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CBT and Depression in Cancer Patients

Zach Stearns

October 5, 2009


        Though there are many evidence-based forms of treatment for depression, there is less research regarding the psychotherapeutic treatment of depression in cancer patients. Some websites make various assertions about the efficacy of cognitive-behavioral therapy (CBT), though no empirical evidence is given to support their statements. Fewer websites declare that CBT is an effective treatment for depression in cancer patients, again with no evidence. The research literature, however, provides data to address the issue, even though there are conflicting results.


Definition of Cognitive-Behavioral Therapy, According to the Web

        Cognitive-behavioral therapy is a grouping of therapeutic interventions that are based upon scientific analyses of human behavior, cognitions, and emotions. Within CBT, there are many treatment strategies that take the etiology of many different mental disorders into account. Moreover, CBT can be used to treat a multitude of mental problems, including anxiety disorders, mood disorders, eating disorders, and drug abuse, according to the website of the National Alliance of Mental Illness (About treatments and supports). In CBT, therapists and patients cooperate to target symptoms, alleviate distress, re-evaluate cognitions, and advocate beneficial behavioral responses. The therapist emphasizes that the patient should apply what s/he has learned into practice between sessions (i.e., “homework”), and the patient learns to accredit progress to his/her own efforts (i.e., self-efficacy). According to the website of the Association for Behavioral and Cognitive Therapies, behavioral interventions are clinical applications of learning theory, which emphasize classical and operant condition, as well as observational learning; on the other hand, cognitive interventions call attention to the ways in which patients create meaning out of situations, symptoms, and life events, as well as cognitions about themselves, others, and the world. Therapists trained in CBT work with individuals, families, and groups, and the duration is usually short – between 6 and 20 sessions, depending on comorbidity. Examples of methods and techniques in CBT include systematic desensitization, exposure/response prevention, modeling, positive and negative reinforcement, cognitive rehearsal, stress management, and problem solving (What is cognitive behavior therapy, About treatments and supports, Cognitive-behavioral therapy a; Cognitive-behavioral therapy b).


CBT for Depression in Cancer Patients, According to the Web

        The University of Michigan Depression Center’s website claims that there are several CBT strategies that are effective interventions for depression, which include cognitive restructuring, behavioral activation, and enhancing problem-solving skills. First, in cognitive restructuring, the therapist and client identity and correct erroneous thoughts associated with depressive emotions. Some erroneous thoughts and habits included distorted self-critical thoughts and decreased desire to partake in potentially enjoyable activities, which influence one another, creating a vicious cycle. Second, behavioral activation seeks to counteract the vicious cycle by discussing gradual increases in rewarding activities with the patient. Third, improving problem-solving skills is important in order provide guidance to surmount problematic situations that may lead to depressive symptoms (About depression). The rationale of these methods revolves around the assumption that depression either partially or totally arises due to the vulnerability of depressive cognitive processes. The Encyclopedia of Mental Disorders suggests that CBT is an effective treatment of depression, and the University of Michigan Depression Center states that 75% of depression patients show improvements, though there is no indication regarding the time frame of that statistic. Regardless, the websites give no quantitative or qualitative data that support their assertions.

        Depression, as suggested on the website of the University of Michigan Comprehensive Cancer Center, is occasionally associated with the diagnosis of cancer (Links between head & neck cancer). Medscape Today states that depression in cancer patients are most effectively treated with a combination of supportive psychotherapy, CBT, and antidepressant medications. The website’s rationale is that psychosocial treatment can help copings skills of individuals, groups, and families, while CBT investigates patients’ appraisals about the diagnosis in order correct inappropriate thoughts and feelings (Treatment of depression in cancer patients).

        Though the motives of these sites to make these statements are unclear, the types of these websites intimate altruistic motives. With most of the sites being related to either universities or national associations committed to the advancement of mental health well-being and awareness, one can assume that these websites care for the treatment of depression.


CBT for Depression in Cancer Patients, According to Research Literature

        Studies have shown that CBT is an effective treatment for many mental health issues (Levesque, Savard, Simard, Gauthier, & Ivers, 2004; Leichsenring et al., 2006). Moreover, CBT is frequently used as an intervention in depression (Edelman, 1999), and is an efficacious treatment (DeRubeis & Crits-Cristoph, 1998). One meta-analysis found that the risk of relapse for patients following CBT was 26% compared to 64% of patients treated only with tricyclic antidepressants (Hollon, 1990). However, there is relatively less research on the efficacy of CBT in the treatment of depression in cancer patients. This is disconcerting, considering that major depression is the most common psychiatric disorder among cancer patients, with ratings of prevalence ranging from 13% to 50% (Croyle & Rowland, 2003).

