Effectiveness of psychological interventions on depression in patients after breast cancer surgery : a meta-analysis of randomized controlled trials

Abstract

INTRODUCTION: Breast cancer has become the most common cancer in women. With the improvement of medical treatment for breast cancer, extended survival and low recurrence rates in breast cancer have been achieved. However, as a threat to the survival and quality of life, long term depression in patients with breast cancer has attracted more and more concern. In clinical practice, individually delivered Cognitive Behavioral Therapy (CBT) is widely used to deal with the depression in patients. Among the articles published, many of them showed that individually delivered CBT intervention could effectively reduce depression symptoms in patients after breast cancer surgery. But the strength of the effectiveness is unknown because these studies had not been combined into a systematic review. On the other hand, some articles have conflicting results showing no significant difference. Thus, it is meaningful to do a meta-analysis to assess the effectiveness of individual delivered CBT interventions on reducing depression in patients after breast cancer surgery.

METHODS: A comprehensive literature search was performed through English electronic databases and Chinese electronic databases, including: Medline (Ovid), PubMed, Cochrane library, CNKI database, WANFANG and VIP database. Only randomized controlled trials (RCTs) with high quality were included in this meta-analysis. Quality assessment of included studies was conducted by two reviewers based on the Jadad scale independently. The pooled effect of mean difference in depressive score between baseline and post-treatment was analyzed based on different outcome measure instruments (SDS, HADS and HAMD) separately.

RESULTS: 1882 articles were identified by the literature search. Of these, 13 RCTs with 966 participants were included in the meta-analysis. In SDS subgroup, the pooled standardized mean difference (SMD) comparing the intervention groups to the control groups was -0.87 (95% CI=-1.03, -0.71; overall effect Z=10.84; p＜0.0001), which indicated a large effect size based on Cohen's d value (Cohen's d =-0.87). In HADS subgroup, the pooled SMD comparing the intervention groups to the control groups was -0.50 (95% CI=-0.98, -0.02; overall effect Z=20.6; p=0.04), which indicated a moderate effect size (Cohen’s d =-0.50). In HAMD subgroup, the pooled SMD comparing the intervention groups to the control groups was -2.61 (95% CI=-4.07, -1.14; overall effect Z=3.49; p=0.0005), which indicated a very large effect size (Cohen’s d =-2.61). In general, the overall effect size of individually delivered CBT on reducing depression in women after breast cancer surgery was large. Meanwhile, there was no evidence of statistical heterogeneity.

CONCLUSION: This meta-analysis showed a significant efficacy of individually delivered CBT in the reduction of major depression in patients after breast cancer surgery. The level of evidence is high. In addition, CBT is feasible and well accepted by breast cancer patients, no matter delivered by psychotherapists or well-trained nurses. Depression is often associated with poor quality of life thus CBT should also be beneficial for improving quality of life by reducing depressive symptoms. Therefore, it is suggested that individually delivered CBT can be used in clinical breast cancer care for patients after surgery. However, further researches with better design and bigger sample size are needed to give more valid and reliable results and greater effect size on long term outcomes.