Dec 25, 2003 - defined (Badger, 2003; Pasacreta, 1997; Stoppard,. 1999). .... Mishel, 1997; Stoppard, 1999). ..... ed and found to be true, with no significant.
Research in Nursing & Health, 2004, 27, 19–28
Depression Burden, Psychological Adjustment, and Quality of Life in Women with Breast Cancer: Patterns over Time Terry A. Badger,1* Carrie Jo Braden,2* Merle H. Mishel,3* Alice Longman1{
1 University of Arizona, Tucson, AZ University of Texas, Health Sciences Center, San Antonio, TX 3 University of North Carolina, Chapel Hill, NC Accepted 25 December 2003
2
Abstract: The purpose of this study was to examine how level of depression burden influences women’s psychological adjustment and quality of life over time and how depression burden interacted with a community-based oncology support program to influence psychological adjustment and life quality. Participants were 169 women who completed a side effects checklist at three data collection points. Women were divided into two groups based on their depression burden scores: 123 women reporting no burden, and 46 women reporting high depression burden. For psychological adjustment, there were significant interaction effects for intervention by time and for intervention by depression burden by time and significant main effects for depression burden. For life quality, there was a significant interaction effect for intervention by time and a significant main effect for depression burden. The findings document the negative impact of depression burden on psychological adjustment and life quality. Oncology support interventions can be effective in reducing this negative impact. ß 2004 Wiley Periodicals, Inc. Res Nurs Health 27:19–28, 2004
Keywords: breast cancer; oncology support interventions; depression; psychological adjustment; quality of life
Breast cancer is a serious health concern and a major public health challenge in the United States (Jemel et al., 2003). Breast cancer is the most common form of cancer, accounting for approximately 30% of new cancer cases, with one in eight women developing breast cancer during their lifetimes (Jemel et al.). A significant number of
women will experience burdensome side effects associated with their cancer experience that will have a significant impact on cancer recovery and quality of life (Badger, Braden, Longman, & Mishel, 2001; Longman, Braden, & Mishel, 1996, 1997; McCorkle, 1987). The most commonly reported psychological side effect of cancer
Contract grant sponsor: National Cancer Institute; Contract grant number: NCI 5201 CA48450. Correspondence to Terry A. Badger, University of Arizona College of Nursing, POB 210203, Tucson, AZ 85721-0203. Professor. { Professor Emeritus. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/nur.20002
ß 2004 Wiley Periodicals, Inc.
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diagnosis and treatment is depression (Maunsell, Brisson, & Deschenes, 1992; Sellick & Crooks, 1999; Shapiro et al., 2001). Women with cancer report severe distress associated with depression, regardless of how the depressive phenomenon is defined (Badger, 2003; Pasacreta, 1997; Stoppard, 1999). Managing this serious psychological side effect is vital to the care of every woman regardless of stage of disease, disease site, or treatment (Holland, 1996). Depression burden is defined as the degree to which depression as a side effect of cancer diagnosis and treatment is perceived as problematic, troublesome, or distressing. The conceptualization of burden in this study is similar to the conceptualization associated with other side effects common to the cancer experience, such as nausea or pain, and to how depression burden has been conceptualized in the mental health literature (e.g., Bookless, Clayer, & McFarlane, 2000; McDonald et al., 1999; Rhodes & McDaniel, 1999). Many unanswered questions remain about the impact of depression burden on health outcomes and about the effectiveness of communitybased oncology support interventions for cancer patients with depression (Simonton & Sherman, 1999). In previous analyses, Self-Help Intervention Project (SHIP) interventions were found to improve interpersonal relationships; decrease nausea, pain, and fatigue burden; decrease uncertainty; and increase resourcefulness in women with high depression burden (Badger, Braden, Longman & Mishel, 1999; Badger et al., 2001; Braden & Mishel, 2000). These findings provided important clues about the role of depression burden and supported the need to examine further the effects of the interaction of depression burden with SHIP interventions on other health outcomes. Therefore, we examined how depression burden influences women’s psychological adjustment and health-related quality of life over time and how depression burden interacted with a communitybased oncology support program to influence psychological adjustment and life quality. In their meta-analysis of the psychological sequelae of cancer, Van’t Spiker, Trijsburg, and Duivenvoorden (1997) found the amount of psychological distress experienced by individuals with cancer did not differ from the general population, except for depression. Depression ranks among the most frequently reported psychological side effects for women with breast cancer (Longman, Braden, & Mishel, 1999; Pasacreta, 1997). In general, the more narrow the definition of the term depression, the lower is the
