Psychological Distress, Depression, and Anxiety

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Chapter

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Psychological Distress, Depression, and Anxiety Arthur M. Nezu and Christine Maguth Nezu

1.0.

INTRODUCTION

This chapter focuses on psychosocial interventions geared to address the serious problems of stress, depression, and anxiety related to the experience of cancer and its treatment. Based on the authors’ research and clinical work in psychosocial oncology, there will be an emphasis on problem-solving therapy approaches to secondary prevention interventions.

2.0.

STATEMENT OF THE PROBLEM

Considerable medical progress has been made in treating the set of diseases known as cancer. Many forms are curable and there is a sustained decline in the overall death rate from cancer when one focuses on the impact on the total population.1 Because of improvements in medical science, however, more people are living with cancer than ever before. Although the extensive medical needs of such patients may be well attended to, psychosocial and emotional needs are often overlooked.2 Almost every aspect of one’s life can be affected, as cancer engenders many stressors and can lead to significantly compromised quality of life.3 Even for people who historically have coped well with major negative life events, cancer and its treatment greatly increases the stressful nature of even routine daily tasks. Weisman and Worden decades ago first referred to this situation for cancer patients as an “existential plight,” where one’s very existence may be endangered.4 Recognizably, not every individual diagnosed with cancer will experience a plethora of problems, but most patients do report significant difficulties.

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324 Arthur M. Nezu and Christine Maguth Nezu

2.1.

Prevalence of Psychiatric Disorders

Estimates of the prevalence of psychological difficulties range between 23% and 66% across cancer populations.5 For example, in a study of 215 cancer patients with mixed diagnoses, 53% were found to be adjusting normally to stress; however, nearly half (47%) had clinically apparent psychiatric disorders.6 Of these individuals, over two thirds (68%) had reactive anxiety and depression (adjustment disorders with depressed or anxious mood), 13% had major depression, 8% had an organic mental disorder, 7% had personality disorders, and 4% had anxiety disorders. In addition, of the psychiatric disorders observed in this population, 90% were reactions to, or manifestations of, the disease or treatment itself. In a more recent study, among a sample of adults diagnosed with first onset head and neck or lung malignancies, the 12-month incidence of posttraumatic stress disorder was found to be 14%, 20% for other anxiety disorders, and 20% for depressive disorders.7 Okamura et al. found that among a sample of women who experienced a first recurrence of breast cancer, 42% met diagnostic criteria for major depressive or adjustment disorder.8

2.2.

Depression

Depression is a common experience among cancer patients. Studies utilizing both self-report and clinical observations suggest that major depression affects approximately 25% of cancer patients.9 It is also responsible for the largest percentage of psychiatric consultations for cancer patients. For example, Massie and Holland found that among 546 patients referred for consultation due to emotional distress, 54% had diagnoses of adjustment disorder with depressed mood and another 9% had diagnoses of major depressive disorder.10 Another study found a fourfold increase in the rate of depression among oncology patients as compared to the general population, underscoring the seriousness of the problem.11 Factors associated with greater prevalence of depression include a higher level of physical disability, advanced disease stage, and the presence of pain.12 Also, higher rates of depression have been associated with the side effects of medications and treatment for cancer. Chemotherapy and oncological surgical procedures are a source of possible iatrogenically-induced depression in cancer patients because of their negative side effects that may include body image disturbances and physical symptoms.13 For example, it has been estimated that 40% to 60% of patients’ emotional distress is directly attributable to the cancer treatment itself.14 Numerous studies have also investigated various psychosocial risk factors for developing depression among cancer patients. Some of these risks identified include premorbid coping skills, social isolation, first degree relatives with a history of cancer and depression, a personal history of depression, a personal history of alcohol or other substance abuse, and socioeconomic pressures.13

2.3.

