Behavioral Activation impacts symptoms of depression and anxiety, psychological distress, and quality of life among colorectal cancer patients in medical settings

doi:10.21203/rs.3.rs-4449715/v1

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Behavioral Activation impacts symptoms of depression and anxiety, psychological distress, and quality of life among colorectal cancer patients in medical settings

https://doi.org/10.21203/rs.3.rs-4449715/v1

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Background and Objectives: The protracted treatment of colorectal cancer often leads to diminished quality of life and the manifestation of psychological symptoms, notably depression, as patient survival increases. Behavioral Activation (BA) therapy is designed to bolster patients' reinforcement sources and diminish avoidance behaviors, thereby progressively fostering proactive engagement. This study aims to assess the influence of BA on the behavioral patterns of colorectal cancer patients, its therapeutic efficacy against negative emotions such as depression, and its impact on their quality of life.

Methods:One hundred and seven colorectal cancer patients with depressive symptoms were randomized into two groups: a BA group (n=54) and a conventional treatment group (n=53). Evaluations were conducted before the intervention (T0), after the fourth intervention session (T1), and upon completion of the intervention (T2).

Results:Notable differences emerged between the BA group and the conventional treatment group. Repeated measures ANOVA revealed BA’s significant efficacy in ameliorating depression (F=39.113, p<0.001, ηp²=0.439), alleviating anxiety (F=29.847, p<0.001, ηp²=0.374), enhancing quality of life (F=23.086, p<0.01, ηp²=0.316), and reducing psychological distress (F=93.684, p<0.001, ηp²=0.652). The analysis also substantiated the correlation between activation and avoidance behavioral patterns and the symptoms of depression.

Conclusion:Behavioral Activation proves to be a potent intervention for ameliorating depressive and other adverse emotional states, as well as for enhancing the quality of life among colorectal cancer patients. It effectively modifies the behavioral patterns of patients undergoing conventional treatments within clinical settings.

Trial registration number: ChiCTR2100052108, 10/17/2021.

Behavioral Activation

Cancer

Quality of Life

Anxiety

Depression

According to 2020 global cancer statistics, colorectal cancer has risen to become the third most commonly diagnosed cancer globally and the second leading cause of cancer-related mortality[1]. In the same year, colorectal cancer represented 10% of all cancer cases worldwide, contributing to 9.4% of total cancer fatalities [1]. Notably, China ranks second globally in terms of colorectal cancer cases. The incidence of colorectal cancer in China is on a sharp incline, expected to increase from 560,000 cases in 2020 to 910,000 by 2040, marking a 64% surge[2]. Advances in early diagnosis, along with enhancements in chemotherapy, surgical techniques, and radiation therapy, have doubled the overall survival rate for patients with advanced stages of the disease to three years[3]. Despite these advances, the long-term adverse effects associated with cancer treatments, the inherently lower survival rates of colorectal cancer, and frequent complications substantially diminish patients' quality of life. Colorectal cancer survivors often experience heightened negative emotions, with a markedly increased prevalence of depression compared to the general population [4,5].Previous studies have linked depression and anxiety strongly with several cancers, including oropharyngeal, pancreatic, breast, and lung cancers, with prevalence rates ranging from 13–25% among colorectal cancer patients [6]. A meta-analysis focused on the psychological distress of individuals with colorectal cancer shows depression rates fluctuating between 1.6% and 57%, and anxiety rates from 1.0–47.2%[7].

Globally, depression is a pervasive and severe mental disorder, affecting over 120 million individuals. The World Health Organization (WHO) estimates that in China alone, around 54 million people suffer from depression, and 41 million exhibit symptoms of anxiety. Depression significantly contributes to the risk of suicide attempts, with a population attributable risk of approximately 28%. Projections indicate that by 2030, depression will become the foremost cause of death worldwide[8,9]. Regrettably, the symptoms of depression and anxiety can activate biological pathways that may expedite tumor progression. In individuals with depression, stress, inflammation, and immune responses are known to hasten the progression of tumors[10]. Stress is implicated at every stage of tumor onset, angiogenesis, and metastasis [11]. Furthermore, sleep disturbances, decreased physical activity, and inadequate dietary habits in depressed and anxious individuals can influence tumor development through pathways involving the immune system, inflammation, and metabolism[12,13]. Certain therapeutic approaches targeting depression and anxiety can also affect cancer outcomes. Antidepressants, for instance, effectively reduce symptoms of anxiety and depression in cancer patients, albeit with a modest efficacy of about 30% in cases of severe depression[14]. Additionally, clinical and experimental research has established a correlation between the use of antidepressants and the incidence of cancer[15–18]. Psychological interventions, such as cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction, have proven effective in ameliorating symptoms of depression and anxiety, enhancing survival by impacting the interrelated pathways of depression pathophysiology and cancer survival[19]. CBT, a primary treatment modality for depression, is renowned for its therapeutic effectiveness, maintenance benefits, and high adherence rates. Nevertheless, the extensive training and high costs associated with employing skilled therapists, along with the complexity of the treatment, restrict its widespread application, particularly among cancer patients. This necessitates the exploration of more suitable psychological interventions tailored for cancer patients grappling with depression.

