Psychotherapy Targeting Depression and Anxiety for Use in Palliative Care: A Meta-Analysis

Abstract

Background:

Research on the effectiveness of evidence-based practices in the treatment of depression and anxiety with palliative care populations is primarily limited to individuals having specific conditions such as cancer.

Objective:

This meta-analysis examined the effect of psychotherapy on depression and anxiety among individuals with any condition appropriate for palliative care.

Methods:

We searched PubMed, PsycINFO, Cochrane Library, and EMBASE databases until August 2017. Eligible studies were randomized controlled trials of psychotherapy that reported outcomes of depression and anxiety and included adults with serious illnesses.

Results:

The current meta-analysis included 32 randomized controlled trials with 36 samples including 1536 participants undergoing psychotherapy. Overall, findings suggest that psychotherapy in palliative care populations reduced depression (large effect) and anxiety (small effect) symptoms. Psychotherapy also improved quality of life (small effect). Significant moderators of intervention effects included type of intervention and provider, number and length of treatment sessions, and sample age. Cognitive-behaviorally based and other therapies (e.g., acceptance, mindfulness) showed significant effects, as did interventions delivered by mental health providers. More treatment sessions were associated with greater effect sizes; longer sessions were associated with decreased effect sizes. As the sample age increased, the study effect size decreased.

Conclusion:

Findings suggest that psychotherapy for individuals with serious illnesses appropriate for palliative care can mitigate symptoms of depression and anxiety and improve quality of life. Methodological reporting and quality of research designs in studies of psychotherapy for palliative patient populations could be improved. Future research is needed with a broader range of patient populations.

Introduction

The National Consensus Project for Quality Palliative Care identified psychological and psychiatric care as one of eight best practice domains in palliative care.¹ Mental health providers assist individuals who are receiving palliative care in managing psychological reactions related to life-limiting diagnoses, prognosis, and disease progression.² Individuals with life-limiting illness may experience normative psychological reactions, new psychological concerns, or exacerbation of existing concerns.^3,4 Reactions vary widely and may include feelings of loneliness, powerlessness, meaninglessness, and identity loss.^5–7 Depression and anxiety are perhaps the most common psychological symptoms experienced by individuals with serious illness receiving palliative care.^8–11 Several reviews and/or meta-analyses have examined the effects of psychotherapy on depression and anxiety but have focused on specific therapies (e.g., life review,¹² dignity therapy¹³) or specific patient populations such as those with cancer.^14–23 Because palliative care mental health providers serve individuals with various conditions, in addition to cancer, information about psychotherapy effectiveness across diverse palliative care populations is needed to inform evidence-based practice.

While research on interventions for psychological distress in the context of palliative care has primarily focused on pharmacotherapy, a growing literature evaluating the efficacy of psychotherapy exists.²⁴ This meta-analysis provides an overview of existing randomized controlled trials of psychotherapy examining effects on depression and anxiety among adults with any condition appropriate for palliative care, without emphasis on a particular disease. Here, psychotherapy is defined as psychological interventions conducted by trained individuals and involve direct verbal and interactive communication to improve distress. Because palliative care seeks to improve quality of life (QoL), a secondary aim was to examine QoL outcomes (when available) in the studies found through our search. Few moderators of the effectiveness of psychotherapy targeting depression and anxiety in palliative care populations have been analyzed in the literature. Knowledge of the intervention characteristics most likely to be effective and of patients most likely to benefit is greatly needed. Therefore, we examined whether patient population, psychotherapy type, provider type, and treatment modality and context moderated the effect of psychotherapy on outcomes. Per PRISMA recommendations,²⁵ we also examined the moderating effect of study quality in the relation between treatment and outcomes. Finally, we examined the role of participant demographic and treatment factors.

Methods

Search methodology

Searches of PubMed, PsycINFO, Cochrane Library, and EMBASE databases for the terms “psychotherapy OR psychological intervention” combined with the terms “palliative OR palliative care” were conducted through August 17, 2017. No specific disease terms were included.

To be included, studies had to (a) be written in English, (b) include adults ages 18 and older, (c) examine the effectiveness of a psychotherapy that involved at least two sessions or a minimum of 60 minutes of intervention, (d) use a randomized controlled design, (e) assess depression or anxiety symptoms as continuous variables, (f) provide sufficient information for computing within group effect size for outcomes, and (g) be published in a peer-reviewed outlet. Psychotherapies focusing on marital functioning, physical symptom reduction (e.g., pain), or health behavior change, and those that involved only psychoeducation, single skill building (e.g., relaxation), or support were excluded. Reference lists of reviews and included articles were also searched.

Data abstraction

Data abstraction was performed by one reviewer and confirmed by another. Studies were coded for population condition (cancer, multiple sclerosis, HIV/AIDS, advanced/terminal illness, other/mixed), sample size, participants' mean age, percentage of female participants, percentage of married participants, and percentage of racial/ethnic minorities participants. Additionally, psychological intervention characteristics, including modality type (individual, group, family), context (face-to-face, telephone), number of sessions, length of sessions, and provider type (mental health providers including psychologists, psychiatrists, and clinical social workers; healthcare providers including physicians, nurses, and occupational therapists) were abstracted. Interventions were categorized based on descriptions provided in the article; intervention categories included (1) cognitive and behaviorally (CB) based therapies, including cognitive behavioral therapy (CBT), cognitive therapy, problem solving therapy, and interpersonal therapy, (2) existential therapies including dignity, legacy, life review, and meaning making, and (3) other (e.g., acceptance and commitment therapy [ACT], mindfulness based stress reduction [MBSR], and supportive expressive therapy). Finally, information was coded to permit computation of effect sizes.