Anxiety

Oncology patients often experience anxiety, for example, while waiting to hear their diagnosis, before procedures, treatment and diagnostic tests, and while waiting for test results.15 In addition, cancer treatments themselves can be anxiety provoking and may contribute to the actual psychological morbidity of patients with cancer.16 Studies indicate that anxiety can increase during certain periods of the disease, such as the

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discovery of the tumor, then peaks during surgery and remains high until a year subsequent when it begins to decline.15 For some patients, anxiety can become so severe that they may be unable to adhere adequately to their medical treatment and seek to avoid fear-provoking procedures.17 Anxiety disorders appear to be more common in persons with cancer than controls or other chronic illnesses in the general population. Maguire et al., for example, found moderate to severe anxiety in 27% of a sample of breast cancer patients as compared to 14% in a control sample.18 In addition, Brandenberg et al. identified 28% of advanced melanoma patients as having anxiety compared to 15% of familial melanoma patients with no diseases.19 Massie and Holland reported that anxiety accounted for 16% of requests for psychiatric consultations among inpatients.10 Some researchers have suggested that cancer survivors may respond to the psychological distress and uncertainty about the future by displaying posttraumatic stress disorder (PTSD)-like symptoms similar to those experienced by victims of war or environmental disasters.20 Some of these symptoms have been reported as somatic vigilance and recurrent recollection of illness-related events, as well as symptomatology around anniversary dates. However, these symptoms appear to dissipate over time as the fear of recurrence lessens. Other studies have reported symptoms characteristic of stress or trauma symptoms in survivors of cancer, such as avoidant behaviors, intrusive thoughts, and heightened arousability.21

3.0.

PSYCHOSOCIAL INTERVENTIONS FOR CANCER PATIENTS

Given the above description documenting the negative psychosocial consequences of cancer, the importance of developing effective interventions to improve the quality of life of cancer patients appears obvious.22,23 In fact, Redd24 suggests that an important factor responsible in part for the birth of psychosocial oncology as a field was the publishing of certain studies that underscored the successful use of behavioral procedures to control the anticipatory side effects of cancer chemotherapy, such as nausea and vomiting.25 Moreover, during the past two decades, a sufficiently large number of intervention studies have been conducted engendering a number of qualitative and quantitative review articles.26−29 The general conclusion that the majority of these reviews reached underscores the efficacy of a wide variety of psychosocial interventions geared to improve the quality of life of adult cancer patients. For example, Meyer and Mark conducted a meta-analysis of 62 treatment-control comparisons and found the beneficial and significant effect size ds were .24 for emotional adjustment measures, .19 for functional adjustment measures, .26 for measures of treatment-and disease-related symptoms, and .28 for compound and global measures.29 However, similar to a qualitative literature review regarding earlier published studies,30 significant differences among varying types of treatment approaches (e.g., behavioral versus supportive group therapy) were not found. Because a comprehensive review of the treatment outcome literature for cancer patients is beyond the scope of this chapter, the reader is directed to the listed review articles (see also Baum and Andersen31 ). However, we should briefly note that such interventions can be grouped into the following general categories: educational interventions, cognitive–behavioral strategies, and group therapy approaches.

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3.1.

Educational Interventions

The major goal of educational strategies is to reduce cancer patients’ distress and improve their sense of control that may be engendered by lack of knowledge and feelings of uncertainty. The topics covered include technical aspects of the disease and its treatment, potential side effects, navigating the medical system, and the physician-patient relationship. Research suggests that providing such information can lead to beneficial effects, such as decreases in depression and anxiety.23

3.2.

