Regular Article

Psychother Psychosom 2010;79:3947 DOI: 10.1159/000259416

Received: December 28, 2007 Accepted after revision: April 12, 2009 Published online: November 18, 2009

Effects of Supportive-Expressive Group Therapy in Breast Cancer Patients with Affective Disorders: A Pilot Study
Luigi Grassi ac Silvana Sabato a, b Elena Rossi a, b Luciana Marmai c Bruno Biancosino c
Department of Behavior and Communication, Section of Psychiatry, University of Ferrara, b Department of Neuroscience/Rehabilitation and Mental Health, University Hospital S. Anna, and c Department of Mental Health, Ferrara Health Agency, Ferrara, Italy
a

Key Words Psychological intervention Group therapy Affective disorders Cancer

Abstract Background: So far, no study has tested supportive-expressive group therapy (SEGT) in cancer patients with an established psychiatric diagnosis. The aim of this 6-month followup study was to evaluate breast cancer patients with an ICD-10 diagnosis of affective syndromes participating in SEGT and a group of breast cancer patients with no ICD-10 diagnosis. Methods: A total of 214 patients were examined in the screening phase (T0) using the ICD-10, the Brief Symptom Inventory (BSI), the Mini-Mental Adjustment-to-Cancer Scale (Mini-MAC), the Multidimensional Scale of Perceived Social Support, the Openness Scale and the Cancer Worries Inventory (CWI). Those with an ICD-10 diagnosis of affective syndromes received 1624 sessions of SEGT (90-min sessions, once a week), while those with no ICD-10 diagnosis were followed up. A second assessment for both samples took place 6 months later (T1). Results: Seventy-eight (36.4%) patients were positive for an ICD-10 diagnosis of affective syndromes at T0, while 127 (59.4%) did not meet any ICD-10 diagnosis. Among the former, 54 patients participat-

ed in the SEGT. At T1, significant differences were observed in all the dimensions of the BSI, hopelessness and anxious preoccupation subscales of the Mini-MAC, the Openness Scale and the CWI. No variable at T0 was a predictor of BSI distress as measured at T1. Among those with no ICD-10 diagnosis at T0, 8.2% were positive for affective disorders at the 6-month follow-up. Conclusions: This study suggested that SEGT is effective for breast cancer patients with affective disorders, and indicates the need for prospective evaluations in order to identify those who may develop psychopathology over time. Copyright 2009 S. Karger AG, Basel

Introduction

Breast cancer is one of the most common cancers among women, and it is the second leading cause of cancer deaths (after lung cancer). According to the World Health Organization, more than 1.2 million people are diagnosed with breast cancer worldwide and over 500,000 die from the disease each year [1].

The authors declare that there is no conflict of interest.

2009 S. Karger AG, Basel 00333190/10/07910039$26.00/0 Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/pps

Luigi Grassi, MD Clinica Psichiatrica Universit di Ferrara Corso Giovecca 203 IT44100 Ferrara (Italy) Tel. +39 0532 236 809, Fax +39 0532 212 240, E-Mail luigi.grassi@unife.it

