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Cognitive Behavioral Therapy for Psychological Distress, Self Care and Quality of Life in Patients with Cancer: A Meta-analysis

Pok Ja Oh1, Eun Ai Lee2
Korean Journal of Adult Nursing 2013;25(4):377-388.
Published online: August 18, 2013

1Department of Nursing, Sahmyook University, Seoul

2Department of Nursing, Graduate School, Sahmyook University, Seoul, Korea

Corresponding author: Oh, Pok Ja Department of Nursing, Sahmyook University, 815 Hwarangro, Nowon-gu, Seoul 139-742, Korea Tel: +82-2-3399-1589, Fax: +82-2-3399-1594, E-mail: ohpj@syu.ac.kr
• Received: March 5, 2013   • Accepted: August 7, 2013

© 2013 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    The purpose of this study was to assess the effects of cognitive behavioral therapy (CBT) on depression, anxiety, self care behavior and quality of life in cancer patients.
  • Methods
    Two thousand and eighty three abstracts were identified through six electronic databases (1980 to June 2012) in Korea. Seventeen studies involving 679 participants met the inclusion criteria for meta analysis. Two authors independently assessed trial quality by Cochrane's Risk of Bias and Methodological Items for Non Randomized Studies and extracted data. The data were analyzed by the RevMan 5.2 program of Cochrane library.
  • Results
    Overall, study quality was moderate to high. CBT was conducted for a mean of 4.2 weeks, 7 sessions and an average of 36.1-minutes per session. CBT was effective for depression (d=-0.85; 95% CI=-1.09, -0.61), anxiety (d=-0.52; 95% CI=-0.75, -0.29), self care behavior (d=-1.34; 95% CI=-1.93, -0.74), and quality of life (d=-0.42; 95% CI=-0.80, -0.04). Publication bias was not detected as evaluated by funnel plot and Egger's test.
  • Conclusion
    CBT has small to large effects on depression, anxiety, self care and quality of life. These finding suggests that various CBT interventions can assist cancer patients in reducing emotional distress and improving self care and quality of life.
  • Key Words: Neoplasm; Distress; Quality of life; Intervention studies; Meta-analysis
Figure 1.
Flow of included studies through database searching.
kjan-25-377f1.jpg
Figure 2.
Forest plot of effect size and 95% CI by cognitive behavioral therapy on psychological distress.
kjan-25-377f2.jpg
Figure 3.
Forest plot of effect size and 95% CI by cognitive behavioral therapy on self-care.
kjan-25-377f3.jpg
Figure 4.
Forest plot of effect size and 95% CI by cognitive behavioral therapy on quality of life.
kjan-25-377f4.jpg
Table 1.
Characteristics of Included Studies (N=17)
ID Design Subject (stage) Sample size Scale Interventions Source Outcomes Direction of effect
Exp. (n) Con. (n) Name/Type Weeks/Number of Sessions /Min
Kam et al (2003) NRCCT Cancer patients 26 26 Oh et al (2007)'s scale/ STAI Self efficacy promoting program/individual 2/2/25 Master's (nursing) Self efficacy/ self care/anxiety +/+/No diff
Shin (2007)† RCT Cancer patients (home based) 17 19 Miller's hope scale/hope index scale from nursing outcomes classification/ Zung (1965)'s depression scale Hope intervention/ individual 8/8/40 Master's (nursing) Hope/hope index/ depression +/+/No diff
Tae & Youn (2006) NRCCT Cancer patients 15 15 Hearth (1991)'s hope scale/ Youn (1997)'s QOL scale Forgiveness nursing intervention program/individual 1/4/60 Journal (nursing) Hope/quality of life +/+
