Efficacy of group therapy to reduce mental distress in women with non-metastatic breast cancer: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Group treatments have proven to be effective for many mental disorders and showed beneficial effects in patients with medical illness. Aim of this systematic review and meta-analysis is to summarize the efficacy of group therapy for women with non-metastatic breast cancer. METHODS: We included studies comparing group therapy for women with non-metastatic breast cancer to non-active control groups, active control conditions, and individual psychotherapy. The primary outcome was mental distress, secondary outcomes were quality of life, coping, existential outcomes, fatigue, pain, and side effects. A comprehensive search was conducted in Medline, Web of Science, CENTRAL, PsycINFO, and DARE complemented by a manual search. Random-effects meta-analyses were run separately for different types of control groups. RESULTS: Thirty-seven studies (5902 patients) were included. Small effects on mental distress in favor of group treatment were found (non-active control groups: n = 19, g = 0.42, 95% CI [0.29; 0.56], I2  = 61.6%; active control conditions: n = 6, g = 0.20, 95% CI [0.06; 0.35], I2  = 0%). Cognitive-behavioral therapy (CBT) and third wave CBT group approaches proved to be most effective. Group treatments also showed beneficial effects on secondary outcomes, with most profound evidence on quality of life and coping. CONCLUSIONS: Results suggest that group interventions have the potential to reduce mental distress in women facing breast cancer. In the light of the considerable heterogeneity of most study effects, there is a need for more rigorous studies to strengthen the promising evidence and for trials examining the impact of patient and intervention characteristics on outcomes. REGISTRATION: PROSPERO international prospective register of systematic reviews, CRD42020184357.

[Communication with seriously ill patients - more than just breaking bad news]. / Kommunikation mit schwerstkranken Patienten ­ mehr als nur Breaking Bad News.

Communication with seriously ill patients - more than just breaking bad news Abstract. In the context of palliative care, specific communication strategies and techniques are needed to adequately meet the special challenges of the palliative care situation. Successful communication is characterized by criteria of patient-centeredness and can positively influence important parameters of patients, caregivers, and clinicians. These parameters include informed and shared decision making, a trustful relationship with the treatment team, improved knowledge and understanding of prognosis, improved treatment adherence and coping with difficult treatment decisions, and increased patient satisfaction and quality of life of patients and caregivers. Communication skills can be learned and reinforced in communication courses. The COMSKIL training program, which was developed for various professional groups in medical oncology care, defines five central components of a professional conversation (communication goals, communication strategies, communication techniques, process tasks, and cognitive assessments) and addresses basic skills as well as communicative challenges in the context of specific conversation occasions.

[Death Wishes in Patients with Advanced Cancer: An Explorative Analysis of Psychotherapeutic Treatment Transcripts]. / Todeswünsche bei Patientinnen und Patienten mit fortgeschrittener Krebserkrankung: Eine explorative Analyse psychotherapeutischer Gespräche.