prevalence of depression reported. For example, when depression is defined as a symptom or symptoms, 56% of cancer patients report symptoms of depression, such as depressed mood, difficulty concentrating, and difficulty sleeping, as problematic side effects of cancer and its treatment (Barsevick, Pasacreta & Orsi, 1995; McDaniel & Nemeroff, 1993; Sachs et al., 1995). However, most cancer patients have depression symptoms of insufficient duration or frequency to meet the diagnostic criteria for a psychiatric diagnosis, which is another way to define depression. When a clinical diagnostic definition is used, about 25% of women with cancer are likely to meet the diagnostic criteria for major depressive disorder (American Psychiatric Association [APA], 1994; Sellick & Crooks, 1999; Valente, Saunders, & Cohen, 1994). Unfortunately, the rates of unrecognized and untreated depression for patients with cancer remain high regardless of the definition used (McDonald et al., 1999; Newport & Nemeroff, 1998). Patients with depression have an increased sideeffect burden, and these side effects may be more frequent and/or intense than those experienced by cancer patients who are not depressed. For example, depression has been found to increase anxiety and pain (McDonald et al., 1999) as well as difficulty in concentrating and in sleeping (Dow, Ferrell, Leigh, Ly, & Gulasekaram, 1996; Greene, Nail, Fieler, Dudgeon, & Jones, 1994). Depression also has been strongly and negatively associated with fatigue, the most frequently reported side effect (Nail, 1996; Visser & Smets, 1998; Winningham et al., 1994). A consistent finding about depression is that initial levels are strong predictors of subsequent depression, slower cancer recovery, and reduced life quality (Coyne, Gallo, Klinkman, & Calarco, 1998; Spiegel, 1997). Rohde, Lewinsohn, and Seeley (1990) hypothesized that such mood disturbances form a psychological scar, leaving the individual vulnerable to subsequent clinical depressive episodes. Yet despite evidence that depression is consistently linked to reduced quality of life, poorer adherence to medical care, longer hospital stays, and higher mortality (Newport & Nemeroff, 1998; Spiegel, 1997), depression is often unrecognized in the early phases of cancer treatment. Depression was conceptualized and measured in this analysis as depression burden. There is increasing evidence documenting the validity of using self-reported burden, defined as the degree an individual finds the side effect problematic, troublesome, or distressing, as a viable method for
DEPRESSION BURDEN AND PSYCHOLOGICAL ADJUSTMENT / BADGER ET AL.
measuring psychological distress (Badger et al., 2001; Bookless et al., 2000; Braden, Badger, & Mishel, 1997; Stoppard, 1999). Holland (1997) reported that a single-item measure of distress, the distress thermometer, was found to have construct validity with the Hospital Anxiety and Depression Scale (HADS). Patients who scored greater than 6 on the distress thermometer had scores on the HADS indicating a need for evaluation and treatment. The single-item indicator was acceptable to patients and clinicians alike for identifying patients in need of psychiatric treatment. Use of the single-item measure not only substantially reduced the response burden associated with completing longer measures but also the stigma associated with the longer psychological measures. Braden et al. (1997) similarly found selfreported burden was a useful outcome indicator for SHIP community-based oncology support interventions. The method used to measure burden in the current study is typical of how specific side-effect burden is addressed in the cancer literature (Daut, Cleeland, & Flanery, 1983; McDonald et al., 1999; Rhodes & McDaniel, 1999). An understanding of both the frequency and intensity of symptom burden is essential for symptom management (Dodd et al., 2001). These types of measures serve as useful outcome indicators for interventions designed to reduce either the intensity or frequency of the burden of side effects. Substantial evidence exists that psychosocial interventions improve cancer patients’ psychological adjustment and health-related quality of life (Bottomley, 1997, 1998; Fawzy, 1999; Fawzy, Fawzy, Arndt, & Pasnau, 1995; Giese-Davis & Spiegel, 2003). A number of therapeutic interventions have been used with cancer patients, including individual psychotherapy, group psychotherapy, hypnosis, guided imagery, relaxation training, psychoeducational groups, and self-help groups (e.g., Cella & Yellen, 1994; Haylock, 1999; McMillan, Tittle, & Hill, 1993; Smith, Holcombe, & Stullenbarger, 1994). Group interventions especially have been found to be a cost-effective method of reducing the psychological distress associated with cancer (Bottomley, 1997). According to Spiegel (1997), there is compelling evidence that psychosocial interventions can influence cancer patients’ daily activities, such as diet, exercise, sleep, and adherence to medical treatment and can have positive effects on psychological distress, including reducing depressive symptoms. Despite these advantages, psychosocial interventions are not routinely offered to cancer patients with depression. To date, articles