Several emotional, interpersonal and social consequences have been reported in breast cancer patients, 25 35% of whom show psychosocial morbidity, especially depressive and anxiety disorders [2, 3]. These disorders are associated with a worsening in quality of life [4], a higher prevalence of pain [5, 6], abnormal illness behavior and problems in interpersonal relationships (including the doctor-patient relationship) [7], a higher rate of emotional burden for the family [8], a reduced efficacy of chemotherapeutic protocols [9] and possibly a higher risk of recurrence and poorer prognosis [10]. Thus, implementation of psychosocial intervention has been repeatedly highlighted as a necessary clinical requirement in cancer settings [1114]. Among the several approaches, group psychotherapy has become popular in oncology for its good cost-effectiveness ratio [15, 16] and positive effects on psychological and biological variables [17]. Supportive-expressive group therapy (SEGT), a cognitive existentially oriented psychotherapy, has been recommended as a feasible and effective model for breast cancer patients. In fact, in both open studies and randomized clinical trials [1820], SEGT has been shown to reduce psychological stress symptoms, improve coping mechanisms and reduce pain, both in advanced and nonadvanced breast cancer patients. However, some studies have indicated that only cancer patients with more marked psychological stress symptoms benefit from group psychotherapy with respect to those with mild or no psychological stress symptoms, who tend to show low or no improvement in their psychological status after treatment [2123]. SEGT, in a study by Kissane et al. [24] on stage IV breast cancer patients, reduced hopelesshelplessness and trauma symptoms, improved social functioning and, for a minority of patients with a DSMIV depressive disorder, ameliorated and prevented new episodes of depression. In a different study on early-stage breast cancer patients, Classen et al. [25] demonstrated that a brief SEGT intervention (12 weeks) did not show any effect in terms of improvements in emotional symptoms in comparison with no intervention, except for those with high distress symptoms. It can be concluded that group therapy cannot be considered as an intervention to be proposed routinely in clinical settings, particularly if patients have not shown significant levels of distress. Thus, a screening phase has been recommended in order to identify cancer patients with comorbid psychiatric disorders and refer only these patients to psychotherapy [26]. On the basis of these considerations and the lack of specific data in this area, the main aim of this study was
40
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to pre-/experimentally evaluate the effects of the SEGT in breast cancer patients with an established ICD-10 diagnosis of affective disorders.
Subjects and Methods
Subjects The population consisted of patients who had received a diagnosis of breast cancer within the past year, who had non-metastatic disease, and had a score of 80 or above on the Karnofsky Performance Status scale [27], indicating a good level of functioning. All the patients were screened during one of their routine follow-up visits at the Oncology Outpatient Clinic, S. Anna University Hospital, Ferrara, Italy. All the subjects gave written informed consent for participation as required by the Institutional Review Board of the hospital. Psychiatric and psychosocial assessment was conducted at the screening phase (T0) and 6 months later (T1). A group of 214 patients participated in the screening phase. Of these, 127 (59.4%) did not receive an ICD-10 psychiatric diagnosis and 87 (40.6%) met the criteria for a psychiatric diagnosis. Those with diagnoses other than affective syndromes (cognitive disorders, n = 3; personality disorders, n = 4; psychotic syndromes, n = 2) were excluded from the study. Affective syndrome (n = 78; 36.4% of the total sample) diagnoses consisted of adjustment syndromes (n = 48; 22.4% of the total sample), major depression (n = 16; 7.4%), other diagnoses (n = 9; 4.2%, mainly minor depression and mixed anxiety-depressive states) and dysthymia (n = 5; 2.3%). Of patients with affective syndromes, 4 patients with major depression (5.1% of this sample) were already receiving treatment from the Psycho-Oncology Service, University of Ferrara and Mental Health Department, and 9 (11.5% of this sample) were referred to individual therapy for clinically relevant disturbances (e.g. suicidal ideation, severe psychopathological symptoms). Of the remaining 65 women, 5 (6.4% of this sample) refused to participate in the groups. Procedure At T0, the subjects were administered the Composite International Diagnostic Interview (CIDI) in order to make a psychiatric diagnosis according to the ICD-10 (CIDI) [28]. Furthermore, the following measures were administered: (1) Brief Symptom Inventory (BSI) [29], a 53-item questionnaire measuring symptoms of psychological stress in 9 primary dimensions (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism) and a global severity index (GSI). (2) Mini-Mental Adjustment to Cancer Scale (Mini-MAC) [30], a 29-item scale evaluating how the person is coping with cancer, namely fighting spirit (the tendency to confront and actively face the illness), hopelessness (the tendency to adopt a pessimistic attitude about the illness), anxious preoccupation (feelings of anxiety and tension concerning the illness), fatalism (resigned and fatalistic attitudes about the illness) and avoidance (tendency to avoid confrontation with illness). (3) Multidimensional Scale of Perceived Social Support [31], a 12-item questionnaire measuring support from family, friends

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Table 1. Comparison of sociodemographic and clinical variables between ICD-10 cases (affective syndromes) and non-cases
Patients without Patients with ICD-10 diagnosis ICD-10 diagnosis (n = 127) (n = 78)

Age, years Education, years Marital status Married Separated/divorced Never married Widowed Job Employed Housewife Retired Estrogen receptor Positive Negative Surgery Mastectomy Quadrantectomy Lumpectomy Treatment Chemotherapy Radiotherapy Hormone therapy