Todeswünsche bei Patienten mit einer fortgeschrittenen Krebserkrankung sind bereits seit längerem Gegenstand der psychoonkologischen Forschung. Auch wenn es inzwischen einige Ansätze gibt, die sich mit der Konzeptualisierung und Beschreibung von Todeswünschen befassen, fehlt es bislang an einem in der klinischen Praxis gut anwendbaren Konzept und dazugehörigen Erhebungsinstrumenten. Ziel der Studie ist deshalb die phänomenologische Beschreibung von Todeswünschen bei Patienten mit fortgeschrittenem Krebs. Dafür wurden N=228 transkribierte Psychotherapiegespräche von 76 Patienten im Rahmen der randomisiert-kontrollierten Psychotherapiestudie Managing Cancer and Living Meaningfully (CALM) hinsichtlich des Themas Todeswunsch explorativ analysiert. Von den untersuchten 76 Patienten berichteten 16 (21%) explizit von Todeswünschen. Mithilfe ihrer Beschreibungen konnten zwei Dimensionen identifiziert werden: (1) Gründe für Todeswünsche mit sieben Unterkategorien (Vermeidung von Schmerz und Leid, Kontrolle und Selbstbestimmung erhalten, körperlicher Abbau und Begrenzungen im Alltag, Angst vor Siechtum, Leben nicht mehr lebenswert, Gefühl der Lebensvollendung und alles getan zu haben, fehlende Zukunftsperspektiven) sowie (2) der Grad des mit dem Todeswunsch verbundenen Handlungsdrucks. Die Ergebnisse stimmen mit existierenden Theorien zu Todeswünschen bei Patienten mit einer fortgeschrittenen Krebserkrankung größtenteils überein. Als zusammengehörige Dimensionen des Phänomens Todeswunsch wurden sie jedoch bisher noch nicht beschrieben. Vor allem für die klinische Praxis scheint dies sehr sinnvoll zu sein, da die Gründe in der Therapie größtenteils bearbeitbar sein dürften und der Grad des Handlungsdrucks Aufschluss über die Notwendigkeit einer Intervention geben kann.Death wishes in patients with advanced cancer is a research topic of high interest in psycho-oncologic research. Despite existing concepts describing death wishes, there is a lack of clinically applicable concepts and appropriate instruments. The objective of this study was the phenomenological description of death wishes in patients with advanced cancer. For this purpose, we qualitatively explored N=228 transcribed psychotherapeutic treatment sessions of 76 patients derived from an RCT evaluating the efficacy of Managing Cancer and Living Meaningfully (CALM) psychotherapeutic intervention. Sixteen out of the 76 patients explicitly reported death wishes (21%). Two dimensions were identified: (1) reasons for a death wish with seven subcategories (avoidance of pain and suffering, maintaining control and self-determination, physical deterioration and limitations in everyday life, fear of infirmity, life not longer worth living, feeling of life completion and having done everything, lack of future perspectives) and (2) the degree of pressure to act associated with the death wish. These results are consistent with existing theories regarding death wishes in patients with advanced cancer. However, they have not yet been described as interrelated dimensions of the phenomenon of the death wish.

Psychometric Evaluation of the German Version of the Demoralization Scale-II and the Association Between Demoralization, Sociodemographic, Disease- and Treatment-Related Factors in Patients With Cancer.

Objective: To test the psychometric properties, internal consistency, dimensional structure, and convergent validity of the German version of the Demoralization Scale-II (DS-II), and to examine the association between demoralization, sociodemographic, disease- and treatment-related variables in patients with cancer. Methods: We recruited adult patients with cancer at a Psychosocial Counseling Center and at oncological wards. Participants completed the 16-item DS-II, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-2 (GAD-2), Distress Thermometer (DT), and Body Image Scale (BIS). We analyzed internal consistency of the DS-II using Cronbach's Alpha (α). We tested the dimensional structure of the DS-II with Confirmatory Factor Analyses (CFA). Convergent validity was expressed through correlation coefficients with established measures of psychological distress. The associations between demoralization, sociodemographic, disease- and treatment-related variables were examined with ANOVAs. Results: Out of 942 eligible patients, 620 participated. The average DS-II total score was M = 5.78, SD = 6.34, the Meaning and Purpose subscale M = 2.20, SD = 3.20, and the Distress and Coping Ability subscale M = 3.58, SD = 3.45. Internal consistency ranged from high to excellent with α = 0.93 for the DS-II total scale, α = 0.90 for the Meaning and Purpose subscale, and α = 0.87 for the Distress and Coping Ability subscale. The one-factor and the two-factor model yielded similar model fits, with CFI and TLI ranging between 0.910 and 0.933, SRMR < 0.05. The DS-II correlated significantly with depression (PHQ-9: r = 0.69), anxiety (GAD-2: r = 0.72), mental distress (DT: r = 0.36), and body image disturbance (BIS: r = 0.58). High levels of demoralization were reported by patients aged between 18 and 49 years (M = 7.77, SD = 6.26), patients who were divorced/separated (M = 7.64, SD = 7.29), lung cancer patients (M = 9.29, SD = 8.20), and those receiving no radiotherapy (M = 7.46, SD = 6.60). Conclusion: The DS-II has very good psychometric properties and can be recommended as a reliable tool for assessing demoralization in patients with cancer. The results support the implementation of a screening for demoralization in specific risk groups due to significantly increased demoralization scores.

Norm Values and Psychometric Properties of the 24-Item Demoralization Scale (DS-I) in a Representative Sample of the German General Population.

