A Systematic Review of Coping Skill Interventions to Reduce Anxiety and Depressive Symptoms among Adults with Hematologic Malignancies

Abstract

Background:

Patients with hematologic malignancies experience anxiety and depressive symptoms from diagnosis through survivorship. The aim of this systematic review is to determine if coping skill interventions can reduce anxiety and depressive symptoms for persons with hematologic cancer.

Methods:

Databases including PubMed, Embase, CINAHL, APA PyschInfo, Scopus, and Cochrane were searched in June of 2021 for coping skill interventional studies with adult patients with hematologic cancer and outcomes of anxiety and depressive symptoms. Search terms, definitions, and inclusion/exclusion criteria were guided by the Transactional Model of Stress and Coping, and quality appraisal utilized the Johns Hopkins Evidence Based Practice Appraisal tool. The study was registered in PROSPERO under “CRD42021262967.”

Results:

Eleven studies met inclusion criteria with ten studies evaluating anxiety symptoms (n = 449) and nine studies evaluating depressive symptoms (n = 429). Of ten studies evaluating anxiety, five studies showed significant reduction (p< 0.05), three found small to moderate effect size reductions not reaching statistical significance (p>0.05), and only two showed no reduction in anxiety symptoms. Of nine studies evaluating depressive symptoms, three had significant reductions (p <0.05), three reported small to moderate effect size reductions not reaching statistical significance (p >0.05), and three found no effect on depressive symptoms. Coping interventions that were problem-focused as opposed to emotion-focused were most effective for both anxiety and depressive symptoms.

Conclusion:

This systematic review finds evidence that problem-focused coping interventions reduce anxiety symptoms among patients with hematologic malignancies, with mixed evidence for reduction of depressive symptoms. Nurses and other clinicians caring for patients with hematologic cancers may employ coping skill interventions as a potential way to mitigate anxiety and depressive symptoms.

PROSPERO registration ID:

CRD42021262967

1. Introduction

Over 18.1 million people worldwide received a new diagnosis of cancer in 2020 (Sung et al., 2021). This diagnosis can be disruptive and emotionally challenging as individuals come to terms with all the decisions that need to be made related to their cancer diagnosis. In fact, persons with hematologic malignancies often have complicated treatment courses with prognostic uncertainty (Gray et al., 2021). The hematologic malignancy population broadly includes persons with diagnoses of leukemia, lymphoma, and multiple myeloma, though there are many cancer diagnoses under these main disease groups. Individuals may receive therapies resulting in significant side effects such as high dose intensive chemotherapy or hematopoietic stem cell transplants (HSCT). This patient population can experience anxiety and depressive symptoms during chemotherapy treatment (Hochman et al., 2018, Senf et al., 2020), before stem cell transplantation (Posluszny et al., 2019), and at the end of life (Ramsenthaler et al., 2019).

Between 15 – 47% of patients with hematologic malignancies report depressive symptoms while 22 – 47% of patients report anxiety symptoms throughout diagnosis, treatment, and recovery (Abuelgasim et al., 2016, Bergerot et al., 2015, Clinton-McHarg et al., 2014, Shreders et al., 2018). Anxiety symptoms often range from restlessness, inability to control worrying, sleep problems, muscle tension, and loss of appetite, among others (Bates et al., 2017), while depressive symptoms may include irritability, loss of interest in previously enjoyed activities, and thoughts of death, or suicide (Smith, 2015). Anxiety and depressive symptoms may persist, leading to formal diagnoses. A recent study reported almost 5% of patients receive a new diagnosis of anxiety or depression after being diagnosed with a hematologic malignancy (Kuczmarski et al., 2022) Anxiety and/or depressive symptoms negatively impact one’s quality of life, and alarmingly, depression is tied to higher mortality rates for persons with cancer (Pinquart and Duberstein, 2010). There is a critical need to better address anxiety and depressive symptoms in persons with cancer to improve quality of life (Niedzwiedz et al., 2019).

2. Background

Persons with hematologic malignancies experience high levels of symptom burden, often comparable to those with advanced solid tumor cancer (Manitta et al., 2011). Unfortunately, the presence of anxiety and depressive symptoms, are associated with poorer quality of life (El-Jawahri et al., 2015, Papathanasiou et al., 2020). Baseline anxiety symptoms are associated with fatigue and shortness of breath during stem cell transplantation (Seo et al., 2019). Pre-cancer treatment depression is correlated with lower overall survival and higher instance of graft vs. host disease among allogeneic stem cell transplant recipients (El-Jawahri et al., 2017). Anxiety and depressive symptoms interfere with other parts of an individual’s life and are correlated with a lower likelihood of returning to work during and after treatment (Horsboel et al., 2015).

Psychosocial interventions such as cognitive behavioral therapy (CBT), offer the potential to mitigate and address anxiety and depressive symptoms in cancer patients. Advantages of psychosocial interventions include minimal risk of harm to patients, accessibility, and improvement of other patient outcomes, such as quality of life and improving coping skills (Forsman et al., 2011, Guo et al., 2013, van Luenen et al., 2018). Coping skill interventions have generally been categorized as problem-focused or emotion-focused per the Transactional Model of Stress and Coping (TMSC) by Lazarus and Folkman (1984). The goal of problem-focused coping is to actively manage or reduce the stressor. CBT is an example of problem-focused coping (Lazarus and Folkman, 1984). Emotion-focused coping centers around managing emotions elicited by the stressor and is used in situations where the stressor is perceived as uncontrollable (Lazarus and Folkman, 1984). Meditation or mindfulness exercises are examples of emotion-focused coping that may benefit persons with cancer.

Adaptive coping, or using positive methods to deal with a stressor, reduces anxiety and depression among persons living with cancer (Niedzwiedz et al., 2019). Maladaptive coping, on the other hand, predicts anxiety and depression in among persons living after cancer (Cheng et al., 2019). Emotion and problem-focused coping interventions, including CBT (Jassim et al., 2015) and mindfulness interventions (Carlson et al., 2016, Reich et al., 2017), are shown to reduce anxiety and depressive symptoms among breast cancer survivors. It is unclear whether coping interventions also reduce anxiety and depressive symptoms among persons with hematologic malignancies (Yi and Syrjala, 2017). While there are differences among various hematologic malignancies and their subtypes, there are similarities across treatments, symptoms, and side effects experienced by this population (Manitta et al., 2011, Society, 2021). Understanding the effectiveness of coping skills interventions in this population is essential to better assist patients to manage anxiety and depressive symptoms, thus improving quality of life.

To our knowledge, no systematic reviews have evaluated the effect of coping interventions on anxiety and depressive symptoms among persons with hematologic malignancies. The aims of this systematic review are to investigate the effects of coping interventions on anxiety and depressive symptoms and to identify whether problem- or emotion-focused coping interventions are effective in adults with hematologic malignancies.