Cognitive–Behavioral Interventions

Cognitive–behavior therapy (CBT) embraces an empirical foundation that focuses on the inter-relationships among behavior, thoughts, emotions, and biological events regarding mental health problems and medical symptom development and persistence. CBT, in this context, incorporates a wide array of intervention strategies that attempt to change those behavioral, cognitive, and affective variables that mediate the negative effects of cancer and its treatment. Many strategies under the CBT umbrella are theoretically based on principles of respondent and operant conditioning, such as contingency management (e.g., changing the consequences of behavior to change the behavior), biofeedback, relaxation training, and systematic desensitization, whereas other strategies are more cognitive in nature and include techniques such as cognitive distraction, cognitive restructuring, guided imagery, and problemsolving training. Applications of CBT for cancer patients have addressed both specific negative symptoms (e.g., anticipatory nausea, pain), as well as overall distress and quality of life.

3.3.

Supportive Group Therapy Approaches

The potential strengths of group psychotherapy for cancer patients are threefold: (a) it can provide for a milieu in which people with similar experiences can provide emotional support to each other; (b) it is cost-effective for the patient; and (c) it is time-efficient for the mental health professional. One cautionary note—research suggests that group therapy programs which focus primarily on providing peer support and emphasize the shared expression of emotions are less effective than either educational protocols or programs that teach coping skills.32

4.0. OUR CONTRIBUTIONS TO SECONDARY PREVENTION OF PSYCHOLOGICAL DISTRESS—THE ROLE OF PROBLEM SOLVING AND PROBLEM SOLVING THERAPY (PST) Problem solving in real-life situations, often referred to as “social problem solving,” is considered to be an important psychological variable that mediates the impact of cancer.23 In this context, it is defined as “a general coping approach that can help people manage or adapt to any stressful situation, thereby enhancing their flexibility and perceived control and minimizing their emotional distress even in situations that cannot be changed for the better” (p.10).33 Therefore training individuals under stress in various problem-solving skills is hypothesized to lead to improved quality of life and decreased emotional distress. Such a hypothesis has been found to be valid across a wide range of patient populations, ages, and psychological difficulties.34

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The conceptual relevance of problem-solving therapy (PST) for persons with cancer in particular is embedded in a general problem-solving model of stress, whereby the experience of cancer is conceptualized both as a major negative life event and the cause of a series of stressful daily problems.35 Both sources of stress are further hypothesized to increase the likelihood that a cancer patient will experience significant psychological distress, such as depression and anxiety. However, one’s problem-solving ability is conceptualized as an important moderator of these relationships, whereby effective problem-solving ability should attenuate the probability of experiencing distress, even when the person is confronted by cancer-related difficulties. The core assumptions of this model have been supported by research findings regarding both university students and clinical patient samples,36−45 as well as among adult cancer patients.36,37 For example, in one study that focused on a group of 105 patients who recently had been diagnosed with cancer, we found that study participants who were characterized by less effective problem solving also reported higher levels of anxiety and depressive symptomatology, as well as greater numbers of cancer-related problems.36 In a second study, we attempted to assess the predictive relationship of problem solving to cancer-related distress among a sample of 64 women who had successfully undergone surgery for breast cancer from one to 13+ years prior to their participation in the investigation. Results indicated that problem solving was found to be a significant predictor of psychological distress, whereas time since surgery was not associated with cancer-related distress symptomatology.36 In a further study, we identified the following relationships—under similarly high levels of cancer-related stress, those patients who were characterized as ineffective problem solvers reported higher levels of depression as compared to their cancer patient counterparts who were characterized as effective problem solvers.37 The major implication of this model for treatment, then, suggests that providing PST to patients with cancer should increase their ability to cope more effectively, and therefore, should impact positively on their distress and quality of life. This is in keeping with Andersen’s (2001) biobehavioral model of cancer stress and disease course, which in part underscores the importance of impacting on a cancer patient’s level of stress as a means of enhancing his or her quality of life and potentially improving the overall disease outcome.46 Previous research that has identified PST to be an efficacious clinical intervention for a variety of psychological disorders,47,48 especially major depression,49−51 offers additional support for the hypothesis that PST would be an efficacious intervention for such goals among adult cancer patients.

4.1.