Quality assessment

Methodological quality of studies was independently assessed by two authors using criteria based on the Jadad Scale²⁶ and the Cochrane Collaboration's tool for assessing risk of bias²⁷ (Table 1). For each criterion met, one point was assigned. Scores ranged from 0 to 7 (0–4 low, 5–6 medium, 7 high quality). Twenty-six authors were contacted for additional information on quality; 10 responded with supplementary information. If author(s) did not respond, unclear criteria were rated as unmet.

Table 1.

Methodological Quality of Studies Included in the Meta-Analysis

First author (year)	RCT type	1. Adequate allocation sequence generation and concealment	2. Blinding of main outcome assessments	3. Drop-outs withdrawals described	4. Intention-to-treat analysis performed or no drop-outs	5. Sample size based on an adequate power analysis (i.e., estimate of sufficient sample size to achieve adequate power)	6. Groups similar on prognostic indicators at baseline or adjustments made to correct for baseline imbalance	7. Diagnostic assessment conducted by professional or no diagnostic assessments necessary for recruitment	Score
Allen (2008)⁵³	P	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
Allen (2014)⁵⁶	P	Yes	Yes	Yes	No	Yes	Yes	Yes	6
Breitbart (2010)³¹	P	Yes	Yes	Yes	No	Unclear	Yes	Yes	5
Breitbart (2012)³²	SF	Yes	Yes	Yes	Unclear	Yes	Unclear	Yes	5
Chochinov (2011)³³	MF	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	6
Davis (1986)³⁴	U	Unclear	Yes	Yes	Unclear	Unclear	Unclear	Yes	3
Edelman (1999a)³⁵	P	Yes	Yes	Yes	Unclear	Unclear	Yes	Yes	5
Edelman (1999b)³⁶	SF	Yes	Yes	Yes	Unclear	Unclear	Yes	Yes	5
Evans (1995)³⁷	U	Unclear	Yes	Yes	Unclear	Unclear	Yes	Yes	4
Greer (2012)³⁸	P	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
Hall (2011)³⁹	P	Yes	Unclear	Yes	Unclear	Unclear	Yes	Yes	4
Hall (2012)⁵⁹	MF	Yes	Unclear	No	Unclear	Yes	Yes	Yes	5
Henry (2010)⁴⁰	P	Yes	Yes	Yes	No	Unclear	Yes	Yes	5
Julião (2013)⁵⁷	U	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
Kissane (2003)⁴¹	SF	Yes	No	No	Yes	Yes	Yes	Yes	5
Kunik (2007)⁶⁰	U	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
Larcombe (1984)⁴⁸	U	Unclear	Yes	Yes	Unclear	Unclear	Yes	Yes	4
Lesperance (2007)⁶³	MF	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
Markowitz (1998)^52,a	SF	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
Markowitz (1998)^52,a	SF	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
McLaughlin (2005)⁶²	U	Unclear	Unclear	Yes	Yes	Unclear	Yes	Yes	4
Mohr (2000)⁵¹	U	Unclear	Unclear	Yes	Yes	Unclear	Yes	Yes	4
Mohr (2001)^49,a	SF	Unclear	Unclear	No	Yes	Unclear	Yes	Yes	3
Mohr (2001)^49,a	SF	Unclear	Unclear	No	Yes	Unclear	Yes	Yes	3
Mohr (2005)^50,a	SF	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
Mohr (2005)^50,a	SF	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
Moorey (1998)⁴²	U	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
Moynihan (1998)⁴³	P	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
Nezu (2003)^44,a	SF	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
Nezu (2003)^44,a	SF	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	6
Ransom (2008)⁵³	U	Yes	Yes	Yes	Yes	No	Yes	Yes	6
Rost (2012)⁵⁴	P	Yes	Unclear	Yes	Yes	Unclear	Yes	Yes	5
Savard (2006)⁴⁶	U	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
Speca (2000)⁴⁷	U	Yes	Yes	Yes	Yes	Unclear	Unclear	Yes	5
Steinhauser (2008)⁵⁸	P	Yes	Yes	Yes	Yes	No	No	Yes	5
Weiss (2003)⁵⁴	SF	Yes	No	No	Yes	Yes	Yes	Yes	5

Study included two active intervention arms.

P, pilot; MF, multi-site full; SF, single-site full; U, unclear.