Behavioral Activation (BA) therapy, derived from CBT, offers a structured, brief psychological intervention aimed at increasing participation in adaptive activities (typically associated with pleasure or a sense of control) and decreasing engagement in activities that perpetuate or escalate the risk of depression. It also tackles challenges related to insufficient rewards, maintenance issues, or increased exposure to unpleasant experiences[20]. A distinctive feature of BA is its adaptable scheduling [21].During the intervention, therapists use activity and emotional monitoring to establish goals, subsequently devising plans to augment activities that counter depressive tendencies and employing problem-solving techniques to modify environments that might trigger or sustain depressive states. The concluding phase of treatment emphasizes consolidating the gains achieved and formulating strategies to prevent relapse. In instances where activity barriers emerge, therapists collaborate with patients to evaluate the functionality of behaviors and formulate solutions for upcoming activation tasks [22]. Empirical studies and meta-analyses have confirmed that BA effectively alleviates depressive symptoms and is comparable in efficacy to CBT and antidepressant medications [23–25]. BA also offers several advantages particularly well-suited to cancer patients: it features a simple structure, straightforward treatment elements that patients can easily comprehend and apply [26]. Its implementation is straightforward, requiring minimal specialist training, enabling even individuals without a psychological background to competently administer it[27]. The intervention can be conducted in various settings, and remote modalities via the internet or telephone maintain effectiveness[28–30]. BA also proves more cost-effective compared to traditional CBT, reducing financial expenditures by 21% [31].

Cancer patients frequently encounter negative emotional states due to the physical discomfort caused by the illness, the side effects of treatment, and psychological pressures, manifesting as behavioral inhibition and avoidance. This psychological state not only impairs their quality of life but can adversely affect the efficacy of treatment protocols[32]. Thus, employing BA to foster positive behavioral responses in patients and enhance their quality of life has emerged as a pivotal area of research within the field of cancer rehabilitation. At the heart of BA lies the goal of identifying and reinforcing healthy behaviors, aiding patients in developing a positive lifestyle. Specifically, the BA method incorporates various change strategies, including identifying avoidance patterns, conducting behavioral function assessments, guiding activities, psychological rehearsals, regular distraction, mindfulness training, meditation cue activation, and skills training. These strategies are designed to help patients recognize their detrimental behavioral patterns, learn to assess the functionality of their behaviors, and gradually guide them towards engaging in activities beneficial for their physical and mental well-being. Cancer patients form a unique demographic that requires regular hospital visits for checks or treatments, yet their condition restricts their mobility. Effectively managing medical appointments and balancing the physical and emotional tolls of cancer treatment is crucial. A meta-analysis on Internet-Delivered Behavioral Activation (iBA) for depressive symptoms indicates that iBA demonstrates statistically significant effects compared to conventional treatment groups, although purely iBA effects are smaller, and unguided iBA interventions do not reach significance[30]. Moreover, compared to face-to-face psychological therapy, telephone-based interventions may result in lower dropout rates[33]. Given the broad availability of telecommunication, phone-based BA represents a promising and effective psychological treatment modality for cancer patients experiencing concurrent depression. Upon completion of the treatment, satisfaction ratings from participants concerning BA will be collected to assess the feasibility of implementing the BA program among cancer patients.