Project Genesis: PST for Distressed Adult Cancer Patients

Given the above context, we conducted a 5-year randomized clinical trial entitled Project Genesis to assess the efficacy of PST as a means of improving the quality of life of distressed adult cancer patients.52 In this clinical trial, adult cancer patients who were experiencing significant distress and depression were randomly assigned to one of three conditions: (a) ten 1.5-hour sessions of individual PST; (b) ten 1.5-hour sessions of PST provided simultaneously to both the cancer patient and his or her designated significant other (e.g., spouse, family member); or (c) a “treatment as usual” control. The condition that involved a significant other was included to assess the enhanced effects of formalizing a social support system where the role of the significant other was conceptualized as a “problem-solving coach.”

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328 Arthur M. Nezu and Christine Maguth Nezu Table 1. Specific Training Activities Associated with Four Rational Problem-Solving Tasks Problem Definition and Formulation

r r r r r

Gather all available facts about the problem Describe these facts in clear and unambiguous terms Differentiate between facts and assumptions Identify those factors that make the situation a problem Set realistic problem-solving goals

Generation of Alternatives

r Generate a comprehensive list of alternative solutions r Defer critical judgment r Think of general strategies, as well as tactics for each strategy, when generating possible solution ideas

Decision Making

r Evaluate each alternative by rating (a) the likelihood that the alternative, if implemented optimally, r

will achieve the desired goals, and (b) the value of the alternative in terms of personal, social, longterm, and short-term consequences Choose the alternative(s) that have the highest utility

Solution Implementation and Verification

r r r r

Carry out the chosen plan Monitor the effects of the implemented solution Compare or match the predicted and actual effects Self-reinforce if the match is satisfactory: recycle through the process if the match is unsatisfactory

PST in this study was based on the empirically validated problem-solving training manual originally developed for major depressive disorder53 and revised specifically for an adult cancer population.33 The overarching goals of PST are to improve an individual’s overall problem orientation and rational problem-solving skills, while inhibiting tendencies to be impulsive or avoidant. Training in problem orientation is geared toward providing patients with a rational, positive, and constructive set or cognitive appraisal to problems in living and problem solving as a means of coping with them. The specific therapy objective is to change those attitudes or beliefs that inhibit or interfere with attempts to adaptively cope with stressful problems. In addition, participants are taught (a) to label emotions as cues as a means of identifying the existence of a problem, and (b) to inhibit the tendency to respond automatically in either an impulsive or avoidant manner, but rather, to engage in a systematic and planful style of problem solving. Training in rational problem-solving involves teaching patients to (a) better define and formulate the nature of problems, (b) generate a wide range of alternative solutions, (c) systematically evaluate the potential consequences of a solution and select the most optimal ones to implement, and (d) monitor and evaluate the actual solution outcome after its implementation (see Table 1 for a list of specific training activities). In Project Genesis, Session 1 of ten sessions involved a general introduction to the program, whereas Sessions 2 and 3 were devoted specifically to the problem-orientation component, and Sessions 4–6 involved didactics and practice in the four rational problem-solving skills. The last four sessions provided for an applied integration of the model, as well as continued practice in the various problem-solving components. Emphasis on the problem-orientation component continued throughout treatment. In addition, between-session homework assignments, relevant to each step (e.g., to generate alternative solutions to a personally-relevant problem), were included as part of the therapy regimen. In an attempt to facilitate maximal therapeutic gain for each patient, as well as to encourage attendance, therapists were