Meta-analytic procedures

The standardized mean gain score (i.e., standardized change in scores from pretreatment to post-treatment; [mean post-treatment score–mean pretreatment score]/pooled standard deviation) was computed as a measure of effect size.²⁸ Statistical analyses were conducted using macros designed for meta-analysis.²⁹ When studies used multiple measures per outcome variable, effect sizes were averaged so each sample was only included once in analyses.³⁰ MeanES macro²⁹ was used to compute mean effect sizes and conduct homogeneity analyses using random effects models. When the homogeneity analysis statistic is significant, the variance in effect sizes exceeds what would be expected due to sampling error alone.³⁰ Forest plots were created using Neyeloff and colleagues' Excel spreadsheet.³¹

MetaF macro²⁹ was used to test the effects of categorical moderator variables. Both between-class (Q_B) and within-class (Q_W) variability are computed. When between-class effect is significant, the moderator explains a significant amount of variability in the effect sizes. When within-class variability is not statistically significant, the moderator fully explains the variability; when within-class variability is still statistically significant, the moderator only partially explains the variability.²⁸

The effects of continuous moderator variables were tested using MetaReg macro.²⁹ The significance of the set of predictors in explaining the variability of effect sizes is tested with the homogeneity test for the regression model (Q_R), and the homogeneity test of the residual (Q_E) evaluates whether there is a significant amount of variance remaining.²⁹ While multiple predictors can be entered simultaneously, each possible moderator was tested separately because not every study included information for every moderator, and we sought to maximize power by including as many studies as possible in each analysis. In MeanES analyses, the homogeneity analyses were significant for all three outcomes; therefore, mixed effects models were used for all moderator analyses.^28,30

Publication bias

The possibility of publication bias (i.e., tendency for studies with statistically significant results to be published and the tendency for studies with nonstatistically significant results to not be published) in the studies included in this meta-analysis was examined by a regression test³²and funnel plots.

Results

Study characteristics

The combined searches yielded 2949 references. After excluding duplicates, 2757 unique citations remained (Fig. 1). Thirty-two studies with 36 samples receiving psychotherapy published between 1984 and 2014 with a total of 1536 participants were included (Table 2); our search found no studies published between November 2014 and August 2017 that met criteria for inclusion in this meta-analysis. The mean baseline sample size per study was 42.67 (SD = 31.51, range = 5–154). Average age ranged from 36.20 to 84.45 (unweighted M = 53.69). Percentage of the sample that was female ranged from 0% to 100% (unweighted M = 61.37), that were minorities ranged from 5% to 65% (unweighted M = 23.95), and that were married ranged from 32% to 75% (unweighted M = 58.53). The average number of sessions across studies was 8.96 (range = 1.96–23.00), and the average session length across studies was 75.37 minutes (range = 8.40–208.80). Half of the interventions included participants with cancer (n = 18),^33–50 six included participants with multiple sclerosis,^51–54 four included participants with HIV,^55–57 four included participants with “advanced” “life-limiting” or “terminal” illnesses,^58–61 and four studies included participants with multiple diagnoses or some other diagnosis.^62–65 Most interventions used individual psychotherapy (n = 23; 63.9%).^{34–36,40–42,44–48,51–55,59–61,63–64} Ten studies used group therapy^{33,37–39,43,56,62}; three used family therapy.^46,57,58 Most interventions involved psychotherapy conducted face-to-face (n = 31; 86.1%)^{33–51,54,56–63} rather than by phone^52,53,55,64 (n = 5; 13.9%), and mental health providers administered the intervention in most studies (n = 29; 80.6%).^{33–40,42–57,62–64} Most interventions were CB-based psychotherapies (n = 21),^{36–40,43–46,48,50–54,62–64} 10 interventions were existential psychotherapies,^{33–35,41,42,57–61} and 5 were other types of psychotherapy.^{47,49,51–52,56}

FIG. 1.

Flowchart of study selection process.

Table 2.

