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Effects of life review on mental health and well-being among cancer patients: A systematic review
International Journal of Nursing Studies 74 (2017) 138–148
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Effects of life review on mental health and well-being among cancer patients: A systematic review
MARK
⁎
Xiaoling Zhang, Huimin Xiao , Ying Chen School of Nursing, Fujian Medical University, Fuzhou, China
A R T I C L E I N F O
A B S T R A C T
Keywords: Life review Neoplasms Nursing Mental health and well-being Systematic review
Background: Cancer patients often experience psychological distress. Life review has increasingly been used to enhance their mental health and well-being. However, no systematic review has synthesized the evidence, and its effects remain unclear. Objective: To examine and synthesize the best available evidence on the effects of life review on mental health and well-being among cancer patients. Design: Systematic review of randomized controlled trials and clinical controlled trials. Data sources: Twelve electronic databases were searched for published studies reported in English or Chinese, from inception to September 2016. Other supplementary sources, such as related websites, professional books, reference lists, and author contacts were also used for published or unpublished studies. Review methods: A comprehensive literature search was conducted to identify eligible randomized controlled trials or clinical controlled trials about the effects of life review on cancer patients. Study selection, quality assessment, and data extraction were independently performed by two reviewers. The results were synthesized without meta-analysis in this review. Results: Fifteen studies (899 participants) were identified; of that total, nine studies were rated as strong in quality, while six studies were of moderate quality. In addition to structured life review interviews, other elements such as memory prompts and a legacy product were integrated into life review programs. A majority of studies indicated that life review programs benefited cancer patients by reducing depression and anxiety, as well as improving their sense of hope, self-esteem and quality of life. Conclusions: Life review can improve mental health and well-being among cancer patients. This suggests that life review can be integrated into typical cancer treatment to enhance patients’ mental health and well-being. More research with rigorous design is necessary to further explore the effects of life review.
What is already known about the topic?
• Cancer patients are vulnerable to psychological distress, which is an urgent matter requiring a solution. • Research related to the effects of life review on cancer patients is reported, but no systematic review has synthesized the evidence, and its effects remain inconclusive. What this paper adds
• Current life review programs tend to include various memory prompts and a legacy product, in addition to life review interviews. • Moderate to strong evidence suggests that life review is effective in enhancing mental health and well-being among cancer patients. • Nearly half of the reviewed studies were rated as moderate in ⁎
quality. More original studies with rigorous designs are required in future research. 1. Introduction By report, the global cancer figure has revealed a general trend of dramatic increase: 14 million people in 2012, expected to increase yearly to 19.3 million in 2025 and 24 million in 2035(World Health Organization, 2015). A meta-analysis has shown that psychological distress is associated with a 13% increase in the risk of cancer incidence and a 27% increase in the risk of cancer mortality (Chida et al., 2009). The distress may negatively weaken cancer patients’ immune defense system, adversely influence their adherence to therapy, and potentially interfere with cancer treatment (Chida et al., 2009; Korte et al., 2009). The distress is also related to lower quality of life (QOL) in terms of
Corresponding author at: School of Nursing, Fujian Medical University NO 1 Xueyuan Road, Shangjie Zhen, Minhou County, Fuzhou City, Fujian Province, China. E-mail address: [email protected] (H. Xiao).
http://dx.doi.org/10.1016/j.ijnurstu.2017.06.012 Received 31 October 2016; Received in revised form 21 June 2017; Accepted 21 June 2017 0020-7489/ © 2017 Elsevier Ltd. All rights reserved.
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(Higgins and Green, 2011) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (Moher et al., 2015).
daily life and interpersonal relationships (Kroenke et al., 2010; Bornbaum et al., 2012). Psychological interventions are therefore increasingly applied to ameliorate psychological distress among cancer patients, enabling them to manage emotional symptomatology, alleviate the burden of concern, and facilitate relationships (Badr and Krebs, 2013; de la Torre-Luque et al., 2016). They also play an important role in coping with maladaptation resulting from cancer sequelae, such as self-image, or new and changing roles (de la TorreLuque et al., 2016). Life review has been recognized as an effective psychological intervention. It is initiatively defined as “a naturally occurring, universal mental process characterized by the progressive return to consciousness of past experiences, and particularly, the resurgence of unresolved conflicts can be surveyed and reintegrated” (Butler, 1963). Later, life review as an intervention was proposed based on Erikson’s psychosocial development theory (Haight and Bahr, 1984). Nowadays, accumulated evidence suggests that life review is effective in reducing psychological distress and improving well-being among the elderly, as well as in palliative patients, such as cancer individuals (Pinquart and Forstmeier, 2012; Kleijn et al., 2014). Some experts explain that reviewing one’s whole life enables reviewees to better retrieve feelings of positive life experiences, re-evaluate bad memories, and finally, integrate positive and negative experiences with the aim of alleviating sense of despair and achieving self-integrity (Haber, 2006; Korte et al., 2009). Chen et al. (2017) has recently supported that reviewees might also learn from the past, regain confidence to cope with the present disease, and foster hope for the future. Meanwhile, recalling and reflecting on their contributions to their families and society encourages them to become aware of the worth of their existence, which can assuage their guilt, improve the sense of low self-esteem and facilitate a good relationship with others. Compared to other psychological interventions, life review appears to be more acceptable and feasible for cancer patients. First, reviewing a life is often prompted and happens naturally in their final life stage (Jenko et al., 2007). Second, patients’ deteriorating health or low functionality cannot prevent the delivery of a life review (Ando et al., 2008). More importantly, various well-trained facilitators are capable of conducting a life review, for example, nurses. Studies have explored a life review’s effects on QOL (Hanaoka and Okamura, 2004; Korte et al., 2012a,b), depression (Riepma et al., 2011; Esmaeily, 2014), self-esteem (Tabourne, 1995), anxiety (Riepma et al., 2011), and life satisfaction (Haight, 1988; Davis, 2004). These life review programs turn out to be diverse in session, duration, frequency, and product, leading to inconsistent results even with identical outcome measurement. Various reviews have been conducted to synthesize these results. The majority were either theoretical reviews (Haber, 2006; Westerhof et al., 2010; Wester et al., 2010), targeted the elderly (Bohlmeijer et al., 2004; Huang et al., 2015), or combined reminiscence with life review as the intervention (Bohlmeijer et al., 2004; Pinquart and Forstmeier, 2012). Another two systematic reviews (Keall et al., 2015; Chen et al., 2017) focused on life review as an intervention, but covered various palliative patients. To date, evidence of life review’s effects on cancer patients has not been synthesized for clinical practice. Therefore, this review sought to:
2.1. Selection criteria 2.1.1. Inclusion criteria (1) Study designs: randomized controlled trials (RCTs) or clinical controlled trials in English or Chinese. (2) Participants: patients with a confirmed diagnosis of any cancer. (3) Interventions: life review, life review program, life review intervention or life review therapy. (4) Controls: no therapy, a placebo treatment, or usual care. (5) Outcomes: outcomes related to mental health and well-being that can be measured through self-reported and commonly used questionnaires or scales, including depression (e.g. Hospital Anxiety and Depression Scale and Zung's Depression Scale), anxiety (e.g. Hospital Anxiety and Depression Scale, Short Form of the Profile of Mood States), hope (e.g. Herth Hope Scale and Good Death Inventory), self-esteem (e.g. Rosenberg Self-Esteem Scale and State Self-Esteem Scale), QOL (e.g. Quality of Life Questionnaire-Core30 and Functional Assessment of Chronic Illness Therapy-Spiritual). 2.1.2. Exclusion criteria (1) Study designs: other types of studies including descriptive paper, reviews and case reports. (2) Participants: participants with cognitive impairment or simultaneously receiving other psychological interventions (e.g. dignity therapy, music therapy, reminiscence) or taking medicine (e.g. antidepressant). (3) Interventions: life review as a component of the interventions or as a control intervention. (4) Outcomes: outcomes related to physical outcomes, nursing outcomes such as treatment attitude and nursing satisfaction rate. (5) Others: studies with duplicate data, deficient data or unavailable full text. 2.2. Search strategy Databases and other resources complemented each other to retrieve all relevant studies. In this review, 12 electronic databases were searched from their inception to September 2016, including Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, Proquest Digital Dissertations, Web of Science, Foreign Medical Retrieval System, China National Knowledge Infrastructure, China Science and Technology Journal Database, China Wanfang Database, and Taiwanese Airiti Library. Search strategies were tailored to each database (see Additional file 1). Other resources were also employed to search additional studies. They contained professional organizations (e.g. Chinese Association for Life Care), related websites (e.g. Open Grey; ClinicalTrials.gov; Controlled-trials.com and Google Scholar), relevant books such as The Handbook of Structured Life Review (Haight and Haight, 2007), and the references of all included studies. Regarding those relevant studies reported neither in Chinese nor in English, we further contacted corresponding authors to check the availability of their English versions.
(1) systematically identify and summarize the characteristics of studies related to life review on mental health and well-being among cancer patients based on PICOS (Participant, Intervention, Control, Outcome, and Study design) framework; (2) synthesize the effects of life review on mental health and well-being among cancer patients.
2.3. Study selection
2. Methods
Two reviewers (ZXL & CY) independently selected the studies based on the review criteria. Before the study selection, the citations of retrieved studies were all imported into EndNote X7 and the duplicates were removed. Pre-screening was conducted to unify the rules of selection and decrease the likelihood of disagreement. Studies were then
The review protocol was registered on the PROSPERP (CRD 42016037493) (PROSPERO, 2016). This systematic review was performed based on the prescribed order in Cochrane Collaboration 139
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participants’ homes (n = 2).
screened by titles and abstracts. Those studies unable to make accurate judgment were tentatively retained for further assessment. After reading the full articles, studies eligible for the selection criteria were identified. Disagreements occurring in selection process were negotiated between the two reviewers, and in consultation with a third person (XHM). The inter-rater reliability (Kappa value) of screening by titles and abstracts was 0.897 (P < 0.001); and by the full articles was 0.938 (P < 0.001).