Purpose: The Demoralization scale (DS-I) is a validated and frequently used instrument to assess existential distress in patients with cancer and other severe medical illness. The purpose of this study was to provide normative values derived from a representative German general population sample and to analyze the correlational structure of the DS-I. Methods: A representative sample of the adult German general population completed the DS-I (24 Items), the Emotion Thermometers (ET) measuring distress, anxiety, depression, anger, need for help, and the Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-fatigue). Results: The sample consists of N = 2,407 adults (mean age = 49.8; range = 18-94 years), 55.7% women). The percentages of participants above the DS-I cutoff (≥30) was 13.5%. The mean scores of the DS-I dimensions were as follows: (1) loss of meaning and purpose: M = 2.78 SD = 4.49; (2) disheartenment: M = 3.19 SD = 4.03; (3) dysphoria M = 4.51 SD = 3.20; (4) sense of failure: M = 6.24 SD = 3.40; and for the DS-I total score: M = 16.72 SD = 12.74. Women reported significantly higher levels of demoralization than men, with effect sizes between d = 0.09 (Loss of Meaning) and d = 0.21 (Dysphoria). Age was not associated with demoralization in our sample. DS-I reliability was excellent (α = 0.94) and DS-I subscales were interrelated (r between 0.31 and 0.87) and significantly correlated with ET, especially depression, anxiety, and need for help and fatigue (r between 0.14 and 0.69). Conclusions: In order to use the DS-I as a screening tool in clinical practice and research the normative values are essential for comparing the symptom burden of groups of patients within the health care system to the general population. Age and sex differences between groups of patients can be accounted for using the presented normative scores of the DS-I.

Efficacy of Hypnosis in Adults Undergoing Surgical Procedures: A meta-analytic update.

In this meta-analysis we updated a review from 2013 investigating the evidence on the efficacy of hypnosis in adults undergoing surgical procedures compared to standard care alone or an attention control. A comprehensive literature search using Medline, CENTRAL, Web of Science, PsycINFO, ProQuest Dissertations and Theses database, and manual searches were conducted to identify randomized controlled trials. In this update, N = 23 eligible studies were added to the existing study pool, resulting in N = 50 studies with 4269 patients. Random effects meta-analyses revealed positive treatment effects on mental distress (g = 0.55, 95% CI [0.39; 0.70], NNT = 3.32), pain (g = 0.37, 95% CI [0.25; 0.50], NNT = 4.78), medication consumption (g = 0.46, 95% CI [0.23; 0.68], NNT = 3.95), recovery (g = 0.26, 95% CI [0.09; 0.42], NNT = 6.91), and surgical procedure time (g = 0.23, 95% CI [0.14; 0.33], NNT = 7.6). No effects were found for physiological parameters (g = 0.13, 95% CI [-0.06; 0.33], NNT = 13.26). 95% prediction intervals included the null effect for all outcomes except for procedure time. In conclusion, although positive effects of hypnosis could be shown, overall generalizability is limited due to high heterogeneity of the study results that could not be explained by characteristics of patients, interventions, or study methods.

The role of attachment avoidance: A longitudinal mediation model predicting existential distress in patients with advanced cancer.

OBJECTIVE: Although a protective effect of reliable interpersonal relationships on existential distress has been established, evidence remains inconclusive for attachment insecurity as an underlying factor of persistent psychological distress. We tested a longitudinal model hypothesizing attachment avoidance as a mediator of high demoralization and anxiety over time. METHODS: We studied 206 patients with advanced cancer (mean age = 59.6, 61% female) participating in an intervention trial. Patients completed self-report measures for demoralization, anxiety, perceived relatedness, attachment insecurity, and death anxiety. Our mediated path model included perceived relatedness and death anxiety at baseline as predictors, attachment avoidance at baseline as mediator, and demoralization and anxiety at 6-month follow-up (N = 125) as outcomes. RESULTS: Attachment avoidance partially mediated the relationship between death anxiety and demoralization (ß = 0.07, 95% CI 0.02-0.12) and anxiety (ß = 0.05, 95% CI 0.001-0.10). Findings for perceived relatedness were less conclusive. Its indirect effects through attachment avoidance were significant for both outcomes (demoralization: ß = -0.07, 95% CI -0.13 to -0.02, anxiety: ß = -0.05, 95% CI -0.11 to -0.003). CONCLUSIONS: Due to its trait-like quality, attachment avoidance may play a less central role in explaining the course of existential distress over time than previous research indicated. Addressing change-sensitive relational concerns in psychosocial interventions may be more effective to alleviate existential distress.

