Effectiveness of group psycho-education on well-being and depression among breast cancer survivors of Melaka, Malaysia
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.110234
Source of Support: None, Conflict of Interest: None
Background: The psychological stress after diagnosis of breast cancer is often severe. Most of the women with breast cancer and their families suffer from emotional, social, financial and psychological disturbances.
Keywords: Breast, Cancer, Depression, Group, Psychological, Survivors, Therapy, Well-being
Breast cancer is the most common neoplasm in women in most developed countries. In the United States (US), approximately 212,920 new cases of invasive breast cancer and 40,970 deaths are expected to occur among women in 2006.  In Malaysia, a total of 18,219 new cancer cases were diagnosed in 2007 and registered at the National Cancer Registry published in 2011. The total number of cancer patients included 8,123 (44.6%) males and 10,096 (55.4%) females. The most frequent cancer in Malaysia was found to be breast cancer (18.1%). In females, the most frequent cancer was also identified as breast cancer (32.1%). The number of breast cancer cases in Malaysia has increased during the last three decades at an alarming rate and has become the number one killer of women in the age group of (50-59) years. It is estimated that one in 19 women in Malaysia are at risk, compared to one in eight in Europe and the United States. The Malaysian Chinese women had a higher chance of getting cancer as compared to the Indians and Malays. This could be due to the difference in their diets and lifestyles. ,,
The five-year survival from breast cancer is between 70% and 90% and it is continuously improving. , However, the psychological stress after diagnosis of breast cancer is severe. Women with breast cancer and their families often suffer from emotional, social, financial and psychological disturbances. The difficulties they face are the uncertainty in future, destruction of self-image, separation from friends and families, worries about uncertain marital status, threat of untimely death and extra financial burden. ,
Social factors are divided into social support for and socio-demographic factors of breast cancer women. There is no clear evidence to show how socio-demographic factors such as ethnicity, education, martial and employment status affect the psychological well-being of breast cancer patients. But evidences showed that breast cancer women with stronger social support were recorded less psychiatric disorders. ,, As a growing recognition of psychological need of breast cancer patients, the development of psychological intervention expanded swiftly in the past few decades. The critical review conducted by Edwards et al.  suggested that there were 4 types of psychosocial intervention available for cancer patients: 1) psycho-educational therapy; 2) individual psychotherapy; 3) cognitive behavioral training; and 4) group intervention. In recent years, researchers begin to incorporate the cognitive behavioral training materials into group intervention, developing the new cognitive behavioral group therapy which is currently tested in many countries.
There are only a few studies conducted across the world which have examined the survival of group psychotherapy on metastatic breast cancer patients. Except for the Spiegel et al.,  the other six showed no benefits in survival of metastatic breast cancer patients. ,,,,, The conflicting effects of group psychotherapy indicate further investigation is required. Kissane et al.  recruited 303 patients with primary breast cancer on cognitive-existential group therapy. The intervention group (n = 154) were assigned to a 20 sessions cognitive-existential group therapy and 3 relaxation classes and the control group (n = 149) received only 3 relaxation classes. The group therapy included the following goals: Promoting the supportive environment; facilitating grief over loss; reframing negative thoughts; enhancing problem solving and coping; fostering hope; and examining priorities for the future. It showed that the intervention group benefited by reduced anxiety, improved family functioning, greater satisfaction with therapy, better social support and coping, and increased knowledge about cancer and its treatment.