3.2.2. Participants A total of 899 participants were included, with female participants accounting for 49.72% in this review. The sample size ranged from 10 to 100, with nine studies including more than 50 participants. Mean age varied from 44.4 to 72.45 years. Studies recruited participants with a single cancer (n = 4), and multiple cancers (n = 11). Majority of the participants were diagnosed with different cancers.
2.4. Quality assessment 3.2.3. Life review programs 3.2.3.1. Basic characteristics of life review. The question-guiding based life review interviews were the basic characteristics of life review. However, the interviews were diverse in terms of theoretical underpinning, guideline questions, session, duration, frequency, and facilitator. Regarding theoretical underpinning, most studies were based on Erikson’s Psychosocial Developmental and Butler’s Life Review theory (n = 11), Hack’s or Skinner’s theory (n = 2). All studies conducted life reviews using guideline questions constructed by Haight (n = 14) or Hack’s standardized framework (n = 1). The sessions ranged from two to six, a majority of which were three sessions (n = 6) or four sessions (n = 4). The duration was reported within one week (n = 5), two weeks (n = 2), three weeks (n = 4), or four to six weeks (n = 4). The frequencies were stated once a week (n = 5), or more frequently (n = 7). As for the facilitators of life review, they consisted of therapists (n = 2), clinical psychologists (n = 3), researchers (n = 6), or nurses (n = 4) who either had rich clinical experience, or were well trained in life review theory (See Table 1).
Studies quality was assessed using the Quality Assessment Tool for Quantitative Studies (Thomas et al., 2004). It has been demonstrated as a valid tool for assessing the quality of studies including randomized and clinical controlled trials (Petticrew and Roberts, 2006; ArmijoOlivo et al., 2012). Six domains were rated as strong, moderate, and weak, and a global rating is also assigned to each study as strong (no weak ratings), moderate (one weak rating), or weak (two or more weak ratings). Quality assessment of the studies was independently conducted by two reviewers, and inter-rater reliability (Kappa value) reached 0.898 (P < 0.001). 2.5. Data extraction The content of data extraction contained publication details, study designs, participants, interventions, controls, outcomes and results. It was extracted independently by two reviewers (ZXL & CY) and a consensus was reached by consulting with a third person (XHM). Contacting the authors for further details was the way to deal with missing or unclear data. The inter-rater reliability (Kappa value) was 0.80 (P < 0.001).
3.2.4. Additional elements of life review 3.2.4.1. Memory prompts. Three studies (Batton, 2000; Liu, 2008; Chen, 2011b) introduced memory prompts into life review, facilitating patients to look back on their past in order to enrich life review process. Batton (2000) created a family tree, a time line of significant life events and made an audio recording of life events to awaken patients’ memory of the past. Additionally, his qualitative results revealed that patients can find the location of family and strengthen the sense of belonging through the use of family trees. Liu (2008) and Chen (2011b) made use of albums to promote their recollections.
2.6. Data synthesis No statistical pooling of outcomes was performed, because there was heterogeneity regarding the clinical characteristics of the study designs, participants, intervention intensity and outcomes, therefore, a qualitative analysis was merited. Results were tabulated and overviewed the characteristics of the included studies and life review programs. Additionally, the effects of life review on cancer patients’ mental health and well-being were synthesized by collating the study designs, sample size, and outcome measures in a narrative manner. Regular meetings of the research team clarified any uncertainties and reached consensus on any changes related to the content of qualitative synthesis, including the characteristics of the included studies and life review programs.
3.2.4.2. A legacy product. Eleven studies not only involved life review interviews but also formulated a legacy product (Ando et al., 2010; Xiao et al., 2013; Chen, 2011a; Chen, 2016; Yu et al., 2014; Hoffman, 2003; Shi et al., 2013; Shi, 2015; Lin et al., 2016; Jin, 2014; Wang, 2015). Life text and pictures were the most common. Generally, the facilitators created the product by selecting key words reflecting both positive and negative experiences in patients’ lives and pictures based on their preference. Then; they reviewed it with patients in order to let them reevaluate and integrate the life events; and finally; left a legacy product. For example; Xiao et al. (2013) made a life review booklet; which recorded patients’ significant experiences; views on life; and words for their loved ones to help patients affirm the value in their life. The qualitative data indicated that it was highly praised because it passed on the values of a patient’s life and preserved these as a memorial for families. Hoffman (2003) developed a structured workbook called The Story of My Life; a reflective journal for recording one’s life. It constituted a series of questions concentrating on family; friendship; school; career; hardship etc. Qualitative results indicated that the finished workbook would stay among the patients’ possessions and become a wonderful legacy for family members to cherish. Increasing studies have tended to make a product during a life review. In this review, 11 studies were involved in creating a product in life review process within previous recent six years. Some limited the life text to patients’ life experiences (Chen, 2011a; Jin, 2014; Wang, 2015), while others added death education into the life review product (Yu et al., 2014; Chen, 2016).
3. Results 3.1. Study selection Up until September 2016, a total of 795 studies were retrieved by comprehensive search and 498 studies remained after duplicates were removed. Judged by titles and abstracts, 35 studies were identified for further assessment. After the full-text screening, the final data set was comprised of 15 studies for this review, derived from the database search. Study selection details see Fig. 1. 3.2. Study characteristics 3.2.1. Study designs Fifteen studies were eligible for this review including nine RCTs and six clinical controlled trials. Eleven studies took place in China, with the rest occurring in Japan and America. Most were published from 2010 to 2016 (n = 11) or earlier (n = 4). A majority of the study settings focused on hospitals (n = 10), the others were palliative units (n = 3) or 140
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Fig. 1. Flowchart over literature search.
3.3. Quality assessment of included studies
3.2.5. Control interventions The control group received usual care (n = 9), general support (n = 2), regular phone calling (n = 1), open recreation (n = 1), or no therapy (n = 2). Usual care was related to routine nursing and health education. General support was the process in which therapists interviewed patients regarding physical and mental status, and responded to the patient’s narrative in a nonjudgmental way.
Table 2 demonstrates the quality assessment of the included studies. Specifically, the majority of participants were somewhat representative of the targeted population (n = 14), or poorly representative (n = 1). The study designs were RCT or clinical controlled trials, all rated as strong (n = 15). Confounders were controlled (n = 12), uncontrolled (n = 1), or unspecific (n = 2). Regarding the use of blinding, specific descriptions for participants were unavailable (n = 15). Outcome assessors were blind (n = 2), not blind (n = 2), or unclear (n = 11). As for data collection methods (reliability and validity), they were reported (n = 14), or unclear (n = 1). The follow-up rate was over 80% (n = 13) or 60-79% (n = 2). From the above, the global ratings of RCTs were strong (n = 8) or moderate (n = 1), of that clinical controlled trials were strong (n = 1) or moderate (n = 5).
3.2.6. Outcome variables, instruments and results Sixteen outcome variables were identified measured by 24 scales, which meant that a considerable variation in the measurement instruments was used. Most studies used validated (self-rating) questionnaires or scales. They measured before and immediately after the intervention (n = 12), three weeks after the intervention (n = 1), two and 30 days after the intervention (n = 1), or three months after the intervention (n = 1). Because the main focus of this review is on the effects of life review on mental health and well-being among cancer patients, only the findings on those outcomes (e.g. depression, anxiety, QOL) were presented (see Table 1).
3.4. Effects of life review 3.4.1. Significant reductions in negative emotions Negative emotions synthesized in this review were depression and anxiety. Seven studies (Ando et al., 2010; Chen, 2011a; Jin, 2014; Ando et al., 2006; Liu, 2008; Hoffman, 2003; Lin et al., 2016) reported 141
142
RCT
RCT
Chen (2011b) China
Jin (2014) China
RCT
Xiao et al. (2013) China
RCT
RCT
Ando et al. (2010) Japan
Chen (2011a) China
Designs
Study Country
N = 43 (54.43 ± 7.21) years 28(65.1%) Multiple cancers
19(47.5%) Multiple cancers
N = 40 (55.95 ± 2.63)years
22(30.99%) Single cancer
N = 71 (56.57 ± 8.15) years
38(47.5%) Multiple cancers
N = 80 (59.16 ± 11.50) years
Session:2 Duration: 1 week
36(46.75%) Multiple cancers
Frequency:1/2–7d Facilitator: the first author Setting: participants’ homes Theory: Erikson’s and Butler’s theory Additional element: life album Control group Regular phone calling Life review group Session: 4 Duration:1 week Frequency:4/1 week
Session:3 Duration:6 weeks
Frequency:1/per week Facilitator: clinical psychologist Setting: hospital(ward) Theory: Erikson’s and Butler’s theory Additional element: life text Control group Usual care Life review group
Session:4 Duration: 1 month
Frequency:1/per week Facilitator: the first author Setting: participants’ homes Theory: Erikson’s and Butler’s theory Additional element: life review booklet Control group Usual care Life review group
Session:3 Duration: 3 weeks
Frequency:2/per week Facilitator: clinical therapist Setting: PCUs Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group general support Life review group
Depression, anxiety sense of meaning burden, hope life completion, preparation
Life review group
N = 77 (64.49 ± 13.92) years
Overall mood state TA,DD,AH,FI,CB, VA POMS-SF Measures at before and at the 3-month
Self-transcendence, spiritual well-being hope STS, SWBS, HHS Measures at before and after the intervention (no)
HADS,HHS Measures at before and after the intervention (I = 6 C = 5)
Anxiety, depression, hope
QOLC-E Measures at immediately after the program and at the 3-week follow-up (I = 26,C = 30)
Overall QOL
FACIT-Sp, HADS, Good Death Inventory Measures at before the first session and after the second session (I = 4 C = 5)
Outcomes Measurements (time & dropouts)
Interventions
Participants (numbers, age, female, number of cancers)
Table 1 Characteristics of included studies.