Testing the Treatment Integrity of the Managing Cancer and Living Meaningfully Psychotherapeutic Intervention for Patients With Advanced Cancer.

INTRODUCTION: The Managing Cancer and Living Meaningfully (CALM) therapy for patients with advanced cancer was tested against a supportive psycho-oncological counseling intervention (SPI) in a randomized controlled trial (RCT). We investigated whether CALM was delivered as intended (therapists' adherence); whether CALM therapists with less experience in psycho-oncological care show higher adherence scores; and whether potential overlapping treatment elements between CALM and SPI can be identified (treatment differentiation). METHODS: Two trained and blinded raters assessed on 19 items four subscales of the Treatment Integrity Scale covering treatment domains of CALM (SC: Symptom Management and Communication with Health Care Providers; CSR: Changes in Self and Relationship with Others; SMP: Spiritual Well-being and Sense of Meaning and Purpose; FHM: Preparing for the Future, Sustaining Hope and Facing Mortality). A random sample of 150 audio recordings (75 CALM, 75 SPI) were rated on a three-point Likert scale with 1 = "adherent to some extent," 2 = "adherent to a sufficient extent," 3 = "very adherent." RESULTS: All 19 treatment elements were applied, but in various frequencies. CALM therapists most frequently explored symptoms and/or relationship to health care providers (SC_1: n_applied = 62; 83%) and allowed expression of sadness and anxiety about the progression of disease (FHM_2: n_applied = 62; 83%). The exploration of CALM treatment element SC_1 was most frequently implemented in a satisfactory or excellent manner (n_sufficient or very adherent = 34; 45%), whereas the treatment element SMP_4: Therapist promotes acknowledgment that some life goals may no longer be achievable (n_sufficient or very adherent = 0; 0%) was not implemented in a satisfactory manner. In terms of treatment differentiation, no treatment elements could be identified which were applied significantly more often by CALM therapists than by SPI therapists. CONCLUSION: Results verify the application of CALM treatment domains. However, CALM therapists' adherence scores indicated manual deviations. Furthermore, raters were not able to significantly distinguish CALM from SPI, implying that overlapping treatment elements were delivered to patients.

Efficacy of the Managing Cancer and Living Meaningfully (CALM) individual psychotherapy for patients with advanced cancer: A single-blind randomized controlled trial.

OBJECTIVE: We aimed to determine whether the Managing Cancer and Living Meaningfully (CALM) therapy is superior to a non-manualized supportive psycho-oncological counselling intervention (SPI). METHODS: Adult patients with advanced cancer and ≥9 points on the PHQ-9 and/or ≥5 points on the DT were randomized to CALM or SPI. We hypothesized that CALM patients would report significantly less depression (primary outcome) on the BDI-II and the PHQ-9 6 months after baseline compared to SPI patients. RESULTS: From 329 eligible patients, 206 participated (61.2% female; age: M = 57.9 [SD = 11.7]; 84.5% UICC IV stage). Of them, 99 were assigned to CALM and 107 to SPI. Intention-to-treat analyses revealed significantly less depressive symptoms at 6 months than at baseline (P < .001 for BDI-II and PHQ-9), but participants in the CALM and SPI group did not differ in depression severity (BDI-II: P = .62, PHQ-9: P = .998). Group differences on secondary outcomes were statistically not significant either. CONCLUSIONS: CALM therapy was associated with reduction in depressive symptoms over time but this improvement was not statistically significant different than that obtained within SPI group.

Spiritual well-being mediates the association between attachment insecurity and psychological distress in advanced cancer patients.