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directed to ensure that the treatment protocol be made relevant to the specific life circumstances of each individual and not simply to teach skills on a “hypothetical or conceptual level.” Last, each patient was provided with written materials reflecting all aspects of PST to use as their own “self-help problem-solving manual.” In particular, patients were encouraged to refer to this material between sessions and especially post-intervention. Participants in the PST condition continued to receive standard medical care regarding their cancer treatment. The second treatment condition assessed involved PST with a significant other (PST/SO). This protocol was implemented identically to that of the PST condition except a designated “significant other (SO)” was included in the training. This SO served as a problem-solving coach by providing social support, encouragement, and feedback regarding the patient’s attempts to resolve problems and cope with cancer-related stressors. SO’s participated in all phases of the intervention and were provided their own set of handouts and training materials. Whereas they were encouraged to use the problem-solving principles to help cope with their own problems when necessary, the primary purpose of their involvement centered around the cancer patient. This condition was included to empirically assess whether incorporating a structured social support component in therapy would augment the effects of individually administered PST. Significant clinical experience providing PST training to family members of cancer patients to foster their own coping skills as a means of minimizing potential burnout and caregiver stress suggested to us the strong possibility of enhanced effects if PST was provided to a patient-significant other team.54,55 Similar to the PST condition, participants in this condition continued to receive standard medical care related to their cancer treatment. Results of this investigation at posttreatment across several self-report, clinicianratings, and ratings by the significant other provide strong evidence in support of the overall efficacy of PST for decreasing emotional distress and improving the overall quality of life of patients with cancer. Specifically, patients in both treatment conditions were found to evidence significant improvement as compared to individuals in the control condition. At posttreatment, no differences were found between these two conditions. However, at a 6-month follow-up assessment, on approximately half of the variables assessed, patients who received PST along with a significant other continued to improve significantly beyond those individuals receiving PST by themselves, highlighting the advantage of formally including a collaborative person in treatment. These positive effects of PST were not only statistically significant, but also found to be highly clinically significant as well. Moreover, analyses indicated that improvements in problem solving were found to correlate significantly with decreases in psychological distress and improvements in overall quality of life.

4.2.

Problem Solving for Caregivers of Cancer Patients

Family members who are responsible for the day-to-day care of cancer patients can also experience high levels of distress and frequent problems. As such, we have also hypothesized that training such individuals themselves in problem-solving skills may be a particularly useful approach in helping family caregivers to cope more effectively in this role.55,56 The “Prepared Family Caregiver Course” adapted the D’Zurilla and Nezu57 PST model as a means of providing the following types of information to family caregivers of cancer patients: (a) understanding the problem; (b) when to get professional help; (c) what can be done to deal with, as well as prevent, a problem; (d) identifying obstacles when they arise and planning to overcome them;

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330 Arthur M. Nezu and Christine Maguth Nezu and (e) carrying out and adjusting the plan. Manuals have been developed that contain guided problem-solving plans across a variety of physical (e.g., fatigue, hair loss, appetite difficulties) and psychosocial (e.g., depression, anxiety) problems that cancer patients commonly experience.58,59 These manuals use the acronym COPE to highlight various problem-solving operations, where C = creativity, O = optimism, P = planning, and E = expert information. Although no controlled studies have yet been conducted with this protocol, a program evaluation concerning participant satisfaction and acceptability of the treatment approach among various samples of caregivers has been very promising.54

5.0.