Kim et al (2008)† RCT Cancer patients (home based) 20 20 Nowtony (1989)'s hope scale/ Index scale from nursing outcomes classification/ Cella (1993)'s functional assessment cancer therapy- general QOL Hope intervention/ individual 6/6/40~60 Journal (nursing) Hope/hope index/ quality of life +/+/No diff
Ko & Park (2011)|| NRCCT Breast cancer patients 17 22 Sherer's self efficacy scale/ Song's self efficacy scale/ Dodd's self care scale/ Tae's QOL scale Self efficacy promoting program/individual and group 4/6/21 Journal (nursing) General self efficacy/ specific self efficacy/ self care behavior/ quality of life No diff/+/No diff/ No diff
Lee (2006)|| NRCCT Lung cancer patients 12 16 Jang (1996)'s QOL scale Programs using strategies for promoting self efficacy/group 4/4/2 Journal (nursing) Knowledge/ self efficacy/ quality of life +/+/No diff
Lee & Oh (2004)ठNRCCT Cancer patients (stage 1-2) 15 15 BDI/STAI Guided imagery program 1/6/15 Journal (nursing) Anxiety/depression -/No diff
Kim a (2008) NRCCT Cancer patients (stage 1-3) 20 20 Yesavage (1986)'s depression scale/Oh, Song, Kim (1998)'s sleep scale Guided imagery with visual screen/individual 1/12/18 Master's (nursing) Depression/sleep -/+
Byun (1997) NRCCT Cancer patients (stage 1-4) 14 17 Rhodes's index of nausea and vomiting/STAI Guided imagery program/individual 2/11/15 Master's (nursing) Nausea & vomiting/ anxiety No diff/-
Oh (2008)‡|| NRCCT Cancer patients (stage 1-4) 21 21 HADS Spirituality/ hope promoting program/individual and group 4/4/30~50 Journal (nursing) Fighting spirit/ helplessness/ anxiety/self-care +/-/No diff/+
Jeong (2011)§ NRCCT Cancer patients (stage 1-4) 8 8 STAI/BAI/PPI/VAS Mindfulness-based stress reduction program/group 8/8/90 Master's (non- nursing) Anxiety/pain/ blood pressure/pulse -/-/-/-
Kim b (2008) NRCCT Gastric cancer patients 20 22 Sherer& Maddux (1982)'s self efficacy scale/Oh (1997)'s self care scale/Tae et al (2002)'s QOL scale Web based self-efficacy promoting program/individual and group 6/6/25 Doctoral (nursing) General self-efficacy/ specific self-efficacy/ self-care behavior/ body weight/BMI/ quality of life +/+/+/-/+/+
Kim et al (2005) NRCCT Cancer patients 19 19 STAI/BDI/Nowotny (1989)'s hope scale/Jang (1993)'s QOL scale Guided imagery program/individual 5/14/45 Journal (nursing) Anxiety/depression/ quality of life/ hope No diff/-/No diff/+
Park (2010)ठNRCCT Cancer patients 15 17 Park (2006)'s mindfulness scale/Hayes et al (2004)'s AAQ;acceptance&action questionnaire-16/ Kim (2006)'s clinging scale/ SCL-90-R/EORTC QLQ-C30 Meditation and group counseling/group unclear/unclear /3night 4days Journal (non-nursing) Mindfulness/ acceptance behavior/ cling/ anxiety/ depression/hostility/ quality of life/ somatization +/+/-/-/-/-/ No diff/ No diff
Shim (2007)ठNRCCT Leuemia patients 30 30 VAS/STAI/Blood test Imagery therapy/ individual 4/12/13 Master's (nursing) Stress/state anxiety/ anxiety/ WBC/ ANC/ lymphocyte -/No diff/-/-/-/+
Jang (2010)∗ RCT Breast cancer patients 21 21 PKPCT/HADS/Fact-B Meditation program/ group 8/8/60 Doctoral (nursing) Power/Anxiety/ Depression/ quality of life +/-/-/+
Park & Oh (2010)§|| NRCCT Cancer patients 39 42 SCL-90-R/Nowontny (1989)'s scale/ C-QOL Psychosocial intervention/individ ual and group 8/8/60 Journal (nursing) Depression/hope/ quality of life -/+/+

Exp.=experimental group; Con.=control group; diff=difference; RCT=randomized controlled trials; NRCCT=non-randomized controlled clinical trial; BDI=beck depression inventory; STAI=state-trait anxiety inventory.