Characteristics of Studies Included in the Meta-Analysis

											Outcomes
First author (year)^a,b	Population	Mean age (SD)	Percent female	Percent minority	Percent married	Intervention (n)	Provider type	Treatment modality	No. sessions	Control groups (n)	Depression	Anxiety	QoL
Allen (2008)⁵⁵	Life-limiting or chronic illness	75.3 (10.5)	71.0	65.0	U	Legacy intervention (17)	Mental health provider	Family, in-person	3	Telephone support contact (14)	CES-D	—	—
Allen (2014)⁵⁶	Advanced illness	78.2 (11.6)	82.0	40.0	U	Legacy intervention (22)	Retired senior volunteers	Family, in-person	3	Telephone support contact (10)	CES-D	—	—
Breitbart (2010)^31,b	Advanced solid tumor cancers or non-Hodgkin's lymphoma	60.1 (11.8)	51.1	19.9	U	Meaning-centered therapy (49)	Mental health provider	Group, in-person	8	Supportive group therapy (41)	HADS-D	HADS-A	—
Breitbart (2012)^32,a	Advanced solid tumor cancers or non-Hodgkin's lymphoma	54.4 (11.6)	60.5	48.3	17.6	Meaning-centered therapy (64)	Mental health provider	Individual, in-person	7	Massage (56)	HADS-D	HADS-A	MQoL
Chochinov (2011)³³	Terminal cancer	64.2 (14.6)	58.0	—	56.0	Dignity therapy (108)	Mental health and healthcare providers	Individual, in-person	3–4	Supportive therapy (107) Standard palliative care (111)	HADS-D	HADS-A	QoL Scale- QoL rating and life satisfaction rating
Chochinov (2011)³³	Terminal cancer	64.2 (14.6)	58.0	—	56.0	Dignity therapy (108)	Mental health and healthcare providers	Individual, in-person	3–4	Supportive therapy (107) Standard palliative care (111)	SISC	HADS-A	QoL Scale- QoL rating and life satisfaction rating
Davis (1986)³⁴	Stage I breast cancer	51.2 (U)	100	—	U	Cognitive therapy (5)	Mental health provider	Individual, in-person	13	Biofeedback (7) No-treatment control (7)	—	STAI-S	—
Edelman (1999a)^35,b	Stage I and II breast cancer	48.6 (9.8)	100	—	62.0	CBT (7)	Mental health provider	Group, in-person	12	Supportive therapy (6)	POMS-D	POMS-A	Functional LivingIndex
Edelman (1999b)^36,b	Metastatic breast cancer	50.0 (U)	100	—	61.0	CBT (62)	Mental health provider	Group, in-person	12	Supportive therapy (62)	POMS-D	POMS-A	—
Evans (1995)³⁷	Stage II cancer: 42% lung, 31% bladder, 22% prostate, 5% head-neck	54.2 (U)	37.0	40.7	U	CBT (29)	Mental health provider	Group, in-person	8	Social support (23) control group (26)	CES-D	SCL-90-R	—
Evans (1995)³⁷		54.2 (U)	37.0	40.7	U	CBT (29)	Mental health provider	Group, in-person	8	Social support (23) control group (26)	SCL-90-R	SCL-90-R	—
Greer (2012)^38,a	Terminal cancer	55.9 (10.9)	70.0	5.0	75.0	CBT (20)	Mental health provider	Individual, in-person	6–7	Waitlist control (20)	MADRS	HAM-AHADS-A	—
Hall (2011)³⁹	Advanced cancer	64.9 (15.9)	59.0	—	32.0	Dignity therapy + standard palliative care (22)	Healthcare provider	Individual, in-person	2	Standard palliative care (23)	HADS-D	HADS-A	EQ-5D Quality and satisfaction with life ratings
Hall (2012)⁵⁹	Frail elders near EOL	84.5 (8.1)	80.6	—	U	Dignity therapy + standard care (31)	Healthcare provider	Individual, in-person	2	Standard psychological care (23)	GDS	—	EQ-5D
Henry (2010)^40,a	Stage III or IV ovarian cancer	55.0 (9.7)	100	—	75.0	Meaning-making intervention (15)	Mental health provider	Individual, in-person	1–4	Waitlist control (13)	HADS-D	HADS-A	MQoL
Julião (2013)^57,a	Terminal illness	66.5 (12.4)	51.7	—	51.7	Dignity therapy (29)	Healthcare provider	Individual, in-person	2	Standard palliative care (31)	HADS-D	HADS-A	—
Kissane (2003)⁴¹	Breast cancer	45.4 (8.0)	100	—	73.0	Cognitive-existential therapy + relaxation classes (154)	Mental health and healthcare providers	Group, in-person	20 + 3	Relaxation classes (149)	HADS-D	HADS-AMACS	—
Kunik (2007)⁶⁰	Chronic obstructive pulmonary disease	66.1 (10.1)	3.4	16.1	U	CBT (118)	Mental health provider	Group, in-person	8	Chronic obstructive airway disease education (120)	BDI-II	BAI	—
Larcombe (1984)^48,a	Multiple sclerosis	42.5 (U)	77.8	—	U	CBT (9)	Mental health provider	Group, in-person	6	Waitlist control (10)	BDI	—	—
Larcombe (1984)^48,a	Multiple sclerosis	42.5 (U)	77.8	—	U	CBT (9)	Mental health provider	Group, in-person	6	Waitlist control (10)	HRSD	—	—
Lespérance, (2007)⁶¹	Coronary artery disease	59.4 (9.3)	24.0	—	62.7	Interpersonal therapy + placebo (75)	Mental health provider	Individual, in-person	12	Interpersonal therapy + citalopram (67)	BDI-II	—	—
Lespérance, (2007)⁶¹	Coronary artery disease	59.4 (9.3)	24.0	—	62.7	Interpersonal therapy + placebo (75)	Mental health provider	Individual, in-person	12	Interpersonal therapy + citalopram (67)	HAM-D	—	—
Markowitz (1998)^52,c	HIV	37.5 (7.4)	20.8	37.5	U	Interpersonal therapy (24)	Mental health provider	Individual, in-person	16	CBT (27)	BDI	—	—