        One study of six female participants with both depression and metastatic cancer showed a significant improvement of depressive symptoms (e.g., anhedonia, anxiety, fatigue) not only at the end of eight therapy sessions, but also at a 6-month follow up (Levesque et al., 2004). Another study of CBT in treatment of depression in metastatic cancer patients found conflicting results (Edelman, Bell, & Kidman, 1999). Though outcome data indicate reduced depression and improved self-esteem, such improvements were not maintained at 3- and 6-month follow-ups. Further, a randomized controlled trial (RCT) found additional disparate results (Moorey et al., 2009). In the study, eight clinical nurse specialists received CBT training while seven nurses continued practice as usual in palliative care in order to observe differences in reduction of anxiety and depression in patients with advanced cancer. Assessments were given at baseline, 6, 10, and 16 weeks. While there was an effect of CBT training on reducing anxiety, there was no effect for depression.

        Hopko et al. (2008) state that one problem with some research of CBT for depression in cancer patients is that some studies did not study well-diagnosed major depression. Thus, using 13 participants diagnosed with major depression and one of various types of cancer, Hopko et al. studied the effect of CBT on depression and self-reported quality of life. Results showed improvements in depressive symptoms and quality of life. There were strong effect sizes and the results were generally maintained at a 3-month follow-up. These results are somewhat conflicting with respect to other studies (e.g., Edelman et al., 1999). See Table 1 for summary of differences between studies.


N of Participants

Cancer Diagnosis

Improvement at post-treatment

Improvement at follow-up

Randomized Control Trial

Edelman et al. (1999)


metastatic breast cancer




Levesque et al. (2004)


females with metastatic cancer




Hopko et al. (2009)


various cancer patients




Moorey et al. (2009)


advanced cancer patients




Table 1.

        Furthermore, the studies mentioned above have several limitations. For example, Levesque et al. (2004) and Hopko et al. (2008) utilized very small sample sizes of 6 and 13, respectively. Ergo, these samples could not account for potential differences in age-of-onset or comorbidity, nor could the results generalize to all patients with any type of cancer. Additionally, neither of these two studies used control groups. Two studies – Levesque et al. and Edelman et al. (1999) – used only women with metastatic cancer, and therefore cannot generalize to patients with other forms of cancer.


        In conclusion, though there are conflicting results, one can be confident that CBT might alleviate depressive symptoms in some cancer patients. While there is only marginal evidence that improvements will still be evident at a 3- or 6-month follow-up, there are multiple studies that reveal a significant difference between pre- and post-therapy measures of depressive symptoms. Thus, websites should take into account that some results cannot be generalized to the entire population of cancer patients. Occasionally, some evidence does not even support the statement that CBT improves depression in cancer patients (e.g., Moorey et al., 2009), while others do (e.g., Hopko et al., 2008). These websites should either note that different populations respond differently to CBT, or they should remove their declarations until more conclusive empirical research is conducted.










About depression: cognitive behavioral therapy. (2006). Retrieve October 5, 2009, from University of Michigan Depression Center. Web site:

About treatments and supports: Cognitive-behavioral therapy. (2009). Retrieved September 30, 2009, from National Alliance on Mental Illness. Web site:

Cognitive-behavioral therapy. (2009a) Retrieved October 6, 2009, from the Encyclopedia of Mental Disorders. Web site:

Cognitive-behavioral therapy. (2009b). Retrieved September 30, 2009, from National Association of Cognitive-Behavioral Therapists. Web site:

Croyle, R. T., & Rowland, J. H. (2003). Mood disorders and cancer: A National Cancer Institute perspective. Biological Psychiatry, 54, 191-194.

DeRubeis, R. J., & Crits-Christoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66(1), 37–52.

Edelman, S., Bell, D. R., & Kidman, A. D. (1999). A group cognitive behaviour therapy programme with metastatic breast cancer patients. Psycho-oncology, 8, 295-305.

Hollon, S. D. (1990). Cognitive therapy and pharmacotherapy for depression. Psychiatric Annals, 20, 249–258.

Hopko, D. R., Bell, J. L., Armento, M., Robertson, S., Mullane, C., Wolf, N., & Lejuez, C. W. (2008). Cognitive-behavior therapy for depressed cancer patients in a medical care setting. Behavior Therapy, 39, 126-136.

Leichsenring, F., Hiller, W., Weissberg, M., & Leibing, E. (2006). Cognitive-behavioral therapy and psychodynamic psychotherapy: techniques, efficacy, and indications. American Journal of Psychotherapy, 60, 233-259.

Levesque, M., Savard, J., Simard, S., Gauthier, J. G., Ivers, H. (2004). Efficacy of cognitive therapy for depression among women with metastatic cancer: a single-case experimental study. Journal of Behavior Therapy and Experimental Psychiatry, 35, 287-305.

Links between head & neck cancer and smoking, depression, and alcohol. (2009). Retrieved October 5, 2009, from University of Michigan Comprehensive Cancer Center. Web site:

Moorey, S., Cort, E., Kapari, M., Monroe, B., Hansford, P., Mannix, K., et al. (2009). A cluster randomized controlled trial of cognitive behaviour therapy for common mental disorders in patients with advanced cancer. Psychological Medicine, 39, 713-723.

Treatment of depression in cancer patients. (1997). Retrieved October 6, 2009, from Medscape Today. Web site:

What is cognitive behavior therapy (CBT). (2009). Retrieved October 2, 2009, from Association for Behavioral and Cognitive Therapies. Web site:




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