While BA's application in cancer patients has been relatively limited, focusing primarily on breast cancer patients, it has not yet been firmly established in colorectal cancer patients. Due to the significant clinical, treatment, and prognostic heterogeneity among different cancer types, coupled with pronounced sociodemographic differences, it is imperative to conduct independent analyses of BA's efficacy across diverse cancer types. This study initiates a randomized controlled trial aimed at evaluating the shifts in depressive and anxiety symptoms, quality of life, psychological distress, and behavioral patterns between colorectal cancer patients receiving standard care and those undergoing BA therapy, to elucidate the impact of BA therapy on enhancing the quality of life for colorectal cancer patients.

Experimental Design

Baseline data, including demographic information (gender, age, tumor staging, treatment modalities, Karnofsky Performance Scale (KPS) scores), as well as assessments of quality of life, depression, anxiety, behavioral patterns, and psychological distress, were collected prior to the intervention. A satisfaction survey was administered to the BA group upon completion of the course to evaluate the program's feasibility. From April to December 2023, 107 patients with Hospital Anxiety and Depression Scale (HADS) depression scores of 8 or higher were recruited for this study. Patients were randomly assigned to either the usual care (UC) or behavioral activation (BA) group. Evaluations were conducted pre-intervention (T0), after the fourth intervention (T1), and post-intervention (T2).

Participants

Inclusion Criteria:

1) Aged 18 years or older, with adequate visual and auditory capabilities.

2)Good functional status, KPS score of 80 or above.

3)No prior psychological interventions.

4)Diagnosed with colorectal cancer, with an expected lifespan of six months or more.

5)HADS depression score of 8 or above.

6)Capable of independently documenting and communicating, or with family support.

7)Regular requirement for in-hospital treatments or check-ups.

Exclusion Criteria:

1)Diagnosed with cognitive impairing neurological diseases.

2)Previous use of medications for cognitive enhancement.

3)Presence of other severe chronic illnesses or organ damage.

Termination Criteria:

1)Severe adverse events or reactions that preclude further participation.

2)Deterioration of physical or psychological symptoms, or emergence of new symptoms that inhibit continued intervention.

3)Withdrawal of consent by the patient.

4)Missing more than three scheduled sessions.

5)Administration of psychiatric medications as deemed necessary by the primary physician during or between intervention phases.

6)Fulfillment of exclusion criteria during the waiting period.

7)Other medically justified reasons for intervention cessation as determined by the attending physician.

Recruitment

Recruitment occurred from April 2023 to March 2024 at the Second Hospital of Anhui Medical University's Oncology Department. After screening with the HADS, baseline data were collected, and participants were informed about the study and consented. Post-consent, participants were notified that the fourth and eighth sessions would be conducted in-hospital to enhance adherence. The intervention schedule was synchronized with patients' treatment schedules, and interventions were conducted offline in accordance with agreements with attending physicians.

Randomization

Participants were randomly allocated to either the BA or UC groups in a 1:1 ratio using a computer-generated schedule. BA therapists provided individualized therapy in the oncology department’s conference room. Evaluators assessed life quality, depression, anxiety, sleep, social support, and psychological distress within 30 minutes post-session. Therapists conducted interventions based on randomization, while evaluators, blind to group assignments, were responsible for ongoing psychological assessments.

Intervention

The BA course, structured according to the Brief Behavioral Activation Therapy for Depression (BATD-R) manual, consisted of eight weekly sessions lasting 30–50 minutes each. Homework lasting 5–10 minutes was assigned post-session, including five specialized and three recurring sessions. After completing the course, patients were able to conduct recurring sessions independently. The overall course duration was two months. The intervention was implemented offline in designated conference rooms, with supplemental sessions via phone or WeChat app. The research team, consisting of three graduate students, one oncologist, and one psychologist, all specializing in psycho-oncology, ensured the therapy's standardization and integrity. Weekly team meetings were held to supervise the therapeutic process, with therapists documenting each session comprehensively for record-keeping and future review.

Scales

Hospital Anxiety and Depression Scale (HADS):

Developed in 1983 by Zigmond and colleagues, the HADS is a 14-item scale divided into two subscales, assessing anxiety (HADS-A) and depression (HADS-D)[34]. Odd-numbered items measure depression, while even-numbered items measure anxiety, with scores ranging from 0 to 21. Higher scores indicate more severe symptoms of anxiety or depression. This scale has been validated as a precise tool for identifying depression[35] and anxiety[36] in cancer patients. For this study, the HADS was used to assess the symptoms of anxiety and depression among the participants.