Similar findings were reported by Hosaka et al.  with significantly reduced depression, anxiety, confusion and improved vigor. Chujo et al.  studied the effects of psychosocial group intervention in women with first recurrent breast cancer. Although the study reported lower mean scores on anxiety, depression, anger, fatigue and confusion in intervention group (n = 28) than the controls (n = 11), the results were insignificant. However, it showed the intervention group has significantly improved body image and future perspective than the controls. The insignificant changes might be resulted from small sample size (n = 39) which greatly reduced the power of the study. The psychological impact of group psychotherapy was most studied in metastatic breast cancer women ,,,,
Group psychotherapy is commonly carried out on face-to-face basis, but this can also been conducted by telephone or via internet. Heiney et al.  conducted group psychotherapy for women with breast cancer via telephone call conferencing. However, the study did not replicate the results of Spiegel et al.  and Fukui et al.  The author explained such insignificance might be due to insufficient sample size and patients in control group might unconsciously over-report their mood states and Quality-of-life (QOL). On the other hand, Winzelberg et al.  and Lieberman et al.  studied the online group psychotherapy for breast cancer patient. Winzelberg et al.  assigned 72 women with primary breast carcinoma randomly to a 12-week, web-based social support group and it showed that web-based social support group was useful in reducing depression and cancer-related trauma. However, Lieberman et al.,  introduced an Internet Based Bulletin Boards for 52 breast cancer patients; the results showed that not all expression of negative emotions were beneficial for breast cancer patients. The expression of fear and anxiety was associated with lower QOL and higher depression. This research article reports the effect of psychological group education in breast cancer patients by assessing WHO-5 Well-being Index before and after psycho-education.
To study the effectiveness of group psycho-education on well-being and depression among the survivors of breast cancer in Melaka, Malaysia.
This cluster non-randomized trial was conducted at Cancer Society in Melaka, Malaysia to assess the effectiveness of psycho-education on well-being status and depression among breast cancer patients. The study period was for one month (11 th June 2011 and 16 th July 2011). Participants in this study were thirty four adult women suffering from non-metastatic breast cancer and on appropriate allopathic medication. They belonged to various age groups (more than 18 years) who were diagnosed and treated in that Cancer Society. The Psycho-educational intervention was aimed to provide medical information and discuss the causes of cancer, prognosis and treatment strategies. It was a more holistic and competence based approach that was focused on improving the well-being status, coping skills and empowerment. Group settings helped to improve communication and problem-solving skills. It also reduced depression, anger and fatigue.
A pre-tested questionnaire was administered to collect information on the socio-demographic profile of the participants such as age, marital status, educational status, occupational status and chronic co-morbidities. Written informed consent was obtained from every participant prior to the administration of the WHO-(five) Well-being Index during the pre-test. This study was also approved by the ethical committees of both the Melaka-Manipal Medical College (MMMC) and the designated Cancer Society in Melaka, Malaysia.
Psychological Well-being Index is a construct that expresses the positive and constructive thinking of people about themselves, which is defined by its subjective nature and includes aspects such as physical functioning, psychological and social elements. This investigation and its area of application are within the clinical field, so the objective was to describe the psychological well-being of individuals by focusing on the quantitative measurement of different dimensions of well-being and depression assessed in the WHO-5 index of psychological well-being. ,,
The WHO-(five) Well-being Index is a validated and standardized Instrument developed by the World Health Organization (WHO). It is a screener for well-being assessment as well as depression in general population. A study by Bonsignore M et al.  conducted in Europe (Germany) was conducted to compare the validity of the first (1995 version) and the second (1998 version) of the WHO-(five) Well-being Index. The findings suggested that due to its higher Loevinger coefficient (0.38) and Mokken coefficient (>0.3 in nearly all items), the second version (1998 version) was superior to the first version (1995 version) for the detection of depression. The external validity ranked highly, as indicated by Receiver-operated-characteristic (ROC) analyses.
A study was conducted by Awata S et al.  to evaluate the validity and the utility of the Japanese version of the WHO (five) Well-being Index (WHO-five-J) in the context of detecting suicidal ideation in elderly community residents. In this study, the Cronbach's alpha was 0.87 and Loevinger's coefficient was 0.64. The internal validity showed sensitivity = 87%, specificity = 75%, negative predictive value = 99%, and positive predictive value = 10%. The receiver-operating characteristic curve analysis indicated that the scale significantly discriminated the subjects with suicidal ideation.