3. Methods

3.1. Design

The reporting of this systematic review is according to the updated PRISMA 2020 guidelines (Page et al., 2021) and was registered with the International Prospective Register of Systematic Reviews (PROSPERO). Due to the heterogeneity of study designs and diverse methodologies of included studies, we have employed narrative synthesis for this review (Siddaway et al., 2019). Narrative synthesis involves finding similarities, differences, relationships between and amongst studies, as well as assessing the quality of studies, to answer a specific question to inform practice (Lisy and Porritt, 2016).

3.2. Definitions and Conceptual Framework

Lazarus and Folkman’s Transactional Model of Stress and Coping (TMSC)(1984), often used in cancer coping literature (Bigatti et al., 2012, Paek et al., 2016, Sumpio et al., 2017), directed the study definitions and search terms. The coping definition included “adaptation” and “resilience” (Audulv et al., 2016, Association, 2021), and excluded the terms “self-care” and “self-management” as these activities refer to disease-controlling or health management strategies. Audulv et al., note that self-care can occur during healthy or a relaxed state of being (2016), while coping occurs in reaction to a specific stressor (Lazarus and Folkman, 1984).

3.3. Inclusion Criteria

The inclusion criteria included for this review were the following: use of a coping skill intervention, evaluation of anxiety or depressive symptoms before and after the intervention, adult participants with a primary diagnosis of a hematological malignancy, and studies published in English between 2001 and 2021. This time frame was selected to reflect changes in standard of care treatment for hematologic malignancies (Pulte et al., 2020) and technological advances for delivering supportive care interventions, such as telehealth. Studies with a variety of cancer diagnoses were included if over half of participants had a primary hematologic malignancy diagnosis.

3.4. Exclusion Criteria

Studies that were observational, qualitative, or published study protocols were excluded from the review. Studies with pediatric participants, participants without a hematologic malignancy, and articles not published in the past twenty years were also excluded.

3.5. Search Strategy

Two librarians experienced in health science literature searches assisted with developing, revising, and finalizing a search strategy. Database searches in PubMed, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase, APA Psych INFO, and Scopus databases using Boolean phrases and MeSH terms occurred in June of 2021 (Table 1). The database search yielded 1,992 articles. In addition, searches of the Cochrane Clinical Trials database, ProQuest dissertation database, the American Society of Clinical Oncology abstracts, and American Society of Hematology abstracts found an additional 246 articles.

Table 1:

Search Strategy:

Database	PubMed	CINAHL	SCOPUS	EMBASE	APA Psych INFO	COCHRANE	PROQUEST	ASCO *	ASH*
Coping / Adaptation / Resilience	(“Coping behavior” OR “Coping behaviors” OR “Coping behaviour*” OR “Coping mechanism*” OR “Coping strateg*” OR “Coping skill*” OR “Coping Style*” OR “Coping and adaptation” OR “Psychological Adaption” OR “Adaptive behavior*” OR “Adaptation, Psychological”[Mesh] “Resilience” or “Psychological resilience” OR “resilience, psychological” OR “post traumatic growth”)	“Coping” OR “Coping behavior* OR “Coping behaviour*” OR “coping mechanism*” OR “Coping strateg*” OR “Coping skill*” OR “Coping style*” Or “Adapt*” OR “Adaptive behavior*” OR “Adaptation, Psychological” OR “Hardiness” OR “post traumatic growth ** “hardiness” = resilience” in CINAHL*	(“Coping behavior*” OR “Coping behaviour*” OR “Coping mechanism*” OR “Coping strateg*” OR “Coping skill*” OR “Coping Style*” OR “Coping and adaptation” OR “Psychological Adaption” OR “Adaptive behavior*” OR “Adaptation, Psychological” “Resilience” or “Psychological resilience” OR “resilience, psychological” OR “post traumatic growth”)	“coping behavior” OR “coping” OR “cope” OR “coping mechanism” OR “coping strategy” OR “coping behaviour” OR “psychological adjustment” OR “adaptation, psychological” Or “emotional adaptation” OR “emotional adjustment” Or “psychologic adaptation” OR “psychological resilience” OR “resilience” OR “post traumatic growth” *“Adaptation” = “psychological adjustment” in EMBASE*	(“Coping behavior” OR “Coping behaviors” OR “Coping behaviour*” OR “Coping mechanism*” OR “Coping strateg*” OR “Coping skill*” OR “Coping Style*” OR “post traumatic growth” or “psychosocial factors” OR “Psychological Adaption” OR “Adaptive behavior*” OR “Adaptation, Psychological” “Resilience” or “Psychological resilience” OR “resilience, psychological” OR “post traumatic growth”)	(“Coping behavior*” OR “Coping behaviour*” OR “Coping mechanism*” OR “Coping strateg*” OR “Coping skill*” OR “Coping Style*” OR “Coping and adaptation” OR “Psychological Adaption” OR “Adaptive behavior*” OR “Adaptation, Psychological” “Resilience” or “Psychological resilience” OR “resilience, psychological” OR “post traumatic growth”)	(“Coping behavior” OR “Coping behaviors” OR “Coping behaviour*” OR “Coping mechanism*” OR “Coping strateg*” OR “Coping skill*” OR “Coping Style*” OR “post traumatic growth” OR “Psychological Adaption” OR “Adaptive behavior*” OR “Adaptation, Psychological” OR “Resilience” OR “Psychological resilience” OR “resilience, psychological” OR “post traumatic growth”)	“cope” 87 of those, 2 were relevant abstracts “adapt” / “resilience” - no articles found	“cope” AND “symptoms” ➔ 52 total results 2 were relevant abstracts “adapt / resilience” AND “symptoms” – no articles
	AND	AND	AND	AND	AND	AND
Symptoms	(“symptom management” OR “symptom burden” OR “symptom*” OR “pain management” OR “pain control” OR “suffering” OR “wellbeing” OR “discomfort” OR “distress” OR “anxiety” OR “depression” OR “pain”)	“Symptom*” OR “behavioral Symptom*” or “pain management” OR “pain control” OR “suffering” OR “wellbeing” OR “discomfort” OR “distress” OR “anxiety” Or “Depress*” OR “pain”)	(“symptom management” OR “symptom burden” OR “symptom*” OR “pain management” OR “pain control” OR “suffering” OR “wellbeing” OR “discomfort” OR “distress” OR “anxiety” OR “depression” OR “pain”)	(“symptomology OR “symptom management” OR “symptom burden” OR “symptom*” OR “pain management” OR “pain control” OR “suffering” OR “wellbeing” OR “discomfort” OR “distress” OR “anxiety” OR “depression” OR “pain”)	(“symptom management” OR “symptom burden” OR “symptom*” OR “pain management” OR “pain control” OR “suffering” OR “wellbeing” OR “discomfort” OR “distress” OR “anxiety” OR “depression” OR “pain”)	(“symptom management” OR “symptom burden” OR “symptom*” OR “pain management” OR “pain control” OR “suffering” OR “wellbeing” OR “discomfort” OR “distress” OR “anxiety” OR “depression” OR “pain”)	(“symptom management” OR “symptom burden” OR “symptom*” OR “pain management” OR “pain control” OR “suffering” OR “wellbeing” OR “discomfort” OR “distress” OR “anxiety” OR “depression” OR “pain”)
	AND	AND	AND	AND	AND	AND	AND	AND
Hematologic malignancies	(“Hematological malignanc*” OR “hematological neoplasms”[Mesh] OR “haematological malignanc*” OR “myeloma” OR “leukemia” OR “lymphoma” OR hematopoietic stem cell transplantation” [mesh])	“Hematological malignanc*” OR “hematological neoplasms” OR “haematological malignanc*” OR “myeloma” OR “leukemia” OR “lymphoma” OR “hematopoietic stem cell transplantation”	“Hematological malignanc*” OR “hematological neoplasms” OR “haematological malignanc*” OR “myeloma” OR “leukemia” OR “lymphoma” OR “hematopoietic stem cell transplantation”	“cell transplantation” OR “Hematological malignanc*” OR “hematological neoplasms” OR “haematological malignanc*” OR “myeloma” OR “leukemia” OR “lymphoma” OR “hematopoietic stem cell transplantation”	“Hematologic* malignanc*” OR “hematologic* neoplasms” OR “haematologic* malignanc*” OR “myeloma” OR “leukemia” OR “lymphoma” OR “hematopoietic stem cell transplantation”	“Hematologic malignanc*” OR “hematologic neoplasm*” OR “haematologic* malignanc*” OR “myeloma” OR “leukemia” OR “lymphoma” OR “hematopoietic stem cell transplantation”	(“Hematologic* malignanc*” OR “hematologic* neoplasms” OR “haematologic* malignanc*” OR “myeloma” OR “leukemia” OR “lymphoma” OR “hematopoietic stem cell transplantation”)