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in the literature primarily has been descriptive in nature, with few investigators examining the longterm effectiveness of psychosocial interventions (McDaniel & Nemeroff, 1993). The SHIP interventions used in this study were based on Braden’s self-help model, which depicts the variables and relationships essential for the learned self-help response to the chronic illness experience, and on Mishel’s uncertainty in illness theory. In the combined model (Braden, Mishel, & Longman, 1998; LeFort, 2000), perceived severity of illness as measured by the side effect experience works as a stimulus to move women into a chronic illness learning frame. The learning frame is specific to the breast cancer treatment experience. SHIP interventions are directed toward the learning frame variables of uncertainty and enabling skills, such that the outcomes of self-care, selfhelp, psychological adjustment, and life quality are maintained or enhanced. In the learned response to the chronic illness experience, these outcomes feed back to the side-effect experience in order to reduce the perception of the side effect as burdensome. Thus, specific activities in the interventions were designed to enhance problem solving and cognitive reframing and to support the management of uncertainty. An effective selfhelp-promoting intervention would, via feedback loops, serve to reduce the burdens associated with the side-effect experience. In this model depression burden interferes with the learning experience, leading to a decrease in self-care, self-help, psychological adjustment, and life quality and to an increase in perceptions that other side effects such as pain or nausea are burdensome. In previous analyses Longman et al. (1996, 1997, 1999) documented the pervasiveness of depression burden and its negative associations across time with self-help, psychological adjustment, and health-related life quality. For women not participating in the SHIP interventions, the magnitude of the association of depression burden with negative psychological adjustment increased over time, demonstrating the strong role that selfreported depression burden plays in adjustment (Longman et al., 1999). A growing body of evidence indicates that a significant depression experience, whether conceptualized as depressive symptoms, clinical depression, or depression burden, leaves a psychological scar that puts the person at risk for recurrent depression and interpersonal, occupational, and health deficits (Rohde, Lewinsohn, & Seeley, 1990). All three are important areas of health-related quality of life. If women reporting high levels of depression burden are helped by the
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intervention to maintain or make gains in psychological adjustment and overall life quality, then depression as a side effect of breast cancer treatment may not form a psychological scar. However, at this point it is not clear whether an array of life-quality deficits are residuals from a prior depression experience or a set of traits that remain stable (Kasper, 1993). What is clear is the need to learn more about the interactive effects of depression burden and a set of oncology support interventions on psychological adjustment and life quality over time for women receiving treatment for breast cancer. Findings may serve as a basis for refining the SHIP intervention and for developing specific interventions for those women with significant depression burden. Findings also may provide insights about how a learned self-help response works over time to decrease perceived severity of illness as measured by depression burden and how perhaps it decreases the risk of clinical depression during the breast cancer experience. Two research questions were addressed: (a) What is the effect of depression burden on psychological adjustment at baseline and over time in women who were randomly assigned to SHIP intervention or control groups? and (b) What is the effect of depression burden on overall quality of life at baseline and over time in women who were randomly assigned to the SHIP intervention or control groups?
One hundred sixty-nine women who completed the side-effect checklist at three data collection points (baseline, after the 6-week interventions, and 3 months after T2) and who reported either no depression burden (n ¼ 123) or high depression burden (n ¼ 46) at baseline provided data for this analysis. Ages ranged from 25 to 82 years (M ¼ 55.6 years; SD ¼ 12.8 years). Ninetyone percent of the women were White, 7.4% were Mexican-American, and fewer than 1% were Native American or other. The majority (64%) were married or partnered. Thirty-six percent of the women were working or going to school either full- or part-time; another 50% were either retired or were homemakers. Average income ranged from $1,000 to $1,249 every 2 weeks. Twenty-six percent of the sample had an educational level of high school or less, and 34% were college graduates. The majority (79%) of the women had Stage I or Stage II disease at time of diagnosis; however, 11% of the women did have metastases at this time. Types of medical treatment included modified radical mastectomy (52%), partial mastectomy (10%), lumpectomy (43%), axillary node dissection (59%), and reconstructive surgery (12%). Approximately half the women received chemotherapy, half radiation therapy, and about one-third received hormone therapy. One-third of the women received more than one type of therapy. Intervention
METHOD Sample The data used in this study were drawn from the Self-Help Intervention Project (SHIP), a study designed to test the effectiveness of a communitybased oncology support program for women receiving treatment for breast cancer (Braden et al., 1998). The five different but complementary interventions in the larger study were combined into one treatment group for this analysis, as prior analyses have demonstrated that any one of the self-help interventions was more effective than no intervention (control) at improving health outcomes among women with breast cancer (Braden, Mishel, & Longman, 1995; Braden et al., 1998; Duong, 1996; Kreulen et al., 2002). For this analysis we were interested in examining how depression burden interacted with any of the interventions to influence psychological adjustment and life quality.