Markowitz (1998)^52,c	HIV	37.5 (7.4)	20.8	37.5	U	Interpersonal therapy (24)	Mental health provider	Individual, in-person	16	Supportive therapy with imipramine (26) Supportive therapy (24)	HAM-D	—	—
Markowitz (1998)^52,c	HIV	36.2 (6.2)	14.8	48.1	U	CBT (27)	Mental health provider	Individual,in-person	16	Interpersonal therapy (24)	BDI HAM-D	—	—
										Supportive therapy with imipramine (26)
										Supportive therapy (24)
McLaughlin (2005)⁶²	Acute coronary syndromes	59.9 (10.2)	31.1	11.1	U	Cognitive therapy (53)	Mental health provider	Individual, telephone	8	Usual care (47)	HADS-D	HADS-A	—
Mohr (2000)⁵¹	Multiple sclerosis	42.6 (12.8)	63.0	U	56.0	CBT (16)	Mental health provider	Individual, telephone	8	Usual care control (16)	POMS-D	—	—
Mohr (2001)^49,a,c	Multiple sclerosis	43.9 (10.0)	73.0	16.0	56.0	CBT (20)	Mental health provider	Individual, in-person	16	Supportive-expressive therapy (22)	BDI	—	—
Mohr (2001)^49,a,c	Multiple sclerosis	43.9 (10.0)	73.0	16.0	56.0	CBT (20)	Mental health provider	Individual, in-person	16	Sertraline (21)	HRSD	—	—
Mohr (2001)^49,a,c	Multiple sclerosis	43.9 (10.0)	73.0	16.0	56.0	Supportive-expressive therapy (22)	Mental health provider	Group, in-person	16	CBT (20)	BDI	—	—
Mohr (2001)^49,a,c	Multiple sclerosis	43.9 (10.0)	73.0	16.0	56.0	Supportive-expressive therapy (22)	Mental health provider	Group, in-person	16	Sertraline (21)	HRSD	—	—
Mohr (2005)^50,c	Multiple sclerosis	48.6 (9.6)	75.8	6.4	61.3	CBT (62)	Mental health provider	Individual, telephone	16	Supportive emotion-focused therapy (65)	BDI-II	—	—
Mohr (2005)^50,c	Multiple sclerosis	48.6 (9.6)	75.8	6.4	61.3	CBT (62)	Mental health provider	Individual, telephone	16	Supportive emotion-focused therapy (65)	HRSD	—	—
Mohr (2005)^50,c	Multiple sclerosis	47.4 (10.1)	78.5	13.8	58.5	Supportive emotion-focused therapy (65)	Mental health provider	Individual, telephone	16	CBT (62)	BDI-II	—	—
Mohr (2005)^50,c	Multiple sclerosis	47.4 (10.1)	78.5	13.8	58.5	Supportive emotion-focused therapy (65)	Mental health provider	Individual, telephone	16	CBT (62)	HRSD	—	—
Moorey (1998)^42,a	Cancer:	51.0 (13.5)	74.5	—	68.0	Adjuvant psychological therapy (29)	Mental health provider	Individual, in-person	8	Supportive counseling (28)	HADS-D BDI	HADS-A STAI-S MACS	—
	47% breast 11% lymphoma
	9% colorectal
	6% teratoma
	6% astrocytoma
	21% other
Moynihan (1998)⁴³	Testicular cancer	U (U)	0.0	—	46.0	Adjuvant psychological therapy (36)	Mental health nurse	Individual, in-person	6	Standard medical care (37)	HADS-D	HADS-A	—
Nezu (2003)^44,c	Cancer:	49.2 (U)	67.0	24.0	60.0	Problem solving therapy (45)	Mental health provider	Individual, in-person	10	Problem solving therapy with significant other (43) Waitlist condition (44)	HRSD	—	—
	44% breast
	23% leukemia, 7% prostate,4% lung, 22% other
Nezu (2003)^44,c	Cancer:	45.8 (U)	64.0	19.0	64.0	Problem solving therapy with significant other (43)	Mental health provider	Family, in-person	10	Problem solving therapy (45) Waitlist condition (44)	HRSD	—	—
	44% breast, 23% leukemia
	7% prostate 4% lung
	22% other
Ransom (2008)^53,a	HIV	44.4 (8.6)	16.0	23.0	U	Interpersonal therapy plus usual care (41)	Mental health provider	Individual, telephone	6	Usual care condition (38)	BDI-II	—	—
Rost (2012)^45,a	Stage III or IV ovarian cancer	56.0 (U)	100	8.0	68.0	Acceptance and commitment therapy (25)	Mental health provider	Individual, in-person	12	Usual care (22)	BDI-II	BAI	FACT-G
Savard (2006)⁴⁶	Metastatic breast cancer	51.5 (8.1)	100	—	57.1	Cognitive therapy (25)	Mental health provider	Individual, in-person	8	Waitlist control (20)	BDI	HADS-A	EORTC-QoL
Savard (2006)⁴⁶	Metastatic breast cancer	51.5 (8.1)	100	—	57.1	Cognitive therapy (25)	Mental health provider	Individual, in-person	8	Waitlist control (20)	HADS-D	HADS-A	EORTC-QoL
Speca (2000)⁴⁷	Cancer: 41% Breast, 59% other	54.9 (10.5)	85.3	—	U	Mindfulness meditation-based stress reduction (61)	U	Group, in-person	7	Waitlist control (48)	POMS-D	POMS-A	—
Speca (2000)⁴⁷	Cancer: 41% Breast, 59% other	54.9 (10.5)	85.3	—	U	Mindfulness meditation-based stress reduction (61)	U	Group, in-person	7	Waitlist control (48)	SOSI-D	SOSI-A	—
Steinhauser (2008)^58,a	Serious illness	U (U)	49.3	42.7	40.0	“Outlook”	Research assistant	Individual, in-person	3	Attention control (26) No treatment control (26)	CES-D	POMS-A	QUAL-E
						• Life review
						• Forgiveness
						• Heritage and legacy (26)
Weiss (2003)⁵⁴	HIV	40.3 (8.1)	0.0	—	U	Supportive-expressive therapy (44)	Mental health provider	Group, in-person	16	Educational control (41)	BDI	POMS-A	—
Weiss (2003)⁵⁴	HIV	40.3 (8.1)	0.0	—	U	Supportive-expressive therapy (44)	Mental health provider	Group, in-person	16	Educational control (41)	POMS-D	POMS-A	—

