Japanese Journal of Clinical Oncology Advance Access originally published online on November 12, 2008
Japanese Journal of Clinical Oncology 2008 38(12):867-870; doi:10.1093/jjco/hyn115
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© The Author (2008). Published by Oxford University Press. All rights reserved
Problem-Solving Therapy for Psychological Distress in Japanese Cancer Patients: Preliminary Clinical Experience from Psychiatric Consultations
1 Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi
2 Center for the Study of Communication Design, Osaka University, Osaka
3 Graduate School of Medicine, Osaka University, Osaka
4 Department of Clinical Psychology, Graduate School of Clinical Psychology, Kansai University of Welfare Sciences, Osaka
5 Nagoya City University School of Nursing, Nagoya, Japan
For reprints and all correspondence: Tatsuo Akechi, Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho, Mizuho-ku, Nagoya 467-8601, Japan. E-mail: takechi{at}med.nagoya-cu.ac.jp
Received August 25, 2008; accepted September 22, 2008
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Abstract |
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Problem-solving therapy (PST) is a brief, structured psychological treatment. Preliminary clinical findings regarding the effectiveness of PST for treating psychological distress experienced by Japanese cancer patients are presented. Our actual clinical experience in administering PST to four consecutive distressed cancer patients was reviewed. All of the patients were breast cancer survivors who were referred to us after undergoing surgery. Three cases received six PST sessions each and one case received three PST sessions. The depression and anxiety scores decreased after PST. Our preliminary experience suggests that PST is an effective treatment for alleviating psychological distress in Japanese cancer patients and that this treatment should be further examined in a clinical trial.
Key Words: cancer • psychological distress • problem-solving therapy • psychological intervention
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INTRODUCTION |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONFundingReferences |
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The experience of cancer causes considerable stress in patients. Depression and anxiety, including adjustment disorders and major depression, are the most prevalent forms of psychological distress experienced by cancer patients (1). Patients sometimes seek psychological treatment to help them cope with their cancer even though their psychological status does not meet the criteria of a formal psychiatric diagnosis (1). Previous Japanese studies investigating the prevalence of psychological distress in cancer patients have reported rates of 15–40% (2,3). Psychological distress not only causes great suffering, but also diminishes quality of life, amplifies pain and other symptoms, and sometimes leads to suicide.
Regarding therapy for psychological distress, two potentially effective management strategies are available: psychotherapy and pharmacotherapy. A previous Japanese study indicated that psychotherapy is deemed more acceptable than pharmacotherapy by cancer patients (4). Although previous reviews have highlighted the general efficacy of various psychosocial interventions, very few studies have addressed which kinds of psychotherapy are feasible or effective for Japanese cancer patients in actual clinical oncology practice. In this context, we have been interested in the effectiveness of problem-solving therapy (PST), which is a brief, structured psychological treatment (5). PST has been shown to be effective for the treatment of common mental disorders, including depression and anxiety, in primary care and oncology settings in Western countries (5).
The current report introduces our preliminary clinical findings regarding the effectiveness of PST for treating psychological distress experienced by Japanese cancer patients.
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PATIENTS AND METHODS |
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Subjects
The subjects were four consecutive cancer patients who were referred to one of the authors for PST. The patients were referred for the treatment of psychological distress and were followed up by one of the authors. The patients received PST for several reasons, such as intolerability and/or reluctance to use medications and refractoriness to general supportive psychotherapeutic approaches. Psychiatric diagnoses were made using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). As this study was conducted in the routine clinical setting, treatments of PST were provided under usual health national insurance system (we therefore could not charge the patients any special fee for PST). In the following, several items of personal information were modified to preserve the anonymity of the patients.