The five 6-week interventions were: (a) a series of six classes offered in a self-help course (SHC), (b) uncertainty management (UM)–focused telephone contact by a nurse case manager (McHenry, Allen, Mishel, & Braden, 1993), (c) an independent study (IS) self-help course, (d) combined SHC plus UM, and (e) IS plus UM (Braden et al., 1995, 1998). The control condition was a natural learning condition in which women accessed any of the resources made available through their own efforts, those of family and friends, or through health care providers. Although SHIP interventions were not specifically designed to decrease the burden of depression as a primary intervention outcome, each of the interventions contained theory-informed components thought to aid in modifying perceived depression burden. They were cognitive reframing of aversive events, problem-solving alternatives to manage side effects, and strategies to mobilize needed resources. Both cognitive-reframing and problem-solving skill enhancement strategies
DEPRESSION BURDEN AND PSYCHOLOGICAL ADJUSTMENT / BADGER ET AL.
were designed to maintain and/or enhance psychological adjustment and overall life quality. Measures Depression burden, the perceived level of problems, trouble, or distress associated with depression as a side effect of breast cancer diagnosis and treatment, was indexed by a constructed measure based on the depression side-effect item from the 16-item side effects checklist developed for this study. The checklist consists of 16 common side effects (e.g., nausea, pain, depression) of breast cancer treatment identified in focus group sessions by women who had completed cancer treatment (Braden, Mishel, & Jacob, 1990). Women were requested to check the side effects experienced and to rank the five side effects most problematic for them from the 16 listed. Burden levels could range from 0 to 2: 0, not experienced, not checked; 1, experienced but not ranked; and 2, ranked among the top five most problematic side effects. Support for the validity of the measure was demonstrated by significant ( p < .05) correlations consistent with theory-predicted relationships (Longman et al., 1996). For example, depression burden negatively correlated with mastery (r ¼ .41; Longman et al., 1999), and mastery is commonly negatively correlated with depression measures (Badger, 2001). Psychological adjustment, addressed as a pessimistic or fatalistic mood, was measured by the Negative Affect Scale (Watson, Clark, & Tellegan, 1988). Respondents use a 5-point Likert-type response format to indicate the extent to which 10 negative feelings and emotions are representative of how the individual is feeling at a given point in time. Scores can range from 0 to 50, with higher scores reflecting a greater negative affective state. A reduction in mean negative affective scale scores over time would indicate an increase in psychological adjustment. An internal consistency reliability of >.90 at all three data collection points indicates satisfactory reliability (Longman et al., 1996; Manne & Fox, 2001). Support for the validity of the scale was demonstrated by significant correlations consistent with theory-predicted relationships. For example, psychological adjustment was negatively correlated with mastery, self-help, and life quality (Braden & Mishel, 2000). Overall life quality, the perceived degree of well-being, was measured by the nine-item Index of Well-Being (IWB; Campbell, Converse, & Rogers, 1976). The IWB uses a visual analogue
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scale response format and has a potential score range of 0–900. A higher score reflects greater perception of overall well-being. Reliability was >.90 across time, indicating satisfactory reliability (Badger, 2001), and the IWB has been reported to have construct validity (Campbell et al., 1976). Support for the validity of the scale was demonstrated in this study by correlations consistent with theory-predicted relationships, such as positive correlations between life quality and psychological adjustment or negative correlations between life quality and side effects (Longman et al., 1999). Procedure Human subjects’ criteria were met and approved by the institutional review board at a university in a southwestern state. Participants were Englishspeaking women, aged 18 years and older, who were currently receiving treatment for breast cancer. Women were referred from the outpatient sites of a regional cancer center, from private practices, and from HMOs. Women who agreed to participate and signed the informed consent were randomly assigned to one of the intervention or control groups. Participants were recruited over a 3-year period, from January 1990 to March 1993. Data were collected at baseline (T1) after radiation, chemotherapy, or hormone therapies were started to allow for treatment-related side effects to emerge. The second data collection point (T2) was after the interventions, and the third (T3) was 3 months following T2. The total time period covered by the study was the first 5–6 months following initiation of cancer treatment. Data Analysis To answer the research questions, repeatedmeasures (multivariate analysis of variance (MANOVA) was used to assess if the high- versus depression intervention and control groups differed with the corresponding low-depression groups in psychological adjustment and overall life quality. Given the unequal cell sizes, assumptions about homogeneity of variance were tested and found to be true, with no significant differences from the variance assumptions. Although cell sizes were unequal, they remained stable over time because only women with complete data at all three times were used in this analysis. Findings from the repeated-measures MANOVA were the main effects for depression
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burden and time and the interaction effects for depression burden by time, intervention by time, and depression by intervention by time.
