered interventions demonstrate a small significant effect across combined trials. Overall evidence does not indicate that individual psychosocial interventions are effective at improving the mood- and quality-of-life–related symptoms of patients newly diagnosed with cancer.
A small number of studies in meta-analysis related to mood changes. Effect sizes in mood changes were small, and study samples comprised high heterogeneity, demonstrating that findings should be interpreted with some caution in terms of clinical relevance.
The fact that nurse-delivered psychosocial interventions demonstrated a positive and statistically significant effect is promising, although the effect size was small. This finding provides some support for interventions delivered by nurses rather than by other healthcare professionals. Other studies have reported this finding. Nurses may be uniquely positioned to provide such interventions: Their knowledge base includes both physiologic and psychosocial components of the cancer experience, and individual interventions can simultaneously and effectively address physical and psychosocial symptom management. The findings of this study provide general support for the effectiveness of psychoeducational interventions.
Garcia, S. (2014). The effects of education on anxiety levels in patients receiving chemotherapy for the first time: An integrative review. Clinical Journal of Oncology Nursing, 18, 516–521.
PURPOSE: To synthesize evidence regarding the effectiveness of education for decreasing anxiety in patients receiving chemotherapy for the first time
PHASE OF CARE: Active antitumor treatment
Three sources were guidelines, two were pilot studies, one was an evidence summary review, one was a systematic review, and one was an expert opinion. Most sources were of poor or fair quality. Not all the studies actually measured anxiety; some measured patient satisfaction. There was no differentiation made between the provision of educational and informational written materials and the provision of psychoeducation or cognitive behavioral therapy interventions.
This review provides minimal actual evidence regarding the effectiveness of educational interventions.
A limited number of actual studies were included, and those included did not all address or measure anxiety.
Patient education prior to receiving chemotherapy is an essential aspect of patient care in providing an informed and empowered patient. The impact of education alone on anxiety is not clear, and this article does not provide substantial evidence or synthesis to clarify this potential effect of educational interventions.
Hoon, L.S., Chi Sally, C.W., & Hong-Gu, H. (2013). Effect of psychosocial interventions on outcomes of patients with colorectal cancer: A review of the literature. European Journal of Oncology, 17, 883–891.
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Pediatrics, elder care, palliative care
Various psychosocial interventions, including educational interventions, cognitive behavioral therapy, relaxation training, and supportive group therapy, were found to reduce the length of patients’ hospital stays, decrease the number of days to proficiency in self-care for stoma, decrease levels hospital anxiety and depression, and increase quality of life.
Various forms of psychosocial interventions were used to improve outcomes, but no clear winner was found. All forms seemed to improve patient outcomes.
Howell, D., Harth, T., Brown, J., Bennett, C., & Boyko, S. (2017). Self-management education interventions for patients with cancer: A systematic review. Supportive Care in Cancer, 25, 1323–1355.
STUDY PURPOSE: To identify core components of self-management education interventions and assess effectiveness
TYPE OF STUDY: Systematic review
DATABASES USED: Ovid, MEDLINE, EMBASE, Cochrane collaboration, CINAHL, PsycINFO
INCLUSION CRITERIA: Adults, use of any type of teaching strategy, addressed any single core element of self-management interventions as defined by the authors, group based or individual structure
EXCLUSION CRITERIA: Psychotherapy or support groups, use of only information such as leaflets or videos, focus on family members, focus on decision making by patients, gray literature, interventions related to diet and exercise
TOTAL REFERENCES RETRIEVED: 4,579
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane risk of bias tool to evaluate study quality. All were at high risk of bias related to lack of blinding
FINAL NUMBER STUDIES INCLUDED: 43
TOTAL PATIENTS INCLUDED IN REVIEW: 6,795
SAMPLE RANGE ACROSS STUDIES: 22 to 483
PHASE OF CARE: Multiple phases of care
Authors attempted to correlate core elements of interventions with outcomes. Overall, there were very few studies that had any common combinations of core elements, so this analysis could not be done. Overall, studies suggested that psychoeducational interventions may be beneficial for relieving symptoms of anxiety and depression. The content, elements, structure duration and frequency of interventions across studies were varied. Many interventions labeled as self-management education did not include components related to self management.
Psychoeducational interventions appear to be beneficial for symptoms of anxiety and depression. It is not possible to determine the specific components of these types of interventions that are most helpful.
Psychoeducational interventions of various types can be beneficial in reducing patients’ anxiety and depressive symptoms.
Naaman, S.C., Radwan, K., Fergusson, D., & Johnson, S. (2009). Status of psychological trials in breast cancer patients: A report of three meta-analyses. Psychiatry, 72, 50–69.
To determine the overall efficacy and magnitude of clinical benefit of psychological interventions in patients with breast cancer, specifically looking at three outcome variables: anxiety, depression, and quality of life (QOL)
Databases searched were MEDLINE (1966–January 2004), EMBASE (1980–2004), Cochrane Controlled Trials Register (1985–February 2004), PsycLit (1973–2004), Biological Abstracts (1990–December 2003), CancerLit (1975–October 2002), CINAHL (1982–December 2003), and Health Star (1975–January 2004).
Search keywords were randomized clinical trial and breast cancer and psychological interventions (cognitive behavioral therapy, group psychotherapy, relaxation, supportive therapy, visual imagery) and psychological adjustment (anxiety, depression, maladjustment, distress, quality of life).
Studies were included in the review if they
Trials examining efficacy of interventions designed to assuage surgical distress were excluded.
Cook, T.D., & Campbell, D.T. (1979). Quasi-experimentation: Design and analysis issues for field settings. Boston, MA: Houghton Mifflin.
Anxiety
Depression
Quality of Life
Overall ES trends among the three outcomes show that more reliable studies were associated with smaller gains. Interventions targeted to patients with clinically important levels of anxiety or depression tended to reap the most benefit, compared to patients who undergo treatment on a prophylactic basis. Group psychotherapy appears to be superior to individual therapy in the treatment of both anxiety and depression. However, a direct impact of group therapy on QOL was not supported in this analysis. CBT interventions appeared to be equally as effective as supportive-experiential therapies. Interventions need not span beyond 20 hours to produce statistically significant ES.
The quality of most studies was not high.
Future trials in psychosocial oncology should incorporate methodological features to enhance internal validity. Evaluation of statistically significant findings on psychometric testing may not reflect clinically significant findings and vice versa. This underscores the need for incorporating qualitative analysis in future studies. There is an absence of studies examining the efficacy of short-term interventions on QOL in advanced breast cancer and should be addressed in future research. Short-term, group interventions may provide the best utilization of scarce resources for the most effect; however, they should be targeted to those patients experiencing clinically important levels of distress. Findings point to the need for higher quality research design and reporting in this field.
Osborn, R.L., Demoncada, A.C., & Feuerstein, M. (2006). Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: Meta-analysis. International Journal of Psychiatry in Medicine, 36, 13–34.
To investigate the effects of cognitive behavioral therapy (CBT) and patient education (PE) on anxiety in adult cancer survivors
Databases searched were MEDLINE, PsycINFO, and the Cochrane Database (1993–2004).
Search keywords were cancer, anxiety, depression, quality of life (QOL), fatigue, stress, pain, physical function, social, self-management, evidence-based, interventions, and random/randomized.
Studies were included in the review if they
Studies were excluded if they were not randomized or controlled, had a score of less than four on checklist, did not report follow-up data, or did not report data on targeted outcomes.
Dissertations were excluded.
CBT is effective for short-term management (less than 8 months) of anxiety. Individually based interventions were more effective than those delivered in a group format. Various CBT approaches provided in an individual format can assist cancer survivors in reducing the emotional distress of anxiety.
Preyde, M., & Synnott, E. (2009). Psychosocial intervention for adults with cancer: A meta-analysis. Journal of Evidence-Based Social Work, 6, 321–347.
To evaluate types of psychosocial interventions employed in patients with cancer
To update and extend a previous review by conducting a search and reporting on recent trials
Databases searched were MEDLINE, CINAHL, PsycINFO, Social Sciences Citation Index, Social Services Abstracts, and PubMed databases from 1999–2007.
Search keywords were psychosocial care, intervention, service, support, oncology, effectiveness (effect*) and evaluation (evaluat*).
Studies were included in the review if they reported
Studies were excluded if they reported on patients with metastatic disease.
A total of 1,702 studies were initially identified. After elimination of studies that did not meet inclusion criteria, 27 studies were included. Study quality was evaluated using a modified Jadad scoring approach. There were 22 final RCTs and 5 pilot studies used.
There were few studies with a high-quality rating, and the mean rating for the entire sample of studies was 2.41 on a 5-point scale. Effect sizes were calculated for only nine studies, in which statistically significant results were reported. Patient outcomes measured in this subgroup of studies varied and included general health, emotional control, social support, global adjustment to illness, relationship quality, optimism, self-esteem, and self-efficacy. Studies were conducted in the United States, Canada, Europe, Hong Kong, Australia, and New Zealand.
The mean effect size was small, at 0.28, across the varied outcomes measured in studies.
Individual interventions: psychosocial, psychoeducational, and cognitive behavioral
Telephone intervention
Group counseling
Miscellaneous
Attrition was a problem in many of the studies. In a few studies, positive effects or trends were seen with individuals who had more severe problems at baseline; however, attrition was also highest among these patients.
There appears to be some evidence supporting interventions targeting stress and coping; however, there is no strong support for any one type of intervention evaluated here. Where significant findings were seen, effect sizes were small and the clinical relevance of this level of effect could not be evaluated. There do not appear to be any long-term effects with the interventions examined here.
The quality of most studies was not high.
While no long-term effects were clearly found, even short-term effects on distress for people with cancer can be important for patients and clinically useful.
Positive results in one study using self-managed approaches for stress reduction suggest that this may be a practical and cost-effective way to address short-term patient needs.
Patients with cancer are a heterogeneous group, and the nature of psychosocial interventions is such that one should expect them to be highly individualized, as is the approach in clinical practice. Further, psychosocial interventions delivered on an individual basis versus group therapy were better supported and easier to maintain. This represents one of the challenges in this area of research that should be addressed in future studies.
Given attrition levels discussed here along with findings that greater effect is seen among patients with more severe baseline problems, in future work, care needs to be taken to consider for whom psychosocial interventions is indicated and how onerous the intervention and study protocol are for participants.
Findings point to the need for higher quality research design and reporting in this field.