Problem-Solving Therapy
PST focuses on the present and helps patients to use their own skills and resources to function better. The patients are taught how their psychological symptoms may be linked to psychosocial problems that they are facing, and PST provides the patients with a structured strategy to solve them. If these problems can be resolved, their symptoms may improve. PST includes the following seven steps (5): (i) explanation of the treatment and its rationale, (ii) identification, definition and breakdown of the problem, (iii) establishing achievable goals, (iv) generating solutions, (v) evaluating and choosing the solution, (vi) implementing the chosen solution, (vii) evaluating the outcome after the solution has been implemented. We developed a PST manual for Japanese cancer patients. The manual was designed to help the patients list and summarize problems commonly encountered by cancer patients, including cancer treatment, symptoms of cancer, treatment side effects, fear of recurrence/metastasis, relationship with medical staff, family and other people, economic problems, information issues, employment/school issues. The manual also includes tips and worksheets for patients to use while progressing through each step of PST. The first treatment session lasted about 90 min, and subsequent sessions lasted 40–50 min. In principle, six treatment sessions were given. In addition, we incorporated a simple behavioral treatment skill, activity scheduling, into the PST (5). In activity scheduling, we helped the patients find and then engage in pleasurable activities on a more frequent basis to help alleviate their psychological distress.
Assessment
We used two psychological measures, the Beck Depression Inventory-II (BDI-II) (6) and the Hospital Anxiety and Depression Scale (HADS) (7), to evaluate psychological distress in clinical practice, depending on the patients’ psychological status. The BDI-II is a 21-item self-reported questionnaire to evaluate the severity of depression. The total score can range from 0 to 63, with higher scores representing severer depression. The validity and reliability of the Japanese version of the BDI-II has been confirmed (8). Depression severity was assessed according to the following BDI scores (9): 0–13, minimal; 14–19, mild; 20–28, moderate; 29–63, severe. The HADS is a 14-item self-reported questionnaire consisting of an anxiety and depression subscale; the total score can range from 0 to 42. Higher scores indicate severer anxiety and depression. The Japanese version of the HADS has been validated for cancer populations, and the optimal cut-off point for screening for adjustment disorder and major depressive disorder was 10 of 11 (10). In this report, the results of these measures before and immediately after intervention were used.
Because of the small sample size, we presented the descriptive statistics of the BDI-II and HADS scores pre- and post-intervention only.
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RESULTS |
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All of the patients were breast cancer survivors who were referred to us after undergoing surgery (Table 1). Their psychiatric diagnoses varied, ranging from normal reaction to major depression. Both the BDI-II scores [pre: 26.8 (SD = 14.0); post: 13.3 (SD = 7.7)] and the HADS scores [pre: 17.0 (SD = 2.6); post: 9.7 (SD = 3.5)] improved after PST. Three patients completed all six PST sessions, while one patient received only three PST sessions (one case, a 32-year woman, terminated PST early because she declined further treatment after finding a new job.). Patient adherences with each therapy session, including activity scheduling, was generally excellent for all the four patients.
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Here, the clinical process of PST is introduced using one example case (Ms. D). Ms. D was a 52-year-old housewife who lived with her husband and two children. She was diagnosed as having early-stage breast cancer (Stage 0) and received a surgical resection (simple mastectomy). Because the results of a sentinel lymph node biopsy were negative, she was told that she would not need any further adjuvant therapy. However, she became nervous and anxious about the possible recurrence of her breast cancer and its development into a serious physical disease. Consequently, she could not sleep and began to feel several kinds of physical discomfort, including dizziness, tinnitus and palpitations. She visited an otolaryngologist and neurologist, but no evidence of organic disease was found. Three months after her operation, she consulted a psychiatric clinic and began to take psychotropic medications, including antidepressants and benzodiazepines, and was subsequently referred to one of the authors. An initial assessment revealed a depressive mood and a fear of recurrence, and she was diagnosed as having an adjustment disorder with mixed emotional features (BDI-II score, 31). Thereafter, we continued to provide her with general psychosocial treatment, including continuous medication and supportive psychotherapy. However, her condition remained unchanged during the next 8 months. We therefore introduced her to the concept of PST and she expressed an interest. At this time, her BDI-II score was 29. During the PST session, various problems were revealed, including a fear of recurrence, dissatisfaction with her communication with her physician, marital discord and tension with her husband, and frequent difficulties with her son. Interestingly, she selected the difficulties with her son as the first problem that she would like to deal with using PST. During the PST session, she stated that much of her distress resulted from quarrels with her son, and these quarrels often began after she had scolded him. Using the PST skills, she defined her problem (‘I can't help scolding my son.’) and defined an achievable goal (‘I will refrain from scolding him for a couple of hours after his return from school.’). She generated nine potential solutions and finally selected three solution strategies. She was able to complete most of the solution strategies. During the evaluation process, she said, ‘I feel better because I am having fewer quarrels with my son.’ After the third PST session, she stated, ‘Lately, I am not so worried about my disease’ and ‘I feel that I shall see what I shall see’. At this time, her BDI-II score was 19. She next tried to resolve her marital discord. Although this problem was not successfully solved, she understood that her goal was too difficult and that she needed to set a smaller goal. She completed a total of six PST sessions over a period of 3 months. By the completion of the PST, her feelings had improved (Table 1). Although the six sessions were not sufficient to deal with all of her problems and she partly failed to resolve one of her problems, as mentioned, she felt that ‘I will be able to cope with my problems using the PST’.