PURPOSE: The diagnosis of a terminal disease bears existential challenges, which activate the attachment system. Attachment insecurity, as well as existential resources, such as spiritual well-being, influences patients' extent of psychological distress. Knowledge about the interrelation of these constructs is limited. Based on current research, we assume spiritual well-being to mediate the association of attachment insecurity and psychological distress. METHODS: We obtained data from the baseline measurement of a randomized controlled trial in advanced cancer patients. Patients were sampled from the University Medical Centers of Hamburg and Leipzig, Germany. Main outcome measures included the Patient Health Questionnaire (PHQ-9), the Death and Dying Distress Scale (DADDS), the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp), and the Experience in Close Relationships Scale (ECR-M16) for assessing attachment insecurity. We tested the mediation hypothesis with two regression analyses using bootstrapping procedure. RESULTS: A total of 190 patients were included. Spiritual well-being mediated the association of attachment insecurity and depression (R2 = 11%), as well as death anxiety (R2 = 15%), in fearful-avoidant attached patients. Neither dismissingly nor preoccupied attached patients differ in terms of spiritual well-being and psychological distress in comparison with secure attached patients. CONCLUSION: Spiritual well-being plays a relevant role in advanced cancer patient's mental health through mediating the association of attachment and psychological distress. Developing a better understanding of the interdependency of the constructs of spiritual well-being and attachment can help to develop individually tailored advanced cancer care programs and psychotherapeutic interventions. TRIAL REGISTRATION: NCT02051660.

[A group intervention to promote work ability in patients with head and neck cancer]. / Eine Gruppenintervention zur Förderung der Arbeitsfähigkeit für Patienten mit Kopf-Hals-Tumoren.

INTRODUCTION: Despite high distress the majority of head and neck cancer patients does not use any psycho-oncological counselling or psychotherapeutic support. Additionally, patients with head and neck cancer have an increased risk of not returning to work compared to other cancer patients. Therefore, we have developed a group intervention program which aims at improving work ability in patients with head and neck cancer as well as their quality of life, self-efficacy and psychological well-being. MATERIAL AND METHODS: In a randomized controlled trial head and neck cancer patients either receive a group intervention or socio-legal counselling. Male head and neck cancer patients with elevated levels of psychological and work-related distress are included. The group intervention consists of eight sessions. Groups are led by both a psychotherapist and a former head and neck cancer patient (peer). Feasibility and acceptability of the group intervention were tested by means of a pilot group. Each session was evaluated by pilot group participants. Semi-structured interviews were used to assess relevance of content and practicability. RESULTS: 113 patients were personally addressed, of which four patients participated in the pilot group. Patients reported that the intervention fit very well with their daily life and expressed satisfaction with it. Three patients emphasized the importance of the peer. DISCUSSION: The presence of the peer as identification figure seems to be of crucial importance. To increase recruitment numbers inclusion criteria will be modified and participation costs will be reduced.

[Assessment of Couples' Communication in Patients with Advanced Cancer: Validation of a German Version of the Couple Communication Scale (CCS)]. / Die Erfassung der Paarkommunikation bei Patienten mit einer fortgeschrittenen Krebserkrankung: Validierung einer deutschen Version der Couple Communication Scale (CCS).

BACKGROUND: There are only a few valid instruments measuring couples' communication in patients with cancer for German speaking countries. The Couple Communication Scale (CCS) represents an established instrument to assess couples' communication. However, there is no evidence regarding the psychometric properties of the German version of the CCS until now and the assumed one factor structure of the CCS was not verified for patients with advanced cancer yet. METHOD: The CCS was validated as a part of the study "Managing cancer and living meaningfully" (CALM) on N=136 patients with advanced cancer (≥18 years, UICC-state III/IV). The psychometric properties of the scale were calculated (factor reliability, item reliability, average variance extracted [DEV]) and a confirmatory factor analysis was conducted (Maximum Likelihood Estimation). The concurrent validity was tested against symptoms of anxiety (GAD-7), depression (BDI-II) and attachment insecurity (ECR-M16). RESULTS: In the confirmatory factor analysis, the one factor structure showed a low, but acceptable model fit and explained on average 49% of every item's variance (DEV). The CCS has an excellent internal consistency (Cronbachs α=0,91) and was negatively associated with attachment insecurity (ECR-M16: anxiety: r=- 0,55, p<0,01; avoidance: r=- 0,42, p<0,01) as well as with anxiety (GAD-7: r=- 0,20, p<0,05) and depression (BDI-II: r=- 0,27, p<0,01). CONCLUSION: The CCS is a reliable and valid instrument measuring couples' communication in patients with advanced cancer.

Perceived doctor-patient relationship and its association with demoralization in patients with advanced cancer.