Psychoeducational interventions addressing patients’ informational needs about cancer, progression, treatment, and side effects were found to be beneficial.
Psychosocial interventions found to be most beneficial include cognitive adaption, coping management, and encouraging patients to practice stress management techniques at home.
Renouf, T., Leary, A., & Wiseman, T. (2014). Do psychological interventions reduce preoperative anxiety? British Journal of Nursing, 23, 1208–1212.
STUDY PURPOSE: To evaluate evidence regarding effects of psychoeducational interventions for preoperative anxiety
PHASE OF CARE: Active antitumor treatment
The report suggests that nursing interventions of a psychoeducational nature can reduce preoperative anxiety, based on findings of six randomized, controlled trials conducted from 1985 to 2005. Samples in these studies were self-selected, and the review identifies a number of study design aspects that would create risk of bias, inappropriate statistical analysis, and high volume of missing data and elimination of patients from data analysis. The review also stated that patients benefit from individualized information and have associated reduction in anxiety; however, review of these studies also suggested multiple design flaws, and this finding appears to be based on various authors’ recommendations rather than actual study findings.
There are multiple limitations of this review, and it does not provide strong support for effectiveness of various nursing interventions to reduce preoperative anxiety.
No information is provided about study sample types or actual quality of studies included. Findings stated in the article are not clearly derived from actual research results.
Due to study limitations, this review does not provide strong support for the efficacy of psychoeducational and informational interventions to reduce preoperative anxiety. Provision of preoperative patient education is a necessary component of care, but it may not be sufficient to alleviate anxiety.
Tao, W.W., Jiang, P., Liu, Y., Aungsuroch, Y., & Tao, X.M. (2014). Psycho-oncologic interventions to reduce distress in cancer patients: A meta-analysis of controlled clinical studies published in People's Republic of China. Psycho-Oncology, 24, 269–278.
PHASE OF CARE: Multiple phases of care
Intervention types that were included in the meta-analysis were educational, psychological support, cognitive behavioral therapy, relaxation training, music therapy, coping skills training, and communication skills training. The majority of studies incorporated two or more interventions together. Fifteen studies showed overall significant effects on anxiety (d = -8.71, p < .001). The combination of education and psychological support (d = -8.17, p = .04) or education combined with relaxation training (d = -12.95, p < .001) were effective in reducing anxiety. Large combined effects were seen on depression (d = -8.12, p < .001). No analysis of effects for specific intervention types was possible. In greater than 69% of studies, the interventions were performed by nurses.
The findings of this study support the effectiveness of psychoeducational interventions to reduce anxiety and depression in patients with cancer in China.
The studies included in this analysis had numerous flaws. The meta-analysis was primarily done across all types of interventions. Because most of the studies used combined interventions, the effectiveness of individual components could not be determined. The authors noted that the trials were carried out in Chinese regions where almost no negative studies are reported, so publication bias cannot be ruled out.
The findings of these studies support the effectiveness of psychoeducational interventions for anxiety and depression in patients with cancer. Although these findings were only in Chinese patients, they are in agreement with the bulk of overall evidence in this area. These results suggest that psychoeducational interventions are likely to have similar levels of effectiveness in various cultural groups.
Yang, Y.L., Sui, G.Y., Liu, G.C., Huang, D.S., Wang, S.M., & Wang, L. (2014). The effects of psychological interventions on depression and anxiety among Chinese adults with cancer: A meta-analysis of randomized controlled studies. BMC Cancer, 14, 956-2407-14-956.
The meta-analysis was completed using all studies in a single analysis. The interventions were highly varied, including patient education, relaxation, cognitive behavioral therapy, etc. An analysis showed an overall effect size of SMD = 1.199 (95% CI 1.095 – 1.303, p < 0.001) for depression in 122 studies and an overall effect size SMD = 1.298 (95% CI 1.187-1.408, p < 0.001) for anxiety in 131 studies. There was high heterogeneity in the analysis. An analysis showed a significant publication bias for both depression and anxiety. A subgroup analysis showed significant effects of cancer type, patient selection, intervention format, and the method of measurement used in moderating results. The findings of this analysis suggested that interventions appeared to be more useful for patients with increased levels of psychological distress.
The findings of this review suggest that various psychological interventions can benefit patients with cancer dealing with symptoms of anxiety and depression.
The major limitation of this analysis was that the meta-analysis was done considering all studies together. This is questionable because it is difficult to see interventions such as cognitive behavioral therapy as equivalent to general patient education or relaxation techniques. The analysis showed high heterogeneity, which is not surprising given the range of interventions considered together and the variety of types of patients. The high risk of publication bias also limits the potential validity of these findings. Reports were restricted to studies involving patients from mainland China, so it is unclear if the findings would be applicable to other cultural groups. Databases outside of China were limited.
This meta-analysis did not provide substantial or useful support for various types of interventions aimed at managing the symptoms of depression and anxiety. To determine which interventions are most effective as supported by evidence, the interventions that are very similar if not exactly the same must be grouped for analysis. This was a major limitation of this report, and it is reflected in its high heterogeneity. Its findings need to be viewed with some caution given the limitations of this study.
Zweers, D., de Graaf, E., & Teunissen, S.C. (2015). Non-pharmacological nurse-led interventions to manage anxiety in patients with advanced cancer: A systematic literature review. International Journal of Nursing Studies, 56, 102–113.
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Palliative care
Four of seven interventions were educational. In some studies, education was combined with telemonitoring or progressive muscle relaxation. Counseling and coaching as self-care strategies for monitoring symptoms were evident in two studies. Two studies focused on expressive writing, and focused narrative interview. One study compared aromatherapy with massage. Interventions were performed by nurses and research nurses, with or without training. Duration of interventions ranged from 1-3 contacts in one week to six months. Contacts were face-to-face or by telephone. None of the studies documented patient adherence to the interventions. The development of the interventions was limited to literature review. Two studies showed significant differences between the intervention and control group at six months (telemonitoring combined with education). One study did not show significance between the control and intervention groups at one week. A study of progressive muscle relaxation showed significance in anxiety at week 6 and week 12. No significant effect on anxiety was found between aromatherapy and massage. There was significantly decreased anxiety after each massage. This was also seen in a study that focused on narrative interview.
Although some of the studies described showed some significance, all had limitations. Studies are scarce; only seven met the inclusion criteria.
Some studies had a high attrition rate. The authors defined several areas of bias including selection, performance, attrition, and reporting. There was limited information regarding development of interventions. There was not enough information on any one intervention to be able to clearly to implement it as evidence.
Evidence regarding nonpharmacologic nursing interventions for anxiety is scarce. More nursing research is indicated, including well-developed interventions.
Badr, H., Smith, C.B., Goldstein, N.E., Gomez, J.E., & Redd, W.H. (2015). Dyadic psychosocial intervention for advanced lung cancer patients and their family caregivers: Results of a randomized pilot trial. Cancer, 121, 150–158.
To test the initial efficacy, acceptability, and feasibility of a dyadic (patient–caregiver) psychosocial, phone-delivered intervention to improve the quality of life of the families of patients with advanced lung cancer within one month of the first cancer treatment
The dyads were randomly assigned to a usual medical care (UMC) or a six-week intervention group. Intervention patients and caregivers received separate standardized, tailored manuals. Manuals addressed self-care, stress and coping, symptom management, effective communication, problem solving, and maintaining and enhancing relationships. Patients and caregivers shared half of the topic information, but other content was tailored to the patient or caregiver role. Patients-tailored content included ways to balance autonomy with asking for and accepting support, sharing support needs, and ways to show caregiver appreciation. Caregiver-tailored content included ways to minimize patient overprotection, show effective communication, and ways to support patient self-care goals. Intervention dyads participated in six weekly 60-minute telephone counseling sessions aimed at alleviating caregiver burden with a trained interventionist who reviewed weekly patient and caregiver homework and manual content. The interventionist mentored participants through sessions and homework assignments to reinforce session skills for patients and caregivers. Participants in UMC and intervention groups completed six paper-and-pencil surveys at baseline and eight-weeks after baseline.
Randomized clinical trial
The study's recruitment rate was 60%, which is comparable to rates reported in other telephone-based cancer dyadic interventions, supporting the feasibility of recruiting advanced LC patients on active treatment and their caregivers for this trial. Patient and caregiver telephone-session participation was 90%. Participants rated the intervention as relevant, convenient, and helpful. Retention was excellent, and dyads completed the majority (88%) of homework assignments. This suggests a highly acceptable intervention. Large effect sizes were found for the impact of the intervention on outcomes of patient and caregiver depression, anxiety, and caregiver burden as contrasted with UMC group outcomes. Large effect sizes for impact of the intervention were also found for additional patient and caregiver outcomes relevant to competence and relatedness and caregiver free choice to provide patient care. Highly depressed and anxious caregivers, identified at the baseline assessment in the intervention group, showed greater improvements in psychological functioning than did those in the UMC group.
This pilot study demonstrated the feasibility and acceptance of a six-session, telephone-based dyadic psychosocial intervention developed for patients with advanced lung cancer and their caregivers and its positive effects on their rates of depression, anxiety, and caregiver burden.
Telephone-based interventions addressing patients with late-stage lung cancer and their caregivers may improve overall dyadic quality of life. This study indicated support for separate patient and caregiver sessions to address private issues posing challenges in a dyadic discussion. Additional research focused on separate sessions balanced with dyadic sessions may strengthen the evidence for telephone interventions.
Barth, J., Delfino, S., & Kunzler, A. (2013). Naturalistic study on the effectiveness of psycho-oncological interventions in cancer patients and their partners. Supportive Care in Cancer, 21, 1587–1595.
To explore the effectiveness of psycho-oncologic interventions for patients and partners on anxiety, depression, psychopathology, and distress
Patients and partners who had been referred for psycho-oncologic service were recruited. Common interventions were psychoeducation, cognitive restructuring, behavior control techniques, guided imagery, relaxation, couples communication training, and other types of counseling in an individualized, nonstandard fashion. Patients and partners were grouped according to propensity scores calculated from variables shown to be significant in regression analysis for outcomes of interest, including gender, age, cancer site, stage of disease, baseline anxiety, and depression. Propensity matched control patients, and partners who did not receive the intervention were identified and used as control comparisons. Analysis was done in groupings according to the level of distress with propensity scores as low-, moderate-, or high-distress.