∗Allocation concealment;

†Blind stated;

‡Intention-to-treat;

§＜5% Attrition rate;

||Calculation of sample size.

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    Cognitive Behavioral Therapy for Psychological Distress, Self Care and Quality of Life in Patients with Cancer: A Meta-analysis
    Korean J Adult Nurs. 2013;25(4):377-388.   Published online August 31, 2013
    DOI: https://doi.org/10.7475/kjan.2013.25.4.377
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    Cognitive Behavioral Therapy for Psychological Distress, Self Care and Quality of Life in Patients with Cancer: A Meta-analysis
    Korean J Adult Nurs. 2013;25(4):377-388.   Published online August 31, 2013
    DOI: https://doi.org/10.7475/kjan.2013.25.4.377
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    Cognitive Behavioral Therapy for Psychological Distress, Self Care and Quality of Life in Patients with Cancer: A Meta-analysis
    Image Image Image Image
    Figure 1. Flow of included studies through database searching.
    Figure 2. Forest plot of effect size and 95% CI by cognitive behavioral therapy on psychological distress.
    Figure 3. Forest plot of effect size and 95% CI by cognitive behavioral therapy on self-care.
    Figure 4. Forest plot of effect size and 95% CI by cognitive behavioral therapy on quality of life.

    Figure 1.

    Figure 2.

    Figure 3.

    Figure 4.

    Cognitive Behavioral Therapy for Psychological Distress, Self Care and Quality of Life in Patients with Cancer: A Meta-analysis

    Characteristics of Included Studies (N=17)