51.3810.7 8.9184.67

56.189.8 9.3784.49

t = 3.2 p = 0.002 t = 0.7 p = 0.48 2 = 0.25 p=1

94 (74) 8 (6.2) 12 (9.4) 13 (10.2) 54 (42.5) 35 (27.5) 38 (29.9) 82 (64.6) 45 (35.4) 42 (33.1) 74 (58.2) 11 (8.7) 86 (66.9) 62 (48.8) 51 (40.1)

56 (71.8) 6 (7.6) 7 (8.9) 9 (11.5) 32 (41.1) 19 (24.3) 27 (34.6) 49 (62.9) 29 (37.1) 30 (38.4) 44 (56.4) 4 (5.1) 54 (69.2) 37 (47.4) 32 (41)

2 = 0.69 p = 0.70

2 = 0.1 p = 0.91 2 = 1.25 p = 0.53

2 = 0.04 p = 0.98

Figures in parentheses are percentages.

Intervention The SEGT consisted of 90-min weekly sessions with 68 patients per group. Each group was led by a conductor (1 psychiatrist) and a co-conductor (1 psychologist), of a total of 4 conductors involved in the study. Each of them had clinical experience in group therapy and one (L.G.), who was trained in SEGT, trained the other therapists according to the guidelines developed by Classen et al. [37] and the research-based SEGT manual, translated into Italian [38]. The SEGT model, as a semi-structured intervention, has the main goals of building bonds, expressing emotions, detoxifying death and dying, redefining lifes priorities, fortifying families and friends, enhancing doctor-patient relationships and improving coping. The role of the therapist was to create a high level of group cohesion and a supportive environment where participants were encouraged to confront their problems, strengthen their relationships, and find enhanced meaning in their lives [39]. Some themes, from among those indicated in the SEGT model, were focused upon with particular emphasis in this study, including: (1) facilitating the expression of depressive feelings (e.g. despair, hopelessness-helplessness, guilt); (2) confronting fears (e.g. death and dying, being burden for caregivers, fears of abandonment and stigmatization); (3) building new bonds of social support in order to counteract loneliness and to receive help; (4) learning and finding more effective and active coping strategies. Each group was videotaped, and analysis of the content of each session was performed in order to evaluate the themes that were not adequately explored and to identify difficult areas to be examined in the next session. A more detailed description of this qualitative analysis is reported elsewhere [40]. The length of the treatment was modified in comparison with the brief intervention (12 sessions) proposed by the authors who developed the treatment, extending the duration to a maximum of 6 months (24 sessions). Eight groups were run over the period of the study, with 68 participants per group (mean 8 SD: 6.75 8 0.9; median: 7). The number of sessions varied from a minimum of 16 to a maximum of 24 (mean: 21.21 8 2.98; median: 20.5). Statistical Analysis Statistical analysis was performed by using SPSS 10.1. Students t test (independent and paired t test), the 2 test and hierarchical regression analysis were used when appropriate. Statistical significance was set at p ! 0.05.

and significant others, which together yield a total support score. (4) Openness Scale [32], a 9-item questionnaire measuring the difficulty (lower scores) in speaking about cancer with family members. (5) A reduced version of the Cancer Worries Inventory (CWI) [33], a 13-item questionnaire investigating the intensity of problems and concerns caused by cancer (e.g. being a burden for my family, the effects of surgery, sexual life, the future). Those who had an ICD-10 diagnosis of affective syndromes were asked to take part in the SEGT. All the instruments were used in their validated Italian forms [3436]. Both patients with a diagnosis of affective disorders who participated in the SEGT and those who did not report any ICD-10 diagnosis at T0 (n = 127) were followed up. At 6 months, both groups were interviewed again using the CIDI and were administered the same questionnaires used at T0. Both assessments were performed by a researcher who did not participate in the running of the groups and did not know (at T1) who had received SEGT and who had received it.