European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30):

The EORTC QLQ-C30 is a cancer-specific instrument that includes 30 items, incorporating five functional scales—physical, emotional, role, cognitive, and social—along with two items assessing overall quality of life, and three symptom scales for fatigue, vomiting, and pain[37]. Additionally, it features six single-item scales for symptoms like shortness of breath, insomnia, appetite loss, constipation, diarrhea, and financial difficulties. The scale is extensively validated, translated into over 80 languages[38], and has proven reliability and validity in a variety of cancers, including gastrointestinal cancers. The comprehensive score is calculated by averaging the scores from 13 QLQ-C30 scales and items (excluding overall quality of life and financial impact)[39,40], with higher scores indicating a better health-related quality of life[41,42].

Distress Thermometer (DT):

The DT is commonly used to measure a patient’s level of psychological distress over the past week, including the day of assessment. It covers a range of issues from practical and family to emotional, spiritual/religious, and physical. The scale ranges from 0 to 10, with a recommended threshold of 4 for identifying significant distress. Higher scores represent greater levels of distress. The DT is particularly effective in evaluating the severity and type of distress in cancer patients[43].

Behavioral Activation for Depression Scale - Short Form (BADS-SF):

The BADS-SF is a 9-item questionnaire intended to assess levels of behavioral activation in patients with depression. It focuses on determining when and how patients are activated during BA therapy. The scale includes two subscales: activation and avoidance. Demonstrating good internal consistency and validity, the BADS-SF is established as a reliable, effective, and useful questionnaire for measuring behavioral activation levels in patients suffering from depression[44].

Statistical Analysis

The analysis was conducted using a modified intention-to-treat (mITT) approach, employing IBM SPSS Statistics 23.0 for all computations. Categorical data were assessed using Chi-square tests, while the equivalence between the Behavioral Activation (BA) group and the Usual Care (UC) group was determined through independent samples t-tests. To evaluate the temporal changes from baseline (T0) at four weeks (T1) and eight weeks (T2), repeated measures Analysis of Covariance (ANCOVA) with Type III Sum of Squares was utilized. This method facilitated the examination of differences in outcome variables between the two groups and analyzed the effect of measurement times. All p-values were obtained from two-tailed tests, with the significance threshold set at 0.05. Adjustments to the degrees of freedom for all repeated measures ANOVA results were made according to the Greenhouse-Geisser method, and effect sizes were calculated using partial eta squared (ηp²).

Baseline Demographics and Clinical Characteristics

As depicted in Table S1 and Figure S1, of the 178 patients who completed the Hospital Anxiety and Depression Scale (HADS), 30 were excluded due to HADS-Depression scores below 8, resulting in 148 eligible participants. Subsequently, 29 individuals opted out for various reasons. The remaining 119 participants were evenly allocated to the Behavioral Activation (BA) group (n = 61) and the Usual Care (UC) group (n = 58). Of these, 7 in the BA group and 5 in the UC group did not complete their respective interventions. Thus, the final cohort consisted of 54 participants in the BA group and 53 in the UC group. No significant differences were observed between groups at baseline in terms of demographic and clinical characteristics such as age (t = 0.426, p = 0.671), BMI (t = 0.278, p = 0.782), gender distribution (χ²=0.225, p = 0.635), education level (χ²=4.785, p = 0.091), primary caregiver presence (χ²=3.116, p = 0.374), Karnofsky Performance Status (KPS) score (χ²=1.315, p = 0.518), tumor location (χ²=3.700, p = 0.157), histological type (χ²=3.365, p = 0.186), cancer stage (χ²=4.850, p = 0.183), and treatment approach (χ²=1.577, p = 0.813).

Dynamics of HADS, EORTC QLQ-C30, BADS-SF, and DT Scores During Treatment

As detailed in Table 1 and Fig. 1, participants in the BA group exhibited significant reductions in depression and anxiety scores on the HADS and psychological distress scores, concurrent with significant improvements in quality of life and activation-avoidance scores (F = 48.302, F = 21.801, F = 57.409, F = 60.477, F = 68.175, F = 71.766, respectively; p < 0.001). In contrast, in the UC group, increases in depression and anxiety scores and slight declines in quality of life and activation-avoidance scores were observed, with significant differences in all metrics except avoidance (F = 12.870, p < 0.001; F = 3.486, p = 0.038; F = 20.062, p < 0.001; F = 17.879, p < 0.001; F = 9.533, p < 0.001; F = 0.523, p = 0.523, respectively;).