Strong
Strong
Strong
Strong
Moderate
Global Rating
(continued on next page)
Significant in overall mood state (P < 0.01) TA,DD,AH,FI, CB (P < 0.01), VA (P < 0.05)
Significant in self-transcendence, spiritual wellbeing hope (P < 0.05)
Significant in anxiety(P < 0.05) depression, hope(P < 0.01)
Significant in overall QOL (P < 0.05)
Significant in depression, anxiety, sense of meaning, burden, life completion, preparation, hope (P < 0.05)
Results
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RCT
Chen (2016) China
RCT
Wang (2015) China
RCT
RCT
Shi et al. (2013) China
Yu et al. (2014) China
Designs
Study Country
Table 1 (continued)
33(55.93%) Single cancer
N = 64 (55.03 ± 11.29)years
33(46.48%) Multiple cancers
N = 71 (59.48 ± 1.51)years
100(100%) Single cancer
N = 100 (44.4 ± 3.1)years
34(34%) Single cancer
N = 100 (57.45 ± 14.23)years
Participants (numbers, age, female, number of cancers)
Frequency:1/2d Facilitator: the first author Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures
Session:6 Duration:2 weeks
Frequency:1/per week Facilitator: nurse Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures, death education Control group Usual care Life review group
Session:3 Duration: 4 weeks
Frequency: unclear Facilitator: clinical psychologist Setting: hospital Theory: Hack’s theory Additional element: life text Control group Usual care Life review group
Session: unclear Duration: 1 week
Frequency:1/peer week Facilitator: nurse Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group Usual care Life review group
Session:3 Duration:3 weeks
Facilitator: nurse Setting: hospital(ward) Theory: Erikson’s and Butler’s theory Additional element: life text Control group Usual care Life review group
Interventions
CT-DAS Measures at before and 2 and 30 days after the intervention (I = 4 C = 1)
Death anxiety
QLQ-C30 Measures at before and after the intervention (no)
QOL
SSES,HHS Measures at before and after the intervention (no)
Self-esteem, hope
ITAQ,QLQ-C30 Measures at before and after the intervention (no)
QOL
follow-up (no)
Outcomes Measurements (time & dropouts)
Significant in death anxiety (P < 0.05)
Significant in QOL(P < 0.01)
Strong
Strong
Strong
Strong
Global Rating
(continued on next page)
Significant in self-esteem, hope (P < 0.05)
Significant in QOL (P < 0.01)
Results
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CCT
Liu (2008) China
CCT
Batton (2000) America
CCT
CCT
Ando et al. (2006) Japan
Hoffman (2003) America
Designs
Study Country
Table 1 (continued)
5(21.74%) Multiple cancers
N = 23 (57.41 ± 11.87)years
10(100%) Unclear
N = 10 46years
10(41.67%) Multiple cancers
N = 24 (72.45 ± 8.46)years
24(66.6%) Multiple cancers
N = 36 (59.42 ± 5.5)years
Participants (numbers, age, female, number of cancers)
Frequency:3/5 days Facilitator: the first author Setting: meeting room Theory: Erikson’s and Butler’s theory Additional element: life album Control group Usual care
Session:3 Duration:5 days
Frequency: unclear Facilitator: the first author Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life review workbook Control group No therapy Life review group
Session: unclear Duration:4–6 weeks
Frequency:4/1 week Facilitator: recreational therapist Setting: hospital oncology unit Theory: Skinner’s theory Additional element: a family tree, a time line of significant life events and an audio recording of life event Control group Open recreation Life review group
Session:4 Duration:1 week
Frequency: 4/3 weeks Facilitator: clinical psychologist Setting: hospital Theory: Erikson’s and Butler’s theory Additiona element: no Control group No therapy Life review group
CBDI-II,PIL Measures at before and after the intervention (I = 1 C = 3)
Depression, purpose in life
Satisfaction with life, meaning in illness, depression, life-regard, death anxiety CL-FODS, CES-D, SWLS, LRI-R,CMS Measures at before and after the intervention (no)
PAIS,FACT-SP Measures at before and after the intervention (I = 2 C = 3)
QOL, psychosocial adjustment
ZDS,RSES Measures at pretest and post- test (about 3 wk. Later later) (no)
Self-esteem, depression
Control group Usual care Life review group Session: 4(5,7) Duration: 3 weeks
Outcomes Measurements (time & dropouts)
Interventions
Moderate
Moderate
Moderate
Moderate
Global Rating
(continued on next page)
Significant in depression (P < 0.05) purpose in life (P < 0.05)
No significant in satisfaction with life, meaning in illness(P = 0.92), depression (P = 0.67) Life-regard (P = 0.83) Significant in death anxiety3 & 4 (P < 0.05)
No significant in QOL (P = 0.69) psychosocial adjustment (P = 0.69)
Significant in self-esteem (P < 0.01), depression (P < 0.01)
Results
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CCT
CCT
Shi (2015) China
Lin et al. (2016) China
30(50%) unclear
N = 60 (61.11 ± 8.25) years
N = 100 (49.45 ± 1.25) years 25(25%) Single cancer
Participants (numbers, age, female, number of cancers)
Facilitator: the first author Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group Usual care
Session: unclear Duration:1 week Frequency: unclear
EORTCQLQ-C30 HAMD, HMMA,SEES Measures at before and after the intervention (no)
QOL, depression, anxiety, self-esteem
QOL QLQ-C30 Measures at before and after the intervention (no)
Life review group Session:3 Duration:3 weeks Frequency:1/per week Facilitator: nurse Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group Usual care Life review group
Outcomes Measurements (time & dropouts)
Interventions
Significant in QOL, depression, anxiety, selfesteem (P < 0.05)
Significant in QOL (P < 0.05)
Results
Strong
Moderate
Global Rating
Note: RCT, randomized controlled trial; CCT, clinical controlled trial; PCUs, palliative care units; HADS, Hospital Anxiety and Depression Scale; QOL-C30, Quality-of-Life Concerns; FACIT-Sp, Functional Assessment of Chronic Illness TherapySpiritual Scale; STS, Self-Transcendence Scale; TA, Tension-Anxiety; DD, Depression-Dejection; AH, Anxiety-Hostility; FI, Fatigue-Inertia; CB, Confusion-Bewilderment; VA, Vigor-Activity; HHS, Herth Hope Scale; SWBS, Spiritual Well-Being Scale; POMS-SF, Short Form of the Profile of Mood States; ITAQ, Insight and Treatment Attitude Questionnaire; QLQ-C30, Quality of Life Questionnaire-Core30; SSES, State Self −Esteem Scale; ZDS, Zung's Depression Scale; RSES, Rosenberg's Self-Esteem Scale; PAIS, Psychosocial Adjustment to Illness Scale; CL-FODS, Collett-Lester Fear Of Death Scale; CES-D, Center for Epidemiological Scale for Depression; SWLS, Satisfaction With Life Scale; LRI-R, Life Regard Index-Revised; CMS, Constructed Meaning Scale; CBDI-II, Carbon Black Dispersion Index; PIL, Chinese version Purpose In Life; HAMD, Hamilton Depression Scale; HAMA, Hamilton Anxiety Scale; RSES, Rosenberg Self-Esteem Scale; CT-DAS, Chinese Version of Templer-Death Anxiety Scale; EORTCQLQ-C30,European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core30.
Designs
Study Country
Table 1 (continued)
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Table 2 Quality assessment of included studies. Author/Year
Selection Bias
Study Design
Confounders
Blinding
Data Collection Methods
Withdrawals and Dropouts (follow-up rate)
Global Rating
Ando et al. (2010) Xiao et al. (2013) Chen (2011a) Chen (2011b) Jin (2014) Shi et al. (2013) Wang (2015) Yu et al. (2011) Chen (2016) Ando et al. (2006) Batton (2000) Hoffman (2003) Liu (2008) Shi (2015) Lin et al. (2016)
2 2 2 2 2 2 2 2 2 2 2 2 3 2 2
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 3 3 3 1 1 1
3 2 2 2 2 2 2 2 2 2 2 2 2 2 2
1 1 1 1 1 1 1 1 1 1 1 1 1 3 1
1 2 1 1 1 1 1 1 1 1 2 1 1 1 1
2 1 1 1 1 1 1 1 1 2 2 2 2 2 1
Note: 1 = strong, 2 = moderate, 3 = weak.
interviews. This review displays the promising effects of life review on reducing depression and anxiety, as well as improving hope, self-esteem, and QOL of cancer patients. The positive results in depression and anxiety may be because life review provides an opportunity to express and re-evaluate negative feelings, and retrieve positive thoughts. Previous studies (Graybeal et al., 2002; Niederhoffer and Pennebaker, 2009) have demonstrated that expressing stressful experiences is a good way to deal with negative feelings. These kinds of face-to-face therapeutic sessions emphasize privacy, which allows patients to feel safe in sharing their personal experiences with a facilitator. To a certain extent, people are willing to reveal their innermost feelings to strangers, helping to alleviate negative feelings (Jin, 2014). During the life review, patients are encouraged to look back on their lives and reflect on past experiences, including positive events, unresolved difficulties and conflicts. Korte et al. (2012a,b) have supported that the reduction in depression and anxiety may be achieved via the accumulation of positive thoughts. As for painful memories that may be picked up in life review process, the facilitator would guide them to consider these memories from other perspectives. Accordingly, patients are able to let go, accept or even gain a fresh insight into their lives, and finally achieve self-integrity (Woods et al., 2005). Apart from significant reductions in negative emotions, significant improvements in hope and self-esteem were perceived among cancer patients in this review. Possible reasons for the effectiveness in increasing hope may be that life review helps patients collate and learn from their past, gain a better understanding of their current situation, and inspire them to take action congruent with the palliative situation. Scholars (Park and Folkman, 1997; Folman and Greer, 2009) have also put forward the idea that establishing an attainable goal can foster hope. Therefore, when patients set goals matched with their ability, they are more likely to be successful, which brings an elevated level of hope. The explanation for the life review’s effectiveness in enhancing self-esteem may be that patients are empowered to acquire a sense of value from their past achievements. Chiang et al. (2008) have supported that patients alter their individual negative understanding, and further affirm life values in order to improve their self-confidence and self-esteem. This review showed that life review has a positive impact on QOL. It may be possible that patients are in a positive state when reviewing their lives. Such feelings are maintained for a period of time if patients view, touch, and appreciate the product made in life review process. It is also because life review has an active impact on individual and social support, as well as on family relationships, which may result in a better QOL. Dahley and Sanders (2016) has found that patients are likely to get in touch with other people after completing a life review.