Time effects within patient groups showed significant decreases over time in depression and distress (p ≤ .05), but not for anxiety and psychopathology. No group effects were seen on outcomes over time. Among partners, no changes were seen over time and no significant effects of the intervention were seen on outcomes. The same pattern was seen in completer and intent to treat analysis. Pre- and post-intervention data showed that patients had significant declines in anxiety (effect size Cohen’s d = 0.32, p = .01), distress (d = .46, p = .001), and depression (d = 0.52, p = .001) at 12 months, and partners had significant declines in anxiety (d = 0.45, p = .01) and distress (d = .42, p = .02) within the highly distressed group. No significant differences were seen in the less distressed group over time.
Findings suggest that psychotherapeutic interventions can reduce anxiety, distress, and depression among patients and partners who are highly distressed. Little benefit may exist for individuals who are less anxious or distressed at baseline.
Psychotherapeutic interventions may be beneficial for patients and caregivers who are highly distressed. Nurses need to be aware of the overall level of patient and caregiver distress and identify those who are likely to benefit from referral for therapy.
Bourmaud, A., Anota, A., Moncharmont, C., Tinquaut, F., Oriol, M., Trillet-Lenoir, V., . . . Chauvin, F. (2017). Cancer-related fatigue management: Evaluation of a patient education program with a large-scale randomised controlled trial, the PEPs fatigue study. British Journal of Cancer, 116, 849–858.
To evaluate the effectiveness of a psychoeducational program on cancer-related fatigue
Patients were randomly assigned to the study intervention or usual care. Patients in the intervention group (PEPs) received written information explaining cancer-related fatigue and difference approaches for management. Patients in this group were also encouraged to participate in five group educational sessions of two hours each over a six-week period. The PEPs content was designed to incorporate NCI and CPEN guidelines. Content included information about the disease, fatigue, self expression of attitude, coping strategies, and skill development for managing fatigue. Educational teams received a two-day intensive training to standardize program content. Patients in the control group received the written documentation as described. After the study, patients in the control group were offered participation in the program.
RCT
There were no differences between groups in fatigue scores after the intervention, and no differences in the trajectory of fatigue. Fatigue declined overall in all patients. There were no differences between groups in anxiety or depression.
The educational program tested here did not demonstrate an effect on fatigue, anxiety, or depression.
Psychoeducation is an intervention that has shown mixed results for impact on cancer-related fatigue and other symptoms. The specific program tested here did not demonstrate an effect. Fatigue in particular is a complex multifaceted symptom. Various psychoeducational and supportive approaches have also been complex in terms of design, content, timing, dose, etc. The effectiveness of psychoeducational-type interventions may relate to all of these aspects of both content and delivery.
Bruera, E., Yennurajalingam, S., Palmer, J.L., Perez-Cruz, P.E., Frisbee-Hume, S., Allo, J.A., . . . Cohen, M.Z. (2013). Methylphenidate and/or a nursing telephone intervention for fatigue in patients with advanced cancer: A randomized, placebo-controlled, phase II trial. Journal of Clinical Oncology, 31(19), 2421–2427.
Compare the effects of methylphenidate (MP) (psychostimulant) with those of a placebo (PL) on cancer-related fatigue. The effect of a combined intervention including MP plus a nursing telephone intervention (NTI) also was assessed.
Patients with a fatigue score of greater than or equal to 4 out of 10 on the Edmonton Symptom Assessment Scale (ESAS) randomly were assigned to one of the following four groups: MP plus NTI, PL plus NTI, MP plus control telephone intervention (CTI), and PL plus CTI.
Randomized, controlled trial; placebo controlled
The groups MP alone, NTI alone, or MP plus NTI proved not significantly better than PL for cancer-related fatigue. Anxiety improved with the telephone intervention (p = .01), as did sleep (p < .001).
MP, used alone or in combination with NTI, was not superior to the control group or the PL for fatigue or depression. NTI was associated with improvement in anxiety and sleep.
Although the use of MP did not prove to be effective for cancer-related fatigue, several cancer-related symptoms significantly were improved with NTI. Further research in this area would be ideal, but NTIs remain potentially effective for patient support and education and can have a positive effect on patient experience.
Chan, C. W., Richardson, A., & Richardson, J. (2011). Managing symptoms in patients with advanced lung cancer during radiotherapy: results of a psychoeducational randomized controlled trial. Journal of Pain and Symptom Management, 41, 347–357.
To examine the effectiveness of a psychoeducational intervention (PEI) on the symptom cluster of anxiety, breathlessness, and fatigue compared with usual care.
Education on symptom management and coaching on the use of progressive muscle relaxation was delivered to patients one week prior to the start of radiotherapy (RT) and repeated three weeks after beginning RT. Symptom data were collected at four times points: prior to the intervention and at three, six, and 12 weeks postintervention.
The study was a randomized, controlled trial using a pre-/posttest design with two groups.
A significant difference (p = 0.003) was seen over time on the pattern of change of the symptom cluster between the PEI intervention and the usual care control group. Significant effects on patterns of changes in breathlessness (p = 0.002), fatigue (p = 0.011), anxiety (p = 0.001), and functional ability (p = 0.000) were found.
PEI is an effective treatment for relieving the symptom cluster of anxiety, breathlessness, and fatigue and each of the individually assessed symptoms.
The study provided evidence to support the symptom cluster of anxiety, breathlessness, and fatigue as interrelated, with assessment and management of those three symptoms as a cluster. Clarification of the nature of their interrelatedness is a potential area of further study. Education and counseling patients through nurses can be helpful in the management of these symptoms.
Chow, K.M., Chan, C.W., Chan, J.C., Choi, K.K., & Siu, K.Y. (2014). A feasibility study of a psychoeducational intervention program for gynecological cancer patients. European Journal of Oncology Nursing, 18, 385–392.
To test the feasibility of the implementation of a psychoeducational intervention program for patients with gynecologic cancer
This study consisted of a series of interventions consisting of multiple components based on a thematic counseling model for patients with newly diagnosed gynecologic cancers. Blinding was performed at randomization. Quantitative data on sexual functioning, uncertainty, quality of life, anxiety, depression, and support systems were collected at recruitment, following surgery, during hospitalization, and eight weeks following surgery. Both quantitative and qualitative methods were used in the data analysis. The intervention consisted of four psychoeducational sessions. An individual format was used for the first three sessions and a group format was used for the last session. All intervention sessions were conducted by the researcher. The researcher also met with the control group on four occasions during the same period: at recruitment, after surgery, once in-hospital, and once via telephone four weeks following surgery during which participants were invited to attend a support group. The researcher was a registered nurse experienced in gynecologic cancer care.
Single-blinded, randomized trial with a mixed-methods design
Thirteen patients were in the intervention group and 13 were in the control group. There were no statistical differences between the populations of the two groups. The compliance rate was 69.2% in the intervention group with the greatest lack of compliance occurring during the final session. The compliance rate for the control group was 46.2%. Statistic significance regarding trends of change in the outcome variables was not obtained. There was no statistic significance in the comparison of baseline outcome variables of the two groups. There was no statistic significance of intervention effects between the two groups, except in the area of uncertainty. The inconsistency subscale showed a statistic significance between the two groups with the intervention group receiving less inconsistent information regarding their illnesses. The intervention group demonstrated better trends for improvement than the control group in all categories although there were contradictory results in the scales measuring quality of life, perceived social support, anxiety, and depression.
This patient population has healthcare needs that currently are not being met. This particular study did not show statistically significant results regarding anxiety, depression, quality of life, and sexual functioning in patients with gynecologic cancer. Further research is indicated.
Further research is indicated regarding anxiety, depression, quality of life, and sexual functioning in patients with gynecologic cancer, particularly during the postoperative period. This study showed trends for overall improvement, indicating the importance of nursing in this population. Understanding the implications of cultural differences regarding the effects of gynecologic therapies is an important nursing responsibility.
Farquhar, M.C., Prevost, A.T., McCrone, P., Brafman-Price, B., Bentley, A., Higginson, I.J., . . . Booth, S. (2014). Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Medicine, 12, 194-014-0194-2.
To evaluate the effects of a specialized breathlessness intervention service compared to usual care
The breathlessness intervention service (BIS) was a multidisciplinary complex intervention including nonpharmacologic and pharmacologic interventions to support patients with advanced disease and dyspnea. The BIS used first-stage interventions such as positioning to reduce the work of breathing, education, individualized exercise plans, relaxation techniques, sleep hygiene, cognitive behavioral therapy approaches, and other supports. Second-stage interventions applied concurrently included opioids, antidepressants, anxiolytics, etc. Patients referred to this service were randomly assigned to the intervention or to a wait-list control group. Study measures were obtained at baseline and after the intervention. Interviews were done before randomization, at two weeks, and at five weeks. The interviews were recorded and transcribed verbatim for analysis. A final qualitative analysis was done from 20 intervention transcripts that were purposefully sampled to obtain a diverse group from those who improved and did not improve.
Randomized, controlled trial
Patients in the intervention group had greater reductions in breathlessness (1.68 versus 0.23 points, p = 0.049). There were no other significant differences in outcomes for patients or caregivers between study groups. Interventions identified as helpful were providing and teaching the use of a handheld fan, encouraging exercise, coaching in breathing techniques and positioning, medication changes, and referrals to other services. Total costs were lower for the intervention group, and a cost effectiveness analysis showed a 66.4% likelihood that the intervention would result in lower cost and better outcomes in terms of reduced distress from breathlessness. Scores for mastery of symptom management did not change significantly.
This complex psychoeducational and pharmacologic intervention was associated with reduced distress from breathlessness. No effects on patient or caregiver distress, anxiety, or depression were found.
Individual interventions such as opioid use have been shown to reduce dyspnea, so it was not possible to determine the relative value and utility of the combined interventions examined here. These study findings suggested that multicomponent, complex interventions to improve symptoms of breathlessness can be cost effective and improve outcomes.
Fernandez-Feito, A., Lana, A., Baldonedo-Cernuda, R., & Mosteiro-Diaz, M.P. (2015). A brief nursing intervention reduces anxiety before breast cancer screening mammography. Psicothema, 27, 128–133.
To determine if a brief nursing intervention could reduce anxiety prior to screening mammography
Women received an intervention protocol consisting of face to face general information about screening as well as emotional support by discussing other topics related to the examination and anxiety. The intervention took about 10 minutes. Anxiety was assessed before the mammography. Anxiety also was assessed among women receiving usual care. The results from both groups were compared.