Table 1

Changes in the HADS, EORTC QLQ-C30, BADS-SF and DT scores over the course of treatment in the BA group and UC group.
Item(mean ± SD)	T0	T1	T2	F	P	ηp2
BA(n = 54)
HADS-D	12.96 ± 3.38	9.33 ± 4.00	6.57 ± 5.12	48.302	<.001**	0.65
HADS-A	9.26 ± 3.77	7.19 ± 3.87	5.07 ± 4.65	21.801	<.001**	0.456
DT	6.07 ± 1.50	4.78 ± 1.45	3.15 ± 1.68	57.409	<.001**	0.688
EORTC QLQ-C30	65.30 ± 18.48	76.58 ± 15.39	88.38 ± 10.18	60.477	<.001**	0.699
BADS-SF-AC BADS-SF-AV	14.07 ± 3.73 9.81 ± 3.36	20.06 ± 3.94 14.26 ± 3.45	20.78 ± 6.11 16.69 ± 4.1	68.175 71.766	<.001 <.001	0.724 0.734
UC(n = 53)
HADS-D	13.32 ± 3.06	13.53 ± 3.13	14.68 ± 3.18	12.870	<.001**	0.335
HADS-A	10.32 ± 3.52	10.85 ± 3.93	11.47 ± 4.52	3.486	0.038	0.12
DT	5.98 ± 1.79	6.08 ± 1.83	6.77 ± 2.02	20.062	<.001**	0.44
EORTC QLQ-C30	67.21 ± 15.79	65.04 ± 17.05	58.81 ± 16.98	17.879	<.001**	0.412
BADS-SF-AC BADS-SF-AV	14.58 ± 3.04 9.43 ± 2.76	13.55 ± 3.23 9.15 ± 2.60	12.92 ± 3.03 9.08 ± 2.34	9.533 0.523	<.001** 0.596	0.272 0.02
Abbreviations: BA, behavioral activation; SD, standard deviation; P, level of significance; T0, before BA treatment; T1, after4 BA sessions; T2, after 8 BA sessions; HADS-D, Hospital Anxiety and Depression Scale-depression; HADS-A, Hospital Anxiety and Depression Scale-anxiety; EORTC QLQ-C30, European Organization for Research and Treatment Core Quality of Life questionnaire of Cancer-30; DT, distress thermometer; BADS-SF, Behavioral Activation for Depression Scale-Short Form; AC, Activation; AV, Avoidance; CSQ, Customer Satisfaction Questionnaire; **P < 0.01.

Table 2

Comparison of HADS, EORTC QLQ-C30, BADS-SF and DT scores between the BA group and the UC group.
Item	group			session			Group*Session
Item	F	P	ηp2	F	P	ηp2	F	P	ηp2
HADS-D	45.411	<.001	0.302	24.971	<.001	0.324	52.213	<.001	0.501
HADS-A	28.543	<.001	0.214	7.827	<.001	0.131	24.062	<.001	0.316
DT	30.371	<.001	0.224	20.009	<.001	0.398	93.684	<.001	0.652
EORTC QLQ-C30 BADS-SF AC AV	21.296 60.124 70.785	<.001 <.001 <.001	0.169 0.364 0.403	18.567 33.054 46.123	<.001 <.001 <.001	0.278 0.389 0.470	69.046 73.316 56.772	<.001 <.001<.001	0.570 0.585 0.522
Abbreviations: P, level of significance; F, Effect size; HADS-D, Hospital Anxiety and Depression Scale-depression; HADS-A, Hospital Anxiety and Depression Scale-anxiety; EORTC QLQ-C30, European Organization for Research and Treatment Core Quality of Life questionnaire of Cancer-30; DT, distress thermometer; BADS-SF, Behavioral Activation for Depression Scale-Short Form; AC, Activation; AV, Avoidance.

Comparative Analysis of HADS, EORTC QLQ-C30, BADS-SF, and DT Scores

As reported in Table 1, comparative analyses via repeated measures ANOVA revealed significant inter-group effects (F = 45.411, F = 28.543, F = 30.371, F = 21.296, F = 60.12, F = 70.785, respectively; p < 0.001) and prominent session main effects (F = 24.971, F = 7.827, F = 20.009, F = 18.567, F = 33.054, F = 46.123, respectively; p < 0.001). Noteworthy were the interactions between session and group (F = 52.213, F = 24.062, F = 93.684, F = 69.046, F = 73.316, F = 56.772, respectively; p < 0.001).