The Indian version of WHO-five Well-being Index (1998 version) by Barua et al.  also showed a high internal validity. It recorded a sensitivity of 97.0%, specificity of 86.4%, and positive predictive value of 66.3% and an overall accuracy of 0.89. The Kappa statistics showed significantly high reliability of k = 0.71. The Indian version of "WHO (five) Well-being Index (1998 version)" was found to be an effective instrument for identifying depression in elderly Indian community.
The Malay version of WHO-five Well-being Index (1998 version) was prepared for the non-English speaking participants. This Malay version of the questionnaire was prepared by an independent language expert not associated with this study. This Malay version was then back-translated into English by an independent language expert not associated with this study. This second English version was then re-translated into Malay by another independent language expert not associated with this study. Both the two sets of English and the Malay versions were compared for their consistency and accuracy by the experts in the Psychiatry department. Pre-testing was also done on a sample of five cancer patients in a private institution to assess the acceptance and time management. The results were verified by the experts of Psychiatry and Community Medicine departments and minor modifications were made wherever applicable.
After obtaining a written informed consent from every participant, the pre-tested questionnaire was administered to collect information on the socio-demographic profile of every participant. This was followed by the administration of the WHO-(five) Well-being Index as a pre-test. After this, a standard psycho-education was administered to all the participants by the principal investigator of this study, who was also an expert Clinical Psychologist. The WHO-(five) Well-being Index was again applied as post-test after the psycho-educational intervention. No randomization or blinding technique was adopted as the participants themselves acted as their own controls. However, the person conducting data tabulation and statistical analysis was blinded.
The data collected were tabulated and analyzed by using the Statistical Package for Social Sciences (SPSS) version 11.0. The results were expressed in terms of proportions, means and their corresponding standard deviation (SD) and standard errors of mean (SEM). Due to the non-parametric distribution of the sample, Wilcoxon Signed-rank Test was applied for comparison between pre-test and post-test scores. A P value <0.05 was considered as statistically significant.
The socio-demographic profile revealed that among the thirty four participants in this study, 47% of them belonged to the age group 50 years. This was followed by the age group (30-49) and less than 30, both of which recorded the same percentage of about 26.5%. Most of the participants were married (70.6%) and 47% of them had completed their secondary level of education. This was followed by primary level (32.3%) and college level (20.6%) of education respectively. In this study, 29.4% were found to be employed working in either government or private organizations and 11% among them were skilled workers. The prevalence of co-morbid chronic conditions among the participants was 9 (26.5%). Among those who were suffering from chronic co-morbid conditions, 5 (55.6%) had Hypertension and 4 (44.4%) Diabetes while only 2 (22.2%) had both.
The comparison between pre-test and post-test results of well-being assessment and depression were done by using the WHO-5 Well-being Index. [Table 1] revealed that majority of the participants was in the state of adequate well-being after the psycho-education 33 (97.1%). This was earlier found to be 25 (73.5%) during the pre-test assessment. Hence, the proportion of individuals with negative well-being had reduced from 9 (26.5%) to 1 (2.9%) after the psychological intervention. Here, the Non-parametric McNemar's test could not be applied as one of the cells in the two-by-two contingency table recorded zero.
[Table 2] revealed that majority of the participants had overcome depression and was found to be normal after the psycho-education 33 (97.1%). This was earlier found to be 26 (76.5%) during the pre-test assessment. Hence, the proportion of depressed individuals had reduced from 8 (23.5%) to 1 (2.9%) after the psychological intervention. Here, the Non-parametric McNemar's test could not be applied as one of the cells in the two-by-two contingency table recorded zero.
In the next part of the study, various items pertaining to WHO-5 Well-being Index were assessed by performing the Wilcoxon Signed-rank Test analysis. It observed that items 2, 4 and 5 were found to be statistically significant as compared to items 1 and 3 which were found to be non-significant [Table 3]. In this study, the post-test results significantly improved after the intervention for the items related to "I have felt calm and relaxed", "I woke up feeling fresh and rested" and "my daily life has been filled with things that interest me" along with the "overall impression" in the WHO-5 Well-being Index.