Randomized, controlled trial
Women in the experimental group had a significantly lower mean state anxiety score (p < 0.001) and a 60% likelihood of having lower anxiety (OR -0.40, 95% CI 0.25, 0.65). There were no differences between the groups in trait anxiety or expectations of pain from the procedure.
A brief psychoeducational intervention prior to a screening mammography appears to be effective in reducing anxiety associated with the screening mammography.
A brief psychoeducational intervention providing information about mammography and breast cancer and giving women the opportunity to express anxiety concerns was associated with lower anxiety. In this study, the intervention took only 10 minutes, suggesting that it could be a practical approach to care. By spending a little time educating women and providing them the opportunity to express concerns, nurses can help reduce the anxiety that may be associated with screening mammographies.
Garssen, B., Boomsma, M.F., Jager Meezenbroek, E., Porsild, T., Berkhof, J., Berbee, M., . . . Beelen, R.H. (2013). Stress management training for breast cancer surgery patients. Psycho‐Oncology, 22, 572–580.
To evaluate the psychological effects of presurgical stress management training
Subjects were randomized to the intervention or control group by week in the hospital. The intervention consisted of four sessions of meditative exercises, relaxation, guided imagery, and counseling to promote active coping and positive attitude. Sessions were completed on days 5 and 1 before surgery and days 2 and 30 postsurgery. Patients were given a CD with the same instructions to use at home. Assessments were done on days 6 and 1 before surgery and days 2, 5, 30, and 90 postsurgery. The control group received usual care.
Randomized, controlled trial
Anxiety decreased after surgery in both groups. Depression decreased in the intervention group after surgery and in the control group at three months postsurgery. Depression was significantly lower in the intervention group on day 5 after surgery (d = 0.47). Fatigue increased in the control group and was significantly higher than baseline at three months postoperatively. In the intervention group, fatigue decreased and was significantly below baseline at days 2 and 5 postoperatively. Sleep problems and pain did not change in either group. Across all study timepoints, differences between groups were inconsistent. Sometimes, symptoms were higher in the intervention group, and other times, they were lower in the intervention group. An analysis was done for changes from baseline for each group rather than between groups. There were only differences in the degree of change from baseline to postoperative days 2 and 5.
The effects of the intervention were inconsistent over time and appeared to be modest and short-lasting.
The findings here were somewhat confusing and inconsistent over time; however, there were some potential short-term benefits for fatigue and depression. The combination of relaxation therapies and counseling is a low-risk intervention that may be helpful for some patients.
Goerling, U., Foerg, A., Sander, S., Schramm, N., & Schlag, P.M. (2011). The impact of short-term psycho-oncological interventions on the psychological outcome of cancer patients of a surgical-oncology department—A randomised controlled study. European Journal of Cancer, 47, 2009–2014.
To examine the influence of psycho-oncologic intervention on the psychological condition of patients with cancer
Patients, who had self-assessed regarding anxiety and depression levels, were placed in high- or low-risk groups. Participants were then randomized to either a psycho-oncologic support group or a control group. Support involved talks with a certified psychologist, who addressed development of a therapeutic relationship, supported the patient’s personal autonomy and defense mechanisms, worked to increase hopefulness and confidence, and facilitated communication between patients and providers. Patients were randomized at the time of surgery. Study measures were obtained at hospital discharge and 12 months later. The number of support sessions varied according to the length of inpatient care. High-risk groups averaged four sessions lasting an average of 41 minutes each. Low-risk patients had two or three sessions lasting an average of 40 minutes each.
Active treatment
Randomized controlled trial
Hospital Anxiety and Depression Scale (HADS), German version
The study showed statistically significant reduction of anxiety and depression in high-risk patients who had undergone psycho-oncologic intervention at the end of inpatient care (p = 0.001). At 12 months, anxiety and depression scores increased in all patients. Depression scores increased in all low-risk patients at the time of discharge.
Patients with cancer who have anxiety may benefit from psycho-oncologic support.
Postsurgical patients with cancer who are anxious may benefit from psycho-oncologic support services. In the study, the effect of the intervention was significant in only those patients who had high anxiety scores at baseline. Study findings are similar to those produced by other research. This fact may suggest that interventions for anxiety are most beneficial for individuals who have meaningful levels of anxiety to begin with. Psycho-oncologic support did not appear to affect depression scores; however, these scores were not high at baseline.
Halkett, G.K., O'Connor, M., Aranda, S., Jefford, M., Shaw, T., York, D., . . . Schofield, P. (2013). Pilot randomised controlled trial of a radiation therapist-led educational intervention for breast cancer patients prior to commencing radiotherapy. Supportive Care in Cancer, 21, 1725–1733.
To determine whether a therapist-led psychoeducational intervention is effective in reducing anxiety, depression, and radiation therapy-related patient concerns
Patients in the control group received usual care. The intervention group received two face-to-face therapist consultations, one prior to radiation planning and one prior to treatment. Therapists received training in how to prepare patients for radiotherapy planning and treatment, focusing on procedure and sensory and side effect information, as well as training in eliciting and responding to emotional cues. Study measures were obtained at baseline and after each intervention time point. Intervention delivery was recorded, and content analysis was completed to determine intervention fidelity by two reviewers from a randomly selected set of 40 recorded sessions.
Randomized, controlled trial
Analysis showed statistically significant intervention effects for anxiety after the first intervention, (p = .0009) but a small size of effect (beta coefficient = –.145). There was no significant effect seen after the second intervention session. There was no effect on depression scores. Knowledge scores increased more on average for the intervention group between baseline and the first intervention session (p < .05) and related concerns dropped more in the intervention group over the same time period (p < .01).
The provision of a psychoeducational intervention was effective in increasing patients’ knowledge, reducing radiation therapy-related concerns, and reducing anxiety in women receiving radiation therapy for breast cancer.
The provision of this type of education and supportive intervention may reduce anxiety and improve patient knowledge prior to beginning radiation therapy.
Hirai, K., Motooka, H., Ito, N., Wada, N., Yoshizaki, A., Shiozaki, M., . . . Akechi, T. (2012). Problem-solving therapy for psychological distress in Japanese early-stage breast cancer patients. Japanese Journal of Clinical Oncology, 42, 1168–1174.
To examine the feasibility and effectiveness of problem-solving therapy for psychological distress among patients with early-stage breast cancer
The problem-solving therapy involved five weekly sessions aimed at assessing problems, setting goals, generating solutions, choosing a solution, and implementing the solution and evaluating results. The therapy included a manual and worksheet for patients to use. Authors collected self-report data prior to the intervention, after the final sessions, and three months after the final sessions.
Patients were undergoing active antitumor treatment.
A pre/post-test design was used.
Four patients dropped out of the study after starting treatment. Analysis showed a significant effect of time on anxiety and depression scores (p < 0.01). Over time scores for global health status, physical functioning, emotional functioning, and role functioning improved significantly.
The study shows that symptoms of anxiety and depression and some aspects of quality of life improved over time. The effect of the intervention cannot be evaluated from these study results. Though authors state that the intervention was feasible, the fact that 17% of the initial sample did not complete the study suggests that the intervention was not of interest to a substantial proportion of the patients.
Study results are insufficient to allow evaluation of the acceptability and efficacy of the problem-solving intervention.
Jones, R.B., Pearson, J., Cawset, A.J., Bental, D., Barrett, A., White, J., . . . Gilmour, W.H. (2006). Effect of different forms of information produced for cancer patients on their use of the information, social support, and anxiety: Randomised trial. BMJ, 332, 942–948.
The interventions included a variety of patient education materials delivered by the following methods.
Participants were divided into eight groups (three factors, 2 x 2 x 2).
Measurements were taken at baseline, after intervention, and at three months follow-up.
Western Scotland
A longitudinal, randomized trial design was used.
At three months follow-up, 45% of patients had improved anxiety scores. There were no statistically significant differences among the three intervention factors using a general linear model.
Kashani, F., Kashani, P., Moghimian, M., & Shakour, M. (2015). Effect of stress inoculation training on the levels of stress, anxiety, and depression in cancer patients. Iranian Journal of Nursing and Midwifery Research, 20, 359–364.
To investigate the effects of inoculation training on stress, anxiety, and depression
Forty patients were randomly selected and randomly assigned to study and control groups. Study group patients had weekly group education sessions for eight weeks. Sessions were aimed at understanding stress, relaxation, education, concepts of cognition, feelings and behaviors, role of negative self-talk, concentration and distraction techniques, and problem solving skills. Data were obtained before and after the intervention period.
Anxiety and depression declined after the intervention, but did not decline in the control group. After eight weeks, anxiety was significantly lower in the intervention group (p = 0.00) and depression was significantly lower than controls (p = 0.04). Stress increased in the control group, but declined in the intervention group (p = 0.01).
The psychoeducational intervention tested here was associated with significantly less anxiety and depression compared to patients who did not receive this intervention.
Findings suggest that the type of psychoeducational intervention provided here was helpful to manage anxiety and depression. Study design limitations affect the strength of evidence from this particular study; however, findings are in general concert with the body of evidence regarding effectiveness of psychoeducational interventions. Various psychoeducational interventions have been shown to be effective for anxiety and depression. These interventions can be incorporated into usual nursing practice.
Katz, M.R., Irish, J.C., & Devins, G.M. (2004). Development and pilot testing of a psychoeducational intervention for oral cancer patients. Psycho-Oncology, 13, 642–653.
The intervention involved a 95-page teaching booklet, What to Expect From Your Oral Cancer Surgery: A Guide for Patients and Families. The booklet included information about oral cancer, treatments, and effective coping strategies. Contents were divided into preparing for surgery, postoperative care, and returning home.
In the intervention group, the booklet was given to patients pre- and postoperatively by a nurse experienced in caring for patients with head and neck cancers. The preop session was 60–90 minutes of individual teaching before admission to the hospital for surgery. The predischarge session was 60–90 minutes of individual teaching several days prior to expected discharge from the hospital.
In the control group, patients received standard level of care, which included a preop meeting with the surgeon for consent to treatment as well as a brief description of the illness and treatment. Also included in the preadmission information was a tour of the ward and a team visit from the physician, dietitian, social worker, speech therapist, and enterostomal nurse. No information about coping or emotional difficulties was provided routinely. Measurements were taken at baseline, predischarge, and three months follow-up.
A randomized controlled trial design was used.
The authors reported significant improvement in anxiety scores within the intervention group from time 1 to time 3 (t = 2.88, df = 9, p = 0.018).