ASH = American Society of Hematology

ASCO = American Society of Clinical Oncology

3.6. Screening Process and Data Extraction

The EndNote reference manager was used to organize all citations and remove duplicate articles (n=628 )(EndnoteTeam, 2013). Rayyan was utilized for title and abstract screening (Ouzzani et al., 2016). Using the inclusion and exclusion criteria, all titles and abstracts were independently screened by L.A. A total of 91 articles remained after the initial title / abstract screening. A full text screening was done on 87 articles, as four articles could not be found with EndNote and manual searches. Of the 87 full text articles, 11 met criteria and were included in the final review, with 8 articles from the formal literature search and 3 studies identified via other methods. Studies were excluded if: no coping intervention was found, non-hematologic cancer, qualitative or observational study, pediatric participants, no depression or anxiety symptom evaluation of participants with cancer, or a study protocol (Figure 1 PRISMA Flow Diagram).

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources.

*Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers).

**If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/

The following information was extracted to create a Table of Evidence: Citation, Sample, Methods, Design, Intervention, Depressive / Anxiety symptom outcomes, Limitations, and Findings (Table 1). An asterisk notes the primary outcome measure of each study (Table 2). We organized studies by the type of intervention (Table 3). Articles were independently assessed by L.A. and M.M. for quality using the Johns Hopkins Nursing Evidence Based Practice (JHNEBP) appraisal tool. The JHNEBP tool consists of a two-part grading system to evaluate the study’s evidence and quality (Dang and Dearholt, 2018). The study gives a numeric level (I, II, or II) based on the overall type of study; for example, a randomized controlled trial (RCT) or systematic review of RCTs receives level I, quasi-experimental studies or systematic review of RCT and quasi-experimental studies receive a level II, and observational studies or qualitative studies receive a level III (Dang and Dearholt, 2018). The second part of the appraisal involves assessing the quality of the evidence with “A” denoting a high quality study with generalizable results, acceptable control, consistent recommendations, and adequate sample size (Dang and Dearholt, 2018). A “B” denotes a good quality study with adequate control, fairly consistent results, and reasonably decisive conclusions while a “C” study denotes a low quality study, including with inconsistencies, limited sample size, or inconclusive findings (Dang and Dearholt, 2018). Any discrepancies in evaluation were discussed between L.A. and M.M. until an agreement was reached (Table 4).

Table 2:

Table of Evidence

Article Citation	Sample	Design	Methods	Intervention	Limitations	Depression / Anxiety Outcomes
(Amonoo et al., 2020)	N=29 HSCT recipient in USA 0.4 – 39 years post-transplant 82.8% Female 89.6% white 79.3% college degree or higher Mean age = 62.3 years	One-arm pilot study design	Qualitative interviews and self-reported assessments	Positive psychology intervention to increase resilience	Participants majority educated, non-Latino, white, and women, single academic sample Small sample size Varied post-HSCT window Unknown treatment fidelity for self-administered exercises No control group	Anxiety – HADS: p>0.05 Depression – HADS: p> 0.05 Exact p values not available
(Amonoo, et al., 2021)	N=25 Allogeneic HSCT adults in USA 95% white 55% female Mean age = 52.6 years	Single arm, proof of concept trial	Convenience sample Baseline assessment at 100-day post HSCT follow up, then post intervention assessments	Positive psychology intervention	Poor attrition: 2 deaths; 9 withdrawals d/t physical symptoms, and 2 lost to follow up Not blinded to study, no control group	Anxiety – HADS: d=−.031 Depression – HADS: D= −0.29
(Balck et al., 2019)	N=95 total N=46 intervention group N = 49 control group >18 years of age, currently undergoing HSCT in Germany 37.8% Female Mean age = 52.58 years	Randomized pre-test post-test control group design	Intervention group and control group completed questionnaires 2 days prior to HSCT, and between days +10 to +12 (T2) between days +20 to +22 (T3) Randomly assigned to intervention and control group	Problem solving training 5 individual sessions at days −1, +2, +4, +7, and + 9	Significant retention issues, including deterioration of physical condition (n = 13), deceased patients (n = 2), and loss of motivation (n=15) Single center study Unknown demographic variables of participants Limited follow up after patient discharged from hospital	Anxiety – HADS*: Intervention group had significantly less anxiety at both time points than control group p = 0.003, p = 0.04 d= 0.13 Depression – HADS*: No significant changes in depression, p = 0.24, p =0.87
(Cohen et al., 2004)	Total N = 39 N = 20 intervention group N = 19 wait list control group Patients with lymphoma CHOP or similar chemo currently or within past year in USA 66.7% Female Mean age: 51 years 36% Hodgkin’s Lymphoma	Quasi-experimental study with waitlist control group	TY “Tibetan yoga” or waitlist control group assigned sequentially using minimization Stratified to group by cancer type status of chemotherapy, age, gender, and baseline anxiety score Baseline measurements, again 1 week, 1 month, and 3 months after intervention	Tibetan yoga – meditative technique “mind body” controlled breathing, visualization, mindfulness techniques, and postures	Measures less responsive to changes per authors Floor effect, scores low at baseline / follow up indicating this group of participants had low levels of anxiety and depression Small sample size, underpowered	Anxiety -State*: P value > 0.90, Depression – CES-D*: P value =0.56,
(de Linares-Fernández, et al. 2017)	N = 36 N=21 intervention group N=15 control group Patients undergoing HSCT in Spain Mean age = 43.6 years 75% autologous HSCT	Pilot study Quasi-experimental design with control group with pre and post-test	Non-random sampling Intervention group received intervention at hospital or clinic Intervention group received pre HSCT chemo or apheresis + Control group admitted directly to hospital Measures on day 0 and at discharge	Adjuvant Psychological Therapy Behavioral Strategies based on CBT	Day 0 = anxiety inducing day, when baseline measures taken Small, nonrandom sample Other demographic information not reported	HADS – Anxiety*: Significantly reduced in intervention group compared to control p< 0.001 HADS -Depression*: Significantly reduced in intervention group compared to control, p < 0.001
(Duhamel, et al., 2010).	N=89 N= 52 intervention group N= 37 control group Adults with a HSCT received 12 – 36 months prior to enrollment and with significant distress in USA 81.2% white 52.55 % Female 47% Autologous 44% Allogeneic 9% unknown HSCT Mean age: 50.8 years	Randomized controlled trial	Random assignment to intervention or control group Baseline assessment, Post intervention assessment at 6, 9, and 12 months after baseline	CBT administered via telephone, individually	Participants majority white, excluded non-English speakers Differences between intervention and control group participants at baseline,	Depression – BSI: Intention to treat analysis, P=0.023 time by study group interaction.
(Faryabi, et al, 2021)	N = 45 N = 15 CBT group N= 15 acceptance and commitment therapy (ACT) group N= 15 control group Patients with leukemia currently hospitalized in Iran 46.6% Female 11% Bachelor’s degree or higher Mean age = 54.8 years	Quasi-experimental study design with pre-test post-test and control group	Convenience sampling Participants randomized to three groups Measures at baseline and post intervention	CBT: focused on minimizing psychological effects of disease ACT: mindfulness and acceptance to change behaviors and increase flexibility	Study did not discuss specifics of intervention, how often and how long patients received therapy Small sample size Unclear why patients were hospitalized of changes in hospitalization status Timing of measures + intervention not discussed	Anxiety – BAI: Both the CBT and ACT groups experienced significant decrease in anxiety compared to the CG p <0.05 The ACT vs. CBT experienced greater decrease in anxiety p < 0.01
(Huberty, et al., 2016)	N = 38 national sample Polycythemia Vera (PV n = 16), Essential thrombocythemia (ET n = 16), and myelofibrosis (MF n=6) nationally distributed sample in USA 89.5% Female 97.3% Caucasian 65.8% Bachelor’s degree or higher Median age = 56 years	Single arm pre-test post-test quasi-experimental intervention Nonrandomized	Recruitment via social media, convenience sample Surveys administered at baseline week 0, midpoint (week 7), post intervention week 12, and follow up week 16	60 minute online streamed yoga weekly for 12 weeks	Small sample size Mostly white, well educated, female sample No control group High risk for bias One adverse event: irritated large spleen	Anxiety – PROMIS: Pre to post intervention with p = 0.002 d = −.67 Depression – PROMIS: Pre to post intervention with p = 0.049 and effect size d= 0.41
(Huberty, et al., 2019)	N=48 N= 27 yoga intervention group N=21 wait list control group Polycythemia Vera = 31% Essential Thrombocythemia = 39% Myelofibrosis 29.2% 93% Female 93% white 83% college degree or higher Mean age = 56.9 years	Pilot randomized trial with a waitlist control group	Online recruitment Randomized to yoga or waist list control group Measures at baseline, midpoint, post intervention, and follow up Self-report measures and online web analytic program	12 weeklong yoga intervention, 60 minutes / week Yoga incorporated mindfulness; hatha and vinyasa style classes – avoided poses that would exacerbate splenomegaly	Homogenous sample Did not account for confounding factors Self-reported data Strict exclusion criteria, excluded participants with depression or current yoga practices	Anxiety –PROMIS: d= -0.27 to -0.37 Depression –PROMIS: d= −0.53 to -0.78
(Moeini, et al., 2014)	N=64 N = 32 Intervention group N = 32 control group Patients with leukemia not undergoing chemotherapy, admitted to intensive care unit in Iran 39% Female 48.4% High school graduate Mean age = 41.2 years	Pretest-posttest randomized clinical trial	Randomized clinical trial with spiritual care program Intervention during hospitalization	Spiritual care program given for three consecutive days Expression of needs, therapeutic listening, active touch, etc.	Limited inclusion criteria for study Short duration implementation and evaluation Limited discussion of intervention and measurement specifics Single center study	Anxiety – DASS-42*: Significant decrease in anxiety in intervention group over time compared to control group p <0.001
(Perez, et al., 2020)	N = 30 Patients with history of lymphoma within 2 years of completing treatment in USA 50% female 96% white 73.3% College degree or higher N=52.4 years	Exploratory mixed methods study with qualitative arm and single arm pilot design	Data captured at baseline, post program completion, and one month post program completion Treatment completers if > 75% of sessions N=20 completed sessions	8-week resiliency group program based on the Stress management and Resilience Training – Relaxation Response Resilience Program	No control groups Single academic center Majority white and highly educated small sample size Patients reported technical challenges and scheduling challenges with the telehealth program	Depression – CES-D: depression decreased; p > 0.05, d= 0.29 Anxiety – GAD-7: anxiety decreased; p = 0.07, d=0.41

Abbreviations in order of use:

JHNEBP (Johns Hopkins Nursing Evidence Based Practice); CBT (Cognitive Behavioral Therapy); HSCT (Hematopoietic Stem Cell Transplant); HADS (Hospital Anxiety and Depression Scale); STATE (Spielberger State Anxiety Inventory); CES-D (Centers of Epidemiologic Studies – Depression); BSI-D (Brief Symptom Inventory – Depression); BAI (Beck Anxiety Inventory); PROMIS (Patient Reported Outcomes Measurement Information System); MPN (Myeloproliferative Neoplasms); DASS (Depression Anxiety Stress Scale); GAD-7 (General Anxiety Disorder)

Table 3:

Table of Study Interventions

Study Citation	Intervention	Intervention type	Interventionist	Delivery format	Individual or group sessions	Session length	Intervention length	Theoretical / conceptual framework	Symptom outcome
Emotion-Focused Interventions
(Amonoo, et al., 2020)	Positive psychology intervention: gratitude, strength, & meaning based, with future planning	Emotion-focused	Clinical research coordinators, (received training for PPI)	Phone with self-complete component	Group	30 minutes	8 weeks	Positive psychology conceptual framework	Anxiety Depression No statistically significant differences
(Amonoo, et. al, 2021)	Positive psychology intervention (same as above)	Emotion-focused	Psychiatrist, MD	Phone with self-complete component	Individual	15 – 20 minutes	8 weeks	Broaden and Build Theory of Positive Emotions	Anxiety, depression Small – medium effect sizes, no significant differences
(Cohen, et al., 2004)	Tibetan yoga + meditative mind body techniques	Emotion-focused	Tibetan Yoga Instructor	In person yoga classes once a week Self-complete component audio tapes + printed materials	Group yoga class Individual component	n/a	7 week program	Tsa Lung and Trul Khor	No statistical significance on anxiety or depression,
(Huberty, et al., 2016)	Yoga and breathing / mindfulness	Emotion – focused	n/a	Online streamed yoga sessions	Individual	60 minute weekly sessions	12 weeks	n/a	Significant reduction in depression and anxiety
(Huberty et al., 2019)	Yoga and breathing / mindfulness	Emotion- focused	Videos by trained yoga instructors Yoga videos selected by MPN specialist MD, PhD researcher/certified yoga instructor, trained bio- mechanist/yoga educator	Online streamed yoga sessions	individual	60 minute weekly sessions	12 weeks	Hatha and Vinyasa yoga; mindfulness	Small effect size in anxiety, moderate effect in depression
(Moeini, et al., 2014)	Spiritual care program, active listening, therapeutic touch, prayer	Emotion-focused	Clergyman and researcher	In person	Individual	n/a	3 days	Spirituality and “meta-religion”	Significant reduction in anxiety
Problem-Focused Coping interventions
(Balck, et al., 2019)	Problem solving training (PST)	Problem-focused	Clinical psychologists trained in PST	In person	Individual	45 minutes	5 sessions over 10 days	Cognitive stress model of Lazarus and Folkman. Problem solving theory	Significant reduction in anxiety Did not reduce depression
(de Linares – Fernandez et al., 2017)	Adjuvant Psychological Behavioral Therapy (Cognitive behavioral therapy)	Problem-focused	“psycho-oncologist”	In person	Individual	90 minutes initial sessions 30 minute follow up sessions	4 – 6 sessions Prior to BMT and sessions every 2 days throughout hospital stay	Cognitive behavioral therapy	Significant reduction in anxiety and depression
(Duhamel et al., 2010)	Cognitive behavioral therapy (CBT)	Problem focused	Trained Psychology postdoctoral fellows	Telephone	Individual	90 minutes initial 40 minute follow up sessions	10 sessions Over 10 –16 weeks	Cognitive behavioral therapy	Significant reduction in depression
(Faryabi, et al., 2021)	Cognitive Behavioral Therapy (CBT)	(CBT = Problem-focused)	n/a	n/a	n/a	N/a	n/a	Beck’s cognitive therapy model	Significant reduction in anxiety for both ACT and CBT
Problem and Emotion Focused
(Faryabi, et al., 2021)	Acceptance and Commitment therapy (ACT)	((ACT = problem and emotion -focused)	n/a	n/a	n/a	N/a	n/a	Beck’s cognitive therapy model	Significant reduction in anxiety for both ACT and CBT ACT had greater improvement on anxiety
(Perez, et al., 2020)	Stress management and resilience training relaxation response – (SMART 3RP) - Mind / body, cognitive behavioral, and positive psychology	Problem and emotion focused	n/a	Telehealth sessions	Group (4–6)	90 minutes	8 weeks	Stress management and resilience training – relaxation response program	Non-significant reduction in anxiety and depression

Table 4:

Quality of Evidence Table

Study citation	Evidence	Quality	Overall grade
(Amonoo et al., 2020)	Level II Quasi experimental study one-arm pilot study	C Small sample size, varied post-HSCT window, unknown fidelity, no control group	IIC
(Amonoo et al., 2021)	Level II Quasi experimental study one arm study	C Low attrition, no blinding, no control, small sample size, participants had moderate baseline QoL	IIC
(Balck, et al., 2019)	Level I Randomized controlled trial	B Both IG and CG experienced retention issues, single center study	IB
(Cohen et al., 2004)	Level II Quasi experimental with control group	B Underpowered study, small sample size, potential for ceiling effect	IIB
(de Linares-Fernández et al., 2017)	Level II Quasi experimental with control group	B Small sample size, control group w/o randomization	IIB
(Duhamel et al., 2010)	Level I Randomized controlled trial	A Robust, randomized trial with adequate power and consistent findings	IA
(Faryabi et al., 2021)	Level II Quasi experimental with control group	B Smaller sample size, limited discussion of intervention + measurements, high risk for bias	IIB
(Huberty, et al., 2016)	Level II Quasi experimental one arm study	C No control group, homogenous sample, high risk for bias	IIC
(Huberty, et al., 2019)	Level I Randomized controlled trial	B Smaller and homogenous sample size, wait list control group	IB
(Moeini et al., 2014)	Level I Randomized controlled trial	B Limited discussion of intervention and measurement specifics, but consistent results	IB
(Perez et al., 2020)	Level II Quasi experimental one arm mixed methods	C No control group, homogenous sample	IIC

4. Results

In total, 11 studies met the eligibility criteria for this systematic review. Seven of the studies were conducted in the United States and four studies were international: two from Iran (Faryabi et al., 2021, Moeini et al., 2014), one from Germany (Balck et al., 2019), and one from Spain (de Linares-Fernández et al., 2017). Ten studies evaluated anxiety symptoms, nine studies evaluated depressive symptoms, and eight studies evaluated both anxiety and depressive symptoms. Studies evaluating anxiety symptoms had a total of 449 participants (sample size ranged from n = 25 (Amonoo et al., 2021) to n= 95 (Balck et al., 2019)) with an average age of 52.3 years. Studies evaluating depressive symptoms had a total of 429 participants (sample size range from n=25 (Amonoo et al., 2021) to n=95 (Balck et al., 2019)) with an average age of 53.1 years. Study interventions included positive psychology interventions (Amonoo et al., 2020, Amonoo et al., 2021), problem-solving training (Balck et al., 2019), Tibetan yoga and meditation (Cohen et al., 2004), CBT (de Linares-Fernández et al., 2017, DuHamel et al., 2010, Faryabi et al., 2021) acceptance and commitment therapy (Faryabi et al., 2021), yoga / mindfulness (Huberty et al., 2019, Huberty et al., 2016), a spiritual care program with active listening (Moeini et al., 2014), and the Stress Management and Resilience Training- Relaxation, Response, Resilience Program (SMART-3RP Lymphoma) (Perez et al., 2020). Study attrition ranged from 0% (Moeini et al., 2014) to 52% (Amonoo et al., 2020) with common reasons for attrition including high symptom burden (Amonoo et al., 2020), worsening health status, death (Balck et al., 2019), or lack of time (Perez et al., 2020).