Table 1. Means and Standard Deviations for Psychological Adjustment by Depression Burden by Intervention Group Psychological Adjustment Depression Burden
Time 1
Time 2
Time 3
14.49 4.88
13.80 5.26
13.94 5.17
14.87 4.88
13.38 3.70
14.09 5.31
21.22 8.52
20.57 9.18
18.82 8.39
22.28 11.84
23.71 6.80
27.28 8.59
RESULTS Sample There were no significant differences found at baseline between women with low depression burden (n ¼ 123) and high depression burden (n ¼ 46) for demographic and treatment characteristics, except for stage of disease. Regardless of assignment to treatment or control group, there was a significant difference for disease stage, F(1, 145) ¼ 5.07, p ¼ .02, with more women in the lowdepression group than women in the high-depression group having Stage II disease. Among the 123 women in the low-depression-burden group, 94 women (71%) who were in the intervention group and 29 (76%) who were in the control group reported no depression burden. Depression was reported as one of the most problematic side effects by 37 (28%) women in the intervention group and by 9 (23%) women in the control group. Research question 1. For psychological adjustment, there were significant interaction effects for intervention by depression burden by time, F(1, 175) ¼ 3.45, p ¼ .03, for intervention by time, F(1, 175) ¼ 3.41, p ¼ .03, and a significant main effect for depression burden, F(1, 175) ¼ 51.14, p ¼ .006. At baseline, women with high depression burden were similar for psychological adjustment regardless of assignment to intervention or control group. Women with high depression burden had poorer psychological adjustment or increased negative affective state compared to women with low depression burden at baseline (Table 1). Across time, women with high depression burden in the intervention group demonstrated improved psychological adjustment (i.e., decreasing negative affective state) from Time 1 (M ¼ 21.22, SD ¼ 8.52) to Time 3 (M ¼ 18.82, SD ¼ 8.39). Women with high depression burden in the control group evidenced a decrease in psychological adjustment (i.e., increased negative affect) from Time 1 to Time 3 (M ¼ 22.28, SD ¼ 11.84; M ¼ 27.28, SD ¼ 8.59). As illustrated in Figure 1, decreases in negative affect over time were the most dramatic for those in the intervention group who had high depression burden. However, even women with low burden in the intervention group evidenced more of a
Low Depression Intervention M SD Control M SD High Depression Intervention M SD Control M SD
decline in negative affect over time than did women with low burden in the control group. Research question 2. For quality of life, there was a significant time-by-intervention effect. F(1, 175) ¼ 4.32, p ¼ .01, and a significant main effect at baseline for depression burden, F(1, 175) ¼ 39.37, p ¼ .001. At baseline, women with high depression burden evidenced lower overall life quality regardless of group assignment (Table 2). Regardless of level of depression burden, women in the intervention group demonstrated improved life quality from Time 1 to Time 3, whereas women in the control group evidenced a sharp decrease in life quality over time (Fig. 2). DISCUSSION The findings from this study document the negative impact of self-reported depression burden on psychological adjustment and quality of life at baseline when women were beginning to experience side effects from their adjuvant therapy. Regardless of group assignment to SHIP intervention or control, women who self-reported high depression burden at the time side effects began to appear also reported less psychological adjustment and overall quality of life. One finding consistent with previous literature (Spiegel, 1997; Visser & Smets, 1998) was that women’s initial mood disturbance was a strong predictor of later negative psychological adjustment. Without intervention, women who were
DEPRESSION BURDEN AND PSYCHOLOGICAL ADJUSTMENT / BADGER ET AL.
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FIGURE 1. Psychological adjustment by group by time.
initially assessed with high depression burden had reduced psychological adjustment over time. This finding supports Holland’s (1996, 1997) argument that managing this distress is essential for providing quality health care to women with breast cancer. Assessment of depression burden during the initial phases of treatment is critical because of the strong relationship over time between initial mood disturbance and future depression and other negative health outcomes (Coyne et al., 1998). Women with high depression burden in the intervention group showed the greatest gains in Table 2. Means and Standard Deviations for Quality of Life by Depression Burden by Intervention Group Quality of Life Depression Burden Low Depression Intervention M SD Control M SD High Depression Intervention M SD Control M SD
Time 1
Time 2
Time 3
726.54 106.62
728.15 115.36
737.66 114.31
763.51 114.80
759.87 137.78
737.22 131.55
615.22 150.03
636.00 165.80
636.22 161.94
590.85 240.50
556.14 113.25
481.85 221.67
psychological adjustment; however, in overall quality of life, both high- and low-depressionburden groups benefited equally from the intervention. Although women with high depression burden showed the largest psychological adjustment gains, these findings highlight that even low levels of depression burden warrant attention. Interventions to increase life quality over the time women are receiving adjuvant therapy are indicated regardless of depression burden level. Consistent with the results of previous studies (e.g., Fawzy, 1999; McMillan et al., 1993; Smith et al., 1994), the findings provide strong support for the effectiveness of oncology support interventions. Regardless of whether the interventions were group- or individually delivered, they increased the learned self-help response to the breast cancer experience as evidenced by the maintaining and/or enhancing of psychological adjustment and life quality. A learned self-help response is hypothesized to include feedback over time that decreases uncertainty and subsequently perceived severity of illness (Braden, 1993). Future model testing analysis will determine if the feedback loops operate as predicted. Given the findings from this study, it is possible that psychological adjustment and overall life quality feedback can decrease the magnitude of depression burden and other side effects over time. If such a feedback relationship is confirmed, oncology support interventions may reduce the risk of clinical depression as an initial or recurrent condition associated with the cancer treatment experience.