BACKGROUND: Advanced diseases pose a great burden on patients and go hand in hand with existential concerns. Demoralization is considered as a syndrome of existential distress with a perceived inability to cope with loss of meaning in life and feelings of helplessness and hopelessness. Professional health care providers play an important role in providing support for patients and unfavorable conversational styles in their relationship can increase patient's distress. In this study, we examine the association between the patient's perceived relationship to health care providers and demoralization. METHODS: We used baseline data of a randomized control trial intervention study for advanced cancer patients (UICC-Stage ≥ III; PHQ ≥ 9 and/or Distress-Thermometer ≥5). We used a subscale of the QUAL-EC-P for assessing doctor-patient relationship, Beck Depression Inventory-II for depressive symptoms, a modified version of the MSAS as physiological symptom checklist, and the Demoralization Scale to assess demoralization. A hierarchical regression analysis was calculated. RESULTS: In our sample of 187 patients with stage III or IV cancer (62% women), demoralization was present in 53.4% (16% moderate demoralization; 37.4% high demoralization) of the patients. Relationship to health care provider was an independent predictor (ß = -.33, t(186) = -6.70, P < .001) of demoralization. CONCLUSIONS: Our findings underline the importance of the physician-patient relationship in the context of coping with existential challenges in advanced cancer patients. Trainings on how to communicate and build a sustainable relationship with patients and their specific needs may increase the buffering effect of social support by the physicians on patient's existential distress.

[Psychooncological Care: A Challenge]. / Psychoonkologische Versorgung: eine Herausforderung.

Cancer patients and their relatives suffer from multiple psychological and social problems associated with the illness itself and its treatment. The major challenge for an excellent psychooncological support is the further development and nationwide implementation of effective, patient-centered, quality assured, and affordable concepts of treatment and care.

Insecure attachment predicts depression and death anxiety in advanced cancer patients.

ABSTRACTObjective:The prevalence of depression as well as adjustment and anxiety disorders is high in advanced cancer patients, and research exploring intraindividual factors leading to high psychological distress is underrepresented. Cancer patients' feelings about security and trust in their healthcare providers have a significant influence on how they deal with their disease. The perception of social support is affected by patients' attachment styles and influences their reactions to feelings of dependency and loss of control. We therefore aimed to explore attachment and its association with psychological distress in patients with advanced cancer. METHOD: We obtained data from the baseline measurements of a randomized controlled trial in advanced cancer patients. Patients were sampled from the university medical centers of Hamburg and Leipzig, Germany. The main outcome measures included the Patient Health Questionnaire, the Death and Dying Distress Scale, the Memorial Symptom Assessment Scale, and the Experience in Close Relationships Scale for assessing attachment insecurity. RESULTS: A total of 162 patients were included. We found that 64% of patients were insecurely attached (fearful-avoidant 31%, dismissing 17%, and preoccupied 16%). A dismissing attachment style was associated with more physical symptoms but did not predict psychological distress. A fearful-avoidant attachment style significantly predicted higher death anxiety and depression, whereas preoccupied attachment predicted higher death anxiety only. Overall, insecure attachment contributed to the prediction of depression (10%) and death anxiety (14%). SIGNIFICANCE OF RESULTS: The concept of attachment plays a relevant role in advanced cancer patients' mental health. Healthcare providers can benefit from knowledge of advanced cancer patients' attachment styles and how they relate to specific mental distress. Developing a better understanding of patients' reactions to feelings of dependency and distressing emotions can help us to develop individually tailored advanced cancer care programs and psychotherapeutic interventions.

Psychological interventions for acute pain after open heart surgery.