Kim, H.S., Shin, S.J., Kim, S.C., An, S., Rha, S.Y., Ahn, J.B., . . . Lee, S. (2013). Randomized controlled trial of standardized education and telemonitoring for pain in outpatients with advanced solid tumors. Supportive Care in Cancer, 21, 1751–1759.
To evaluate whether standardized educational tools, with or without telemonitoring, can improve the pain levels, pain interference, anxiety, depression, distress, performance, and quality of life of outpatients with cancer who have advanced tumors
Patients were randomized to receive either standard pain education plus telemonitoring or standard education alone. A nurse practitioner (NP) performed telemonitoring of pain every day for one week. The NP telephoned the patients and asked for average visual analog scale (VAS) pain score and worst VAS pain score in the last 24 hours. This provided patients with the opportunity to assess the severity of pain themselves. Using the National Comprehensive Cancer Care Network (NCCN) guidelines for pain management, the NP advised patients whether to increase or decrease medication. The NP was trained in pain management but had no specific training for other psychosocial interventions. Standard education included a video and booklet with individual coaching, to correct misconceptions, and an outline of decision making for pain control. Outcomes were measured at one week, and average pain was measured at two months.
A randomized controlled trial design was used.
Pain intensity, for all patients, had significantly improved at one week, including worst pain (7.3–5.7, p < 0.01) and average pain (4.6–3.8, p < 0.01). Additionally, anxiety (HADS score ≥ 11, 75%–56%, p < 0.01), depression (HADS score ≥ 11, 73%–51%, p < 0.01), quality of life (fatigue and insomnia), and Karnofsky score (32–66, p < 0.01) were significantly improved at one week. However, the level of distress did not improve. The study revealed no significant differences between groups in these areas.
Standardized pain education delivered by a nursing specialist is an efficient means of improving not only pain but also anxiety, depression, performance, and quality of life. This study did not show that the addition of telemonitoring substantially improved pain management in the outpatient setting.
Findings show that comprehensive pain education was associated with short-term reduction in pain, anxiety, and depression scores. The addition of telemonitoring follow-up for pain management did not result in a significant difference in these scores; however, the follow-up period was only one week. Longer-term studies of the effects of monitoring via telephone and other technologies, for the purpose of improved symptom management, may be helpful in identifying effective methods of improving symptom control in outpatient settings.
Krischer, M.M., Xu, P., Meade, C.D., & Jacobsen, P.B. (2007). Self-administered stress management training in patients undergoing radiotherapy. Journal of Clinical Oncology, 25, 4657–4662.
The intervention was a self-administered stress management training (SSMT) program for patients treated with radiation therapy. The usual care only (UCO) intervention included the usual psychosocial care typically provided at the institution where patients were receiving treatment. Participants in the SSMT program met individually with a nurse for approximately five minutes to receive instructional materials and explanations. The instructional materials consisted of a 15-minute prerecorded videotape, a 12-page booklet, and a 35-minute prerecorded audiotape titled “Active Relaxation,” which taught paced breathing, active relaxation, and positive thinking with guided imagery instructions. Data were collected at baseline and weeks 1, 2, and 3.
Multiple centers in South Florida
A randomized controlled trial design was used.
SSMT is effective only in those patients receiving radiotherapy with initially higher levels of psychological distress at baseline.
Special training needs include the creation of the SSMT tool (instructional materials, video tables, and audiotapes).
Intervention requires screening for psychological distress.
Lee, J.Y., Park, H.Y., Jung, D., Moon, M., Keam, B., & Hahm, B.J. (2014). Effect of brief psychoeducation using a tablet PC on distress and quality of life in cancer patients undergoing chemotherapy: A pilot study. Psycho‐Oncology, 23, 928–935.
To examine the benefits of a single-session psychoeducational intervention using a tablet PC during chemotherapy
Patients were assigned to intervention or control groups according to their dates of informed consent rather than strict randomization. Study measures were obtained at baseline and two to four weeks later. The study group was given a single-session psychoeducational intervention using a tablet PC to administer the education.
Two-group trial
Compared to the control group, the intervention group showed a positive score change on the HADS scale. The mental component summary score of the SF-8, the IES-R avoidance subscale, the ISI, and the total score of the HADS scale were the following. HADS (p = .0002), SF-8 (p = .011), ISI (p = .021), and IES-R (p = .036) declined from baseline more in the intervention group. Scores did decline in both groups.
A tablet-based, 20-minute psychoeducational intervention could be an effective intervention for managing depression, sleep disturbance, and quality of life.
Liao, M.N., Chen, S.C., Lin, Y.C., Chen, M.F., Wang, C.H., & Jane, S.W. (2014). Education and psychological support meet the supportive care needs of Taiwanese women three months after surgery for newly diagnosed breast cancer: A non-randomised quasi-experimental study. International Journal of Nursing Studies, 51, 390–399.
To investigate the effects of education and psychological support on anxiety, symptom distress, social support, and unmet supportive care needs of Taiwanese women newly diagnosed with breast cancer over three months following surgery
Education and psychological support was provided in the form of three individual face-to-face sessions and two telephone follow-up sessions. A standardized educational booklet was used. Sessions were done at the first postoperative visit, the first chemotherapy session, and three months after surgery. The telephone follow-up call was made seven days before chemotherapy and two months after surgery. Study measures were obtained at baseline, one month after surgery, and three months after surgery.
Two-group, nonrandomized, quasiexperimental study
All forms were in Chinese.
The experimental group experienced lower levels of overall unmet supportive care needs and had lower levels of unmet needs in other dimensions as well. Levels of state anxiety and symptom distress also were lower in this group. Primary concerns across groups were self-care and supportive care. Anxiety declined in both groups at similar levels by the first follow-up measure. By three months after surgery, there was a greater reduction in anxiety scores in the experimental group, which were significantly lower than those of the control group (p < .001).
The educational and psychological support components of the intervention improved the unmet supportive care needs of patients newly diagnosed with breast cancer three months after surgery.
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, 57–65.
To examine the effect of a support intervention on immune function and levels of depression, anxiety, and fatigue in patients with breast cancer after completion of surgery and adjuvant treatment
A total of 41 women were chosen from an ongoing prospective randomized study. The first patients in each stratum of treatment were chosen for current study. Twenty-one women received adjuvant combined radio-chemotherapy (CT-RT), and 20 women received radiotherapy (RT). Eleven CT-RT patients and 10 RT patients were randomized to the support group, while 10 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 then for another four days two months later. Study measures were obtained at baseline, 2 months, 6 months, and 12 months.
Patients were in the transition phase after initial treatment.
A randomized controlled trial design was used.
There was no significant immune effect from the support intervention. More patients in the support group had higher anxiety scores at the start of the intervention compared to the nonsupport group. The mean value anxiety score in the support group was also higher compared to the nonsupport group and improved significantly over time. Low levels of depression were reported in both groups, with no significant difference in depression scores. There was no significant difference in fatigue, but fatigue significantly improved over time in all patients. There were no significant differences in study measures between groups.
The support intervention had no effect on depression or immune parameters. There was no difference in improvement of anxiety and fatigue over time associated with the intervention.
Findings do not support effectiveness of the intervention tested here. Results show that depression, anxiety, and fatigue improved significantly over time.
Liu, C.J., Hsiung, P.C., Chang, K.J., Liu, Y.F., Wang, K.C., Hsiao, F.H., . . . Chan, C.L. (2008). A study on the efficacy of body–mind–spirit group therapy for patients with breast cancer. Journal of Clinical Nursing, 17, 2539–2549.
To examine the effects of body–mind–spirit group therapy on anxiety, depression, and well-being in women with breast cancer
The intervention was 10 group sessions based on positive psychology and forgiveness therapy to enhance physical strength, increase emotional release, and develop positive meaning of life. Specific exercises included things such as self-care planning, massage of acupuncture points, drawing, creating love cards for others, and sharing strategies.
Patients were undergoing the active treatment phase of care.
A mixed-methods study design was used: randomized controlled trial with focus group interview.
There was no difference over time for depression or well-being. The intervention group had a greater reduction in anxiety (p = 0.03) compared to the control group, with an effect size estimate of 0.56, suggesting a medium clinical significance. Qualitative analysis demonstrated that reduced anxiety was facilitated through a group process.
Results of focus group interviews demonstrated that these effects were facilitated through a group process. There were no apparent effects of the intervention on depression or well-being.
Qualitative results suggest that the main effects of the intervention were associated with provision of information and the peer group interactions. It is not clear if the philosophic foundations and exercises used in the interventions were essential to these effects.
Mahendran, R., Lim, H.A., Tan, J.Y., Chua, J., Lim, S.E., Ang, E.N., & Kua, E.H. (2015). Efficacy of a brief nurse-led pilot psychosocial intervention for newly diagnosed Asian cancer patients. Supportive Care in Cancer, 23, 2203–2206.
To determine if psychosocial interventions, led by nurses instead of mental health professionals, for patients newly diagnosed with cancer in Singapore could help ease distress, minor psychiatric morbidity, and psychosocial worry
This quasiexperimental study researched the benefits of a six-month nurse-led psychosocial intervention program for patients with newly diagnosed with cancer receiving chemotherapy. The program consisted of 20- to 30-minute sessions with a nurse and occurred monthly for two visits and bimonthly for two more visits. Participants were offered this intervention along with their treatment. Training of the oncology RNs at the National Cancer Institute in Singapore included personal training by a psychiatrist and a psychologist on psychoeducation for managing stress, sleep hygiene, anxiety, and depression and included resources, deep breathing exercises, muscle relaxation, and inspirational self-talk. Patients also received counseling, supportive therapy, and printed/audio education to encourage practice at home. The RN training also included simulated one-on-one sessions with feedback on performance. Demographic and medical data were collected. Primary outcomes were measured by questionnaires at baseline and at six months.
PHASE OF CARE: Active antitumor treatment
One hundred twenty-one participants were recruited. Seventy (58%) chose to participate, and the rest received treatment as usual (TAU). Sixty-three (90%) participants completed the four nurse-led sessions and were available at six months for reassessment. No significant demographic difference was reported between the intervention and TAU groups at baseline. No significant demographic difference existed between those followed up with and those lost to follow-up, but those lost to follow-up did have higher anxiety and depression scores at baseline. The intervention group had significantly increased distress, anxiety, and depression scores and lower EQ-5D scores at baseline. The intervention group participants had significantly reduced distress (p = 0.001), anxiety (p < 0.001), and depression (p < 0.001) scores, as well as greatly improved quality of life over time. Participants receiving TAU also showed a decline in anxiety and depression over time, with essentially stable distress scores.