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FIGURE 2. Quality of life by group by time.
These findings have provided ideas for refining the interventions for women with high depression burden. Increasing the content on the active processing of problems and perceptions related to depression, cognitive reframing, and problem solving could strengthen self-help interventions for women who experience a high level of depression burden at baseline. For example, people with recent diagnoses of depression described factors such as lack of energy, loss of self-efficacy, fear of recurrence and of taking risks, inability to trust oneself, self-presentation and concealment, concern about being a burden to others, and reduced involvement in interpersonal relationships as affecting how they saw the future and how they structured their lives (Coyne & Calarco, 1995; Coyne et al., 1998). These factors could be incorporated within SHIP problem-solving and cognitive-reframing learning activities. Supplementary materials whose focus is on cognitive– behavioral techniques, such as popular self-help books on depression, may be useful for refining and processing the depression content. Using SHIP as a vehicle for increasing opportunities to strengthen women’s social network is also recommended, given the persistent findings about the interpersonal contributors to developing and maintaining depression (Joiner, 2000) and about the depression-buffering effects of support when present (Badger et al., 1999; Segrin, 2001). Oncology support programs have the potential to assist women to decrease their depression burden, and to improve their psychological adjustment and life quality. Although some caution must be exercised in interpreting these results because of the use of a non–clinically based depression measure, these findings do support the clinical significance of using self-report measures
of depressive symptoms or distress (Holland, 1997; Pasacreta, 1997). The self-report singleitem measure may be an efficient and nonstigmatizing way to identify those women who require further assessment with a more structured instrument (e.g., Center for Epidemiological Studies– Depression scale, Beck Depression Inventory), including appropriate referral to specialty care. In future SHIP intervention research, recommended strategies for measuring depression will be used to provide further information about the interaction of depression symptoms and oncology support interventions on psychological adjustment and life quality (Tennen, Hall, & Affleck, 1995a,b). Nurses and other health care professionals need such information to understand more about the influence of depressive symptoms and to assist women to gain the maximum benefit from oncology support interventions. Nurses clearly have an important role in preventing the negative long-term sequelae of cancer treatment and in improving the psychological adjustment and life quality of women with breast cancer. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: Author. Badger, T.A. (2003). Conceptualization and measurement of depressive phenomena in breast cancer. Unpublished manuscript. Badger, T.A. (2001). Depression, psychological resources and health-related quality of life in older adults: Aged 75 and older. Journal of Clinical Geropsychology, 7, 189–199. Badger, T.A., Braden, C.J., Longman, A.J., & Mishel, M.H. (1999). Depression burden, self-help interven-
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tions, and social support among women receiving treatment for breast cancer. Journal of Psychosocial Oncology, 17, 17–35. Badger, T.A., Braden, C.J., Longman, A.J., & Mishel, M.H. (2001). Depression burden, self-help interventions and side effects experienced by women with breast cancer. Oncology Nursing Forum, 28, 567–574. Barsevick, A.M., Pasacreta, J., & Orsi, A. (1995). Psychological distress and functional dependence in colorectal cancer patients. Cancer Practice, 3, 105– 110. Bookless, C., Clayer, J., & McFarlane, A.C. (2000). Individual differences in appraisal of depression. Personality and Individual Differences, 28, 7–15. Bottomley, A. (1997). Where are we now? Evaluating two decades of group interventions with cancer patients. Journal of Psychiatric and Mental Health Nursing, 4, 251–265. Bottomley, A. (1998). Depression in cancer patients: A literature review. European Journal of Cancer Care, 7, 181–191. Braden, C.J. (1993). Research