BACKGROUND: This is an update of a Cochrane review previously published in 2014. Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is associated with a risk of negative consequences. Several trials investigated the effects of psychological interventions to reduce acute postoperative pain and improve the course of physical and psychological recovery of participants undergoing open heart surgery. OBJECTIVES: To compare the efficacy of psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention control in adults undergoing open heart surgery for pain, pain medication, psychological distress, mobility, and time to extubation. SEARCH METHODS: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and PsycINFO for eligible studies up to February 2017. We used the 'related articles' and 'cited by' options of eligible studies to identify additional relevant studies. We checked lists of references of relevant articles and previous reviews. We searched the ProQuest Dissertations and Theses Full Text Database, ClinicalTrials and the WHO International Clinical Trials Registry Platform to identify any unpublished material or ongoing trials. We also contacted the authors of primary studies to identify any unpublished material. In addition, we wrote to all leading heart centres in Germany, Switzerland, and Austria to check whether they were aware of any ongoing trials. SELECTION CRITERIA: Randomised controlled trials comparing psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery. DATA COLLECTION AND ANALYSIS: Two review authors (SZ and SK) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We calculated effect sizes for each comparison (Hedges' g) and meta-analysed data using a random-effects model. We assessed the evidence using GRADE and created 'Summary of findings' tables. MAIN RESULTS: We added six studies to this update. Overall, we included 23 studies (2669 participants).For the majority of outcomes (two-thirds), we could not perform a meta-analysis since outcomes were not measured, or data were provided by one trial only.No study reported data on the number of participants with pain intensity reduction of at least 50% from baseline. Only one study reported data on the number of participants below 30/100 mm on the Visual Analogue Scale (VAS) in pain intensity (very low-quality evidence). Psychological interventions did not reduce pain intensity in the short-term interval (g 0.39, 95% CI -0.18 to 0.96, 2 studies, 104 participants, low-quality evidence), medium-term interval (g -0.02, 95% CI -0.24 to 0.20, 4 studies, 413 participants, moderate-quality evidence) or in the long-term interval (g 0.05, 95% CI -0.20 to 0.30, 2 studies, 200 participants, moderate-quality evidence).No study reported data on median time to re-medication or on number of participants re-medicated. Only two studies provided data on postoperative analgesic use in the short-term interval, showing that psychological interventions did not reduce the use of analgesic medication (g 1.18, 95% CI -2.03 to 4.39, 2 studies, 104 participants, low-quality evidence). Studies revealed that psychological interventions reduced mental distress in the medium-term (g 0.37, 95% CI 0.13 to 0.60, 13 studies, 1388 participants, moderate-quality evidence) and likewise in the long-term interval (g 0.32, 95% CI 0.10 to 0.53, 14 studies, 1586 participants, moderate-quality evidence). Psychological interventions did not improve mobility in the medium-term interval (g 0.23, 95% CI -0.22 to 0.67, 3 studies, 444 participants, low-quality evidence), nor in the long-term interval (g 0.09, 95% CI -0.10 to 0.28, 4 studies, 458 participants, moderate-quality evidence). Only two studies reported data on time to extubation, indicating that psychological interventions reduced the time to extubation (g 0.56, 95% CI 0.08 to 1.03, 2 studies, 154 participants, low-quality evidence).Overall, the very low to moderate quality of the body of evidence on the efficacy of psychological interventions for acute pain after open heart surgery cannot be regarded as sufficient to draw robust conclusions.Most 'Risk of bias' assessments were low or unclear. We judged selection bias (random sequence generation) and attrition bias to be mostly low risk for included studies. However, we judged the risk of selection bias (allocation concealment), performance bias, detection bias and reporting bias to be mostly unclear. AUTHORS' CONCLUSIONS: In line with the conclusions of our previous review, there is a lack of evidence to support or refute psychological interventions in order to reduce postoperative pain in participants undergoing open heart surgery. We found moderate-quality evidence that psychological interventions reduced mental distress in participants undergoing open heart surgery. Given the small numbers of studies, it is not possible to draw robust conclusions on the efficacy of psychological interventions on outcomes such as analgesic use, mobility, and time to extubation respectively on adverse events or harms of psychological interventions.