A six-month intervention of psychoeducation, counseling, and behavior technique teaching improved participants’ distress, quality of life, anxiety, and depression.
Merckaert, I., Lewis, F., Delevallez, F., Herman, S., Caillier, M., Delvaux, N., . . . Razavi, D. (2016). Improving anxiety regulation in patients with breast cancer at the beginning of the survivorship period: A randomized clinical trial comparing the benefits of single-component and multi-component group interventions. Psycho-Oncology. Advance online publication.
To compare the benefits of two interventions on anxiety in women after initial treatment for breast cancer
Women were randomly assigned to study groups in cohorts of 12 patients. One group received 15 sessions of a single-component support intervention, and the other received a 15-session group intervention combining support with psychoeducational interventions focusing on problem-solving skills, optimizing communications and use of personal and social resources, and self-hypnosis. Interventions were delivered in group settings by clinical psychologists following a structured manual. Sessions were audio and video recorded for use in clinical supervision as needed. Psychologists delivered only one type of intervention to avoid contamination. Study measures were obtained at baseline and after the intervention. All instruments were used with dynamic tasks through completion of the Mental Adjustment to Cancer (MAC) Scale followed by 12 minutes of self-relaxation and through completion of the Fear of Cancer Recurrence Inventory (FCRI) followed by a 12-minute guided hypnosis exercise.
PHASE OF CARE: Transition phase after active treatment
A significant group by time effect was observed in the multicomponent intervention compared to controls for state anxiety after self-relaxation (p = 0.006), for anxiety after guided hypnosis (p = 0.013), and for everyday anxiety level (p = 0.005). No differences were reported between groups in HADs scores. Anxiety and depression scores declined over time in both groups (p < 0.001). The item of psychological distress on the FCRI was reduced in both groups over time, with slightly better improvement in the multicomponent intervention group (p = 0.017).
Both supportive and multicomponent interventions were associated with a decline in anxiety and depression scores over time. The findings suggest that the multicomponent intervention was more effective in enabling women to manage their level of anxiety from triggers that could produce anxiety.
Both supportive and multicomponent psychoeducational type interventions were associated with a decline in anxiety and depression over time; however, determining if these changes were associated with the general supportive atmosphere of the group-based intervention is not possible. Anxiety has been shown to decline over time in general as well, without specific intervention. The findings suggest that the combination of self-hypnosis techniques and psychoeducation may enable individuals to manage their anxiety responses more effectively.
Mohabbat-Bahar, S., Maleki-Rizi, F., Akbari, M.E., & Moradi-Joo, M. (2015). Effectiveness of group training based on acceptance and commitment therapy on anxiety and depression of women with breast cancer. Iranian Journal of Cancer Prevention, 8, 71–76.
To evaluate the effects of group therapy on anxiety and depression
Acceptance and commitment therapy (ACT) is described as a type of “third wave” of cognitive behavioral therapy that focuses on values and goals clarification and acceptance-based behavioral strategies and mindfulness processes. Participants were randomly assigned to experimental and control groups. The experimental group had ACT held in eight sessions of 90 minutes during four consecutive weeks. These were provided in a group setting. Study measures were obtained at baseline and after the intervention.
Randomized, controlled trial
Anxiety and depression scores declined in the experimental group, while increasing in the control group. These differences, however, were not statistically significant (p = 0.000).
Findings suggest that a psychoeducational intervention based on acceptance and commitment therapy can be of benefit in reducing anxiety and depression among women with breast cancer.
This type of psychoeducational intervention may be of benefit to reduce anxiety and depression in women with breast cancer. It is not clear to what extent results here were an effect of the protocol used or the participation in group sessions, which could have been supportive. Psychoeducational interventions are generally low-risk and relatively low-cost approaches that may be of benefit to patients.
Nguyen, L.T., Alexander, K., & Yates, P. (2018). Psychoeducational intervention for symptom management of fatigue, pain and sleep disturbance cluster among cancer patients: A pilot quasi-experimental study. Journal of Pain and Symptom Management, 55, 1459–1472.
To assess the feasibility of conducting a trial of a psycho-educational intervention involving the provision of tailored information and coaching to improve management of a cancer-related symptom cluster (fatigue, pain, and sleep disturbance) and reduce symptom cluster effects on patient health outcomes in the Vietnamese context, and to undertake a preliminary evaluation of the intervention.
A parallel-group, single-blind, pilot, quasiexperimental trial with pre-/post-test follow up was conducted in a cancer department of a general public hospital in Hanoi, Vietnam. Participants in the control group received standard treatment. Patient assigned to the intervention group received the psycho-educational program which consisted of three individualized psychoeducational sessions of up to one hour, tailored to meet patient’s major symptom concerns. Strategies such as energy conservation and restorative activities for fatigue management, sleep hygiene for sleep disturbance, and adherence to prescribed therapy for pain management were explored. A patient self-management booklet was provided at the first session to facilitate education and support.
Single-blind, pilot, quasi-experimental trial with pre-/post-test follow up.
The intervention group demonstrated a significant reduction in symptom cluster severity (p < 0.0001), fatigue severity, fatigue interference (p = 0.03), sleep disturbance (p < 0.0001), depression, and anxiety when compared to the control group. For fatigue severity, while the intervention group witnessed no change in fatigue severity (p = 0.4), the control group observed a significant increase (p = 0.01). Depression (p = 0.004) and anxiety (p < 0.0001) decreased significantly in the intervention group, there was significant increase in depression (p = 0.04) and no change in anxiety (p = 0.08) in the control group. There were no significant differences in pain severity, pain interference, functional status, or health-related quality of life.
Psychoeducational interventions may help to achieve improvement in some symptoms such as fatigue and sleep disturbances, but future RCTs are needed to test the effectiveness of a symptom cluster intervention in Vietnam.
Study provides preliminary evidence to support potential efficacy of a psycho-education intervention in improving symptom cluster severity, fatigue burden, sleep disturbance, and psychological distress.
Oh, P.J., & Kim, S.H. (2010). Effects of a brief psychosocial intervention in patients with cancer receiving adjuvant therapy. Oncology Nursing Forum, 37, E98–E104.
To test the effects of a brief psychosocial intervention (BPIC) delivered using CD-ROM on psychosocial and behavioral outcomes in patients with cancer undergoing adjuvant treatment
Participants viewed a 15-minute CD-ROM education program and received a booklet as well as 20 minutes of health education in the first session. A follow-up 15-minute telephone session was delivered one week later. The program focused on health education, coping, and stress management.
Patients were undergoing the active treatment phase of care.
A randomized controlled trial design was used.
There were no differences between groups for helplessness, hopelessness, anxiety, or depression. There were significant differences in fighting spirit (p = 0.005) and self-care behaviors (p < 0.001) between the two groups. The scores increased in the experimental group but declined in the control group.
Findings support effectiveness of the intervention in improving fighting spirit and self-care behaviors; however, the intervention had no significant effect on anxiety or depression.
Mean anxiety and depression scores at baseline were relatively low, suggesting very limited potential for these outcomes to be significantly improved.
Owen, J., O'Carroll Bantum, E., Pagano, I., Stanton, A., Owen, J.E., & Pagano, I.S. (2017). Randomized trial of a social networking intervention for cancer-related distress. Annals of Behavioral Medicine, 51, 661–672.
To evaluate the effects of a web-based social networking and coping skills training intervention on cancer-related patient based outcomes: distress, depression, anxiety, and psychological well-being. Secondary outcomes are vigor and fatigue.
Participants initially completed a baseline survey following which they were given access to the online health space intervention or waitlisted for the intervention (waitlist control group) randomly. Intervention included an evidence-based online distress management intervention for a period of 12 weeks, including modules, chats, discussion boards, and web mails.
PHASE OF CARE: Multiple phases of care
Randomized controlled clinical trial
No baseline difference was noted between the intervention and control group in terms of demographic and clinical characteristics. All the five outcomes improved over time, but no significant difference between the treatment and control group for psychological functioning, depression, anxiety, and vigor. Interaction between time and treatment group fatigue (time fatigue declined in the treatment group compared to control group). No significant reduction in distress and depression between the groups, although it reduced within the groups over time, association between intervention and engagement.
Health space social networking did not improve the cancer-related distress outcomes.
Online interventions could be suggested to patients as it is associated with strong engagement.
Rawl, S.M., Given, B.A., Given, C.W., Champion, V.L., Kozachik, S.L., Barton, D., . . . Williams, S.D. (2002). Intervention to improve psychological functioning for newly diagnosed patients with cancer. Oncology Nursing Forum, 29, 967–975.
The intervention consisted of three parts:
The research team created this computer-based intervention for 38 symptoms that may occur during chemotherapy. The computer-based nursing intervention was a menu-driven computer program that guided clinical assessment, problem identification, selection of interventions, and measurement of outcomes. It was designed based on current literature, oncology nursing practice standards, and practice guidelines for cancer symptom management. Each symptom or problem had a problem-specific list of appropriate interventions. Emotional support and counseling consisted of the nurse using active listening and teaching of active communication techniques to patients and their caregivers to enhance communication between patients, caregivers, family, and healthcare providers. The intervention occurred over 18 weeks and consisted of nine visits (five in person and four via telephone). Visits took approximately one hour. Telephone encounters took about 20 minutes.
Dyads were recruited within 56 days of chemotherapy initiation. After completion of baseline telephone interviews, dyads were randomly assigned to groups. Data were collected via telephone interviews at three time points during the six-month study: time 1 = entry into study, time 2 = nine weeks or halfway through the intervention, and time 3 = 24 weeks or one month after the intervention.
A randomized controlled trial (RCT) design was used.
Role emotional, mental health, and mental component scores were significant for the group-by-time intervention (p = 0.1). The intervention did not have a significant effect on anxiety when examining the date from the three time points. However, a trend toward group-by-time interaction (p = 0.09) occurred between baseline and time 2, favoring the intervention group. Pair-wise comparisons of the means showed that the intervention group improved (lower anxiety scores) from baseline to time 2 (p = 0.09), whereas the standard care group remained unchanged. Time 3 data were collected approximately four weeks after completion (24 weeks following enrollment), and any effect the intervention had may have been lost by time 3. Additional analyses were performed on baseline and time 2 data only.
