Many survivors of stem cell transplants experience long-term medical and psychological adjustment problems, including symptoms of posttraumatic stress disorder (PTSD). A recent study conducted by investigators from Mount Sinai School of Medicine, Memorial Sloan-Kettering Cancer Center, and Hackensack University Medical Center suggests that a course of cognitive behavior therapy — even if conducted by telephone — can help reduce the symptoms of PTSD in such patients.
Posttraumatic stress disorder is an anxiety disorder that may develop after a person witnesses or experiences a traumatic event. It is commonly associated with combat veterans and survivors of sexual assault. However more recently it has been recognized that cancer survivors — including those who have undergone stem cell transplants — can also experience reactions to triggers that remind them of their treatment.
“Noises or smells can make patients feel anxious, nauseated, or distressed,” says Katherine DuHamel, PhD, a health psychologist at Memorial Sloan-Kettering and co-principal investigator for the study. “This can occur, for example, when they have to go to the hospital for follow-up visits or undergo imaging studies to monitor for a possible recurrence of cancer. These symptoms have been documented before, but it was not until 1994, when the diagnostic criteria changed, that people with illness-related trauma could qualify for a diagnosis of PTSD.”
Cognitive behavior therapy is a form of psychotherapy that combines cognitive therapy — a type of talk therapy that seeks to identify and help change self-destructive thought patterns — with behavior therapy, an approach that assists people to identify unhealthy beliefs and behaviors and replace them with positive ones. Cognitive behavior therapy has been shown to be effective in other PTSD populations and also for cancer-related adjustment problems such as anxiety and depression. The current study, published in the August 2010 issue of the Journal of Clinical Oncology [PubMed Abstract], details the first cognitive therapy program that specifically addresses PTSD for stem cell transplant survivors.
An Unexpected, But Treatable Condition
In 2000, Dr. DuHamel and colleagues published a report of a 40-year-old male survivor of a bone marrow transplant. Nearly three years after the procedure, he was suffering disturbing memories along with sweats and chills triggered by cues such as the color of a medicine he took during treatment. He was subsequently diagnosed with PTSD.
“This patient really thought he was losing it and, at that time, there was not much awareness out there that a cancer survivor could have PTSD,” Dr. DuHamel recalls. “Many people didn't expect or recognize these symptoms, nor did they know that there was treatment for them.”
Dr. DuHamel goes on to explain that after receiving cognitive behavior therapy developed for treating PTSD symptoms post-transplantation, the man experienced fewer PTSD symptoms, was able to return to work, and regained much of his pre-transplant quality of life. This occurred despite ongoing medical problems and continued exposure to trauma-related triggers.
While this patient received therapy in person, Dr. DuHamel and her colleagues theorized that offering therapy by telephone might be equally successful. “After stem cell transplants, some patients may have physical impairments that limit their ability to receive in-person treatment — for instance, difficulty with mobility,” she says. “They also may have to travel great distances to get to an appropriate treatment center.”
The questions that needed to be answered were, would cognitive behavior therapy be as effective when conducted by telephone? and did Dr. DuHamel's case study and anecdotal evidence of cognitive behavior therapy successes reflect the responses that might be expected in patients who had survived stem cell transplants?
Testing the Therapy
To answer these and other questions, Dr. DuHamel, William H. Redd, PhD, the study's principal investigator and a professor of Oncological Sciences at Mount Sinai School of Medicine, and colleagues at Hackensack University Medical Center studied 89 stem cell transplant survivors recruited from Memorial Sloan-Kettering and the other two institutions. All study participants were suffering from PTSD symptoms and had had a transplant one to three years before they were enrolled in the study. Each patient was randomly assigned to receive either telephone-based cognitive behavior therapy or standard follow-up assessments without therapy.
The regimen of telephone-administered cognitive behavior therapy consisted of ten sessions delivered over a course of ten to 15 weeks. It included education regarding illness-related PTSD symptoms, self-monitoring of attitudes, guided exposure to cues associated with symptoms, communication skills to improve social support, and relaxation training.
During assessments at six, nine, and 12 months, significant differences appeared between the two groups. At 12 months, those in the standard follow-up assessment group were about 15 times more likely to be diagnosed with PTSD than those in the treatment group. The researchers also saw significant overall reductions in PTSD symptoms, as well as in general distress and depression, for those undergoing cognitive behavior therapy compared to those receiving standard follow-up. In fact, depression scores dropped to near zero in the treatment group.
Telephone Treatment of Tomorrow
The study results are promising, but Dr. DuHamel notes that more research is needed, including comparing telephone-administered cognitive behavior therapy to other treatments for illness-related PTSD, as well as to cognitive behavior therapy for more-traditional triggers of PTSD, such as exposure to combat.
Given the various techniques and interventions used in cognitive behavior therapy, researchers don't yet know which piece may be the “active ingredient.” Dr. DuHamel explains that further investigations may reveal that one technique should be emphasized over others to achieve maximum effectiveness.
But even as research continues, “it's important to increase awareness among oncologists and other healthcare professionals about PTSD symptoms in their patients,” says Dr. DuHamel. “And just as important, patients and their families need to know they can get help. It's a very reassuring message for everyone.”