A cluster randomized controlled trial of cognitive behaviour therapy for common mental disorders in patients with advanced cancer

Abstract

Cognitive behaviour therapy (CBT) has been shown to reduce psychological morbidity in people with cancer, but no randomized controlled trial (RCT) exists in palliative care. We aimed to determine whether home care nurses could be taught to deliver basic cognitive behavioural techniques and so reduce symptoms of anxiety and depression. Clinical nurse specialists (CNSs) at St Christopher's Hospice were randomly allocated to receive training in CBT or continue their usual practice. At the end of the trial, nurses were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Home care patients who scored as possible cases on the Hospital Anxiety and Depression Scale (HADS) entered the trial. Participants received home care nursing visits. Assessments were carried out at baseline, 6, 10 and 16 weeks. Eight nurses received CBT training and seven continued practice as usual. The mean CTFARS scores were 35.9 for the CBT nurses and 19.0 for the controls (p=0.02). A total of 328 patients (54%) were possible cases and 80 entered the trial; most of those excluded were too ill to participate. There was an interaction between group and time: individuals receiving CBT had lower anxiety scores over time [coefficient -0.20, 95% confidence interval (CI) -0.35 to -0.05, p=0.01]. No effect of the training was found for depression. It is possible to conduct a randomized trial of psychological interventions in palliative care but there is considerable attrition from physical morbidity and mortality. Nurses can learn to integrate basic CBT methods into their clinical practice. This training may be associated with better outcomes for symptoms of anxiety.