Results

Differences between Patients with and without ICD-10 Diagnosis Sociodemographic, clinical and psychosocial characteristics of patients without an ICD-10 psychiatric diagnosis and patients with affective syndromes are presented in tables 1 and 2. The former group differed from the latter in being younger (t = 3.21, p = 0.002). No differences were found with regard to marital status, education, employment, stage (local and locoregional), type of surgery and adjuvant treatment (chemotherapy, hormone therapy, radiotherapy) and estrogen receptor characteristics.
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Supportive Expressive Therapy and Breast Cancer

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Table 2. Comparison of psychosocial

variables between patients without ICD-10 diagnosis and those with ICD-10 diagnosis (affective syndromes) BSI-GSI Mini-MAC Fighting spirit Hopelessness Anxious preoccupation Fatalism Avoidance Social support total Openness Concerns

Patients without ICD-10 diagnosis (n = 127) 0.3580.21 12.1882.67 11.0284.15 19.0386.31 14.2384.56 10.9883.12 75.82815.98 18.7485.72 6.9485.71

Patients with ICD-10 diagnosis (n = 78) 1.0680.77 11.3482.72 15.5986.79 23.1586.01 14.4783.89 11.1883.88 62.76822.13 14.6188.01 16.4488.92

9.8 2.17 5.98 4.62 0.38 0.4 4.89 4.29 9.3

0.001 0.03 0.001 0.001 0.70 0.68 0.001 0.001 0.001

Furthermore, no difference between the groups was found regarding time since diagnosis (5.4 8 3.8 vs. 6.3 8 4.6 months; t = 1.5, p = 0.13). As expected, patients with affective syndromes reported higher scores on the BSI-GSI, Mini-MAC anxious preoccupation and hopelessness factors, and CWI total, while lower scores were reported on Mini-MAC fighting spirit factor, Multidimensional Scale of Perceived Social Support total and Openness Scale. SEGT participants (n = 60) differed from those with severer disorders and those excluded from SEGT (both those already followed by the Mental Health Services or those who were referred for individual therapy) in reporting lower scores on the GSI, Mini-MAC hopelessness and anxious preoccupation. Of those who started the groups, 6/60 patients (10%) had dropped out by the third session. Thus, data were available for 54 subjects who completed the SEGT (41 with a diagnosis of adjustment disorder with depressed mood, 4 with a diagnosis of major depression mild type, 7 with a diagnosis of minor depression and mixed anxiety-depressive states, 2 with a diagnosis of dysthymia) and who also participated in the 6-month follow-up evaluation. No difference was found between patients without an ICD-10 diagnosis (n = 127), refusers (n = 5), drop-out patients (n = 6) and those who completed the SEGT (n = 54) with regard to sociodemographic and medical variables, including time since diagnosis (p = 0.23). Among the 127 patients who had no ICD-10 diagnosis at T0, 22 (17.3%) were not available at the 6-month followup evaluation, while 105 (82.7%) took part. Patients who dropped out did not differ from the total group.

Differences between T0 and T1 among Patients with Affective Syndromes At the end of the SEGT, the patients reported significant improvements in several BSI dimensions, specifically anxiety (t = 5.24, p ! 0.001), depression (t = 5.13, p ! 0.001), phobic anxiety (t = 5.84, p ! 0.001), interpersonal sensitivity (t = 3.18, p ! 0.01), hostility (t = 3.5, p ! 0.01), paranoia (t = 2.51, p ! 0.01), psychoticism (t = 3.08, p ! 0.01) and the general stress index (t = 4.73, p = 0.001) (table 3). Furthermore, 2 core maladaptive coping strategies, namely hopelessness (t = 2.83, p ! 0.01) and anxious preoccupation (t = 3.02, p ! 0.01), as well as the intensity of concerns (t = 3.27, p ! 0.01) significantly decreased after the SEGT, whereas the ability to talk openly about illness within the family context improved (t = 2.37, p = 0.02). No difference was found with regard to the social support dimensions. In order to explore if changes in psychological distress, as measured by the BSI, in patients receiving SEGT were associated with changes in the remaining variables, the patients who clinically improved at T1 were compared with those who marginally improved or did not improve at all at T1. Clinical improvement was based on the BSI scoring system where the cut-off T score of 62 on the GSI on 2 subscales was employed to discriminate between patients with significant clinical distress and those with no distress [29]. With respect to patients with non-clinical improvement (T score 162; n = 9, 16.6%), those who clinically improved (T score !62; n = 45, 83.3%) showed lower scores on the Mini-MAC hopelessness (15.5 8 3.87 vs. 11.08 8 3.23, t = 3.62, p = 0.001), anxious preoccupation (23.75 8 6.13 vs. 18.05 8 5.43; t = 2.81, p = 0.01), CWI (8.66 8 5.04 vs. 13.56 8 9.3; t = 2.22, p = 0.02), and highGrassi /Sabato /Rossi /Marmai /Biancosino