depression in 320 participants using six measurements. Three studies with strong quality and four studies with moderate quality except for the study by Hoffman (2003), indicated a statistically significant effect of life review on depression reduction among cancer patients. Three studies (Ando et al., 2010; Chen, 2011a; Jin, 2014) explored the effects of life review on anxiety with HADS or POMS-SF in 191 participants, and positive results were observed in these studies. The study by Ando et al. (2010) demonstrated that life review was effective in alleviating depression and anxiety. It is worth mentioning that he discovered that short-term intervention contributed to lowering the drop-out rate resulting from cancer patients’ physical deterioration. 3.4.2. Significant improvement in hope, self-esteem and QOL Significant improvement in positive well-being included hope, selfesteem and QOL. Four studies (Ando et al., 2010; Chen, 2011a; Chen, 2011b; Wang, 2015) with 268 participants measured the level of hope by HHS except for Ando et al. (2010). Self-esteem was tested in three studies (Wang, 2015; Ando et al., 2006; Lin et al., 2016) with 196 participants using the State Self-Esteem Scale and Rosenberg Self-Esteem Scale. Participants of the life review group found elevated levels of hope and self-esteem when compared to the control group. Some studies found a significant decrease in hope and self-esteem in the control group (Ando et al., 2010; Wang, 2015; Lin et al., 2016). Six studies (Xiao et al., 2013; Shi et al., 2013; Yu et al., 2014; Batton, 2000; Shi, 2015; Lin et al., 2016) identified a positive effect on QOL measured by QLQ-C30, QOLC-E, and FACT-Sp in 435 participants. Although no statistical significance could be established in the study by Batton (2000), it found a positive relationship between psychosocial adjustment and QOL improvements confirmed by quantitative analysis. These studies have indicated that life review with a product can allow patients to relive personal life experiences, share knowledge and wisdom, and improve their relationships with others, which facilitates their perceived QOL. 4. Discussion 4.1. Primary findings This is the first review to determine the effects of life review on cancer patients. Fifteen studies met the inclusion criteria through the comprehensive search. We speculated that the research on life review specific to cancer patients was immature. But it shows an upward tendency in research of this field in recent years, according to the distribution of time in current studies. Noticing the characteristics of life review, more researchers are inclined to include various memory prompts and a legacy product, in addition to conducting life review 146
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Connecting with others can open communication, enhance understanding, and bridge distant relationships between family members and friends.
further explore the effects of life review.
4.2. Methodological limitations of the studies
The study was supported by the Chinese National Nature Science Foundation of China [8140, 1863] and Fujian Provincial National Nature Science [2017J01814].
Funding
The quality of eight RCTs was strong (one was moderate); that of five clinical controlled trials was moderate (one was strong). The key issues of the quality were confounders. Most moderate quality clinical controlled trials indicated a lack of randomization, leading to the confounders between groups. Another issue was lack of blinding. When not blinded to psychological interventions, participants are prone to generate the Hawthorne effect, as well as being affected by psychological suggestion; the outcome assessors may also overestimate the effects of intervention group; and the facilitators may have different expectations of intervention group. Although the blind is required for experimental trials, it is difficult to totally blind both participants and facilitators to treatment in psychological research.
Ethical approval None declared. Conflict of interest None declared. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ijnurstu.2017.06.012.
4.3. Limitations of the review
References
Some limitations may exist in this review. First, grey literature was incompletely identified and studies with deficient data or unavailable full text were not included in this review. However, this may not have much influence on the results, because grey literature usually has a small number of small participants as well as inconclusive results (Mc Auley et al., 2000). Second, only English or Chinese studies were included, eligible studies in other languages may have been omitted. Third, the long-term effects of life review were rarely explored in the included studies, and therefore remain unknown. Finally, this review synthesized the results without meta-analysis, due to different control interventions in the included studies.
Ando, M., Tsuda, A., Moorey, S., 2006. Preliminary study of reminiscence therapy on depression and self-esteem in cancer patients. J. Psychol. Rep. 98 (2), 339–346. Ando, M., Morita, T., Okamoto, T., Ninosaka, Y., 2008. One-week short-term life review interview can improve spiritual well-being of terminally ill cancer patients. PsychoOncology 17 (9), 885–890. Ando, M., Morita, T., Akechi, T., Okamoto, T., 2010. Efficacy of short-term life-review interviews on the spiritual well-being of terminally ill cancer patients. J. Pain Symptom Manage. 39 (6), 993–1002. Armijo-Olivo, S., Stiles, C.R., Hagen, N.A., Biondo, P.D., Cummings, G.G., 2012. Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. J. Eval. Clin. Pract. 18 (1), 12–18. Badr, H., Krebs, P., 2013. A systematic review and meta-analysis of psychosocial interventions for couples coping with cancer. Psycho-Oncology 22, 1688–1704. http://dx. doi.org/10.1002/pon.3200. Batton, J.E., 2000. The Effect of an Activity-based Intervention on the Psychosocial Adjustment of Cancer Patients. Temple University. Bohlmeijer, E., Smit, F., Cuijpers, P., 2004. Effects of reminiscence and life review on latelife depression: a meta-analysis. Int. J. Geriatric Psychiatry 18 (12), 1088–1094. Bornbaum, C.C., Fung, K., Franklin, J.H., Nichols, A., Yoo, J., Doyle, P.C., 2012. A descriptive analysis of the relationship between quality of life and distress in individuals with head and neck cancer. Support. Care Cancer 20, 2157–2165. Butler, R., 1963. The life review: an interpretation of reminiscence in the aged. J. Psychiatry 26, 65–76. Chen, Y., Xiao, H.M., Yang, Y.Q., Lan, X.Y., 2017. The effects of life review on psychospiritual well-being among patients with life-threatening illness: a systematic review and meta-analysis. J. Adv. Nurs. 73 (7), 1539–1554. Chen, L.X., 2011a. Effect of life review interviews on mental health and hoping level of pancreatic cancer patients. Chin. J. Mod. Nurs. 17 (20), 2385–2387. Chen, S.H., 2011b. Effectiveness of Lire Review in Increasing Self-transcendence, Hope, and Spiritual Well-being of Patients with Cancer. Department of Nursing Fooying University. Chen, S.J., 2016. Effects on death anxiety among malignant tumor patients with life review intervention. J. Med. Philos. 37 (8B), 86–89. Chiang, K.J., Lu, R.B., Chu, H., Chang, Y.C., Chou, K.R., 2008. Evaluation of the effect of a life review group program on self-esteem and life satisfaction in the elderly. Int. J. Geriatr. Psychiatry 23 (1), 7–10. Chida, Y., Hamer, M., Molloy, G.J., 2009. Psychological distress and cancer mortality. J. Psychosom. Res. 66 (3), 255–258. Dahley, L., Sanders, G.F., 2016. Use of a structured life review and its impact on family interactions. Activities Adapt. Aging 40 (1), 53–66. Davis, M.C., 2004. Life review therapy as an intervention to manage depression and enhance life satisfaction in individuals with right hemisphere cerebral vascular accidents. Issues Mental Health Nurs. 25 (5), 503–515. de la Torre-Luque, A., Gambara, H., López, E., Cruzado, J.A., 2016. Psychological treatments to improve quality of life in cancer contexts: a meta-analysis. Int. J. Clin. Health Psychol. 16 (2), 211–219. Esmaeily, M., 2014. P8: efficacy of life review therapy with emphasis on Islamic ontology on decreasing PTSD symptoms. Neurosci. J. Shefaye Khatam 2 (4), 58. Folman, S., Greer, S., 2009. Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other. Psycho-Oncology 9, 11–19. Graybeal, A., Sexton, J.D., Pennebaker, J.W., 2002. The role of story-making in disclosure writing: the psychometrics of narrative. J. Psychol. Health 17, 571–581. Haber, D., 2006. Life review: implementation, theory, research, and therapy. Int. J. Aging Hum. Dev. 63 (2), 153–171.
4.4. Implications for clinical practice and research In view of the strengths of life review with regard to mental health and well-being, it is suggested that life review is suitable for clinical practice. Some recommendations may be helpful when a life review is conducted. First, life review can be implemented as early as possible when cancer patients begin suffering from psychological problems. To a certain extent, early intervention can guarantee the completeness of a life review. Second, facilitators should appropriately schedule the time of life review. Ando et al. (2010) echoed that a long-term life review contributed to a high drop-out rate due to the physical deterioration of cancer patients. Third, a life review product should be considered when designing a life review program. It could be a life review album, a life review booklet, or a short video. Such a product not only adds an element of fun for participants, but also leaves them with a life legacy. Moreover, participants will likely continue to review their lives after the life review, when viewing the products alone or with their families. The review also reveals suggestions for future research. Given the methodological flaws of previous studies, multi-center, interdisciplinary and transregional research with rigorous design is necessary. Apart from reporting those promising outcomes mentioned above, adverse effects of life review should also be observed and recorded. Future research can further explore the long-term effects and cost-effectiveness of life review, which are still inconclusive. 5. Conclusion Life review can reduce depression and anxiety, foster hope, and improve self-esteem and QOL among cancer patients. This suggests that life review can be integrated into usual care to enhance cancer patients’ well-being. However, these findings were derived from moderate quality data in half of the studies, and the firmness of our conclusion is limited. More research with rigorous design is necessary in order to 147
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University. Mc Auley, L., Pham, B., Tugwell, P., Moher, D., 2000. Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? Lancet 356 (9237), 1228–1231. Niederhoffer, K.G., Pennebaker, J.W., 2009. Sharing one’s story: On the benefits of writing or talking about emotional experience, vol. 1. Oxford University, New York, pp. 573–583. International Prospective Register of Systematic Reviews, PROSPERO [on-line]. Available at www.crd.york.ac.uk/prospero/ (Accessed 12 April 2016). Park, C.L., Folkman, S., 1997. Meaning in the context of stressand coping. Rev. Gen. Psychol. 1, 115–144. Petticrew, M., Roberts, H., 2006. Systematic Reviews in the Social Sciences: A Practical Guide. (Available from: http://catdir.loc.gov/catdir/toc/ecip0512/2005011632. html). Pinquart, M., Forstmeier, S., 2012. Effects of reminiscence interventions on psychosocial outcomes: a meta-analysis. Aging Mental Health 16 (5), 541–558. Riepma, I., Steunenberg, B., Bree, R., 2011. Power of the past: a randomized controlled trial testing the efficacy of a life review therapy in depressed palliative cancer patients. Psycho-oncology 20, 219–220. Shi, M., Li, L., Zhang, L., 2013. Influence of care approach of life review on patients with advanced gastrointestinal cancer. Chin. J. Mod. Nurs. 19 (33), 4109–4111. Shi, Q.H., 2015. Analysis of the effect of life review nursing intervention on advanced gastrointestinal cancer patients. China Foreign Med. Treat. 14 (21), 152–154. Tabourne, C.E., 1995. The effects of a life review program on disorientation, social interaction and self-esteem of nursing home residents. Int. J. Aging Hum. Dev. 41 (3), 251–266. Thomas, B.H., Ciliska, D., Dobbins, M., 2004. A process for systematically reviewing the literature providing the research evidence for public health nursing interventions. Worldviews Evid.-Based Nurs. 1 (3), 176–184. Wang, Y.C., 2015. Effects on self-esteem and hope among cervical cancer patients with life review intervention. Today Nurse 21 (5), 73–75. Westerhof, G.J., Bohlmeijer, E., Webster, J.D., 2010. Reminiscence and mental health: a review of recent progress in theory, research and interventions.J. Ageing Soc. 30 (4), 697–721. Woods, B., Spector, A.E., Jones, C.A., 2005. Reminiscence therapy for dementia. The Cochrane Library. Fact sheet on cancer, 2015. World Health Organization. Available from: http://www. who.int/mediacentre/factsheets/fs297/en/. Xiao, H.M., Kwong, E., Pang, S., Mok, E., 2013. Effect of a life review program for Chinese patients with advanced cancer: a randomized controlled trial. Cancer Nurs. 36 (4), 274–283. Yu, L., Pu, L.L., Lin, L.H., 2014. Effect of a life review interview on the quality of life patients with advanced cancer. J. Nurs. 21 (8), 70–71.