Studies used a variety of validated measures to evaluate anxiety and/or depressive symptoms. The most commonly used was the Hospital Anxiety and Depression Scale (HADS). Four studies used the HADS scale (Amonoo et al., 2020, Amonoo et al., 2021, Balck et al., 2019, de Linares-Fernández et al., 2017), two used the Patient Reported Outcomes Measurement Information System (PROMIS) for anxiety and depressive symptoms (Huberty et al., 2016, Huberty et al., 2019), and two used the Center of Epidemiologic Studies – Depression (CES-D) scale (Perez et al., 2020, Cohen et al., 2004). Other studies used the Spielberger State Anxiety Inventory (Cohen et al., 2004), the Brief Symptom Inventory – Depression scale (BSI-D) (DuHamel et al., 2010), the Beck Anxiety Inventory (BAI) (Faryabi et al., 2021), the Depression, Anxiety, and Stress Scale (DASS −42) (Moeini et al., 2014), and the General Anxiety Disorder scale (GAD – 7) (Perez et al., 2020). These scales are typically screening tools for anxiety and depressive symptoms and are not often used for diagnostic purposes.

4.1. Quality Appraisal

Of the eleven studies included in this review, one was IA quality, indicating a randomized controlled trial of high quality (DuHamel et al., 2010), and three met level IB quality, indicating a randomized controlled trial with “good” quality (Balck et al., 2019, Huberty et al., 2019, Moeini et al., 2014). Three studies were of IIB quality, indicating a quasi-experimental study with “good” quality (Cohen et al., 2004, de Linares-Fernández et al., 2017, Faryabi et al., 2021). The remaining four studies were of IIC quality, indicating a quasi-experimental study with of lower quality, commonly due to no control group, small sample size, and/or unknown treatment fidelity (Amonoo et al., 2020, Amonoo et al., 2021, Huberty et al., 2016, Perez et al., 2020). Overall, study quality was moderate, with four excellent or good quality RCTs and seven good or lower quality quasi-experimental studies.

4.2. Synthesis

Study-reported p values determined a significant effect (p <0.05), a small to moderate ES reduction in anxiety or depressive symptoms that did not reach statistical significance (p > 0.05), or no effect on anxiety or depressive symptoms (no reduction in symptoms and p > 0.05). Of the ten studies that evaluated the effects of coping skill interventions on anxiety, five reported a significant reduction in anxiety, p <0.05 with study quality of IB, (Balck et al., 2019, Moeini et al., 2014), IIB (de Linares-Fernández et al., 2017, Faryabi et al., 2021) and IIC (Huberty et al., 2016). Three studies reported small to moderate ES reductions that did not reach statistical significance (ES, d =0.027 to 0.037) with study quality IB (Huberty et al., 2019), d=0.18 to 0.41 with study quality IIC, (Perez et al., 2020) and d = 0.31 with study quality IIC (Amonoo et al., 2021). Two studies reported no reduction in anxiety, with study quality IIB (Cohen et al., 2004) and study quality IIC (Amonoo et al., 2020). Interventions that reduced anxiety included problem-solving (Balck et al., 2019), CBT (de Linares-Fernández et al., 2017, Faryabi et al., 2021),, acceptance and commitment therapy (Faryabi et al., 2021), yoga / mindfulness (Huberty et al., 2016), and a spirituality program (Moeini et al., 2014). Interventions showing small to moderate ES anxiety reduction but did not reach statistical significance included the SMART-3RP Lymphoma program (Perez et al., 2020) yoga / mindfulness (Huberty et al., 2019) and positive psychology (Amonoo et al., 2021). The interventions that did not reduce anxiety were positive psychology (Amonoo et al., 2020) and Tibetan yoga and meditation (Cohen et al., 2004). Overall, five studies showed significant reductions, three showed small to moderate ES reductions that did not reach statistical significance, and two showed no reduction in anxiety symptoms.

Of the nine studies that evaluated coping skill intervention effectiveness on depressive symptoms, three resulted in a significant reduction in depressive symptoms and were of IA (DuHamel et al., 2010), IIB (de Linares-Fernández et al., 2017), and IIC quality (Huberty et al., 2016). The interventions that significantly reduced depressive symptoms included CBT (de Linares-Fernández et al., 2017, DuHamel et al., 2010) and a yoga / mindfulness intervention (Huberty et al., 2016). Three studies found small to moderate ES reductions that did not reach statistical significance (p>0.05) in depressive symptoms with the SMART-3RP program with d = 0.23 to 0.29 of IIC quality (Perez et al., 2020), a yoga / mindfulness intervention with d = −0.53 to −0.78 of IB quality (Huberty et al., 2019), and a positive psychology intervention with d = −0.29 of IIC quality (Amonoo et al., 2021). The remaining three interventions did not reduce depressive symptoms: A problem-solving training of IB quality (Balck et al., 2019), Tibetan yoga and meditation of IIB quality (Cohen et al., 2004), and a positive psychology intervention of IIC quality (Amonoo et al., 2020). Of nine studies, three found significant reductions, three studies reported small to moderate ES reductions not reaching statistical significance, and three found no reduction in depressive symptoms.

4.3. Synthesis by Intervention Type

To further understand coping intervention effectiveness, we categorized interventions according to Lazarus and Folkman’s definition of problem-focused and emotion-focused coping (Lazarus and Folkman, 1984). Of interventions evaluating anxiety, six were emotion-focused, four were problem-focused and two were combined problem and emotion-focused, as Faryabi et al. compared CBT and acceptance and commitment therapy (2021). Emotion-focused interventions included yoga (Cohen et al., 2004, Huberty et al., 2016, Huberty et al., 2019) to positive psychology interventions (Amonoo et al., 2020). Of the emotion-focused interventions, only two showed significant reduction in anxiety; the spirituality program (Moeini et al., 2014) and yoga/mindfulness (Huberty et al., 2016). Another yoga (Huberty et al., 2019) and positive psychology intervention had small to medium effect sizes (Amonoo et al., 2021). However, a similar positive psychology intervention (Amonoo et al., 2020) and a Tibetan yoga intervention had no effect on anxiety (Cohen et al., 2004). Of the interventions that evaluated depressive symptoms, five were emotion-focused, four were problem-focused and one was combined problem and emotion-focused. Five emotion-focused coping interventions evaluated depressive symptoms, with a positive psychology intervention (Amonoo et al., 2020) and Tibetan yoga (Cohen et al., 2004) also not reducing depressive symptoms. A positive psychology intervention resulted in a small effect size (d=−0.29) (Amonoo et al., 2021) and a yoga / mindfulness intervention resulted in a medium effect in reducing depressive symptoms (d=−0.53 – 0.78) (Huberty et al., 2019). However, a similar yoga/mindfulness intervention found a significant reduction in depressive symptoms (Huberty et al., 2016). The emotion-focused coping interventions had varied results on anxiety and depressive symptoms, with most having a small to moderate ES reductions that did not reach statistical significance effect. The type of intervention did not align with patient outcomes, as the yoga/mindfulness and positive psychology interventions had mixed results across the four studies.