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Table 3. Mean scores (T0 and T1) on the psychosocial measures among cases participating in the SEGT and non-cases at the

follow-up assessment Group therapy (n = 54) baseline BSI Somatization Anxiety Depression Phobic anxiety Obsessive Interpersonal sensitivity Hostility Paranoia Psychoticism Global stress Mini-MAC Fighting spirit Hopelessness Fatalism Anxious preoccupation Avoidance MSPSS Family Friends Others Total Openness Scale Cancer Worries Inventory 0.9880.71 1.2380.79 1.3280.98 0.7380.53 1.0280.79 0.9880.97 0.6380.45 0.6880.62 0.6880.66 0.9780.61 11.4882.67 14.3986.81 14.7383.76 22.1186.89 10.6183.87 22.4587.62 21.8688.84 24.9286.22 70.61819.23 15.1485.23 14.1589.75 follow-up 0.7780.45 0.5780.48 0.5280.59 0.2280.36 0.7880.81 0.5180.49 0.3480.41 0.4180.49 0.3580.43 0.5180.37 11.7682.97 11.4583.42 14.1282.89 18.4485.67 11.0283.74 24.8687.43 21.9887.54 25.2385.67 72.58816.34 17.4584.89 9.1785.43 t 1.86 5.24 5.13 5.84 1.55 3.18 3.5 2.51 3.08 4.73 0.51 2.83 0.9 3.02 0.56 1.66 0.76 0.27 0.57 2.37 3.27 p 0.07 0.001 0.001 0.001 0.12 0.002 0.002 0.014 0.003 0.001 0.61 0.005 0.45 0.003 0.57 0.09 0.94 0.78 0.56 0.02 0.001 Patients without ICD-10 diagnosis (n = 105) baseline 0.6580.46 0.7980.54 0.6080.61 0.2380.37 0.6380.68 0.4280.65 0.4480.58 0.3880.52 0.2880.34 0.5180.47 11.7682.64 11.5885.34 13.8484.57 20.3186.45 11.8483.84 24.4386.87 19.7689.56 25.76810.87 69.45817.61 19.2487.45 6.7185.23 follow-up 0.6880.44 0.5180.53 0.5380.49 0.2280.31 0.5280.47 0.2380.46 0.3880.67 0.3180.39 0.2580.37 0.4180.32 11.8782.43 11.9684.76 14.3783.58 19.3885.78 11.2783.64 24.3286.88 19.71810.43 24.3187.76 68.65819.24 18.7186.54 8.1386.12 t 0.48 3.79 0.91 0.12 1.36 2.44 0.69 1.1 0.61 1.80 0.31 0.54 0.93 1.10 1.12 0.03 0.03 1.11 0.13 0.54 1.81 p 0.63 0.001 0.36 0.83 0.17 0.01 0.48 0.27 0.54 0.07 0.75 0.58 0.35 0.27 0.28 0.97 0.97 0.26 0.75 0.58 0.07

MSPSS = Multidimensional Scale of Perceived Social Support.

er scores on the Openness Scale (17.29 8 5.32 vs. 13.25 8 4.42; t = 2.13, p = 0.03). The improvement in the psychosocial dimensions, as measured by psychometric instruments, was confirmed by the reduction in ICD-10 psychiatric diagnoses (2 = 79.71; d.f. = 1, p = 0.001), which were still present in a small group of patients (n = 7, 12.9%), although they showed a response to treatment in terms of reduced intensity of symptoms and dysfunctional patterns (mild to moderate response). Hierarchical multiple regression analysis was then performed in order to explore if some of the psychosocial variables measured at T0 predicted changes in psychological distress at T1, after controlling for GSI score at T0. More specifically, GSI scores at T0 were included in the first block. Next, predictors measured at T0 (Mini-MAC scales, Multidimensional Scale of Perceived Social Support total, Openness Scale and CWI) were entered simultaneously in the second block. Results indicated that in
Supportive Expressive Therapy and Breast Cancer