IMPACT OF PROBLEM SOLVING

Others have also looked to problem-solving training as a potentially important intervention strategy to help cancer patients and their families. For example, Fawzy et al. developed a multicomponent treatment package that included PST and focused on patients who were newly diagnosed with malignant melanoma.60 Cancer patients were randomly assigned to one of two conditions—a 6-week structured group intervention that included PST, stress management training, group support, and health education, and a no-treatment control. At the end of six weeks, patients receiving the structured intervention began showing reductions in psychological distress as compared to control participants. However, six months posttreatment, the group differences were very pronounced. Moreover, five years following the intervention, treated patients continued to show significantly lower levels of anxiety, depression, and total mood disturbance.61 In addition, at the end of the original 6-week program, patients receiving the treatment evidenced significant increases in the percentage of large granular lymphocytes, suggesting a positive treatment effect on immune functioning. Further, six months posttreatment, this increase in granular lymphocytes continued and increases in natural killer cells were also evident. Last, although not originally structured to determine the effects of treatment on actual health outcomes, it was found six years posttreatment that treated patients experienced longer overall survival as compared to control participants, as well as a trend for a longer period to recurrence for the treated patients.62 This same intervention was later adapted for a Japanese population and found to be effective for Japanese women with breast cancer.63 Mishel et al. paired training in problem solving with a cognitive reframing strategy as a means of helping 134 Caucasian and 105 African-American men with localized prostate carcinoma to manage their levels of uncertainty and symptom control.64 Participants were randomly assigned to one of three experimental conditions—the combined psychosocial treatment provided only to the patient himself, treatment provided to the patient and a selected family member, and the control (“medical treatment as usual”). Both forms of treatment were provided by trained nurses through weekly phone calls for eight weeks. In general, regardless of ethnicity, participants who received either form of the intervention improved significantly as measured at the 4-month post-baseline assessment. It is during this period of time that cancer treatment side effects are most prevalent. As such, it is particularly noteworthy that the combined PST and cognitive reframing treatment led to significant improvement in control of incontinence at 4-months post-baseline. Allen et al. assessed the efficacy of PST, as compared to a no-treatment control, with regard to a population of 164 women diagnosed with breast cancer and for

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whom a first course of chemotherapy had been recently initiated.65 PST consisted of two in-person and four telephone sessions with an oncology nurse who provided problem-solving skills training to the women over a 12-week period. This treatment program was designed to empower women with breast carcinoma to cope more effectively with a range of difficulties when diagnosed in mid-life. Participants in both conditions were assessed for physical and psychosocial adjustment. At a 4-month evaluation, participants in general tended to have significantly less unmet needs and better mental health as compared to baseline. At the 8-month assessment, differences between the treated and control conditions emerged, pointing to the efficacy of the training. In general, PST led to improved mood and more effective coping with problems associated with daily living tasks. Further, the intervention was effective for the majority of women in resolving a range of problems related to cancer and its treatment, including physical side effects, marital and sexual difficulties, and psychological problems. However, an unexpected finding emerged with regard to women who had baseline scores characteristic of “poor problem solving.” In essence, such individuals, relative to the control participants, were less likely to resolve such cancer-related problems. Qualitative analyses suggested that such individuals became especially overwhelmed by expectations to “go it alone” after only one in-person treatment session. As such, these authors concluded that an important outcome of this study was the advisability of prescribing treatment based on one’s level of need or risk. In other words, for individuals who are initially identified as poor problem solvers, a more intensive program (e.g., more face-to-face sessions) may be necessary as compared to those who at baseline are average or good problem solvers. A study by Given et al. focused on 237 adult cancer patients recently diagnosed with a solid tumor and who were undergoing a first course of chemotherapy.66 Participants were randomly assigned to either a “symptom management intervention” or conventional care. The cognitive–behavioral intervention was based on the PST model of D’Zurilla and Nezu67 in order to generate a listing of possible strategies to provide to patients and their caregivers in order to more effectively cope with a variety of cancer-related problems (e.g., alopecia, depression, fatigue, pain, insomnia). Based on discussions between a nurse and patient-caregiver dyad, various interventions were selected for implementation. Treatment occurred within ten contacts (in person and telephone) over the course of 20 weeks. Results indicated that treated patients who had higher baseline symptom severity levels reported lower depression at ten, but not 20 weeks. Unexpectedly, patients in the experimental condition characterized by higher baseline depression were found to be more depressed at ten weeks that control patients. Further, the intervention was found to be more effective in lowering depression at ten weeks as a function of its impact on other symptoms rather than on depression directly. However, at 20 weeks, a significant main effect for treatment on depression was not identified. As such, these authors concluded that the intervention influenced depression differentially over time. Specifically, it appeared to lower depression through enhanced ability to manage symptoms unrelated to depression and only later did it impact depression directly. In a subsequent assessment of the impact of this intervention on the limitations imposed on patients by symptoms of cancer and its medical treatment, Doorenbos et al. recently reported that on average, after ten weeks, patients receiving the problem-solving based intervention reduced such symptom limitations by a statistically significant 13 points more than the control group.68 Moreover, this positive