The problem-focused coping interventions consisted of CBT or problem solving training. All three interventions significantly decreased anxiety (Faryabi et al., 2021, de Linares-Fernández et al., 2017, Balck et al., 2019). Of the three problem-focused interventions measuring their effects on depressive symptoms, two CBT interventions significantly decreased depressive symptoms (de Linares-Fernández et al., 2017) (DuHamel et al., 2010) while the problem solving intervention did not. Problem-focused coping interventions were all effective in significantly reducing anxiety, though only the CBT interventions significantly reduced depressive symptoms.

Two interventions involved components of both problem and emotion-focused coping. One was the SMART-3RP program, involving CBT, mindfulness, and positive psychology, which resulted in small ES in reducing anxiety and depressive symptoms (Perez et al., 2020). The other was acceptance and commitment therapy, which significantly reduced anxiety but did not measure its impact on depressive symptoms (Faryabi et al., 2021). Over half of the interventions in this systematic review utilized emotion-focused coping and had mixed results in reducing anxiety. However, problem-focused interventions, such as CBT, were more effective, and all resulted in significant reductions in anxiety. A similar trend was found for depressive symptoms, with emotion-focused interventions less effective, and problem-focused interventions more effective at reducing depressive symptoms.

4.4. Synthesis by Intervention Delivery

Three interventions were delivered to groups of participants and five were delivered to individuals. Two of the group interventions found no significant improvement in depressive or anxiety symptoms (Amonoo et al., 2020, Cohen et al., 2004), and one had a small ES in reducing depressive and anxiety symptoms (Perez et al., 2020). Of the individual interventions that evaluated anxiety, three of the four had significant reductions in anxiety symptoms (Balck et al., 2019, de Linares-Fernández et al., 2017, Moeini et al., 2014), while another had a small ES, d=−0.31 (Amonoo et al., 2021). Of the individual interventions that evaluated depressive symptoms, two of the four found significant reduction in depressive symptoms, (de Linares-Fernández et al., 2017, DuHamel et al., 2010), one found a small ES, d=−0.29 (Amonoo et al., 2021), and one had no reduction in depressive symptoms (Balck et al., 2019).

Of the 11 total studies, four interventions were in person: three resulted in significant reductions in anxiety (Balck et al., 2019, de Linares-Fernández et al., 2017, Moeini et al., 2014), though one in person intervention did not reduce anxiety nor depressive symptoms (Cohen et al., 2004). Four utilized phones (Amonoo et al., 2020, Amonoo et al., 2021, DuHamel et al., 2010),, or video apps (Perez et al., 2020). One of the three phone delivered interventions had a significant reduction in depressive symptoms (DuHamel et al., 2010), one resulted in small ES reductions in depressive and anxiety symptoms (Amonoo et al., 2021), and one had no reduction in depressive nor anxiety symptoms (Amonoo et al., 2020). The SMART-3RP program used a video app and found small-medium ES reductions in anxiety and depressive symptoms (Perez et al., 2020). Two online asynchronous yoga/mindfulness interventions resulted in significant (Huberty et al., 2016) or small-medium ES reductions in anxiety and depressive symptoms (Huberty et al., 2019). One study did not report whether it was in-person or remote (Faryabi et al., 2021). Though interventions varied, in person and individual sessions seemed more effective in reducing anxiety, with less evidence available to evaluate the effect on depressive symptoms.

4.5. Synthesis by Intervention Duration

We also evaluated the duration of interventions, with one study not disclosing the length of the intervention period (Faryabi et al., 2021). One intervention was delivered over three days, with a significant reduction in anxiety (Moeini et al., 2014). Two interventions, both problem-focused, were delivered over 1 to 2 weeks, both with significant reductions in anxiety, but only one intervention found a significant reduction in depressive symptoms (de Linares-Fernández et al., 2017), while the other did not (Balck et al., 2019). Four interventions were between 7 to 8 weeks in length, with two resulting in small-medium ES in symptom reduction (Amonoo et al., 2021, Perez et al., 2020) and two with no improvement in depressive or anxiety symptoms (Amonoo et al., 2020, Cohen et al., 2004). Three interventions continued for over 10 weeks, with two showing significant reduction in anxiety and/or depressive symptoms (DuHamel et al., 2010, Huberty et al., 2016) and one with small to medium ES in reducing anxiety and depressive symptoms (Huberty et al., 2019). Assessing outcomes based on intervention duration is difficult due to heterogeneity in intervention type and participants, as well as the intervention “dose” (e.g. multiple sessions per week vs. once per week). However, it appears that interventions occurring more than once per week and over a longer period of time showed some effectiveness.

4.6. Synthesis by Type of Cancer / Treatment

The studies recruited a heterogenous mix of participants by type of cancer. Two studies enrolled patients with lymphomas: one study had no reduction in anxiety or depressive symptoms (Cohen et al., 2004) and the other had small ES reductions in anxiety and depressive symptoms (Perez et al., 2020). Two studies enrolled patients with leukemia (Faryabi et al., 2021, Moeini et al., 2014), with both interventions reducing anxiety and not measuring depressive symptoms. Finally, two yoga / mindfulness studies enrolled patients with myeloproliferative disorders (Huberty et al., 2016, Huberty et al., 2019). One study found significant reductions and the other found small-medium ES reductions in anxiety and depressive symptoms. One study enrolled only allogeneic stem cell transplants and found small ES reductions in anxiety and depressive symptoms (Amonoo et al., 2021). Four studies enrolled allogeneic and autologous HSCT recipients. One found significant reduction in both anxiety and depressive symptoms (de Linares-Fernández et al., 2017), one found significant reduction in anxiety but not depressive symptoms (Balck et al., 2019), one found in significant reductions in depressive symptoms only (DuHamel et al., 2010), and one study had no symptom reductions (Amonoo et al., 2020). Time since transplant varied, with one study starting before day 0 (de Linares-Fernández et al., 2017) and another including participants who were 39 years post-transplant (Amonoo et al., 2020). We did not identify any commonalities in coping skill intervention effectiveness by cancer type or treatment due to the heterogeneity of the participant’s illnesses and treatments.