Haight, B.K., Bahr, R.T., 1984. The therapeutic role of the life review in the elderly. Acad. Psychol. Bull. 6, 287–299. Haight, B.K., Haight, B.S., 2007. The Handbook of Structured Life Review, first ed. Health Professions Press, U.S. Haight, B.K., 1988. The therapeutic role of a structured life review process in homebound elderly subjects. J. Gerontol. 43 (2), 40–44. Hanaoka, H., Okamura, H., 2004. Study on effects of life review activities on the quality of life of the elderly: a randomized controlled trial.J. Psychother. Psychosom. 73 (5), 302–311. Higgins, J., Green, S., 2011. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March2011]. The Cochrane Collaboration(Available from www.cochrane-handbook.org). Hoffman, N., 2003. Subjective Well-being Before and After a Life Review in Women Living with Cancer. California Institute of Integral studies. Huang, A.X., Delucchi, K., Dunn, L.B., Nelson, J.C., 2015. A systematic review and metaanalysis of psychotherapy for late-life depression. Am. J. Geriatric Psychiatry 3 (3), 261–273. Jenko, M., Gonzalez, L., Seymour, M.J., 2007. Life review with the terminally ill. J. Hosp. Palliat. Nurs. 9 (3), 159–167. Jin, L.H., 2014. Effect of life review interviews on mental health of cancer patients in recovery period. Today Nurse 2, 75–76. Keall, R.M., Clayton, J.M., Butow, P.N., 2015. Therapeutic life review in palliative care: a systematic review of quantitative evaluations. J. Pain Symptom Manage. 49 (4), 747–761. Kleijn, G., Bohlmeijer, E., Steunenberg, B., Bree, R., Leemans, R., Becker, A., Vorst, M., 2014. Power of the past: a randomized controlled trial to assess effectiveness of life review therapy in palliative cancer patients. Psychooncology 23, 86. Korte, J., Bohlmeijer, E.T., Smit, F., 2009. Prevention of depression and anxiety in later life: design of a randomized controlled trial for the clinical and economic evaluation of a life-review intervention. BMC Public Health 9, 250. Korte, J., Bohlmeijer, E.T., Cappeliez, P., Smit, F., Westerhof, G.J., 2012a. Life review therapy for older adults with moderate depressive symptomatology: a pragmatic randomized controlled trial. Psychol. Med. 42 (6), 1163–1173. Korte, J., Westerhof, G.J., Bohlmeijer, E.T., 2012b. Mediating processes in an effective life-review intervention. Psychol. Aging 27 (4), 1172–1181. Kroenke, K., Theobald, D., Wu, J., Loza, J.K., Carpenter, J.S., Tu, W., 2010. The association of depression and pain with health-related quality of life, disability, and health care use in cancer patients. Pain Symptom Manage. 40, 327–341. Lin, H.Y., Huang, L.T., Shi, Y.R., 2016. The research of life review intervention on psychological status of patients with end-stage cancer application. Chin. J. Gen. Pract. 14 (5), 814–816. Liu, H.L., 2008. The Effects of a Life Album on Depression and Meaning of Life in Cancer Patients Receiving Hospice and Palliative Care. Department of Nursing Fooying
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International Journal of Nursing Studies journal homepage: www.elsevier.com/locate/ijns
Effects of life review on mental health and well-being among cancer patients: A systematic review
MARK
⁎
Xiaoling Zhang, Huimin Xiao , Ying Chen School of Nursing, Fujian Medical University, Fuzhou, China
A R T I C L E I N F O
A B S T R A C T
Keywords: Life review Neoplasms Nursing Mental health and well-being Systematic review
Background: Cancer patients often experience psychological distress. Life review has increasingly been used to enhance their mental health and well-being. However, no systematic review has synthesized the evidence, and its effects remain unclear. Objective: To examine and synthesize the best available evidence on the effects of life review on mental health and well-being among cancer patients. Design: Systematic review of randomized controlled trials and clinical controlled trials. Data sources: Twelve electronic databases were searched for published studies reported in English or Chinese, from inception to September 2016. Other supplementary sources, such as related websites, professional books, reference lists, and author contacts were also used for published or unpublished studies. Review methods: A comprehensive literature search was conducted to identify eligible randomized controlled trials or clinical controlled trials about the effects of life review on cancer patients. Study selection, quality assessment, and data extraction were independently performed by two reviewers. The results were synthesized without meta-analysis in this review. Results: Fifteen studies (899 participants) were identified; of that total, nine studies were rated as strong in quality, while six studies were of moderate quality. In addition to structured life review interviews, other elements such as memory prompts and a legacy product were integrated into life review programs. A majority of studies indicated that life review programs benefited cancer patients by reducing depression and anxiety, as well as improving their sense of hope, self-esteem and quality of life. Conclusions: Life review can improve mental health and well-being among cancer patients. This suggests that life review can be integrated into typical cancer treatment to enhance patients’ mental health and well-being. More research with rigorous design is necessary to further explore the effects of life review.
What is already known about the topic?
• Cancer patients are vulnerable to psychological distress, which is an urgent matter requiring a solution. • Research related to the effects of life review on cancer patients is reported, but no systematic review has synthesized the evidence, and its effects remain inconclusive. What this paper adds
• Current life review programs tend to include various memory prompts and a legacy product, in addition to life review interviews. • Moderate to strong evidence suggests that life review is effective in enhancing mental health and well-being among cancer patients. • Nearly half of the reviewed studies were rated as moderate in ⁎
quality. More original studies with rigorous designs are required in future research. 1. Introduction By report, the global cancer figure has revealed a general trend of dramatic increase: 14 million people in 2012, expected to increase yearly to 19.3 million in 2025 and 24 million in 2035(World Health Organization, 2015). A meta-analysis has shown that psychological distress is associated with a 13% increase in the risk of cancer incidence and a 27% increase in the risk of cancer mortality (Chida et al., 2009). The distress may negatively weaken cancer patients’ immune defense system, adversely influence their adherence to therapy, and potentially interfere with cancer treatment (Chida et al., 2009; Korte et al., 2009). The distress is also related to lower quality of life (QOL) in terms of
Corresponding author at: School of Nursing, Fujian Medical University NO 1 Xueyuan Road, Shangjie Zhen, Minhou County, Fuzhou City, Fujian Province, China. E-mail address: [email protected] (H. Xiao).
http://dx.doi.org/10.1016/j.ijnurstu.2017.06.012 Received 31 October 2016; Received in revised form 21 June 2017; Accepted 21 June 2017 0020-7489/ © 2017 Elsevier Ltd. All rights reserved.
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(Higgins and Green, 2011) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (Moher et al., 2015).