The study was a strong RCT with a good sample size.
Schofield, P., Gough, K., Lotfi-Jam, K., Bergin, R., Ugalde, A., Dudgeon, P., . . . Aranda, S. (2016). Nurse-led group consultation intervention reduces depressive symptoms in men with localised prostate cancer: A cluster randomised controlled trial. BMC Cancer, 16, 637-016-2687-1.
To investigate the benefits of a group nurse-led intervention on psychological morbidity, unmet needs, treatment-related concerns, and quality of life in men with prostate cancer receiving radiotherapy with curative intent
This phase-III, randomized trial assessed the relative benefits of a tailored, group consultation intervention for men receiving curative intent radiotherapy for prostate cancer compared to the best supportive care. The aim was to communicate information about diagnosis, treatment, and side effects, and coaching in self-management. Content and discussion were based on expressed needs and concerns. It included four group consultation sessions and one individual consultation completed by uro-oncology nurse specialists. Survey assessments occurred before treatment, at the end of treatment, and six months postcompletion of treatment. Sessions were tape recorded, and random selections were used to evaluate intervention fidelity.
Phase-III, two-arm cluster, randomized, controlled trial
A higher consent rate existed at one site, but no other statistically significant differences in patient characteristics existed between the two groups. One hundred thirteen (out of 165) participants attended all sessions in the intervention group (p = 0.02). Mixed models analysis indicated that group consultations were statistically more beneficial on depressive symptoms (p = 0.009) and procedural concerns relating to cancer treatment (p = 0.049). Ninety-two percent completed surveys at all three time points. Descriptive analysis showed a slight reduction in depressive symptoms in the intervention group between baseline and the end of radiotherapy; the control (usual care) group reported an increase in these symptoms during the same time period. The difference between groups persisted six months post radiotherapy, although between groups, differences in mean changes was substantially reduced. No significant difference existed in rate of change in anxiety between the intervention group and the usual care group noted from the HADS. Descriptive analysis indicated a reduction in anxious symptoms in both groups at the follow-up assessments. Differences in mean changes from baseline to six months post-radiation also occurred, as it did with depressive symptoms.
Nurse-led group consultations may help address patient education, particularly among men who are experiencing depression.
Nurses must realize the importance of patient education and their role in counseling patients experiencing depression not only during treatment but following treatment as part of survivorship care.
Schofield, P., Jefford, M., Carey, M., Thomson, K., Evans, M., Baravelli, C., & Aranda, S. (2008). Preparing patients for threatening medical treatments: Effects of a chemotherapy educational DVD on anxiety, unmet needs, and self-efficacy. Supportive Care in Cancer, 16, 37–45.
Primary aim: To evaluate effect of an educational DVD about chemotherapy on pretreatment anxiety, self-efficacy, unmet informational needs, and satisfaction with information received
Secondary aim: To determine if effects differ between those who perceived treatment to be curative rather than palliative
Control group patients received usual care and completed questionnaires before beginning their treatment. Experimental group patients were recruited at a later time. They were given a copy of the DVD to take home to watch, several days before their first treatment. They then completed questionnaires on the first day of chemotherapy treatment. The DVD focused on preparation for chemotherapy and self-management of side effects, including nausea and vomiting, constipation, diarrhea, mucositis, fever and infection, hair loss, infertility, and effects on sexuality and intimacy. Content was evidence-based, derived from a systematic review of the literature to support recommended self-care approaches. Most content was delivered by cancer survivors who also discussed their experiences and the self-care strategies they used to manage side effects. An oncologist and oncology nurse presented medical and nursing information. The DVD was 25 minutes long and had been previously pilot tested. Usual care education consisted of a brief description of the procedure and side effects provided by the patient’s oncologist and a 30-minute education session with a chemotherapy nurse. Analysis was done within curative and palliative care patient groupings.
Patients were undergoing the active treatment phase of care.
The study used a prospective quasi-experimental design with use of historical controls.
There were no differences in anxiety or depression scores between usual care and intervention groups. Those who watched the DVD rated themselves as more confident about seeking social support than the usual care group (p = 0.044). There were no differences between groups in any supportive care needs that were unmet. Both curative and palliative patients reported having more psychological needs than any other type of care, and reported sexuality as the least needed area. Those in the intervention group were more satisfied with information they had received (p = 0.026) compared to the control group. There were significant differences between self-perceived curative and palliative patients in confidence for maintaining activity (p = 0.028), stress management (p = 0.044), coping with side effects (p = 0.002), maintaining a positive attitude (p = 0.008), managing emotions (p = 0.005), and seeking social support (p = 0.012).
The intervention appeared to have an influence on aspects of self-efficacy and satisfaction with information received. There were no findings to support an effect on anxiety or depression prior to chemotherapy.
Prechemotherapy education is an important part of nursing management of these patients, but there is little evidence to guide the timing, content, format, and style of this type of education. Additional research in this area will be helpful to guide nursing practice. The use of adjuncts to direct face-to-face patient teaching and support by nurses may be helpful in the face of workforce shortages and increasing shifts of patient care to suggest that provision of basic information and orientation to the setting are not sufficient approaches to impact feelings of anxiety. Further study of such approaches can be helpful to determine how to best meet patient needs.
Schou Bredal, I., Karesen, R., Smeby, N.A., Espe, R., Sorensen, E.M., Amundsen, M., . . . Ekeberg, O. (2014). Effects of a psychoeducational versus a support group intervention in patients with early-stage breast cancer: Results of a randomized controlled trial. Cancer Nursing, 37, 198–207.
To investigate which approach, psychoeducation or support, provides the greatest benefit to patients with early-stage breast cancer
Women who had undergone surgery for breast cancer were randomly assigned to receive either a support group (SG) or psychoeducational group (PEG). The PEG intervention consisted of health education about breast cancer and side effects of treatments, stress management (including training and a DVR in progressive muscle relaxation), enhancing problem solving skills, and psychological support from research staff and other group members. Sessions were two hours weekly for five weeks. The SG intervention was part of routine care, consisted of three weekly two-hour sessions on topics women introduced for discussion. A surgeon, physical therapist, and a breast cancer survivor attended the group for 30 minutes each to provide information in a question and answer format. Study assessments were done at baseline, at 2 months, 6 months, and 12 months.
Ninety-seven percent of patients attended all sessions in both groups. Both groups showed significant decline in anxiety. With adjustment for baseline anxiety level, there were no differences in anxiety levels between groups after the intervention. Depression declined significantly in all patients over time, with no difference between groups. At various time points, there were differences in mental adjustment to cancer between optimists and pessimists, but these differences were not consistent, and there were no significant differences at 12 months. Within the first six months, there was greater decline in anxiety and depression among those in the PEG group.
Women in both groups showed reduced anxiety and depression over time. There were no differences in results between those receiving a support group versus a psychoeducational intervention except in the first 6 months. Psychoeducation may be more helpful in the short term at a time when patients are likely to have more distress.
Findings suggest that both psychoeducational and support group interventions can be beneficial to women dealing with breast cancer. In the short term, findings suggest that psychoeducation may yield some greater benefits, but there were no long-term differences based on the type of intervention provided. It may be beneficial to incorporate more psychoeducational components into routine support group and supportive interventions.
Targ, E.F., & Levine, E.G. (2002). The efficacy of a mind–body–spirit group for women with breast cancer: A randomized controlled trial. General Hospital Psychiatry, 24, 238–248.
The study compared a complementary and alternative medicine (CAM) group intervention to a standard psychosocial support group.
The 12-week standard psychosocial support group meeting was offered weekly. A trained clinical psychologist taught cognitive behavioral therapy using group sharing and supportive therapies. Topics included coping with real-life issues, communication, body image, sexuality, grief, anger, anxiety management, and problem solving.
The 12-week CAM group meeting was offered twice a week. This group was taught meditation, affirmation, imagery, and ritual. Each session was two and one-half hours. The Tuesday session was a one-hour, RN-run, health-series discussion group, with topics including nutrition, exercise, menopause, lymphedema, pain management, sexuality, and others as requested by the group. The next 90 minutes were spent in six yoga classes and six dance therapy sessions. The Thursday session was one hour of experiential work using silent meditation, guided imagery, and writing and drawing exercises. The final 90 minutes was devoted to a discussion group led by a licensed clinical social worker exploring themes of experiential work as well as general support by the group. Topics included relationship with cancer, views of healing, sexuality, body image, death and dying, compassion, anger, forgiveness, and healing.
A randomized controlled trial design was used.
Wenzel, L., Osann, K., Hsieh, S., Tucker, J.A., Monk, B.J., & Nelson, E.L. (2015). Psychosocial telephone counseling for survivors of cervical cancer: Results of a randomized biobehavioral trial. Journal of Clinical Oncology, 33, 1171–1179.
To study the effects of psychosocial telephone counseling on anxiety, quality-of-life domains, and biomarkers
Eligible patients were randomly assigned to the telephonic intervention or usual care. Those receiving the intervention received a five-minute pre-call to reintroduce the purpose of the intervention and schedule initial sessions. Patients received four sessions of 20-60 minutes for education and counseling for problem solving, social support, communication skill development, and problem identification based on the transactional model of stress and coping. Follow-up letters with session summary and suggested homework assignments were mailed after each session. Surveys were mailed to participants for completion at baseline, 4 months, and 9 months.
Randomized, controlled trial
Patients assigned to the intervention had significantly better scores for depression (p = 0.041) and cancer-specific concerns at four months (p < 0.05). There was no difference between groups in anxiety at four months. Patients assigned to the intervention demonstrated continued improvement in gynecologic problems at nine months. At nine months, there was no difference between groups in depression or anxiety.
Longitudinal evaluation of a telephonic psychoeducational intervention among survivors of cervical cancer showed benefit for depression and gynecologic problems in the first four months after the intervention. These differences were not maintained over the longer term.
Telephone-delivered psychoeducational intervention was associated with reduced depression and cancer concerns within the first few months of the intervention; however, these benefits did not appear to be maintained over the longer term. It is possible that there is a need for continued intervention in order to benefit patients in the longer term. Findings suggest that a telephone intervention delivery can be effective, and may be a practical way to be able to deliver this type of intervention, particularly for patients in rural areas, or those otherwise unable to travel to healthcare facilities.
Willems, R.A., Bolman, C.A., Mesters, I., Kanera, I.M., Beaulen, A.A., & Lechner, L. (2016). Short-term effectiveness of a web-based tailored intervention for cancer survivors on quality of life, anxiety, depression, and fatigue: Randomized controlled trial. Psycho-Oncology. Advance online publication.