Trends and Correlations in Scale Changes Across Groups

Illustrated in Fig. 2, the BA group showed consistent declines in depression, anxiety, and psychological distress scores, while experiencing rises in quality of life, activation, and avoidance scores. Conversely, the UC group demonstrated rising trends in depression, anxiety, and psychological distress scores, with corresponding decreases in quality of life, activation, and avoidance scores.

Further analysis, as detailed in Figs. 3, revealed that in both the BA and UC groups, depression scores were inversely correlated with activation and avoidance scores, indicating that higher levels of activation and avoidance were associated with more severe depressive symptoms. Specifically, pre-course correlations in the BA group were activation r=-0.768, avoidance r=-0.741; post-four sessions: activation r=-0.908, avoidance r=-0.767; and post-course: activation r=-0.545, avoidance r=-0.860. Corresponding correlations in the UC group were also significant (p < 0.001).

Similarly, negative correlations between depression scores and quality of life scores were evident in both groups, signifying that higher depression levels correlated with poorer quality of life (BA group—pre-course: r=-0.573; post-four sessions: r=-0.606; post-course: r=-0.648; UC group—pre-course: r=-0.682; post-four sessions: r=-0.701; post-course: r=-0.607, p < 0.001).

Depression, psychological distress, and other negative emotional states are exceedingly prevalent among colorectal cancer patients, leading to significant disruptions in their daily lives. Given the structured routines and substantial economic pressures faced by these patients, it is crucial to identify effective strategies to alleviate such negative emotions. Behavioral Activation (BA) stands out from other psychological interventions by relying on the principles of behavioral models, focusing on behavior change, and employing behavioral interventions[45]. This approach is well-adapted to the routine care of cancer patients, whose activities vary based on differences in treatment methods, medications, environmental conditions, tumor progression, and family dynamics.

Although previous studies have demonstrated the effectiveness of self-help apps and internet-delivered BA across various demographics, our findings emphasize the need for personalized programs with moderate guidance[46]. In clinical settings, the development of straightforward intervention measures could be particularly valuable. BA’s flexibility, low cost, and simplistic course design hold promise for effectively managing the psychological distress of cancer patients[26–30]. Implementing these services in hospitals significantly enhances treatment accessibility and adherence, thereby reducing the stress experienced by cancer patients[47].

To our knowledge, this study is the first randomized controlled trial to assess the effectiveness of Behavioral Activation in reducing depressive symptoms among colorectal cancer patients. Our findings confirm that BA significantly improves both the emotional well-being and quality of life of these patients. The primary focus on depression showed that the BA group experienced significant changes, consistent with other related research[47–49]. At the end of the intervention, 68.5% of participants (37 out of 54) achieved HADS-D scores below the clinical threshold. However, some patients did not benefit, potentially due to insufficient adherence to the intervention. While most participants noted a significant reduction in depressive symptoms, the phenomenon of 'sudden gains' frequently discussed in other studies was not observed, likely due to the small sample size or specific characteristics of the colorectal cancer population. Secondary outcomes indicated marked differences between the BA and UC groups: patients in the BA group reported improvements in anxiety symptoms and psychological distress, as well as enhanced quality of life. In contrast, the UC group exhibited slight increases in anxiety and psychological distress, with a corresponding decline in overall quality of life.

Behavioral Activation posits that the core behavioral issue in depression is the avoidance of aversive events. Its central aim is to activate patients by organizing activities that provide high levels of pleasure and control, thus increasing positive reinforcements while minimizing withdrawal behaviors[50]. This ultimately helps reintegrate patients into normal life[22]. Derived from Cognitive Behavioral Therapy (CBT), BA is a brief, structured treatment that emphasizes activation without cognitive adjustment, focusing on problem-solving, long-term behavioral changes, and maintaining goal integrity[23]. This helps patients overcome maladaptive behaviors and establish a positive lifestyle and habits, thereby gradually overcoming depression.