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DISCUSSION |
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Many types of psychosocial interventions exist for reducing psychological distress among cancer patients. However, very few studies have confirmed the effectiveness of such interventions in Japan, and the available studies were limited to group psychosocial interventions (11,12) and progressive muscle relaxation (PMR) (13). Several barriers to providing such interventions exist in the Japanese medical system and/or culture, including the difficulty of accruing a homogeneous cancer patient group for appropriate interventions, disadvantages of group interventions for some patients (e.g. reluctance to share individual experiences), and the patient's dissatisfaction with simple behavioral interventions such as PMR. Furthermore, although Western studies have systematically reviewed the effectiveness of psychosocial interventions for cancer patients, demonstrating that cognitive behavioral therapy is recommended (14), our clinical experience suggests that most cancer patients do not have extreme distortions of cognition and that traditional cognitive therapeutic interventions are often not appropriate for cancer patients. Additionally, fewer trained clinical psychologists are available to provide formal psychological intervention for cancer patients in Japan, and this situation creates a barrier to its dissemination among them. In this context, we are interested in using PST to alleviate psychological distress in cancer patients within the Japanese medical system, based on the appropriateness and simplicity of PST.
The current findings suggest that PST can be used to alleviate common forms of psychological distress experienced by cancer patients, such as adjustment disorders and/or major depression. In addition, good adherence to the therapy suggests PST is an acceptable therapy for Japanese cancer patients. Furthermore because PST is a brief therapy that consists of six treatment sessions, PST can be a cost effective psychotherapy. The fact that the subjects were cancer survivors, including both short and long duration after cancer diagnosis, who continued to experience psychological distress after cancer diagnosis, suggests that one of possible subjects who benefit from PST may be distressing cancer survivors, irrespective of duration after cancer. Although many cancer survivors experience a fear of recurrence and a previous Japanese survey indicated that the most common distress experienced by Japanese cancer patients is a fear of recurrence and/or disease metastasis (15), no standard interventions for alleviating this form of distress exist (16). Our experience suggests that PST may be useful for reducing fears of recurrence, although PST does not directly deal with fear or anxiety itself but instead focuses on present daily problems. In addition, a previous study suggested the usefulness of PST for alleviating distress among palliative care patients (17). These findings suggest that PST can be used for a broad range of psychological distress in clinical oncology settings. On the other hand, because we could not find the long-lasting effect of PST (e.g. 6 or 12 months after treatment), whether the effect of PST is persistent or not should be addressed in a future study. In addition, because treatment period ranged widely from 4 to 20 weeks in the current study, we could not determine the best treatment period for cancer patients' illness trajectory. We also need to address this issue in a future study.
The present findings are very limited because our case series is seriously flawed by many methodological weaknesses, especially many types of bias resulting from systematic and random errors. However, our experience indicates that the PST is a promising psychosocial intervention that should be investigated in further well-designed clinical trials in Japanese clinical oncology settings. We are now planning a clinical trial to investigate the effectiveness of PST on fear of recurrence among breast cancer survivors.
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Funding |
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This study was supported in part by a Grant-in-Aid for Cancer Research from the Japanese Ministry of Labor, Health and Welfare.
Conflict of interest statement
None declared.
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Footnotes |
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Research Fellow of the Japan Society for the Promotion of Science. 
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References |
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