Efficacy of therapeutic suggestions under general anesthesia: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: General anesthesia does not block central nervous processing of auditive information. Therefore, positive suggestions even given during surgery might have the potential to encourage well-being and recovery of patients. Aim of this review was to summarize the evidence on the efficacy of therapeutic suggestions under general anesthesia in adults undergoing surgery compared to an attention control (i.e. white noise). METHODS: We included randomized controlled trials that investigated therapeutic suggestions presented during general anesthesia to adult patients undergoing surgery or medical procedures. Outcomes on pain intensity, mental distress, recovery, use of medication, measured postoperatively within hospitalization were considered. Electronic searches were carried out in the following databases (last search February 23, 2015): MEDLINE, CENTRAL, Web of Science, PsycINFO, ProQuest Dissertations and Theses. RESULTS: Thirty-two eligible randomized controlled trials were included, comprising a total of 2102 patients. All studies used taped suggestions. Random effects meta-analyses revealed no effects on pain intensity (Hedges' g = 0.04, CI 95% [-0.04; 0.12], number needed to treat [NNT] = 44.3) and mental distress (g = 0.03, CI 95% [-0.11; 0.16], NNT = 68.2). In contrast, we found small but significant positive effects on use of medication (g = 0.19, CI 95% [0.09; 0.29], NNT = 9.2) and on recovery (g = 0.14, CI 95% [0.03; 0.25], NNT = 13.0). All effects were homogeneous and robust. CONCLUSIONS: Even though effects were small, our results provide indications that intraoperative suggestions can have the potential to reduce the need for medication and enhance recovery. Further high quality trials are needed to strengthen the promising evidence on the efficacy of therapeutic suggestions under general anesthesia for patients undergoing surgery.

Psychological interventions for acute pain after open heart surgery.

BACKGROUND: Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is associated with a risk of negative consequences. Several trials investigated the effects of psychological interventions to reduce acute postoperative pain and improve the course of physical and psychological recovery of participants undergoing open heart surgery. OBJECTIVES: To compare the efficacy of psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery on pain, pain medication, mental distress, mobility, and time to extubation. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE (1946 to September 2013), EMBASE (1980 to September 2013), Web of Science (all years to September 2013), and PsycINFO (all years to September 2013) for eligible studies. We used the 'related articles' and 'cited by' options of eligible studies to identify additional relevant studies. We also checked lists of references of relevant articles and previous reviews. We also searched the ProQuest Dissertations and Theses Full Text Database (all years to September 2013) and contacted the authors of primary studies to identify any unpublished material. SELECTION CRITERIA: Randomised controlled trials comparing psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery. DATA COLLECTION AND ANALYSIS: Two review authors (SK and JR) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We calculated effect sizes for each comparison (Hedges' g) and meta-analysed data using a random-effects model. MAIN RESULTS: Nineteen trials were included (2164 participants).No study reported data on the number of participants with pain intensity reduction of at least 50% from baseline. Only one study reported data on the number of participants below 30/100 mm on the Visual Analogue Scale (VAS) in pain intensity. Psychological interventions have no beneficial effects in reducing pain intensity measured with continuous scales in the medium-term interval (g -0.02, 95% CI -0.24 to 0.20, 4 studies, 413 participants, moderate quality evidence) nor in the long-term interval (g 0.12, 95% CI -0.09 to 0.33, 3 studies, 280 participants, low quality evidence).No study reported data on median time to remedication or on number of participants remedicated. Only one study provided data on postoperative analgesic use. Studies reporting data on mental distress in the medium-term interval revealed a small beneficial effect of psychological interventions (g 0.36, 95% CI 0.10 to 0.62, 12 studies, 1144 participants, low quality evidence). Likewise, a small beneficial effect of psychological interventions on mental distress was obtained in the long-term interval (g 0.28, 95% CI 0.05 to 0.51, 11 studies, 1320 participants, low quality evidence). There were no beneficial effects of psychological interventions on mobility in the medium-term interval (g 0.23, 95% CI -0.22 to 0.67, 3 studies, 444 participants, low quality evidence) nor in the long-term interval (g 0.29, 95% CI -0.14 to 0.71, 4 studies, 423 participants, low quality evidence). Only one study reported data on time to extubation. AUTHORS' CONCLUSIONS: For the majority of outcomes (two-thirds) we could not perform a meta-analysis since outcomes were not measured, or data were provided by one trial only. Psychological interventions have no beneficial effects on reducing postoperative pain intensity or enhancing mobility. There is low quality evidence that psychological interventions reduce postoperative mental distress. Due to limitations in methodological quality, a small number of studies, and large heterogeneity, we rated the quality of the body of evidence as low. Future trials should measure crucial outcomes (e.g. number of participants with pain intensity reduction of at least 50% from baseline) and should focus to enhance the quality of the body of evidence in general. Altogether, the current evidence does not clearly support the use of psychological interventions to reduce pain in participants undergoing open heart surgery.