5. Discussion

To our knowledge, this is the first systematic review to evaluate whether and which types of coping skill interventions reduces anxiety and depressive symptoms in adults with hematologic cancers. Included studies ranged from quasi-experimental studies with limited study quality to high quality RCTs. This review found coping skill interventions can be effective in reducing anxiety symptoms but are less effective in reducing depressive symptoms in the hematologic malignancy population. Interventions that were most effective at reducing anxiety included problem-focused coping interventions such as CBT and problem-solving training. We found that problem-focused interventions, such as CBT, were more effective in reducing anxiety and depressive symptoms for persons with hematologic malignancies, though some emotion-focused interventions were somewhat effective in reducing anxiety. Reported effect sizes ranged from small to medium for both anxiety and depressive symptoms. Underlying mechanisms behind these differences are unclear, however a recent longitudinal study among healthy adolescents exposed to stressful life events found those who used problem-focused coping were less likely to experience depressive symptoms compared to those using emotion-focused coping (Pelekanakis et al., 2022). While coping skill interventions may not reduce anxiety or depressive symptoms in all persons with hematologic cancer, they may be effective for some. Our findings were less clear for intervention duration and delivery, though interventions lasting more than 8 weeks appeared to be more effective. In addition, differences among disease subtypes or treatment stage were not apparent, in part due to the heterogeneity of participants in our included studies. This review did find that problem-focused interventions, such as CBT, were more effective at anxiety and depressive symptom reduction than emotion-focused interventions alone.

A recent systematic review with meta-analysis found patients with early-stage breast cancer benefit from CBT in reducing anxiety symptoms, but the effectiveness of CBT on depressive symptoms was unclear (Sun et al., 2019). In a systematic review with meta-analysis of coping skills training among mostly patients with solid tumor cancers, coping interventions were found to significantly reduce both anxiety and depressive symptoms, though effects were small (Buffart et al., 2020). The Buffart et al. review of coping skills training aligns with our results indicating some significant reduction or small to medium effects among anxiety and depressive symptoms among persons with hematologic malignancies (2020). We found in-person sessions to be more effective for anxiety symptoms, with less clarity around depressive symptoms, however, the Buffart et al. review found that in-person sessions were effective in reducing both anxiety and depressive symptoms in the solid tumor cancer population (2020). The in person- experience may be more personalized and / or therapeutic to patients than remote interventions, however, further research is needed to determine optimal settings for coping skill interventions.

It is critical to address anxiety and depressive symptoms in persons with hematologic malignancies throughout and after treatment: survivors of hematologic malignancies remain at an elevated risk for experiencing depressive symptoms even twenty years after diagnosis (Kuba et al., 2019). A benefit of coping skill interventions is that they can be delivered in tandem with medications to reduce anxiety or depression. Notably, some anti-depressants can interact with chemotherapy and may not be an option for certain patients due to drug interactions (Smith, 2015). Of note, the Oncology Nursing Society recommends CBT, mindfulness stress reduction, music therapy, psychoeducation, and yoga to reduce anxiety, and antidepressants, CBT, behavioral health care, mindfulness, and psychoeducation to reduce depressive symptoms in their general guidelines for oncology patients (2019a, 2019b). Novel interventions are needed given the small to medium effect sizes of current coping and other interventions that are recommended to reduce depressive and anxiety symptoms among persons with cancer.

5.1. Limitations

This review has the following notable limitations. We were unable to distinguish between depressive and anxiety symptoms and a clinical diagnosis of depression or anxiety, which may have influenced the overall effect of the coping skill interventions. Furthermore, the heterogeneity of the types of coping interventions, method of delivery, and type of evaluation created a challenge for synthesizing the study results. Also, some of the included studies did not include theoretical frameworks and were of lower quality evidence: no control group or randomization as well as other risks of bias. Participants tended to be white and college educated for studies that reported patient characteristics, similar to our other systematic review in this population (Andersen et al., 2022). Moreover, our findings may not be generalizable to non-white persons and those with lower educational attainment due to underrepresentation of these groups in the final sample of the studies. Unfortunately, disparities in treatment for hematologic cancers exist among non-white, lower socioeconomic status, and Medicare beneficiaries who are less likely to receive HSCT (Vardell et al., 2019) and may be diagnosed at later stages (Becnel et al., 2017). Despite limitations, this systematic review presents critical findings to inform targeted future research and current psychosocial interventions for persons with hematologic malignancies.

Coping skills should be evaluated throughout the illness trajectory, both before and after the intervention to determine whether the outcomes stem from the improvement of coping skills or therapeutic aspects of the intervention. Future interventions evaluating the effects of coping skill and pharmaceutical interventions on anxiety and depressive symptom outcomes are needed in this population. In addition, the timing of the intervention can be investigated to determine the optimal time to introduce coping skills to the patient. Attrition of these studies indicates that these interventions may be burdensome and that patients experience high symptom burden leading to attrition. Further research is needed to find effective and feasible interventions to reduce anxiety and depressive symptoms among persons with hematologic cancer and to identify from patients what they find to be most burdensome about the different types of coping skill interventions. Future research should emphasize inclusion of diverse participants by age, sex, and social determinants of health such as race, ethnicity, gender, socioeconomic status, and educational attainment. These factors may modify the relationship between coping intervention and patient outcomes (Brouwer and Menard, 2020). Persons with hematologic malignancies experiencing anxiety and depressive symptoms may require novel interventions in order to cope with and manage their symptoms.

5.2. Practice Implications

Unfortunately, patients with hematologic malignancies often have inaccurate perceptions of their prognosis, with El-Jawhari et al. finding 71.7% of participants had an inaccurate perception of their prognosis compared to their oncologist (2014). Patients that did have a more accurate understanding of their prognosis reported worsening depressive symptoms, higher rates of depression, and poorer quality of life (El-Jawahri et al., 2014). Cancer supportive care programs should consider including problem-focused coping interventions to support patients and their caregivers as they navigate the uncertainty of a hematologic malignancy and discuss goals of care. Clinicians must be aware of the potential for heightened anxiety or depressive symptoms, and initiate screening. If a patient is flagged as having symptoms, clinicians should discuss appropriate interventions with patients and their families and ascertain their preferences and goals for their care trajectory.

6. Conclusion

Our systematic review found that coping skill interventions can reduce anxiety among persons with hematologic malignancies, although effect sizes were small to medium. Persons with depressive symptoms were found to benefit from problem-focused coping skill interventions, however, this review found general coping skill interventions did not reduce depressive symptoms. Notably, problem-focused interventions were more effective in reducing anxiety and depressive symptoms than interventions that were emotion-focused only. Persons with hematologic cancers can suffer from heightened levels of anxiety and depression that affect their overall well-being and quality of life. Future research should focus on the most effective types of coping skill interventions to best meet the needs of this cancer population; and, to provide them with the most timely and useful resources to support their emotional health.