Several studies have demonstrated that 30%-40% of cancer patients suffer from psychiatric problems such as depression, anxiety and adjustment disorders.1–3 The more positively the breast cancer patients rated their appraisal and tangible dimensions of social support, the lower value their mean cortisol level.4 Malignant melanoma patients who received 6-week structured intervention showed a lessening of emotional discomfort, augmentation of immune function and a decreased recurrence rate and mortality.5,6
Brief structured psychological intervention is a new type of psychotherapy,7 which can help relieve negative emotions of patients who experience stress and give psychological support to reduce posttraumatic syndrome.8 We developed a brief structured psychological intervention covering knowledge of breast cancer treatment, coping strategy and social support.
Patients were excluded if they were reported to use prescription or illicit drugs or had a history of psychiatric disease, diabetes or hypertension. Sixty patients from the Department of General Surgery (Qilu Hospital, Shandong University) during February 2003 to August 2003 were volunteered, aged 30–60 years, married, and diagnosed as breast cancer stage II following fine-needle aspiration and pathological examination. All patients received the standard eradicative operation of breast cancer with the mean hospitalization time 21 days. After signing the written informed concents, they were randomly divided into two equal groups: intervention group (n=30) and control group (n=30) with the balance in gender, age, career, educational level, economic status, religious belief and residential area.
Psychological rating scale
Anxiety mood was assessed with the Chinese language version of self-rating anxiety scale (SAS) written by William W.K. Zung. Depression mood was determined by Chinese language version of self-rating depression scale (SDS) written by William W.K. Zung. Symptom checklist 90 (SCL-90) of Derogatis was used to measure patients' psychological and physiological symptoms. The self-esteem inventory (SET) was measured self-esteem of patients. Coping style was measured with trait coping style questionnaire (TCSQ) designed by Dr. JIANG Qian-jin and the results were presented as positive coping score (PC) and negative coping score (NC). Life event scale (LES) revised by Dr. YANG De-sen was used to investigate the significant events happened during the previous 5 years. Life satisfaction index A (LSIA) was used to investigate how much satisfaction the patient felt with her life.
Serum cortisol test
The fasting blood samples were obtained in the morning 7:00–7:30 on the day after being hospitalized and the tenth day after operation and tested for cortisol by radioimmunoassay (Institute of Beijing North Biological Technique, China).
Electronic skin resistance test
Electronic skin resistance was tested before and after operation using electronic skin resistance recording instrument (DT-830, Peking University, China). Electronic skin resistance tests were done on the same day as the psychological scales.
Brief structured intervention
The brief structured intervention includes three parts: education, stress management and improving social support. Education included knowledge about breast cancer, operations and diet.9 Stress management included an explanation of coping styles and suitable coping skills. Social supporting explained to patients how to use social support and improve social ties. The intervention involved five psychological factors: (1) clarifying the medical condition including diagnosis, prognosis and treatment; (2) methods to release anxiety by relaxation techniques and selfhypnosis; (3) encouraging the patients to express their feeling freely and get social support by establishing social ties; (4) complying with medical regimens; (5) suitable coping with cancer and therapeutic consequences. These managements directly addressed how to increase positive cognition, emotions and behaviours and reduce the harmful effects of stressful life events.10
All tests were done before and after the standard operation. The patients in intervention group underwent 45-minute structured intervention before the operation, the control group had 45 minutes' free talk without intervention (both sessions were finished by Dr. YU Hong-luan).
SPSS 10.0 and Sigmaplot 2000 were used in this study. All data were presented as mean±standard deviation (SD) and analyzed using independent t test, paired sample t test and Pearson regression analysis. P value less than 0.05 was considered statistically significant.
There were no significant differences between the two groups in psychological rating scales before the intervention. Compared with the control group after intervention, the patients in the intervention group had significantly lower scores in SAS, SDS, SCL-90, NC, and higher scores in SET, PC (Table).
There was no significant difference in plasma cortisol between two groups before and after intervention. The intervention group had a lower level of plasma cortisol after intervention and the control group had a higher level than that before intervention (Fig.).
Electronic skin resistance
There was no significant difference in electronic skin resistance between the two groups before intervention (P>0.05); however, electronic skin resistance in the intervention group was significantly higher than that in the control group after intervention ((0.92±0.17) MΩ vs (0.79±0.24) MΩ, P<0.05).
The score of SCL-90 significantly positively correlated with LES (r=0.362, P<0.01), and negatively with PC (r=-0.361, P<0.01). The score of PC significantly negatively correlated with SAS (r=-0.265, P<0.05), and LES (r=-0.299, P<0.01). The score of NC significantly negatively correlated with LSIA (r=-0.303, P<0.05). The score of SET significantly negatively correlated with SDS (r=-0.308, P<0.05) and positively with LSIA (r=0.437, P<0.01).
The diagnosis of breast cancer and surgery are major life events that may destroy patients' selfesteem because of changes in body image and sexual function. Psychological intervention could contribute to relief and prevent negative emotion stemming from encounters. Four areas for psychotherapy effecting physiological change are: health maintenance behaviour, healthcare utilization, endocrine environment and immune function.11 Social support is related to higher activity of natural killer cells in patients with stage I and II breast cancer.12 Active confrontation with a fighting spirit may help patients to live longer than surrendering themselves to helplessness and hopelessness.13
Patients in perioperative period stayed in hospital in a very short time and had obvious psychological problems. The aims of brief intervention are to correct coping styles, reduce distress, reclaim personal control ability, increase the solving problem skills and improve morale.14 The results showed that after treatment, compared to the control group, patients in intervention group had significantly lower anxiety, depression, negative coping scores, and significantly higher selfesteem and positive coping scores. This showed that brief intervention could improve significantly psychological states such as anxiety and depression, but had less influence on personality factors such as coping style.
Glucocorticoids play a central role in stress responses, the association between cortisol level and clinical depression is well established. Cortisol recovery in blood after acute stress may be associated with the experience of recent minor life stress leading to enhanced subjective activation during acute challenge.12 This study showed different tendencies in two groups, a increasing tendency in the control group and a decreasing tendency in the intervention group, indicating that patients in the intervention group had lower physiological stress. Even so, we need to observe the different tendencies of two groups for longer times.
Electronic skin resistance reflects the excitability of the sympathetic nervous system facing a stressor, which makes patients secrete more sweat. The patients in the intervention group had higher electronic skin resistance, indicating they had lower level of anxiety.
The results of this study showed that patients' anxiety had significant negative association with the positive coping styles, depression mood had significant negative association with selfesteem, life quality had significant negative association with the negative coping style and positive association with selfesteem. These indicate that brief structured intervention can improve the psychological factors and the life quality of patients with breast cancer. These results should be tested in a larger sample and for a longer time.
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