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332 Arthur M. Nezu and Christine Maguth Nezu treatment effect was maintained over the course of the remainder of the treatment. Parenthetically, these authors concluded that this intervention was particularly helpful for younger individuals in managing cancer-related symptom limitations. With regard to problem-solving interventions for family caregivers of cancer patients, Toseland et al. reported a study that evaluated the efficacy of an intervention for spouses of cancer patients that included support, problem-solving, and coping skills.69 Forty male and forty female spouses of cancer patients were randomly assigned to this intervention or a “usual treatment” condition. Results indicated that little change occurred over time for caregivers in either the treatment or control condition. However, this lack of effects were probably due to the low level of distress and problems that existed across this sample at pretreatment. Thus, when focusing on a subsample of distressed caregivers, significant effects were in fact evident. For example, distressed caregivers undergoing the PST-based intervention were found to significantly improve in their physical, role, and social functioning, as well as their ability to cope with pressing problems. The actual cancer patients related to this subsample of distressed caregivers receiving the intervention were also found to be significantly less depressed at posttreatment. Moreover, in a subsequent 6-month post-baseline follow-up, it was found that, overall, patients whose spouses received the PST intervention became significantly less depressed than did control patients.70 Schwartz et al. assessed the impact of a brief PST intervention regarding cancerspecific and general distress among 341 women with a first degree relative who had recently been diagnosed with breast cancer.71 This investigation included two conditions: PST and a general health counseling (GHC) protocol. Both interventions were conducted during a single 2-hour individual session with a health educator. Initial analyses indicated that both approaches equally led to decreases in cancer-specific and general distress. However, when PST participants were divided into those who practiced the skills and those who did not, significant differences did emerge. Specifically, “PST-practicers” had significantly greater decreases in cancer-specific distress compared to both “non-practicers” and GHC participants. In addition, controlling for baseline education and distress differences between the groups did not reduce the magnitude of these results. Adding to this same sample to eventually include 510 women who had a firstdegree relative with breast cancer, a different question was now asked—does a brief PST intervention increase the likelihood of adherence to breast self-examination?72 Whereas initial results found no differences between conditions, a cancer-specific distress by treatment interaction was identified. Specifically, among women who participated in the PST condition, those with high levels of distress were two times more likely to improve in adherence than women low in cancer-specific distress. No such effect was identified among control participants. The authors suggest that women with a family history of breast cancer who have high levels of distress may be most likely to benefit from PST when attempting to promote adherence to breast cancer screening. Sahler et al. focused on the well-being of mothers of newly diagnosed pediatric cancer patients.73 Ninety-two such mothers were randomly assigned to one of two conditions—PST and a control (standard psychosocial care). The problem-solving intervention consisted of eight 1-hour individual sessions and was adapted for this population based on the work of D’Zurilla and Nezu.67 At posttreatment, results indicated that mothers in the PST condition has significantly enhanced problemsolving skills and significantly decreased negative affectivity as compared to their control counterparts. Moreover, analyses revealed that changes in self-reports of

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problem-solving behaviors accounted for 40% of the difference in mood scores between the two conditions. In addition, the intervention appeared to have the greatest impact on improving constructive problem solving, whereas improvement in mood was most influenced by decreases in dysfunctional problem solving. In an extension of their previous investigation, Sahler et al. further assessed the efficacy of PST among a sample of 430 English- and Spanish-speaking mothers of pediatric cancer patients.74 Again, the 8-week PST condition was compared to a usual care control. Replicating their previous work, results from this study indicated that mothers receiving the PST protocol reported significantly enhanced problemsolving skills and significantly decreased negative affectivity. Whereas treatment effects appeared to be greatest at posttreatment, several differences were maintained at the 3-month follow-up. Interestingly, the efficacy of PST for Spanish-speaking mothers exceeded that for English-speaking mothers. Moreover, results suggest that young, single mothers befitted the most from the problem-solving intervention.