program on learned response to chronic illness experience: Self-help model. Holistic Nursing Practice, 8, 38–44. Braden, C.J., Badger, T.A., & Mishel, M.H. (1997, August). Depression among low income and minority women receiving treatment for breast cancer. In C.J. Braden (Chair), Self-help interventions among Anglo and minority women receiving treatment for breast cancer. Symposium at the meeting of Women’s Health Issues: A Global Nursing Perspective, St. Thomas, U.S. Virgin Islands. Braden, C.J., & Mishel, M.H. (2000). Highlights of the self-help intervention project (SHIP): Health-related quality of life during breast cancer treatment. Innovations in Breast Cancer Care, 5, 27–34. Braden, C.J., Mishel, M.H., & Jacob, M. (1990, February). Matching evolving knowledge with existing knowledge: Issues in use of focus group technique for needs assessment. Paper presented at the Qualitative Health Research Conference, Edmonton, Alberta, Canada. Braden, C.J., Mishel, M.H., & Longman, A. (1995). Efficacy of the self-help course for women receiving treatment for breast cancer. Oncology Nursing Forum, 22, 350–359. Braden, C.J., Mishel, M.H., & Longman, A. (1998). Self-help intervention project: Women receiving treatment for breast cancer. Cancer Practice, 6, 87– 98. Campbell, A., Converse, P., & Rogers, W. (1976). The quality of American life. New York: Russell Sage. Cella, D.F., & Yellen, S.B. (1994). Cancer support groups: The state of the art. Cancer Practice, 1, 56– 61. Coyne, J.C. & Calarco, M.M. (1995). Effects of the experience of depression—Application of focus group and survey methodologies. Psychiatry—Interpersonal and Biological Processes, 58, 149–163. Coyne, J.C., Gallo, S.M., Klinkman, M.S., & Calarco, M.M. (1998). Effects of recent and past major
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depression and distress on self-concept and coping. Journal of Abnormal Psychology, 107, 86–96. Daut, R.L., Cleeland, C.S., & Flanery, R.C. (1983). Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain, 17, 197–210. Dodd, M., Janson, S., Facione, N., Faucett, J., Froelicher, E.S., Humphreys, J., et al. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33, 668–676. Dow, K.H., Ferrell, B.R., Leigh, S., Ly, J., & Gulasekaram, P. (1996). An evaluation of the quality of life among long-term survivors of breast cancer. Breast Cancer Research & Treatment, 39, 261– 273. Duong, D.N. (1996). Evaluation of the self-help intervention program (SHIP): Psychoeducational interventions for patients with breast cancer. Unpublished doctoral dissertation, University of Arizona, Tucson. Fawzy, F.I. (1999). Psychosocial interventions for patients with cancer: What works and what doesn’t. European Journal of Cancer, 35, 1559–1564. Fawzy, F.I., Fawzy, N.W., Arndt, L.A., & Pasnau, R.O. (1995). Critical review of psychosocial interventions in cancer care. Archives of General Psychiatry, 52, 100–113. Giese-Davis, J., & Spiegel, D. (2003). Emotional expression and cancer progression. In R.J. Davidson, K.R. Scherer, & H.H. Goldsmith (Eds.), Handbook of affective disorders (pp. 1053–1082). New York: Oxford University Press. Greene, D., Nail, L.M., Fieler, V.K., Dudgeon, D., & Jones, L.S. (1994). A comparison of patient-reported side effects among three chemotherapy regimens for breast cancer. Cancer Practice, 2, 57–62. Haylock, P.J. (1999). Cancer Survival Toolbox facilitates teaching of patient advocacy skills. ONS News 14, 6. Holland, J.C. (1996). Cancer’s psychological challenges. Scientific American, 275, 158–161. Holland, J.C. (1997). Preliminary guidelines for the treatment of distress. Oncology: NCCN Proceedings, 11, 109–117. Jemel, A., Murray, T., Samuels, A., Ghafoor, A., Ward, E., & Thun, M. (2003). Cancer statistics, 2003. CA: A Cancer Journal for Clinicians, 53, 5–26. Joiner, T.E. (2000). Depression’s vicious scree: Selfpropagating and erosive processes in depression chronicity. Clinical Psychology—Science and Practice, 7, 203–218. Kasper, S. (1993). The rationale for long-term antidepressant therapy. International Clinical Psychopharmacology, 8, 225–235. Kreulen, G.J., Stommel, M., Gutek, B.A., Burns, L.R., & Braden, C.J. (2002). Utility of retrospective pretest ratings of patient satisfaction with health status. Research in Nursing & Health, 25, 233–241. LeFort, S.M. (2000). A test of Braden’s self-help model in adults with chronic pain. Journal of Nursing Scholarship, 32, 153–160.