Furthermore, the mechanisms of action for BA are multifaceted. BA engages the brain’s reward system, primarily mediated by dopamine neurotransmission within the midbrain limbic pathways. Encouraging individuals to participate in beneficial activities stimulates dopamine release, enhancing pleasure and motivation. This activation plays a crucial role in regulating mood and motivation, aiding in the alleviation of depressive symptoms[51]. BA also promotes neuroplasticity, enhancing the brain’s capacity to reorganize and form new connections between neurons. Increased involvement in meaningful activities fosters neuronal activity and synaptic plasticity, particularly in areas related to emotional regulation and cognitive control. This enhanced neuroplasticity may help reshape neural circuits associated with depression, improving mood and emotional regulation[52]. Lastly, BA interventions that involve structured goal setting and planning activities stimulate the prefrontal cortex, particularly the dorsolateral prefrontal cortex (DLPFC), which is vital for emotional regulation and cognitive control. Strengthening prefrontal cortex activity enhances cognitive flexibility and emotional regulation, further alleviating depressive symptoms[53].

Our study also indicates that BA improves patients' quality of life, supporting findings similar to those by Fernández et al[54]. WHO defines quality of life as individuals' perceptions of their position in life within the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. Quality of life is generally regarded as a comprehensive measure of an individual or group's well-being across physiological, psychological, and social domains. This broad concept intricately combines aspects of physical health, mental state, level of independence, social relationships, personal beliefs, and their relationship with significant environmental features. BA actively engages with patients to address and resolve encountered issues, scientifically schedules activities to ensure their implementation, and therapists continually educate about cancer, altering patients’ misconceptions about the disease. Finally, the program employs psychological strategies such as mindfulness practices, cognitive restructuring, self-monitoring, and social skills training, all contributing to improved quality of life and reduced negative emotions.

This study has limitations. First, as a small sample randomized controlled trial, the sample size may be insufficient for comparing outcomes across patient subgroups or identifying specific moderating factors influencing treatment results. Second, while HADS is effective as a screening tool for depressive symptoms, the enrolled patients did not have a clear clinical diagnosis. Lastly, although BA is an excellent psychological intervention method with high retention rates, this experiment lacked follow-up studies, preventing further verification of BA's long-term impact on patients. Future research will aim to expand the sample size, include post-treatment follow-ups, and ensure the study's rigor and completeness.

BA may alleviate depression and anxiety symptoms, reduce psychological distress, and improve the quality of life for colorectal cancer patients. Strengthening psychological interventions is crucial for cancer survivors. According to BA theory, implementing BA can help change the behavioral patterns of cancer survivors. This study suggests that BA may be an effective method in medical settings for improving negative emotions among cancer survivors.

Acknowledgements

We would like to thank all the patients who participated in the study.

Author contributions

LA, GH, HR planned the study. LA, GH and LL took part in the process of data collection. LA carried out analysis, interpreted results and drafted the manuscript. HR and CH revised it for critically important intellectual content and all gave final approval of the version to be published. All listed authors should have seen and approved the final version of the manuscript.

Conflict of interest The authors declare that they have no conflict of interest.

Compliance with Ethical Standards All procedures, including the informed consent process, were conducted in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Participation was strictly voluntary, and all responses were anonymous. Besides, the research was approved by the Research Ethics Board at Anhui Medical University (Ethical number: 83242392). The trial protocol is also registered in the Chinese Clinical Trial registry system (ChiCTR2100052108).

Data availability

The datasets used and/or analyzed in this study can be handed out in anonymized form. Please contact the author Anlong Li ([email protected]) in this regard.

Funding

No funds, grants, or other support was received.

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No competing interests reported.

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Behavioral Activation impacts symptoms of depression and anxiety, psychological distress, and quality of life among colorectal cancer patients in medical settings

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Abstract

Figures

Introduction

Materials and Methods

Experimental Design

Participants

Exclusion Criteria:

Termination Criteria:

Recruitment

Randomization

Intervention

Scales

Hospital Anxiety and Depression Scale (HADS):

European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30):

Distress Thermometer (DT):

Behavioral Activation for Depression Scale - Short Form (BADS-SF):

Statistical Analysis

Results

Baseline Demographics and Clinical Characteristics

Dynamics of HADS, EORTC QLQ-C30, BADS-SF, and DT Scores During Treatment

Comparative Analysis of HADS, EORTC QLQ-C30, BADS-SF, and DT Scores

Trends and Correlations in Scale Changes Across Groups

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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