6.0.

NEW DIRECTIONS FOR FUTURE RESEARCH

Based on our review of the general literature regarding psychosocial interventions for the treatment of stress, anxiety, and depression among cancer patients, we offer several recommendations for future research that focus mainly on intervention studies. 1. More research should be conducted regarding efficacious interventions to improve the quality of life of cancer survivors and their families. Although a substantial body of research already exists, we need to know more about what types of treatment approaches are effective for what types of patients as a function of type of cancer, stage of cancer, socioeconomic status, ethnic background, level of stress experienced, where in the continum of survivorship and other important patient-relevant psychosocial variables. Because of the significant personal, medical, and economic impact cancer and its treatment represents, more research evaluating the efficacy of a wide range of psychosocial strategies should be conducted in the future. 2. More research should be conducted regarding the effects of psychosocial interventions on health outcome (i.e., prolonged survival). Currently, the literature is equivocal in its ability to indicate whether psychosocial treatments can have an impact on health outcome, particularly with regard to prolonging the life of a cancer patient.23 While wellcontrolled investigations capable of addressing such a question requires extensive resources, preliminary results suggest that such efforts may be worthwhile. 3. Improve the methodological rigor of the research. Because a thorough critical analysis of the literature was beyond the scope of this chapter, we did not document the many methodological limitations identified across studies. We will not belabor the point, except to list specific recommendations: (a) include adequate control groups; (b) use manualized protocols; (c) include treatment integrity (i.e., therapist adherence and competence) measures; and (d) use more multi-modal assessment procedures (e.g., multi-trait, multi-method approaches) for outcome measurement. In addition, special care needs to be taken in describing each population under study in detail in order to better allow for meaningful comparisons across studies. 4. Conduct component analyses of the intervention studies. Beyond simply comparing an intervention to either an alternative treatment approach (e.g., education) or a control condition (e.g., waiting-list), additional research strategies should be implemented to help answer the question “which treatment components are responsible

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334 Arthur M. Nezu and Christine Maguth Nezu for the actual improvement in symptoms?” Future research needs to be more explicit in delineating specific treatment strategies and provide for an assessment of the specific impact of a particular intervention on a given hypothesized mechanism of action and its resulting impact on changes of interest. In that manner, a more comprehensive and microanalytic understanding of cause-effect relationships can be obtained. 5. Identify important moderators of treatment efficacy. Identification of important moderator variables (e.g., race, age, gender, cultural background, severity of symptoms, number of symptoms) can potentially lead to better matching of a given treatment for a particular patient, as well as the development of more effective interventions per se. 6. Identify important mechanisms of action. Future research should also address the relationship between outcome (e.g., psychological well being, improved health) and a variety of variables (e.g., cognitive, emotional, behavioral, immune system function) hypothesized to contribute to the etiopathogenesis and course of that outcome. In this manner, salient treatment targets can be identified and more empiricallybased decisions about treatment design can be made. 7. Improve treatment implementation and access. Related to the issue of health economics, future research should also attempt to save costs directly related to implementing psychosocial interventions. Having a doctoral-level psychologist, for example, providing individual or group therapy to cancer patients and their families is likely to be viewed as too high a price to the health care delivery system. As such, studies geared to assess alternative means of conducting psychosocial interventions should be conducted in the future. For example, additional methods exist to conduct such treatment approaches besides the traditional use of a single therapist in face-to-face situations. Use of videos, computers, the internet, or telemedicine support systems represent further possibilities regarding ways to cut costs, as well as to increase accessibility to patients not living close to a major medical center.

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