model 1 GSI at T0 alone accounted for 5.9% of the variance in GSI at T1, resulting in an R 2 value of 0.059, which was not statistically significant (F change = 1.88, p 1 0.05; ANOVA F ratio = 1.88, p = 0.18). In model 2, the predictors accounted for 21% of the variance after controlling for GSI at T0, resulting in an R 2 value of 0.27 (R 2 change = 0.21), which also was not statistically significant (F change = 0.80, p 1 0.05; ANOVA F ratio = 0.91, p = 0.52). Coefficients of the models 1 and 2 (B, , t and p) are given in table 4. Follow-Up of Patients without an ICD-10 Diagnosis Among those who did not show any ICD-10 diagnosis at T0, certain dimensions also improved at T1, namely anxiety (t = 3.79, p = 0.001) and interpersonal sensitivity (t = 2.44, p = 0.01). Nine patients (8.6%) developed symptoms meeting the criteria for affective disorders at the 6month follow-up (2 = 7.43, d.f. = 1, p = 0.006) and were thus referred for treatment (4 patients with a diagnosis of
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Table 4. Hierarchical regression and values of the single variables in model 1 and model 2

Unstandardized coefficients B Model 1 (Constant) 0.358 GSI T0 0.109 Model 2 (Constant) 0.294 GSI T0 0.020 MSPSS total 0.005 Fighting spirit 0.010 Hopelessness 0.004 Fatalism 0.020 Anxious preoccupation 0.007 Avoidance 0.019 Openness Scale 0.006 CWI 0.005 SE 0.075 0.079 0.412 0.141 0.004 0.022 0.012 0.018 0.011 0.014 0.008 0.008

Standardized coefficients

95% CI for B lower upper 0.510 0.271 1.148 0.312 0.002 0.057 0.020 0.057 0.030 0.011 0.023 0.021

0.243 0.045 0.396 0.112 0.100 0.294 0.175 0.313 0.225 0.187

4.791 1.374 0.713 0.142 1.406 0.459 0.315 1.136 0.634 1.325 0.818 0.575

0.000 0.180 0.483 0.888 0.174 0.651 0.756 0.268 0.533 0.199 0.422 0.571

0.205 0.053 0.561 0.272 0.012 0.036 0.028 0.017 0.016 0.049 0.010 0.012

MSPSS = Multidimensional Scale of Perceived Social Support.

adjustment disorder, 3 patients with a diagnosis of major depression, 3 patients with a diagnosis of anxiety disorders).