When values for demographic variables (age, % female, % minority, % married) were not available for the active treatment sample, values for the entire sample were used.

Publication years followed by a or b indicate two publications from the same author in 1 year.

Study included two active intervention arms.

BAI, beck anxiety inventory; BDI, beck depression inventory; BDI-II, beck depression inventory-II; CES-D, Center for Epidemiological Studies Depression Scale; COPD, chronic obstructive airway disease; CBT, Cognitive Behavioral Therapy; EOL, end of life; EORTC-QoL, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; EQ- 5D, EuroQol 5 Dimensions; FACT-G, Functional Assessment of Cancer Therapy-General Measure; GDS, Geriatric Depression Scale; HADS-A, Hospital Anxiety and Depression Scale-Anxiety Subscale; HADS-D, Hospital Anxiety and Depression Scale-Depression Subscale; HAM-A, Hamilton Anxiety Rating Scale; HAM-D, Hamilton Depression Rating Scale; HIV, Human Immunodeficiency Virus; HRSD, Hamilton Rating Scale for Depression; MACS, Mental Adjustment to Cancer Scale -Anxious preoccupation subscale; MQoL, McGill Quality-of-Life Scale; MADRS, Montogomery Asberg Depression Rating Scale; POMS-A, Profile of Mood States-Anxiety Subscale; POMS-D, Profile of Mood States-Depression Subscale; QoL, quality of life; QUAL-E, quality of life at the end of life; SCL-90-R, Symptom Checklist-90 Revised; SISC, Structured Interview for Symptoms and Concerns; SOSI-A, Symptoms of Stress Inventory-Anxiety; SOSI-D, Symptoms of Stress Inventory-Depression; STAI-S, State Form of the State-Trait Anxiety Inventory; U, Unknown.

Quality assessment

Quality assessment ratings ranged from 3 to 7 (Table 1). Most studies (n = 24) were of medium quality. All studies met Criterion 7 (diagnostic assessment of the primary outcome conducted by a professional or no diagnostic assessment necessary for recruitment). Conducting a power analysis (i.e., to estimate a sufficient sample size to achieve adequate power) and basing the study sample size on this power analysis (Criterion 5) was the criterion met most infrequently (n = 12).

Mean effect sizes and homogeneity analyses

Effect sizes are interpreted based on Cohen's d effect size criteria⁶⁵ (i.e., 0.2 = small, 0.5 = medium, and 0.8 = large). Mean effect sizes and results of the homogeneity analyses are presented in Table 3; Forest plots are presented in Figures 2 –4. The mean effect sizes for depression and anxiety were significant and negative, indicating that, overall, psychotherapy in palliative care populations reduced depression and anxiety symptoms. Psychotherapy had a large effect on depression symptoms and a small effect on anxiety symptoms. The mean effect size for measures of QoL was significant, small, and positive, indicating that these interventions improved QoL. The homogeneity analyses for all effect sizes were significant, indicating that the variability in effect sizes was greater than would be expected by sampling error alone,²⁸ which suggests that there are possible moderators contributing to study effect sizes.

FIG. 2.

Forest plot of depression effect sizes.

FIG. 3.

Forest plot of anxiety effect sizes.

FIG. 4.

Forest plot of quality of life effect sizes.

Table 3.

Mean Effect Sizes

Outcome variable	No. of studies	Mean ES	SE of ES	95% CI	Homogeneity analysis, Q (df)	I²
Depression	35	−0.82^**	0.10	−1.02 to −0.62	901.92 (34)^**	96.23
Anxiety	21	−0.38^**	0.07	−0.52 to −0.24	186.90 (20)^**	89.30
QoL	9	0.47^*	0.16	0.17 to −0.78	75.75 (8)^**	89.44

p < 0.01, ^**p < 0.001.

CI, confidence interval; ES, effective size; SE, standard error.

Analyses of categorical moderators

Categorical moderators could only be tested when there were at least three studies per category for a given effect size. Thus, population condition was dichotomized (i.e., cancer vs. other) when examining studies that included anxiety as an outcome. For treatment modality, only individual versus group was examined as no studies that included anxiety as an outcome used family therapy. Additionally, the effects of population condition, psychotherapy type, provider type, treatment modality, treatment context, and study quality could not be examined for QoL effect sizes. Results of MetaF tests for categorical moderators are presented in Table 4.

Table 4.