To present the short-term effects of a web-based computer-tailored intervention on quality of life, anxiety, depression, and fatigue in cancer survivors
A stand-alone web-based computer-tailored intervention (Cancer Aftercare Guide: KNW) was applied that aims to increase cancer survivor quality of life by providing personalized information and support on specific topics by promoting lifestyle changes. The eHealth intervention was based on principles of the problem-solving theory (PST) and cognitive behavioral theory (CBT). The KNW consists of eight training modules on topics of return to work, fatigue, anxiety, depression, social relationship and intimacy, physical activity, diet, and smoking cessation. After online registration, the computer randomly assigned participants to the intervention or waiting control group. Both groups had to complete questionnaires at 3, 6, and 12 months from baseline. The 6 and 12 month measures revealed the effectiveness. Participants filled in baseline questionnaires, modules were selected by the program, and the information was tailored to the participant, resulting in a personalized action plan. After 30 days, participants were invited to a second session to evaluate goal attainment and to set new goals.The program was unrestricted so that participants could self-select modules they wished to use and skip assignments.
Randomized, controlled trial comparing the KNW intervention with a waiting list control group
With the exception of treatment type, the intervention and control group were comparable. Participants in the intervention group used an average of 2.22 modules from first login to last use of 10.67 weeks. The authors indicated that the KNW intervention had a significant effect on increasing emotional and social functioning (p = 0.022, p = 0.011) and decreased depressions and fatigue (d = 0.019, p = 0.007, d = 0.020, p = 0.02) six months after baseline. The only effect for fatigue occurred in participants who used the module Fatigue (p = 0.009). No significant differences existed between groups for anxiety. For those who used the therapist face-to-face component, available effect sizes ranged from 0.26 to 0.38.
While the use of the web-based intervention showed statistically significant results, the effect sizes for depression, anxiety, and social functioning were extremely small. The module use and program were not fully automated and offered direct therapist contact. The authors reported substantially higher effect sizes with therapist contact, raising the question of overall effectiveness of the web-based content.
eHealth interventions, such as web-based PST or CBT approaches, may be useful for improving quality of life in cancer survivors. Further research is necessary to target the desired information and to provide support specifically for fatigue, anxiety, and depression in cancer survivors. The findings showed much greater size of effects with direct therapist intervention, suggesting that an eHealth system may be best used as an initial step in a multicomponent intervention with additional steps, in which increasing intervention is provided based upon patient need and response.
Williams, S.A., & Schreier, A.M. (2004). The effect of education in managing side effects in women receiving chemotherapy for treatment of breast cancer [Online exclusive]. Oncology Nursing Forum, 31, E16–E23.
To determine the effectiveness of audiotapes on self-care behaviors, state anxiety, and the use of self-care behaviors and to describe the occurrence and intensity of common side effects in patients with breast cancer
Two 20-minute audiotapes provided information on nutritional management of side effects, exercise, and relaxation techniques along with written transcripts that were professionally developed at a fifth-grade reading level. All participants received standard education for the clinic but not standardized education. The experimental group received audiotapes and transcripts via mail and were provided with a cassette player if they did not have one at home. All participants were interviewed three times via telephone.
The study reported on 70 women with newly diagnosed stage I or II breast cancer starting the first cycle of chemotherapy treatment. Most of the women were receiving docorubicin and cyclophosphamide.
The setting was outpatient chemotherapy clinics operated by a university center in satellite clinics in rural areas of southeastern United States that covered 29 counties.
The design was an experimental, randomized, clinical trial.
Yun, Y. H., Lee, K. S., Kim, Y. W., Park, S. Y., Lee, E. S., Noh, D. Y., . . . Park, S. (2012). Web-based tailored education program for disease-free cancer survivors with cancer-related fatigue: a randomized controlled trial. Journal of Clinical Oncology, 30, 1296–1303.
To determine if an internet-based, tailored, psychoeducational program was effective in the management of fatigue and other symptoms for patients with cancer-related fatigue.
Patients were randomly assigned to a tailored, web-based, health navigation program or usual care. The 12-week intervention program covered energy conservation, physical activity, nutrition, sleep hygiene, pain control, and distress management. The program included online education, health advice, message services, caregiver monitoring, and support and educational sessions. Principles of cognitive-behavioral therapy were used in the program design. The program was provided via a health navigation web site. Study measures were obtained at baseline and at the end of 12 weeks. Intention-to-treat (ITT) analysis was performed using the last observation carried forward for missing values.
The study was a randomized, controlled trial with a wait-list control.
The intervention group had a significantly larger reduction in fatigue scores (p = 0.0011), with an effect size of 0.29 (Cohen’s d). The intervention group also had a greater improvement in anxiety score and several quality of life–related scale scores (p < 0.05). Multiple variables were statistically significant predictors of change in fatigue scores.
Health navigation, the psychoeducational intervention used here, had a slight to moderate positive effect in reducing fatigue.
The findings suggested that a psychoeducational program delivered via a web-based program may be helpful for some patients for the management of fatigue. Although the study was limited by a high withdrawal rate in the intervention group, the majority of patients continued with the program. This may be a practical approach that is helpful to some patients. Further research in the area of facilitating and encouraging patient participation in such programs would be useful.
Zhang, M., Sally Wai-chi, C., You, L., Wen, Y., Peng, L., Liu, W., & Zheng, M. (2014). The effectiveness of a self-efficacy-enhancing intervention for Chinese patients with colorectal cancer: A randomized controlled trial with 6-month follow up. International Journal of Nursing Studies, 51, 1083–1092.
To test the effects of a nurse-led, self-efficacy-enhancing intervention for patients with colorectal cancer compared to routine care over a six-month follow-up period
Verbal and written information on self-efficacy and techniques to increase self-efficacy were distributed, and 20–40 minute coaching follow-up sessions were conducted via telephone. The control group received routine care, which included information provided by the nurse on knowledge of chemotherapy and side effects before patients started treatment (about 30 minutes). The intervention was based on Bandura’s (1977, 1986) self-efficacy theory. The self-efficacy intervention was complex and included an hour-long, face-to-face education session conducted by an oncology nurse, an educational handbook that contained information on the core components of self-efficacy, a 30-minute audiotape on relaxation, and four monthly health-coaching telephone follow-up sessions (20–30 minutes each) with an oncology nurse.
Randomized, controlled trial with repeated measures and a two-group design
The intervention group experienced a significant improvement in self-efficacy (f = 7.26, p = .003), a reduction in symptom severity (f = 5.30, p = .01), symptom interference (f = 4.06, p = .025), anxiety (f = 6.04, p = .006), and depression (f = 6.96, p = .003) at three and six months compared to the control group. No statistically-significant main effect was observed in quality of life perception between the two groups.
A nurse-led, self-efficacy-enhancing intervention was effective in promoting self-efficacy and psychological well being for three and six months compared to the control group. The findings of this study suggest that the intervention is feasible, and improvements could be sustained for six months after the intervention.
Self-efficacy-enhancing interventions that are lead by nurses may improve the psychological well-being of patients with colorectal cancer.
Andersen, B.L., DeRubeis, R.J., Berman, B.S., Gruman, J., Champion, V.L., Massie, M.J., . . . American Society of Clinical Oncology. (2014). Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: An American Society of Clinical Oncology guideline adaptation. Journal of Clinical Oncology, 32, 1605–1619.
The guideline provides an algorithm for the screening and assessment of anxiety, a care map for anxiety in adults with cancer, an algorithm for the screening and assessment of depression, a care map for depression in adults with cancer, the Patient Health Questionnaire (PHQ 9) symptom depression scale and generalized anxiety disorder (GAD) items, and selected measures for depression and anxiety (modified).
Nurses play a vital role in the early screening, assessment, and treatment of patients who may have significant symptoms of anxiety and depression. By screening and making appropriate referrals, we can impact the emotional, interpersonal, and financial costs for patients and reduce the economic impact for providers and the healthcare system.
Butow, P., Price, M.A., Shaw, J.M., Turner, J., Clayton, J.M., Grimison, P., . . . Kirsten, L. (2015). Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines. Psycho-Oncology, 24, 987–1001.
PHASE OF CARE: Multiple phases of care
No information is provided regarding literature retrieved, quality of evidence, or how the evidence was used to develop the guidelines provided.
Outlines relevant healthcare provider roles. Identified the following assessment tools for use: Edmonton Symptom Assessment Scale, the NCCN's Distress Thermometer, and the Hospital Anxiety and Depression Scale. Provides a stepped path of interventions based on ongoing monitoring of symptoms and effectiveness of previous interventions. Recommendations for initial intervention are patient education (in-person or online) and brief emotional support. Ongoing interventions for those with cancer-related anxiety and depression include coping skills training, relaxation skills, communication skills, mindfulness, and a variety or psychological therapies.
Despite an extensive review process for guidelines, as well as input from stakeholders, there is little information on the evidence base for the recommendations provided.
This guideline outlines recommended providers, and nurses are not specifically outlined as recommended providers in the written pathway other than as “other appropriately trained staff,” although nurses are identified as having roles in screening, assessment, and educational and counseling types of roles. This guideline provides no new information and does not directly provide the evidence base on which recommendations are based. The guideline suggests more limited roles for nurses than has been demonstrated in relevant research.
National Comprehensive Cancer Network. (2012). NCCN clinical practice guidelines in oncology: Distress management [v.2.2013]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf
To provide clinical practice guidelines for the evaluation and treatment of distress — a normal feeling of vulnerability to a feeling that leads to disabling problems, such as depression and anxiety — in adult patients with cancer
Results were not stated.
Recommended standards of care include
Evaluation should include measures relating to level of distress, behavior symptoms, psychiatric history and medications, pain and symptom control, body image and sexuality issues, impaired capacity, safety, potential medical causes, and psychological disorders.
Management algorithms should be provided for dementia, delirium, mood disorder, psychotic disorder, adjustment disorder, anxiety disorder, personality disorder, and substance-related disorder.
Treatments identified for use include psychotherapy, anxiolytics, antidepressants, psychoeducation, cognitive behavioral therapy, social work and counseling interventions, spiritual counseling and ethics, and palliative care consultation according to algorithms.
The guidelines provide recommended pathways regarding assessment and management of distress. They do not provide a nursing perspective or identify a role for nursing in patient management.