Research roundup: Psychological interventions for individuals coping with a terminal illness

In 2022, the Centers for Disease Control and Prevention reported approximately 3.28 million deaths from various illnesses in the United States (Kochanek et al., 2022). Out of the many illnesses, cancer and heart disease were the leading cause of death. This data reflects a considerable number of individuals facing terminal disease, which is defined as a medically confirmed disease that is incurable and will ultimately result in death within 6 months.

Individuals near the end of life face both physical and psychological struggles. Their journey through terminal illness often amplifies their distress, anxiety, depression, loss of control, etc. These problems can further worsen their terminal illness symptoms and reduce their pain tolerance, which likely increases suffering. In addition, the individual’s loved ones undergo equal suffering as they accompany them throughout their illness, experiencing a high degree of distress and impaired quality of life. Therefore, it is imperative to address these psychological challenges to ensure that patients and their loved ones have the highest quality of life.

In this installment of Research Roundup, we explore the latest research on psychological interventions for helping patients and their families cope with a terminal illness. The first study analyzes the effects of dignity therapy on patients with terminal cancer and their family caregivers. Next, we summarize a study that investigates the impact of cognitive-behavioral therapy (CBT)-based psychoeducation for patients receiving chemotherapy. The final study compares psychotherapy and antidepressants for treating depression in patients with heart failure.

Note: In addition to reviewing the research summaries, psychologists are encouraged to further explore the literature to determine what may be useful to them in practice, particularly as it relates to patients’ values, culture, and preferences.

Seiler, A., Amann, M., Hertler, C., Christ, S. M., Schettle, M., Kaeppeli, B. M., Jung-Amstutz, J., Nigg, C., Pestalozzi, B. C., Imesch, P., Dummer, R., Blum, D., & Jenewein, J. (2024). Effects of dignity therapy on psychological distress and wellbeing of palliative care patients and family caregivers - a randomized controlled study. BMC Palliative Care, 23(1), Article 73. https://doi.org/10.1186/s12904-024-01408-4opens in new window

Terminal illness brings about significant psychological, emotional, and spiritual distress to the patient and their loved ones. This distress can manifest in various forms, including anxiety, depression, and existential suffering, impacting the overall quality of life for both patients and their loved ones. Although standard palliative care (SPC) addresses a couple of dignity-related concerns such as symptom management, privacy, and respect, it is not enough to address other aspects of dignity like avoiding dehumanization, maintaining a sense of identity, or attaining existential fulfillment. Thus, dignity therapy (DT) intervention emerged so that individuals can reflect on their meaningful moments and memories. This personalized intervention aims to create a written legacy for their families, referred to as a “generative document,” reflecting the patient’s personal history, important achievements, hopes, wishes, and anything that the patient wishes to share about themselves.

A randomized, multicenter-controlled trial was conducted across Zurich, Switzerland to understand the feasibility, acceptability, and effectiveness of DT intervention for patients with terminal cancer and their loved ones. Sixty-eight participants, including their partners or family caregivers, were randomly allocated to three groups: DT, DT+, and SPC alone (usual care). In the DT group, the patients received SPC with DT while patients in the DT+ group received SPC and DT alongside their loved ones. The control group, the SPC, did not receive DT.

The intervention group consisted of three sessions, each lasting 60 minutes, conducted over two weeks. The first session was a brief introduction followed by the main session, where the patient engaged in guided conversation to create the generative document, and the final session was to review the document. During the guided conversation, facilitated by the therapist, they focused on expressing desired thoughts and expressions that the patients wish to communicate to their loved ones. In the DT+ group, their loved ones contributed to the patient’s narrative for the document.

Results showed that most of the patients and their loved ones received DT well. The participants reported that DT helped them reflect on the memorable moments in their lives and transformed this reflection into a sense of gratitude. The researchers found no significant changes in anxiety, depression, or psychological distress levels in the 2-week and 3-month postintervention. However, when both the intervention groups (DT and DT+) were combined and compared to their pre- and postintervention scores, there was a significant increase in the quality of life and a decrease in suffering compared to the control group. Additionally, the combined intervention groups showed families how to cope with end-of-life situations, explicitly facilitating end-of-life conversations and sharing memorable experiences.

Togluk, S., & Budak, F. K. (2024). The effect of cognitive behavioral therapy-based psychoeducation on anger management and death anxiety in individuals receiving chemotherapy: A randomized controlled trial. Omega—Journal of Death and Dying. Advance online publication. https://doi.org/10.1177/00302228241237279opens in new window

Chemotherapy can be a great hindrance in an individual’s personal and professional life, resulting in the loss of their career, fear about the future, depression, helplessness, loneliness, anxiety, and other issues. One notable and determinantal effect that the researchers noted is the inability to express emotions, more specifically, anger. Many people’s struggle with anger emotion and death anxiety can greatly contribute to their psychological distress and well-being and, thus, impact their quality of life and treatment outcomes. While previous research has focused on using group cognitive-behavioral therapy (CBT) to help patients undergoing chemotherapy manage their anger, there is little research focusing on the effectiveness of individual psychosocial interventions that addresses the unique challenges patients receiving chemotherapy may experience. This study aimed to evaluate the effectiveness of a CBT-based psychoeducation in managing anger and death anxiety for those undergoing chemotherapy.