Tests of Categorical Moderators

Outcome variable	Moderator variable and class	Between-class effect (Q_B)	k	Effect size by class	Within-class effect (Q_W)
Depression	Population condition	8.35
	Cancer		17	−0.80^***	81.83^***
	Multiple sclerosis		6	−1.38^***	8.76
	HIV/AIDS		4	−0.65^*	2.48
	Advanced illness		4	−0.31	2.30
	Other or mixed		4	−0.73^*	7.35
	Psychotherapy type	21.54^***
	CBT, CT, CET, PST, IPT		17	−1.06^***	68.97^***
	DT, Legacy, LR, MM, Ex		10	−0.12	3.82
	Other		8	−1.09^***	30.83^***
	Provider type	13.72^***
	Mental health provider		28	−0.97^***	110.88^***
	Other		7	−0.13	3.71
	Treatment modality	2.95
	Individual		22	−0.91^***	58.15^***
	Group		10	−0.57^**	14.21
	Family		3	−1.15^**	29.25^***
	Treatment context	0.17
	In-person		30	−0.80^***	110.50^***
	Telephone		5	−0.91^***	2.81
	Study quality	0.30
	Low		6	−0.90^***	14.74^*
	Medium		23	−0.78^***	86.20^***
	High		6	−0.89^***	8.76
Anxiety	Population condition	0.00
	Cancer		16	−0.38^***	26.36
	Other or mixed		5	−0.39^**	0.53
	Psychotherapy type	10.16^**
	CBT, CT, CET, PST, IPT		11	−0.44^***	16.25
	DT, Legacy, LR, MM, Ex		7	−0.12	7.21
	Other		3	−0.67^***	4.23
	Provider type	1.77
	Mental health provider		16	−0.43^***	24.28
	Other		5	−0.22	2.78
	Treatment modality	2.21
	Individual		13	−0.48^***	18.10
	Group		8	−0.25^*	5.28
	Study quality	2.15
	Low		4	−0.25	4.47
	Medium		13	−0.35^***	15.68
	High		4	−0.59^***	4.59
QoL	Provider type	21.31^***
	Mental Health Provider		5	0.74^***	1.76
	Other		4	0.08	5.48

p < 0.05, ^**p < 0.01, ^***p < 0.001.

HIV, Human Immunodeficiency Virus; AIDS, Acquired Immune Deficiency Syndrome; CT, Cognitive Therapy; CET, Cognitive-Existential Therapy; PST, Problem Solving Therapy; DT, Dignity Therapy; LR, Life Review; MM, Meaning Making; Ex, Existential therapy; IPT, interpersonal therapy.

Psychotherapy type had a significant effect on depression and anxiety outcomes. For studies examining effects on depression, CB-based therapies and other therapies resulted in large, statistically significant effect sizes; however, studies that used existential therapies did not have an overall significant effect size. Similarly, among studies examining anxiety as an outcome, CB-based therapies and other therapies resulted in statistically significant effects (small and medium, respectively); existential therapies did not result in a significant effect.

Provider type was a significant moderator of depression and QoL effect sizes. Specifically, studies in which mental health providers administered the treatment had statistically significant average effects on depression (large effect) and QoL (medium effect), but studies in which other types of providers (e.g., healthcare providers) administered the treatment did not have a significant average effect size for depression or QoL.

Analyses of continuous moderators

Analyses of continuous moderators were possible for most moderators on each outcome; however, too few studies examining QoL as an outcome reported the mean session length and the percentage of minority participants in the sample, so these moderators were not tested for studies that examined QoL outcomes. Results of analyses for continuous moderators are presented in Table 5.

Table 5.

Tests of Continuous Moderators

Outcome variable	Moderator variable	k	Regression model homogeneity (Q_R)	Residual homogeneity (Q_E)	b	β
Depression	Mean no. of sessions	34	6.55^*	106.33^***	−0.05^*	−0.24^*
	Mean length of sessions (in minutes)	26	9.33^**	111.89^***	0.01^**	0.28^**
	Mean age of sample	32	9.86^**	92.41^***	0.03^**	0.31^**
	% of sample female	35	1.02	104.19^***	−0.00	−0.10
	% of sample minority	20	2.23	70.97^***	0.01	0.17
	% of sample married	22	2.41	56.38^***	−0.02	−0.20
Anxiety	Mean no. of sessions	20	0.51	22.08	−0.01	−0.15
	Mean length of sessions (in minutes)	13	0.24	18.37	0.00	0.11
	Mean age of sample	19	1.44	22.98	0.01	0.24
	% of sample female	21	2.06	23.32	−0.00	−0.28
	% of sample minority	9	0.53	9.08	0.01	0.23
	% of sample married	14	0.52	14.42	−0.01	−0.19
QoL	Mean no. of sessions	9	3.69	4.88	0.06	0.66
	Mean age of sample	8	5.27^*	3.11	−0.03^*	−0.79^*
	% of sample female	9	0.94	5.53	0.01	0.38
	% of sample married	8	0.15	2.96	0.01	0.22

p < 0.05, ^**p < 0.01, ^***p < 0.001.

For studies examining depression symptoms as an outcome, mean number of treatment sessions, mean length of sessions, and mean age of the sample were significant predictors of the study effect size. Because the mean effect size for depression was negative, a negative beta indicates an increase in effect size and a positive beta indicates a decrease in effect size. Therefore, as the mean number of treatment sessions increased, the effect size increased, but as the mean length of sessions and the mean age of the sample increased, the study effect size decreased.

For studies examining anxiety symptoms as an outcome, no continuous moderator analyses were significant. Among studies examining QoL, mean age of the sample was a significant predictor of effect size. Specifically, as mean age of the sample increased, study effect size decreased.