Receiving the diagnosis of breast cancer is a significant stressor for women. Anxiety and depression are commonly observed in breast cancer patients.  The prevalence of psychiatric disorders in breast cancer patients was found to range from 22% to 50%  and those with more advanced disease were prone to develop psychiatric disorders.  Despite this, up to 50% of psychiatric disorders remain unrecognized by medical, nursing and health-care personnel. Wong-Kim et al.  suggested three system factors namely biological, psychological and social factors contributing to the psychological well-being of breast cancer patients.
Biological factors that affect patient's well-being include the severity of the disease, treatment received, and the side-effects related to the treatment. In common belief, women diagnosed with more advanced breast cancer would experience greater threat in their survival and hence, higher level of depression. However, Aragona  and Hopwood  suggested there were no definite correlation between level of depression and disease severity. There are three types of breast cancer treatments: Chemotherapy, radiotherapy and surgery. Patients receiving chemotherapy and radiotherapy usually suffer from side-effects such as nausea, fatigue and pain.
Previous studies have shown that women who felt tired and experienced treatment-related nausea were associated with more distress and lower quality of life. , Bishop et al.  also found that higher level of pain experienced by patients was positively linked with depression and hence, lower quality of life. Surgery is more invasive than chemotherapy and radiotherapy to breast cancer women. Women receiving mastectomy will considered themselves as incomplete and develop a sense of loss. Studies have also shown that women receiving surgery with less radical procedure (lumpectomy) reported less depression symptoms than those with mastectomy. Psychological factors that correlate with depressive symptoms in breast cancer patients include low self-esteem, low emotional support and poor body image. Howard-Anderson et al.,  found self-esteem significantly affected the quality of life of young breast cancer women. Low self-esteem in breast cancer women may be due to changed body image, limited functional status during treatment and poor body image brought on by surgery.
Edelman et al.,  Spiegel et al.,  coincidentally reported reduction in depression and anxiety, together with enhanced mood in their studies. But Edmonds et al.  reported no significant improvement in mood of the patients. In contrast to the psychological benefits reported by these studies, Edmonds et al.  and Bordeleau et al.  also examined the health-related quality of life of metastatic breast cancer women, but no benefits were found. Goodwin  suggested that although the quality-of-life questionnaires used were well validated but they were not sensitive in detecting small, important psychological changes.
Spiegel et al. 1981 reported on a "supportive-expressive" group therapy intervention delivered on a weekly basis to metastatic breast cancer women. Patients were randomized into intervention group (n = 50) or control group (n = 36). The content of intervention included supportive interaction between participants, sharing of emotion and discussion of problems. After 1 year of recruitment, the intervention group experienced significant reductions in anxiety, depression, confusion and fatigue. This study opened up a new route of psycho-oncology and many support groups sprang up around the world since then.
The study by Wong-Kim et al.  revealed that group psycho-education poses adequate well-being and indicates absence of depression in the post test of WHO-5 Well-being Index (WBI), indicating the need of group psycho-education.
This study focused on the effect of effect of group psycho-education for patients with breast cancer. The data presented are the first look at data from a larger on-going project. Although the findings are interesting, it is important to emphasize that they are not the final statement. However, the results revealed that group psycho-education played a significant role in improving the well-being status and reducing depression of breast cancer survivors as analyzed by the WHO-5 Well-being Index.
A small, homogeneous sample does restrict the generalizability of this study to other stages of breast cancer, other phases of treatment and people with other forms of cancers. This sample also included women who were primarily from a single geographic area, which also restricted the applicability of these findings to other populations.
A multi-centric prospective study with large sample size can throw more light to confirm these findings.
The authors would like to acknowledge the contribution of Ms. Michaelina Chua, Manager of the Melaka Cancer Society in Melaka, Malaysia for organizing the group psychotherapy programme for the breast cancer patients and helping in the data collection.
[Table 1], [Table 2], [Table 3]