daily life and interpersonal relationships (Kroenke et al., 2010; Bornbaum et al., 2012). Psychological interventions are therefore increasingly applied to ameliorate psychological distress among cancer patients, enabling them to manage emotional symptomatology, alleviate the burden of concern, and facilitate relationships (Badr and Krebs, 2013; de la Torre-Luque et al., 2016). They also play an important role in coping with maladaptation resulting from cancer sequelae, such as self-image, or new and changing roles (de la TorreLuque et al., 2016). Life review has been recognized as an effective psychological intervention. It is initiatively defined as “a naturally occurring, universal mental process characterized by the progressive return to consciousness of past experiences, and particularly, the resurgence of unresolved conflicts can be surveyed and reintegrated” (Butler, 1963). Later, life review as an intervention was proposed based on Erikson’s psychosocial development theory (Haight and Bahr, 1984). Nowadays, accumulated evidence suggests that life review is effective in reducing psychological distress and improving well-being among the elderly, as well as in palliative patients, such as cancer individuals (Pinquart and Forstmeier, 2012; Kleijn et al., 2014). Some experts explain that reviewing one’s whole life enables reviewees to better retrieve feelings of positive life experiences, re-evaluate bad memories, and finally, integrate positive and negative experiences with the aim of alleviating sense of despair and achieving self-integrity (Haber, 2006; Korte et al., 2009). Chen et al. (2017) has recently supported that reviewees might also learn from the past, regain confidence to cope with the present disease, and foster hope for the future. Meanwhile, recalling and reflecting on their contributions to their families and society encourages them to become aware of the worth of their existence, which can assuage their guilt, improve the sense of low self-esteem and facilitate a good relationship with others. Compared to other psychological interventions, life review appears to be more acceptable and feasible for cancer patients. First, reviewing a life is often prompted and happens naturally in their final life stage (Jenko et al., 2007). Second, patients’ deteriorating health or low functionality cannot prevent the delivery of a life review (Ando et al., 2008). More importantly, various well-trained facilitators are capable of conducting a life review, for example, nurses. Studies have explored a life review’s effects on QOL (Hanaoka and Okamura, 2004; Korte et al., 2012a,b), depression (Riepma et al., 2011; Esmaeily, 2014), self-esteem (Tabourne, 1995), anxiety (Riepma et al., 2011), and life satisfaction (Haight, 1988; Davis, 2004). These life review programs turn out to be diverse in session, duration, frequency, and product, leading to inconsistent results even with identical outcome measurement. Various reviews have been conducted to synthesize these results. The majority were either theoretical reviews (Haber, 2006; Westerhof et al., 2010; Wester et al., 2010), targeted the elderly (Bohlmeijer et al., 2004; Huang et al., 2015), or combined reminiscence with life review as the intervention (Bohlmeijer et al., 2004; Pinquart and Forstmeier, 2012). Another two systematic reviews (Keall et al., 2015; Chen et al., 2017) focused on life review as an intervention, but covered various palliative patients. To date, evidence of life review’s effects on cancer patients has not been synthesized for clinical practice. Therefore, this review sought to:
2.1. Selection criteria 2.1.1. Inclusion criteria (1) Study designs: randomized controlled trials (RCTs) or clinical controlled trials in English or Chinese. (2) Participants: patients with a confirmed diagnosis of any cancer. (3) Interventions: life review, life review program, life review intervention or life review therapy. (4) Controls: no therapy, a placebo treatment, or usual care. (5) Outcomes: outcomes related to mental health and well-being that can be measured through self-reported and commonly used questionnaires or scales, including depression (e.g. Hospital Anxiety and Depression Scale and Zung's Depression Scale), anxiety (e.g. Hospital Anxiety and Depression Scale, Short Form of the Profile of Mood States), hope (e.g. Herth Hope Scale and Good Death Inventory), self-esteem (e.g. Rosenberg Self-Esteem Scale and State Self-Esteem Scale), QOL (e.g. Quality of Life Questionnaire-Core30 and Functional Assessment of Chronic Illness Therapy-Spiritual). 2.1.2. Exclusion criteria (1) Study designs: other types of studies including descriptive paper, reviews and case reports. (2) Participants: participants with cognitive impairment or simultaneously receiving other psychological interventions (e.g. dignity therapy, music therapy, reminiscence) or taking medicine (e.g. antidepressant). (3) Interventions: life review as a component of the interventions or as a control intervention. (4) Outcomes: outcomes related to physical outcomes, nursing outcomes such as treatment attitude and nursing satisfaction rate. (5) Others: studies with duplicate data, deficient data or unavailable full text. 2.2. Search strategy Databases and other resources complemented each other to retrieve all relevant studies. In this review, 12 electronic databases were searched from their inception to September 2016, including Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, Proquest Digital Dissertations, Web of Science, Foreign Medical Retrieval System, China National Knowledge Infrastructure, China Science and Technology Journal Database, China Wanfang Database, and Taiwanese Airiti Library. Search strategies were tailored to each database (see Additional file 1). Other resources were also employed to search additional studies. They contained professional organizations (e.g. Chinese Association for Life Care), related websites (e.g. Open Grey; ClinicalTrials.gov; Controlled-trials.com and Google Scholar), relevant books such as The Handbook of Structured Life Review (Haight and Haight, 2007), and the references of all included studies. Regarding those relevant studies reported neither in Chinese nor in English, we further contacted corresponding authors to check the availability of their English versions.
(1) systematically identify and summarize the characteristics of studies related to life review on mental health and well-being among cancer patients based on PICOS (Participant, Intervention, Control, Outcome, and Study design) framework; (2) synthesize the effects of life review on mental health and well-being among cancer patients.
2.3. Study selection
2. Methods
Two reviewers (ZXL & CY) independently selected the studies based on the review criteria. Before the study selection, the citations of retrieved studies were all imported into EndNote X7 and the duplicates were removed. Pre-screening was conducted to unify the rules of selection and decrease the likelihood of disagreement. Studies were then
The review protocol was registered on the PROSPERP (CRD 42016037493) (PROSPERO, 2016). This systematic review was performed based on the prescribed order in Cochrane Collaboration 139
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participants’ homes (n = 2).
screened by titles and abstracts. Those studies unable to make accurate judgment were tentatively retained for further assessment. After reading the full articles, studies eligible for the selection criteria were identified. Disagreements occurring in selection process were negotiated between the two reviewers, and in consultation with a third person (XHM). The inter-rater reliability (Kappa value) of screening by titles and abstracts was 0.897 (P < 0.001); and by the full articles was 0.938 (P < 0.001).
3.2.2. Participants A total of 899 participants were included, with female participants accounting for 49.72% in this review. The sample size ranged from 10 to 100, with nine studies including more than 50 participants. Mean age varied from 44.4 to 72.45 years. Studies recruited participants with a single cancer (n = 4), and multiple cancers (n = 11). Majority of the participants were diagnosed with different cancers.
2.4. Quality assessment 3.2.3. Life review programs 3.2.3.1. Basic characteristics of life review. The question-guiding based life review interviews were the basic characteristics of life review. However, the interviews were diverse in terms of theoretical underpinning, guideline questions, session, duration, frequency, and facilitator. Regarding theoretical underpinning, most studies were based on Erikson’s Psychosocial Developmental and Butler’s Life Review theory (n = 11), Hack’s or Skinner’s theory (n = 2). All studies conducted life reviews using guideline questions constructed by Haight (n = 14) or Hack’s standardized framework (n = 1). The sessions ranged from two to six, a majority of which were three sessions (n = 6) or four sessions (n = 4). The duration was reported within one week (n = 5), two weeks (n = 2), three weeks (n = 4), or four to six weeks (n = 4). The frequencies were stated once a week (n = 5), or more frequently (n = 7). As for the facilitators of life review, they consisted of therapists (n = 2), clinical psychologists (n = 3), researchers (n = 6), or nurses (n = 4) who either had rich clinical experience, or were well trained in life review theory (See Table 1).
Studies quality was assessed using the Quality Assessment Tool for Quantitative Studies (Thomas et al., 2004). It has been demonstrated as a valid tool for assessing the quality of studies including randomized and clinical controlled trials (Petticrew and Roberts, 2006; ArmijoOlivo et al., 2012). Six domains were rated as strong, moderate, and weak, and a global rating is also assigned to each study as strong (no weak ratings), moderate (one weak rating), or weak (two or more weak ratings). Quality assessment of the studies was independently conducted by two reviewers, and inter-rater reliability (Kappa value) reached 0.898 (P < 0.001). 2.5. Data extraction The content of data extraction contained publication details, study designs, participants, interventions, controls, outcomes and results. It was extracted independently by two reviewers (ZXL & CY) and a consensus was reached by consulting with a third person (XHM). Contacting the authors for further details was the way to deal with missing or unclear data. The inter-rater reliability (Kappa value) was 0.80 (P < 0.001).
3.2.4. Additional elements of life review 3.2.4.1. Memory prompts. Three studies (Batton, 2000; Liu, 2008; Chen, 2011b) introduced memory prompts into life review, facilitating patients to look back on their past in order to enrich life review process. Batton (2000) created a family tree, a time line of significant life events and made an audio recording of life events to awaken patients’ memory of the past. Additionally, his qualitative results revealed that patients can find the location of family and strengthen the sense of belonging through the use of family trees. Liu (2008) and Chen (2011b) made use of albums to promote their recollections.
2.6. Data synthesis No statistical pooling of outcomes was performed, because there was heterogeneity regarding the clinical characteristics of the study designs, participants, intervention intensity and outcomes, therefore, a qualitative analysis was merited. Results were tabulated and overviewed the characteristics of the included studies and life review programs. Additionally, the effects of life review on cancer patients’ mental health and well-being were synthesized by collating the study designs, sample size, and outcome measures in a narrative manner. Regular meetings of the research team clarified any uncertainties and reached consensus on any changes related to the content of qualitative synthesis, including the characteristics of the included studies and life review programs.
3.2.4.2. A legacy product. Eleven studies not only involved life review interviews but also formulated a legacy product (Ando et al., 2010; Xiao et al., 2013; Chen, 2011a; Chen, 2016; Yu et al., 2014; Hoffman, 2003; Shi et al., 2013; Shi, 2015; Lin et al., 2016; Jin, 2014; Wang, 2015). Life text and pictures were the most common. Generally, the facilitators created the product by selecting key words reflecting both positive and negative experiences in patients’ lives and pictures based on their preference. Then; they reviewed it with patients in order to let them reevaluate and integrate the life events; and finally; left a legacy product. For example; Xiao et al. (2013) made a life review booklet; which recorded patients’ significant experiences; views on life; and words for their loved ones to help patients affirm the value in their life. The qualitative data indicated that it was highly praised because it passed on the values of a patient’s life and preserved these as a memorial for families. Hoffman (2003) developed a structured workbook called The Story of My Life; a reflective journal for recording one’s life. It constituted a series of questions concentrating on family; friendship; school; career; hardship etc. Qualitative results indicated that the finished workbook would stay among the patients’ possessions and become a wonderful legacy for family members to cherish. Increasing studies have tended to make a product during a life review. In this review, 11 studies were involved in creating a product in life review process within previous recent six years. Some limited the life text to patients’ life experiences (Chen, 2011a; Jin, 2014; Wang, 2015), while others added death education into the life review product (Yu et al., 2014; Chen, 2016).
3. Results 3.1. Study selection Up until September 2016, a total of 795 studies were retrieved by comprehensive search and 498 studies remained after duplicates were removed. Judged by titles and abstracts, 35 studies were identified for further assessment. After the full-text screening, the final data set was comprised of 15 studies for this review, derived from the database search. Study selection details see Fig. 1. 3.2. Study characteristics 3.2.1. Study designs Fifteen studies were eligible for this review including nine RCTs and six clinical controlled trials. Eleven studies took place in China, with the rest occurring in Japan and America. Most were published from 2010 to 2016 (n = 11) or earlier (n = 4). A majority of the study settings focused on hospitals (n = 10), the others were palliative units (n = 3) or 140
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Fig. 1. Flowchart over literature search.