28
RESEARCH IN NURSING & HEALTH
Longman, A.J, Braden, C.J., & Mishel, M.M. (1996). Side effects burden in women with breast cancer. Cancer Practice, 4, 1–7. Longman, A.J., Braden, C.J., & Mishel, M.M. (1997). Patterns of association over time of side-effects burden, self-help and self-care in women with breast cancer. Oncology Nursing Forum, 24, 1155–1160. Longman, A.J., Braden, C.J., & Mishel, M.M. (1999). Side-effects burden, psychological adjustment and life quality in women with breast cancer: Patterns of association over time. Oncology Nursing Forum, 26, 909–915. Manne, S., & Fox, C. (2001). Measuring cancer patients’ psychological distress and well-being: A factor analytic assessment of the Mental Health Inventory. Psychological Assessment, 13, 99–109. Maunsell, E., Brisson, J., & Deschenes, L. (1992). Psychological distress after initial treatment of breast cancer. Cancer, 70, 120–125. McCorkle, R. (1987). The measurement of symptom distress. Seminars in Oncology Nursing, 3, 248–256. McDaniel, J.S., & Nemeroff, C.B. (1993). Depression in the cancer patient: Diagnostic, biological and treatment aspects. In C.R. Chapman & K.M. Foley (Eds.), Current and emerging issues in cancer pain: Research and practice (pp. 1–19). New York: Raven Press. McDonald, M.V., Passik, S.D., Dugan, W., Rosenfeld, B., Theobald, D.E., & Edgerton, S. (1999). Nurses’ recognition of depression in their patients with cancer. Oncology Nursing Forum, 26, 593–599. McHenry, J., Allen, C., Mishel, M., & Braden, C.J. (1993). Uncertainty management for women receiving treatment for breast cancer. In S. Funk, E. Tornquist, M. Champagne, & R.Wiese (Eds.), Key aspects of caring for the chronically ill (pp. 170– 177). New York: Springer. McMillan, S.C., Tittle, M.B., & Hill, D. (1993). A systematic evaluation of the ‘‘I Can Cope’’ program using a national sample. Oncology Nursing Forum, 20, 455–461. Nail, L.M. (1996). Differentiating fatigue and depression in cancer patients. In C.M. Hogan and R. Wickham (Eds.), Issues in managing the cancer patient: A Current reference and bibliography (pp. 36– 42). New York: Phillips Healthcare Communications. Newport, D.J., & Nemeroff, C.B. (1998). Assessment and treatment of depression in the cancer patient. Journal of Psychosomatic Research, 45, 215–237. Pasacreta, J.V. (1997). Depressive phenomenon, physical symptom distress, and functional status among women with breast cancer. Nursing Research, 46, 214–221. Rhodes, V.A., & McDaniel, R.W. (1999). The Index of Nausea, Vomiting and Retching: A new format of the Index of Nausea and Vomiting. Oncology Nursing Forum, 26, 889–900. Rohde, P., Lewinsohn, P.M., & Seeley, J.R. (1990). Are people changed by the experience of having an episode of depression—a further test of the SCAR hypothesis. Journal of Abnormal Psychology, 99, 264–271.
Sachs, G., Rasoul-Rockenshaub, S., Aschauer, H., Spiess, K., Gober, I., Staffen, A., et al. (1995). Lytic effector cell activity and major depressive disorder in patients with breast cancer: A prospective study. Journal of Neuroimmunology, 59, 84–89. Segrin, C. (2001). Interpersonal processes in psychological problems. New York: Guildford. Sellick, S.M., & Crooks, D.L. (1999). Depression and cancer: An appraisal of the literature for prevalence, detection, and practice guideline development for psychological interventions. Psycho-Oncology, 8, 315–333. Shapiro, S.L., Lopez, A.M., Schwartz, G.E., Bootzin, R., Figueredo, A.J., Braden, C.J., et al. (2001). Quality of life and breast cancer: Relationship to psychosocial variables. Journal of Clinical Psychology, 57, 501–519. Simonton, S., & Sherman, A.C. (1999). Psychological aspects of mind–body medicine: Promises and pitfalls from research with cancer patients. Alternative Therapies, 4, 50–67. Smith, M.C., Holcombe, J.K., & Stullenbarger, E. (1994). A meta-analysis of intervention effectiveness for symptom management in oncology nursing research. Oncology Nursing Forum, 21, 1201– 1210. Spiegel, D. (1997). Psychological aspects of breast cancer treatment. Seminars in Oncology, 24, S1-36– S1-47. Stoppard, J.M. (1999). Why new perspectives are needed for understanding depression in women. Canadian Psychology, 40, 79–90. Tennen, H., Hall, J.A., Affleck, G. (1995a). Depression research methodologies in the Journal of Personality and Social Psychology: A review and critique. Journal of Personality and Social Psychology, 68, 870–884. Tennen, H., Hall, J.A., & Affleck, G. (1995b). Rigor, rigor mortis and conspirational views of depression research. Journal of Personality and Social Psychology, 65, 895–900. Valente, S.M., Saunders, J.M., & Cohen, M.Z. (1994). Evaluating depression among patients with cancer. Cancer Practice, 2, 65–71. Van’t Spijker, A., Trijsberg, R.W., & Duivenvoorden, H.J. (1997). Psychological sequelae of cancer diagnosis: A meta-analytical review of 58 studies after 1980. Psychosomatic Medicine, 59, 280–293. Visser, M.R.M., & Smets, E.M.A. (1998). Fatigue, depression and quality of life in cancer patients: How are they related. New York: Springer-Verlag. Watson, D., Clark, L., & Tellegan, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 34, 1063– 1070. Winningham, M.L., Nail, L.M., Burke, M.B., Brophy, L., Cimprich, B., Jones, L.S., et al. (1994). Fatigue and the cancer experience: The state of the knowledge. Oncology Nursing Forum, 21, 23–36.