    ID Design Subject (stage) Sample size Scale Interventions Source Outcomes Direction of effect
    Exp. (n) Con. (n) Name/Type Weeks/Number of Sessions /Min
    Kam et al (2003) NRCCT Cancer patients 26 26 Oh et al (2007)'s scale/ STAI Self efficacy promoting program/individual 2/2/25 Master's (nursing) Self efficacy/ self care/anxiety +/+/No diff
    Shin (2007)† RCT Cancer patients (home based) 17 19 Miller's hope scale/hope index scale from nursing outcomes classification/ Zung (1965)'s depression scale Hope intervention/ individual 8/8/40 Master's (nursing) Hope/hope index/ depression +/+/No diff
    Tae & Youn (2006) NRCCT Cancer patients 15 15 Hearth (1991)'s hope scale/ Youn (1997)'s QOL scale Forgiveness nursing intervention program/individual 1/4/60 Journal (nursing) Hope/quality of life +/+
    Kim et al (2008)† RCT Cancer patients (home based) 20 20 Nowtony (1989)'s hope scale/ Index scale from nursing outcomes classification/ Cella (1993)'s functional assessment cancer therapy- general QOL Hope intervention/ individual 6/6/40~60 Journal (nursing) Hope/hope index/ quality of life +/+/No diff
    Ko & Park (2011)|| NRCCT Breast cancer patients 17 22 Sherer's self efficacy scale/ Song's self efficacy scale/ Dodd's self care scale/ Tae's QOL scale Self efficacy promoting program/individual and group 4/6/21 Journal (nursing) General self efficacy/ specific self efficacy/ self care behavior/ quality of life No diff/+/No diff/ No diff
    Lee (2006)|| NRCCT Lung cancer patients 12 16 Jang (1996)'s QOL scale Programs using strategies for promoting self efficacy/group 4/4/2 Journal (nursing) Knowledge/ self efficacy/ quality of life +/+/No diff
    Lee & Oh (2004)ठNRCCT Cancer patients (stage 1-2) 15 15 BDI/STAI Guided imagery program 1/6/15 Journal (nursing) Anxiety/depression -/No diff
    Kim a (2008) NRCCT Cancer patients (stage 1-3) 20 20 Yesavage (1986)'s depression scale/Oh, Song, Kim (1998)'s sleep scale Guided imagery with visual screen/individual 1/12/18 Master's (nursing) Depression/sleep -/+
    Byun (1997) NRCCT Cancer patients (stage 1-4) 14 17 Rhodes's index of nausea and vomiting/STAI Guided imagery program/individual 2/11/15 Master's (nursing) Nausea & vomiting/ anxiety No diff/-
    Oh (2008)‡|| NRCCT Cancer patients (stage 1-4) 21 21 HADS Spirituality/ hope promoting program/individual and group 4/4/30~50 Journal (nursing) Fighting spirit/ helplessness/ anxiety/self-care +/-/No diff/+
    Jeong (2011)§ NRCCT Cancer patients (stage 1-4) 8 8 STAI/BAI/PPI/VAS Mindfulness-based stress reduction program/group 8/8/90 Master's (non- nursing) Anxiety/pain/ blood pressure/pulse -/-/-/-
    Kim b (2008) NRCCT Gastric cancer patients 20 22 Sherer& Maddux (1982)'s self efficacy scale/Oh (1997)'s self care scale/Tae et al (2002)'s QOL scale Web based self-efficacy promoting program/individual and group 6/6/25 Doctoral (nursing) General self-efficacy/ specific self-efficacy/ self-care behavior/ body weight/BMI/ quality of life +/+/+/-/+/+
    Kim et al (2005) NRCCT Cancer patients 19 19 STAI/BDI/Nowotny (1989)'s hope scale/Jang (1993)'s QOL scale Guided imagery program/individual 5/14/45 Journal (nursing) Anxiety/depression/ quality of life/ hope No diff/-/No diff/+
    Park (2010)ठNRCCT Cancer patients 15 17 Park (2006)'s mindfulness scale/Hayes et al (2004)'s AAQ;acceptance&action questionnaire-16/ Kim (2006)'s clinging scale/ SCL-90-R/EORTC QLQ-C30 Meditation and group counseling/group unclear/unclear /3night 4days Journal (non-nursing) Mindfulness/ acceptance behavior/ cling/ anxiety/ depression/hostility/ quality of life/ somatization +/+/-/-/-/-/ No diff/ No diff
    Shim (2007)ठNRCCT Leuemia patients 30 30 VAS/STAI/Blood test Imagery therapy/ individual 4/12/13 Master's (nursing) Stress/state anxiety/ anxiety/ WBC/ ANC/ lymphocyte -/No diff/-/-/-/+
    Jang (2010)∗ RCT Breast cancer patients 21 21 PKPCT/HADS/Fact-B Meditation program/ group 8/8/60 Doctoral (nursing) Power/Anxiety/ Depression/ quality of life +/-/-/+
    Park & Oh (2010)§|| NRCCT Cancer patients 39 42 SCL-90-R/Nowontny (1989)'s scale/ C-QOL Psychosocial intervention/individ ual and group 8/8/60 Journal (nursing) Depression/hope/ quality of life -/+/+

    Exp.=experimental group; Con.=control group; diff=difference; RCT=randomized controlled trials; NRCCT=non-randomized controlled clinical trial; BDI=beck depression inventory; STAI=state-trait anxiety inventory.

    ∗Allocation concealment;

    †Blind stated;

    ‡Intention-to-treat;

    §＜5% Attrition rate;

    ||Calculation of sample size.
    Table 1. Characteristics of Included Studies (N=17)

    Exp.=experimental group; Con.=control group; diff=difference; RCT=randomized controlled trials; NRCCT=non-randomized controlled clinical trial; BDI=beck depression inventory; STAI=state-trait anxiety inventory.

    Allocation concealment;

    Blind stated;

    Intention-to-treat;

    ＜5% Attrition rate;

    Calculation of sample size.

    Table 1.

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