3.3. Quality assessment of included studies
3.2.5. Control interventions The control group received usual care (n = 9), general support (n = 2), regular phone calling (n = 1), open recreation (n = 1), or no therapy (n = 2). Usual care was related to routine nursing and health education. General support was the process in which therapists interviewed patients regarding physical and mental status, and responded to the patient’s narrative in a nonjudgmental way.
Table 2 demonstrates the quality assessment of the included studies. Specifically, the majority of participants were somewhat representative of the targeted population (n = 14), or poorly representative (n = 1). The study designs were RCT or clinical controlled trials, all rated as strong (n = 15). Confounders were controlled (n = 12), uncontrolled (n = 1), or unspecific (n = 2). Regarding the use of blinding, specific descriptions for participants were unavailable (n = 15). Outcome assessors were blind (n = 2), not blind (n = 2), or unclear (n = 11). As for data collection methods (reliability and validity), they were reported (n = 14), or unclear (n = 1). The follow-up rate was over 80% (n = 13) or 60-79% (n = 2). From the above, the global ratings of RCTs were strong (n = 8) or moderate (n = 1), of that clinical controlled trials were strong (n = 1) or moderate (n = 5).
3.2.6. Outcome variables, instruments and results Sixteen outcome variables were identified measured by 24 scales, which meant that a considerable variation in the measurement instruments was used. Most studies used validated (self-rating) questionnaires or scales. They measured before and immediately after the intervention (n = 12), three weeks after the intervention (n = 1), two and 30 days after the intervention (n = 1), or three months after the intervention (n = 1). Because the main focus of this review is on the effects of life review on mental health and well-being among cancer patients, only the findings on those outcomes (e.g. depression, anxiety, QOL) were presented (see Table 1).
3.4. Effects of life review 3.4.1. Significant reductions in negative emotions Negative emotions synthesized in this review were depression and anxiety. Seven studies (Ando et al., 2010; Chen, 2011a; Jin, 2014; Ando et al., 2006; Liu, 2008; Hoffman, 2003; Lin et al., 2016) reported 141
142
RCT
RCT
Chen (2011b) China
Jin (2014) China
RCT
Xiao et al. (2013) China
RCT
RCT
Ando et al. (2010) Japan
Chen (2011a) China
Designs
Study Country
N = 43 (54.43 ± 7.21) years 28(65.1%) Multiple cancers
19(47.5%) Multiple cancers
N = 40 (55.95 ± 2.63)years
22(30.99%) Single cancer
N = 71 (56.57 ± 8.15) years
38(47.5%) Multiple cancers
N = 80 (59.16 ± 11.50) years
Session:2 Duration: 1 week
36(46.75%) Multiple cancers
Frequency:1/2–7d Facilitator: the first author Setting: participants’ homes Theory: Erikson’s and Butler’s theory Additional element: life album Control group Regular phone calling Life review group Session: 4 Duration:1 week Frequency:4/1 week
Session:3 Duration:6 weeks
Frequency:1/per week Facilitator: clinical psychologist Setting: hospital(ward) Theory: Erikson’s and Butler’s theory Additional element: life text Control group Usual care Life review group
Session:4 Duration: 1 month
Frequency:1/per week Facilitator: the first author Setting: participants’ homes Theory: Erikson’s and Butler’s theory Additional element: life review booklet Control group Usual care Life review group
Session:3 Duration: 3 weeks
Frequency:2/per week Facilitator: clinical therapist Setting: PCUs Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group general support Life review group
Depression, anxiety sense of meaning burden, hope life completion, preparation
Life review group
N = 77 (64.49 ± 13.92) years
Overall mood state TA,DD,AH,FI,CB, VA POMS-SF Measures at before and at the 3-month
Self-transcendence, spiritual well-being hope STS, SWBS, HHS Measures at before and after the intervention (no)
HADS,HHS Measures at before and after the intervention (I = 6 C = 5)
Anxiety, depression, hope
QOLC-E Measures at immediately after the program and at the 3-week follow-up (I = 26,C = 30)
Overall QOL
FACIT-Sp, HADS, Good Death Inventory Measures at before the first session and after the second session (I = 4 C = 5)
Outcomes Measurements (time & dropouts)
Interventions
Participants (numbers, age, female, number of cancers)
Table 1 Characteristics of included studies.
Strong
Strong
Strong
Strong
Moderate
Global Rating
(continued on next page)
Significant in overall mood state (P < 0.01) TA,DD,AH,FI, CB (P < 0.01), VA (P < 0.05)
Significant in self-transcendence, spiritual wellbeing hope (P < 0.05)
Significant in anxiety(P < 0.05) depression, hope(P < 0.01)
Significant in overall QOL (P < 0.05)
Significant in depression, anxiety, sense of meaning, burden, life completion, preparation, hope (P < 0.05)
Results
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RCT
Chen (2016) China
RCT
Wang (2015) China
RCT
RCT
Shi et al. (2013) China
Yu et al. (2014) China
Designs
Study Country
Table 1 (continued)
33(55.93%) Single cancer
N = 64 (55.03 ± 11.29)years
33(46.48%) Multiple cancers
N = 71 (59.48 ± 1.51)years
100(100%) Single cancer
N = 100 (44.4 ± 3.1)years
34(34%) Single cancer
N = 100 (57.45 ± 14.23)years
Participants (numbers, age, female, number of cancers)
Frequency:1/2d Facilitator: the first author Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures
Session:6 Duration:2 weeks
Frequency:1/per week Facilitator: nurse Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures, death education Control group Usual care Life review group
Session:3 Duration: 4 weeks
Frequency: unclear Facilitator: clinical psychologist Setting: hospital Theory: Hack’s theory Additional element: life text Control group Usual care Life review group
Session: unclear Duration: 1 week
Frequency:1/peer week Facilitator: nurse Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group Usual care Life review group
Session:3 Duration:3 weeks
Facilitator: nurse Setting: hospital(ward) Theory: Erikson’s and Butler’s theory Additional element: life text Control group Usual care Life review group
Interventions
CT-DAS Measures at before and 2 and 30 days after the intervention (I = 4 C = 1)
Death anxiety
QLQ-C30 Measures at before and after the intervention (no)
QOL
SSES,HHS Measures at before and after the intervention (no)
Self-esteem, hope
ITAQ,QLQ-C30 Measures at before and after the intervention (no)
QOL
follow-up (no)
Outcomes Measurements (time & dropouts)
Significant in death anxiety (P < 0.05)
Significant in QOL(P < 0.01)
Strong
Strong
Strong
Strong
Global Rating
(continued on next page)
Significant in self-esteem, hope (P < 0.05)
Significant in QOL (P < 0.01)
Results
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CCT
Liu (2008) China
CCT
Batton (2000) America
CCT
CCT
Ando et al. (2006) Japan
Hoffman (2003) America
Designs
Study Country
Table 1 (continued)
5(21.74%) Multiple cancers
N = 23 (57.41 ± 11.87)years
10(100%) Unclear
N = 10 46years
10(41.67%) Multiple cancers
N = 24 (72.45 ± 8.46)years
24(66.6%) Multiple cancers
N = 36 (59.42 ± 5.5)years
Participants (numbers, age, female, number of cancers)
Frequency:3/5 days Facilitator: the first author Setting: meeting room Theory: Erikson’s and Butler’s theory Additional element: life album Control group Usual care
Session:3 Duration:5 days
Frequency: unclear Facilitator: the first author Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life review workbook Control group No therapy Life review group
Session: unclear Duration:4–6 weeks
Frequency:4/1 week Facilitator: recreational therapist Setting: hospital oncology unit Theory: Skinner’s theory Additional element: a family tree, a time line of significant life events and an audio recording of life event Control group Open recreation Life review group
Session:4 Duration:1 week
Frequency: 4/3 weeks Facilitator: clinical psychologist Setting: hospital Theory: Erikson’s and Butler’s theory Additiona element: no Control group No therapy Life review group
CBDI-II,PIL Measures at before and after the intervention (I = 1 C = 3)
Depression, purpose in life
Satisfaction with life, meaning in illness, depression, life-regard, death anxiety CL-FODS, CES-D, SWLS, LRI-R,CMS Measures at before and after the intervention (no)
PAIS,FACT-SP Measures at before and after the intervention (I = 2 C = 3)
QOL, psychosocial adjustment
ZDS,RSES Measures at pretest and post- test (about 3 wk. Later later) (no)
Self-esteem, depression
Control group Usual care Life review group Session: 4(5,7) Duration: 3 weeks
Outcomes Measurements (time & dropouts)
Interventions
Moderate
Moderate
Moderate
Moderate
Global Rating
(continued on next page)
Significant in depression (P < 0.05) purpose in life (P < 0.05)
No significant in satisfaction with life, meaning in illness(P = 0.92), depression (P = 0.67) Life-regard (P = 0.83) Significant in death anxiety3 & 4 (P < 0.05)
No significant in QOL (P = 0.69) psychosocial adjustment (P = 0.69)
Significant in self-esteem (P < 0.01), depression (P < 0.01)
Results
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CCT
CCT
Shi (2015) China
Lin et al. (2016) China
30(50%) unclear
N = 60 (61.11 ± 8.25) years
N = 100 (49.45 ± 1.25) years 25(25%) Single cancer
Participants (numbers, age, female, number of cancers)
Facilitator: the first author Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group Usual care
Session: unclear Duration:1 week Frequency: unclear
EORTCQLQ-C30 HAMD, HMMA,SEES Measures at before and after the intervention (no)
QOL, depression, anxiety, self-esteem
QOL QLQ-C30 Measures at before and after the intervention (no)
Life review group Session:3 Duration:3 weeks Frequency:1/per week Facilitator: nurse Setting: hospital Theory: Erikson’s and Butler’s theory Additional element: life text and pictures Control group Usual care Life review group
Outcomes Measurements (time & dropouts)
Interventions
Significant in QOL, depression, anxiety, selfesteem (P < 0.05)
Significant in QOL (P < 0.05)
Results
Strong
Moderate
Global Rating
Note: RCT, randomized controlled trial; CCT, clinical controlled trial; PCUs, palliative care units; HADS, Hospital Anxiety and Depression Scale; QOL-C30, Quality-of-Life Concerns; FACIT-Sp, Functional Assessment of Chronic Illness TherapySpiritual Scale; STS, Self-Transcendence Scale; TA, Tension-Anxiety; DD, Depression-Dejection; AH, Anxiety-Hostility; FI, Fatigue-Inertia; CB, Confusion-Bewilderment; VA, Vigor-Activity; HHS, Herth Hope Scale; SWBS, Spiritual Well-Being Scale; POMS-SF, Short Form of the Profile of Mood States; ITAQ, Insight and Treatment Attitude Questionnaire; QLQ-C30, Quality of Life Questionnaire-Core30; SSES, State Self −Esteem Scale; ZDS, Zung's Depression Scale; RSES, Rosenberg's Self-Esteem Scale; PAIS, Psychosocial Adjustment to Illness Scale; CL-FODS, Collett-Lester Fear Of Death Scale; CES-D, Center for Epidemiological Scale for Depression; SWLS, Satisfaction With Life Scale; LRI-R, Life Regard Index-Revised; CMS, Constructed Meaning Scale; CBDI-II, Carbon Black Dispersion Index; PIL, Chinese version Purpose In Life; HAMD, Hamilton Depression Scale; HAMA, Hamilton Anxiety Scale; RSES, Rosenberg Self-Esteem Scale; CT-DAS, Chinese Version of Templer-Death Anxiety Scale; EORTCQLQ-C30,European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core30.