Discussion

To our knowledge, this is the first study specifically applying SEGT in breast cancer patients with an established ICD-10 diagnosis of affective syndromes. A first result of the study was that in comparison to a sample of well-adjusted cancer patients without any ICD10 diagnosis, those with affective syndromes who participated in SEGT reported a significant improvement in several dimensions of psychosocial morbidity, such as emotional symptom scores (e.g. depression, anxiety, hostility) and maladaptive coping styles (i.e. hopelessness and anxious preoccupation). In our study, after controlling for psychological stress symptoms at the baseline, the coping mechanisms, social support and illness-related worries did not seem to influence the level of psychological distress at follow-up, suggesting a positive effect of SEGT. This result is in line with studies showing that SEGT can improve coping mechanisms and helps adjustment in cancer patients [19, 20] as well as other medical illness [41], especially in those reporting mood and anxiety symptoms at the baseline. The particular significance
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of the present study was that the sample was selected according to the presence of an ICD-10 diagnosis of adjustment disorders, mild major depression and minor depressive or depressive-anxiety syndromes, stressing the efficacy of the SEGT. Future randomized clinical trials may investigate the efficacy of SEGT in patients with severer psychiatric disorders, as already done with other kinds of psychotherapy in patients affected by life-threatening illness, such as HIV infection [42]. A second interesting result of the study is the improvement in the ability to speak openly with family members about cancer. This seems to be particularly important in Italy, where the tendency to hide emotions related to cancer, and sometimes the diagnosis itself, is still a problem [43, 44]. Patients receiving and benefiting from SEGT found that expressing feelings and their own needs was a way to obtain more authentic and practical support, with positive consequences for their psychological status, i.e. a reduction in anxious preoccupation and concerns about cancer. A third aspect regards the patients who had no ICD-10 diagnosis at the baseline. In fact, almost 10% developed psychopathological symptoms across time. This result confirms findings from other research indicating that about 2025% of well-adjusted patients at the time of the diagnosis develop affective disorders within the following year [45]. As reported by some authors [46], life events
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(including cancer-related events), changes in support received from the interpersonal domains, and personality variables may be risk factors for psychopathology over time. Because of the small size of the sample of patients whose psychological conditions worsened over the 6month follow-up in this study, no statistical evaluation was carried out and thus no data are available as far as the possible psychosocial and/or biological determinant factors. Our data however support the notion that careful attention and the prospective evaluation of cancer patients are necessary in order to avoid the possibility that those who seem to react positively to the diagnosis of cancer and its treatment may develop emotional disorders over time. Significant limitations of the study should be considered. The absence of a randomized approach prevents us from ruling out spontaneous regression of symptoms, changes in support from interpersonal ties, and variability in the medical course of the disease. A randomized replication of this study is necessary to confirm the data presented here. A second issue regards the small size of the group in comparison with other multicenter studies. It has to be pointed out, however, that these studies did not select patients according to the presence or absence of a psychiatric diagnosis, and that replication on larger samples of cancer patients with a comorbid psychiatric disorder is therefore necessary. This is especially important in relation to the larger number of patients with an adjustment disorder in our sample with respect to the smaller sample of patients with a major depressive episode. Third, the absence of patients in an advanced stage of illness does not permit generalization the effects of the SEGT, as indicated by other authors [18, 20, 21]. A fourth caveat regards the absence of analysis of the influence of SEGT attendance, which could have explained a dose effect in those who participated more. However, in examining adherence to the treatment protocol, Classen et al. [20] did not find any correlation between number of sessions attended and reduction in mood disturbance. A further aspect to be discussed is that the experience of the therapists was not specifically taken into consideration in this non-randomized naturalistic study. With respect to this, Kissane et al. [47] showed that experienced therapists reached better results than less experienced ones. However, in this study, therapists included a variety of professions, such as psychiatrists, psychologists, occupational therapists, social workers and oncology nurses. Furthermore, breast cancer patients participating in their study consisted of mixed samples, most of whom (66%) had no psychiatric diagnosis and only 1/3 were affected
Supportive Expressive Therapy and Breast Cancer

by a depressive disorder. On the other hand, Classen et al. [25] have recently shown that therapist training and psychotherapy experience were not associated with a treatment effect. Further research is needed to evaluate this aspect. Lastly, the use of the ICD-10 system in this study may have some limitations in terms of identification of patients presenting psychosocial morbidity. In fact, the ICD-10 was not able to recognize significant psychosocial dimensions that were identified by the Diagnostic Criteria for Psychosomatic Research (DCPR), e.g. health anxiety, demoralization, irritable mood [48]. On the other hand, DSM-IV did not work better, with 58% of cancer patients not meeting a formal DSM-IV psychiatric diagnosis, whilst having at least 1 syndrome according to the DCPR [49]. Furthermore, a DCPR diagnosis was associated with maladaptive coping styles, poor quality of life and a high level of cancer-related worries [50]. Studies are needed that evaluate the effects of group intervention on psychological disorders, as assessed by both standard nosographic systems and the DCPR, given the negative consequences of DCPR diagnoses on quality of life and other measures of health [5154]. The analysis of the effects of SEGT on stress-related biological variables was also not examined here. Some recent data indicated that SEGT may improve the biological concomitants of stress (e.g. cortisol level) among cancer patients [53, 54]. Future research should examine this area among depressed cancer patients. In spite of all these limitations, the results presented here seem to suggest that SEGT is a useful intervention in breast cancer patients with an ICD-10 diagnosis of affective syndrome. Since SEGT is a manualized treatment that can be taught to health professionals, the method can be easily implemented in clinical services. Furthermore, the development of group psychotherapy programs to be applied specifically in a selected population that is more in need, rather than routinely, also has clinical implications in an era of economic constraints and a need for rationalization of resources in health services.

Acknowledgments
The study has been supported by the University of Ferrara (Research Project Local Funds 20042007) and the Fondazione Cassa di Risparmio di Ferrara. The authors are indebted to all the patients who participated in the groups, the nurse staff for cooperation in this study, and Paul Packer for the revision of the manuscript.

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