Investigation of publication bias

Funnel plots for studies that provided effect sizes for each outcome are presented in Figures 5 –7. The results of the regression tests demonstrated funnel plot asymmetry for depression [b = −4.33, t(33) = −2.83, p = 0.008] and QoL [b = 4.45, t(7) = 3.80, p = 0.007] but not anxiety [b = −2.10, t(19) = −1.59, p = 0.128], suggesting publication bias in studies examining depression and QoL as outcomes (i.e., depression and QoL effect sizes may be overestimated).

FIG. 5.

Funnel plot for studies reporting outcomes for depression.

FIG. 6.

Funnel plot for studies reporting outcomes for anxiety.

FIG. 7.

Funnel plot for studies reporting outcomes for quality of life.

Discussion

Although palliative care guidelines recommend psychological treatment of distress¹ among palliative care populations, an evaluation of the evidence for psychotherapy being used with this population has not been conducted. The primary aim of this meta-analysis was to examine whether psychotherapy among individuals with conditions that could warrant palliative care resulted in reductions in depression and anxiety symptoms between pre- and post-treatment. In a meta-analytic review of 32 studies with 36 samples, psychotherapy was found to be effective for reducing depression and anxiety symptoms and improving QoL among patients appropriate for palliative care. While there was significant variability in effect sizes across studies, on average, the reduction in depression symptoms between pre- and post-treatment was large. Although the results also revealed that psychotherapy reduced anxiety symptoms, the mean effect size was small. The secondary aim was to examine whether these interventions resulted in improvements in QoL. In general, psychotherapy resulted in a significant increase in QoL, but the effect size was small.

Multiple moderators of study effect sizes were examined. Psychotherapy type was significantly associated with depression and anxiety effect sizes. Specifically, the mean effect size for studies that used therapies typically designed to target existential distress (e.g., dignity therapy, life review) was not significant, indicating that these therapies did not improve depression or anxiety symptoms. In contrast, both CB-based therapies and other types of psychotherapy (e.g., ACT, MBSR) did result in reductions in depression and anxiety symptoms. Interestingly, while interventions with a greater number of treatment sessions resulted in greater reduction in depression symptoms, longer treatment sessions resulted in less reduction in depression symptoms. This finding may reflect the inability of patients with serious illness to tolerate lengthy sessions (i.e., on average 75 minutes long), suggesting that more shorter sessions is preferable to fewer longer sessions.

In addition, studies in which mental health providers administered the treatment had significant effects on both depression and QoL, but studies that used other types of providers did not have significant effects on depression or QoL. When the mean age of the sample was older, the effect size for depression and QoL was smaller (i.e., treatment was less effective). This finding possibly reflects the fact that older patients generally report lower levels of distress⁶⁶ and therefore may be less likely to benefit from intervention. Alternatively, older adults compared to younger adults may not fully benefit from interventions like CBT without treatment modifications (e.g., adjusting pacing of treatment, providing written material) that account for age and health-related factors.^67–69

Taken together, these findings suggest that CB-based and other (e.g., acceptance, mindfulness) therapies delivered by mental health providers are effective methods of mitigating depression and anxiety among adults appropriate for palliative care. The large effect size on depression is notable in comparison to effect sizes reported in meta-analyses of psychotherapy for cancer patients that are generally in the small range.⁷⁰ This finding may reflect the higher symptom burden among patients whose conditions warrant palliative care. It may also reflect the relatively high dose of the interventions tested. While existential therapies did not have a significant effect on anxiety, depression, or overall QoL, it is likely that they impact other important outcomes such as spiritual well-being that may not be reflected in measures of psychological distress.⁷¹

Overall, these findings suggest that the clinical care of palliative care patients with anxiety and depression could be improved by the provision of cognitive-behavioral and other (acceptance, mindfulness) therapies by mental healthcare providers. This may require greater integration of psychologists, who have doctoral-level training in the provision of such therapies, into palliative care teams.¹ While psychological and psychiatric care is a recommended part of palliative care practice, it is not currently required, and mental health providers are likely not included in most palliative care programs.⁷² Future studies should also evaluate the effects of including psychotherapy for psychological distress as part of palliative care services.

The results of this meta-analysis should be interpreted in light of limitations. First, results indicate likely publication bias in studies examining depression and QoL. Second, most studies identified focused on patients with cancer. Given the limited number of studies examining interventions with other conditions (e.g., HIV), these studies had to be combined into a single group to examine condition as a moderator. In addition, due to limited information on treatment settings (e.g., inpatient, outpatient), setting could not be examined as a moderator. Thus, the degree to which these findings generalize to specific medical conditions and palliative care settings remains unknown. Third, there was a confound between psychotherapy and treatment provider variables, as only one of the seven studies that used nonmental health providers implemented CBT and the others examined existential therapies.

This meta-analysis also revealed limitations of the current literature on this topic. First, the methodological quality of research designs and reporting could be improved. On average, the quality rating was medium, and we noted a possibility of publication bias in studies examining depression and QoL as outcomes. Methods of improving quality of studies could include tracking reasons for participant attrition, using intention-to-treat analysis to address missing data, and using a priori power analysis to determine adequate sample sizes. Future research should also focus on a wider range of patients appropriate for palliative care and those most at risk for poor outcomes without intervention. Finally, future studies should include greater detail about population and study characteristics (e.g., race/ethnicity, disease stage, concurrent psychopharmacological treatment, treatment setting) and the specialty care being received in addition to disease-specific treatment/care.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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