Eighty adults between 18 and 65 years of age undergoing chemotherapy were randomized to receive either eight biweekly, 50-minute sessions of CBT-based psychoeducation intervention or no intervention. The overall focus of each psychoeducation session consisted of anger management and death anxiety, incorporating different techniques like breathing-relaxation exercises, imaginary exposure, cognitive restructuring, and awareness building. Assessments on patients’ anger and death anxiety were gathered during the initial session and then after the eight sessions.

In the CBT-based psychoeducation intervention, the individuals had greatly improved their anger management and reduced their anxiety when compared to the control group. This finding demonstrated the effectiveness of CBT-based psychoeducation intervention in improving emotion regulation and reducing anxiety levels among patients undergoing chemotherapy. While the study showed effectiveness, it also addressed certain limitations. The researchers did not address the potential harms or burdens of the participant’s experience. Participating in this study might impose a burden on the individual, such as requiring time commitments to attend the sessions or travel to the location. These burdens might be salient to individuals already dealing with tremendous challenges. Analyzing some of these aspects might be helpful for any future studies. Overall, incorporating CBT-based approaches alongside medical treatment can provide valuable support in managing the psychological challenges associated with cancer treatment.

IsHak, W. W., Hamilton, M. A., Korouri, S., Diniz, M. A., Mirocha, J., Hedrick, R., Chernoff, R., Black, J. T., Aronow, H., Vanle, B., Dang, J., Edwards, G., Darwish, T., Messineo, G., Collier, S., Pasini, M., Tessema, K. K., Harold, J. G., Ong, M. K…Danovitch, I. (2024). Comparative effectiveness of psychotherapy vs antidepressants for depression in heart failure: A randomized clinical trial. JAMA Network Open, 7(1), Article e2352094. https://doi.org/10.1001/jamanetworkopen.2023.52094opens in new window

Millions of people around the world are affected by heart failure (HF), which is a terminal illness that causes significant morbidity and mortality. For these individuals, depression is widespread and can significantly worsen overall health outcomes. Regardless of this knowledge, depression often goes undiagnosed and untreated in HF populations, resulting in low quality of life, increased hospital utilization, and increased caregiver burden. Additionally, there is a limited understanding of effective treatment approaches for depression in individuals with HF. This gap in knowledge leaves health care providers with difficulty navigating treatment without clear guidance. The researchers were interested in examining whether there was a reduction in depression symptoms in individuals with HF who received behavioral activation or antidepressant medication.

A randomized clinical trial was conducted in a California health system where 416 individuals with HF and depression were randomly assigned to receive either behavioral activation or an antidepressant medication (e.g., paroxetine, bupropion, mirtazapine, venlafaxine, and many others). The researchers provided both interventions using video or phone due to the disruption of covid-19 and the disease burden of patients with HF. Behavioral activation consisted of 12 weekly sessions where individuals discuss values, perform activities aligned with those values, promote social engagement, and take part in activities that are enjoyable. Patients in the control group were prescribed antidepressant medications by their primary care providers. The researchers’ primary outcome was depression while their secondary outcomes consisted of health-related quality of life, caregiver burden, morbidity, and mortality. These outcomes were assessed during 3-, 6-, and 12-month follow ups.

Participants in both the behavioral activation and medication groups showed significant reduction in depression symptoms during the 6-month period. While individuals assigned to the behavioral activation group reported significant improvement in their health-related quality of life 6 months after the intervention more so than the medications group, overall, there were no significant differences in the other secondary outcomes.

These findings mean that both interventions improved the quality of life, with behavioral activation showing more substantial improvement in physical health compared to medications. Additionally, patients who received behavioral activation had lower hospital utilization rates. This finding indicates the potential advantages of behavioral activation in reducing hospital and emergency room visits. While more research is needed on the potential harms and burdens of behavioral activation for patients with heart failure, overall, the researchers highlighted that both interventions led to a nearly 50% reduction in depression symptoms at six months.

The researchers of these studies highlight the significance of integrating psychosocial intervention in patient care to address the holistic needs of the individuals diagnosed with a terminal illness. For people facing cancer, heart failure, or any other terminal disease, their psychological distress is elevated, and it worsens the individual’s suffering. By understanding which intervention is most effective for the patient and their caregivers, the clinicians can tailor the treatment to support the patient better. This strategy also helps clinicians allocate resources more efficiently by recognizing effective interventions. This way, patients still receive the necessary care while minimizing unnecessary costs and decreasing the financial strain.

Additionally, out of the three studies noted above, one study focused on implementing a telehealth intervention for patients with heart failure. Using the information from the study, clinicians can consider integrating telehealth services into their practice to provide remote sessions. It might be a better option for individuals facing terminal illness who are facing physical and mental impairments in attending in-person sessions. By delivering telehealth services, clinicians can expand their practice further, even in underserved areas. Thus, further research should examine the effectiveness of different psychological intervention methods in using telehealth. Also, comparing the in-person and telehealth sessions with patients and their loved ones would be helpful for the clinicians.

Furthermore, these studies did not discuss the potential harms or burden of the treatments. So, future research is needed to expand more on this topic so the clinicians can make informed decisions about the treatment options available. In conclusion, developing a more in-depth understanding of the effectiveness of the various evidence-based interventions can help make informed decisions, guide treatment, and improve overall well-being and quality of life for patients with terminal illness and their loved ones.