Designs
Study Country
Table 1 (continued)
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Table 2 Quality assessment of included studies. Author/Year
Selection Bias
Study Design
Confounders
Blinding
Data Collection Methods
Withdrawals and Dropouts (follow-up rate)
Global Rating
Ando et al. (2010) Xiao et al. (2013) Chen (2011a) Chen (2011b) Jin (2014) Shi et al. (2013) Wang (2015) Yu et al. (2011) Chen (2016) Ando et al. (2006) Batton (2000) Hoffman (2003) Liu (2008) Shi (2015) Lin et al. (2016)
2 2 2 2 2 2 2 2 2 2 2 2 3 2 2
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 3 3 3 1 1 1
3 2 2 2 2 2 2 2 2 2 2 2 2 2 2
1 1 1 1 1 1 1 1 1 1 1 1 1 3 1
1 2 1 1 1 1 1 1 1 1 2 1 1 1 1
2 1 1 1 1 1 1 1 1 2 2 2 2 2 1
Note: 1 = strong, 2 = moderate, 3 = weak.
interviews. This review displays the promising effects of life review on reducing depression and anxiety, as well as improving hope, self-esteem, and QOL of cancer patients. The positive results in depression and anxiety may be because life review provides an opportunity to express and re-evaluate negative feelings, and retrieve positive thoughts. Previous studies (Graybeal et al., 2002; Niederhoffer and Pennebaker, 2009) have demonstrated that expressing stressful experiences is a good way to deal with negative feelings. These kinds of face-to-face therapeutic sessions emphasize privacy, which allows patients to feel safe in sharing their personal experiences with a facilitator. To a certain extent, people are willing to reveal their innermost feelings to strangers, helping to alleviate negative feelings (Jin, 2014). During the life review, patients are encouraged to look back on their lives and reflect on past experiences, including positive events, unresolved difficulties and conflicts. Korte et al. (2012a,b) have supported that the reduction in depression and anxiety may be achieved via the accumulation of positive thoughts. As for painful memories that may be picked up in life review process, the facilitator would guide them to consider these memories from other perspectives. Accordingly, patients are able to let go, accept or even gain a fresh insight into their lives, and finally achieve self-integrity (Woods et al., 2005). Apart from significant reductions in negative emotions, significant improvements in hope and self-esteem were perceived among cancer patients in this review. Possible reasons for the effectiveness in increasing hope may be that life review helps patients collate and learn from their past, gain a better understanding of their current situation, and inspire them to take action congruent with the palliative situation. Scholars (Park and Folkman, 1997; Folman and Greer, 2009) have also put forward the idea that establishing an attainable goal can foster hope. Therefore, when patients set goals matched with their ability, they are more likely to be successful, which brings an elevated level of hope. The explanation for the life review’s effectiveness in enhancing self-esteem may be that patients are empowered to acquire a sense of value from their past achievements. Chiang et al. (2008) have supported that patients alter their individual negative understanding, and further affirm life values in order to improve their self-confidence and self-esteem. This review showed that life review has a positive impact on QOL. It may be possible that patients are in a positive state when reviewing their lives. Such feelings are maintained for a period of time if patients view, touch, and appreciate the product made in life review process. It is also because life review has an active impact on individual and social support, as well as on family relationships, which may result in a better QOL. Dahley and Sanders (2016) has found that patients are likely to get in touch with other people after completing a life review.
depression in 320 participants using six measurements. Three studies with strong quality and four studies with moderate quality except for the study by Hoffman (2003), indicated a statistically significant effect of life review on depression reduction among cancer patients. Three studies (Ando et al., 2010; Chen, 2011a; Jin, 2014) explored the effects of life review on anxiety with HADS or POMS-SF in 191 participants, and positive results were observed in these studies. The study by Ando et al. (2010) demonstrated that life review was effective in alleviating depression and anxiety. It is worth mentioning that he discovered that short-term intervention contributed to lowering the drop-out rate resulting from cancer patients’ physical deterioration. 3.4.2. Significant improvement in hope, self-esteem and QOL Significant improvement in positive well-being included hope, selfesteem and QOL. Four studies (Ando et al., 2010; Chen, 2011a; Chen, 2011b; Wang, 2015) with 268 participants measured the level of hope by HHS except for Ando et al. (2010). Self-esteem was tested in three studies (Wang, 2015; Ando et al., 2006; Lin et al., 2016) with 196 participants using the State Self-Esteem Scale and Rosenberg Self-Esteem Scale. Participants of the life review group found elevated levels of hope and self-esteem when compared to the control group. Some studies found a significant decrease in hope and self-esteem in the control group (Ando et al., 2010; Wang, 2015; Lin et al., 2016). Six studies (Xiao et al., 2013; Shi et al., 2013; Yu et al., 2014; Batton, 2000; Shi, 2015; Lin et al., 2016) identified a positive effect on QOL measured by QLQ-C30, QOLC-E, and FACT-Sp in 435 participants. Although no statistical significance could be established in the study by Batton (2000), it found a positive relationship between psychosocial adjustment and QOL improvements confirmed by quantitative analysis. These studies have indicated that life review with a product can allow patients to relive personal life experiences, share knowledge and wisdom, and improve their relationships with others, which facilitates their perceived QOL. 4. Discussion 4.1. Primary findings This is the first review to determine the effects of life review on cancer patients. Fifteen studies met the inclusion criteria through the comprehensive search. We speculated that the research on life review specific to cancer patients was immature. But it shows an upward tendency in research of this field in recent years, according to the distribution of time in current studies. Noticing the characteristics of life review, more researchers are inclined to include various memory prompts and a legacy product, in addition to conducting life review 146
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Connecting with others can open communication, enhance understanding, and bridge distant relationships between family members and friends.
further explore the effects of life review.
4.2. Methodological limitations of the studies
The study was supported by the Chinese National Nature Science Foundation of China [8140, 1863] and Fujian Provincial National Nature Science [2017J01814].
Funding
The quality of eight RCTs was strong (one was moderate); that of five clinical controlled trials was moderate (one was strong). The key issues of the quality were confounders. Most moderate quality clinical controlled trials indicated a lack of randomization, leading to the confounders between groups. Another issue was lack of blinding. When not blinded to psychological interventions, participants are prone to generate the Hawthorne effect, as well as being affected by psychological suggestion; the outcome assessors may also overestimate the effects of intervention group; and the facilitators may have different expectations of intervention group. Although the blind is required for experimental trials, it is difficult to totally blind both participants and facilitators to treatment in psychological research.
Ethical approval None declared. Conflict of interest None declared. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ijnurstu.2017.06.012.
4.3. Limitations of the review
References
Some limitations may exist in this review. First, grey literature was incompletely identified and studies with deficient data or unavailable full text were not included in this review. However, this may not have much influence on the results, because grey literature usually has a small number of small participants as well as inconclusive results (Mc Auley et al., 2000). Second, only English or Chinese studies were included, eligible studies in other languages may have been omitted. Third, the long-term effects of life review were rarely explored in the included studies, and therefore remain unknown. Finally, this review synthesized the results without meta-analysis, due to different control interventions in the included studies.
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4.4. Implications for clinical practice and research In view of the strengths of life review with regard to mental health and well-being, it is suggested that life review is suitable for clinical practice. Some recommendations may be helpful when a life review is conducted. First, life review can be implemented as early as possible when cancer patients begin suffering from psychological problems. To a certain extent, early intervention can guarantee the completeness of a life review. Second, facilitators should appropriately schedule the time of life review. Ando et al. (2010) echoed that a long-term life review contributed to a high drop-out rate due to the physical deterioration of cancer patients. Third, a life review product should be considered when designing a life review program. It could be a life review album, a life review booklet, or a short video. Such a product not only adds an element of fun for participants, but also leaves them with a life legacy. Moreover, participants will likely continue to review their lives after the life review, when viewing the products alone or with their families. The review also reveals suggestions for future research. Given the methodological flaws of previous studies, multi-center, interdisciplinary and transregional research with rigorous design is necessary. Apart from reporting those promising outcomes mentioned above, adverse effects of life review should also be observed and recorded. Future research can further explore the long-term effects and cost-effectiveness of life review, which are still inconclusive. 5. Conclusion Life review can reduce depression and anxiety, foster hope, and improve self-esteem and QOL among cancer patients. This suggests that life review can be integrated into usual care to enhance cancer patients’ well-being. However, these findings were derived from moderate quality data in half of the studies, and the firmness of our conclusion is limited. More research with rigorous design is necessary in order to 147
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