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Article Analysis 1

The interpretation of research in health care is essential to decision making. By understanding research, health care providers can identify risk factors, trends, outcomes for treatment, health care costs and best practices. To be effective in evaluating and interpreting research, the reader must first understand how to interpret the findings. You will practice article analysis in Topics 2, 3, and 5.

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Search the GCU Library and find three different health care articles that use quantitative research. Do not use articles that appear in the Topic Materials or textbook. Complete an article analysis for each using the “Article Analysis 1” template.

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Doi: 10.5152/TJAR.2020.29863

Shilpa Goyal1 , Ankur Sharma2 , Devalina Goswami3 , Nikhil Kothari1 , Amit Goyal4 , Varuna Vyas5 ,
Richard Kirubakaran6 , Ranjit Sahu7 , Surjit Singh8
1Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Rajasthan, Jodhpur, India
2Department of Trauma and Emergency (Anaesthesia) All India Institute of Medical Sciences (AIIMS), Rajasthan, Jodhpur, India
3Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
4Department of Otorhinolaryngology, All India Institute of Medical Sciences (AIIMS), Rajasthan, Jodhpur, India
5Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Rajasthan, Jodhpur, India
6Department of Biostatistics, (South Asian Cochrane Centre), Christian Medical College Vellore, Tamil Nadu, India
7Department of Plastic Surgery, All India Institute of Medical Sciences (AIIMS), Rajasthan, Jodhpur, India
8Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Rajasthan, Jodhpur, India

Cite this article as: Goyal S, Sharma A, Goswami D, Kothari N, Goyal A, Vyas V, et al. Clonidine and Morphine as Adjuvants for Caudal Anaesthesia in Children: A Systematic Review

and Meta-Analysis of Randomised Controlled Trials. Turk J Anaesthesiol Reanim 2020; 48(4): 265-72.

Introduction

Caudal anaesthesia is the most commonly used mode of analgesia for patients in the paediatric age group who are
undergoing upper or lower abdominal surgeries. Caudal anaesthesia is safe and effective and can be used for both
intraoperative and postoperative analgesia in this age cohort (1). Local anaesthetic agents have a short duration of
action when used as single modalities; the addition of adjuvants to local anaesthetics prolongs the duration of post-
operative analgesia (2). There are many adjuvants which can be used to prolong the duration of caudal analgesia,
however, we have limited this analysis to a comparison between the effects of clonidine vs. morphine because, at this
moment in time, these are the only two drugs currently approved by US Food and Drug Administration for epidural
injection.

Received: 27.06.2019 Accepted: 05.09.2019
Available Online Date: 18.01.2020

Clonidine and Morphine as Adjuvants for
Caudal Anaesthesia in Children:
A Systematic Review and Meta-Analysis of
Randomised Controlled Trials

Abstract

Objective: The aim of this systematic review and meta-analysis is to compare the outcomes of morphine vs. clonidine use as adjuvants in caudal
anaesthesia. We are specifically focused on analgesic and side effect profiles.
Methods: We searched databases and trial registration sites and include here randomised controlled trials that compare the analgesic effects
of caudal clonidine vs. morphine as adjuvants on postoperative pain. The risk ratio for evaluating pain scores, the need for rescue analgesia
and all adverse effects were assessed. The i2 statistic was used to assess heterogeneity. We also assessed risk of bias with Cochrane’s Collab-
oration tool. The quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE)
system.
Results: Four randomised controlled trials (including 166 patients) that evaluated the use of clonidine vs. morphine as adjuvants in caudal block
were included in this systematic review and meta-analysis. The pooled estimate for postoperative analgesia revealed no statistically significant
differences between the clonidine group compared to morphine group (MD=2.90; 95% CI 4.05 to 9.85; i2 93%). Significantly less postoperative
nausea and vomiting were reported among the patients that received clonidine vs. those that were treated with morphine (RR 0.57, 95% CI
−0.36 to −0.90, i2 26%). There were no statistically significant differences between the two groups in assessments that included urinary retention,
pain scores or need for rescue analgesia at 24 hours.
Conclusion: Clonidine is just as effective as morphine when used an adjuvant to local anaesthetic for caudal block, and has a more desirable
side effect profile, particularly with respect to postoperative nausea and vomiting.
Keywords: Anaesthesia, analgesia, caudal, children, clonidine, morphine

265

Systematic Review
Paediatric Anaesthesia

https://orcid.org/0000-0002-8983-0953

https://orcid.org/0000-0001-9339-6988

https://orcid.org/0000-0002-5353-3383

https://orcid.org/0000-0002-9829-905X

https://orcid.org/0000-0002-4339-7541

https://orcid.org/0000-0002-1927-0487

https://orcid.org/0000-0002-5799-0303

https://orcid.org/0000-0003-2321-6798

https://orcid.org/0000-0002-8990-3235

Introduction of opioids, such as morphine, into the caudal
space can be advantageous; in contrast to the effects of local
anaesthetics, opioid drugs do not promote motor or sympa-
thetic blockade. Opioids promote adjuvant analgesia via local
action on spinal cord with limited systemic effects (3). Patients
receiving this treatment should be monitored for at least 24
hours in a post-anaesthesia care unit (PACU) and observed on
a frequent basis for level of consciousness and with sedation
scores (4).

The analgesic effect of epidural clonidine relates to direct
stimulation of α1 and α2 adrenoreceptors on the dorsal horn
grey matter of the spinal cord, thereby inhibiting the release
of nociceptive neurotransmitters (5). The most commonly en-
countered side effects of epidural clonidine are hypotension,
bradycardia and sedation. The hypotensive effect of clonidine
relates to its capacity to stimulate the α2 inhibitory neurons in
the vasomotor centre of medulla, which are actions that lead
to inhibition of norepinephrine release and central sympa-
thetic outflow. Clonidine also decreases the electrical activity
of preganglionic sympathetic nerves, stimulates central para-
sympathetic outflow and reduces sympathetic drive, thereby
resulting in bradycardia (6). Clonidine also activates α2 recep-
tors in locus coeruleus which suppresses the spontaneous dis-
charge from the nucleus and activates inhibitory neurotrans-
mitters including gamma aminobutyric acid. Clonidine also
depresses CNS function and results in sedation (6, 7).

Although there are many published randomised controlled
trials that have compared the efficacy of clonidine and
morphine as adjuvants in caudal blockade, we were unable
to identify any systematic reviews or meta-analyses on this
subject. As such, the aims of this review and systematic me-
ta-analysis are to compare the effects of adjuvant clonidine
vs. morphine for prolongation of postoperative analgesia
in paediatric surgical patients. Furthermore, we will review
the findings that address pain scores and the need for rescue
analgesia, as well as the incidence of side effects associated

with these drugs including postoperative nausea and vomiting
(PONV) and urinary retention.

Methods

We followed the recommendations of PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses)
(8) and Cochrane database (9) in preparing this systematic re-
view and a meta-analysis. Our study protocol and methods of
analysis were pre-specified and are registered in PROSPERO,
the international prospective register of systematic reviews,
Registration no.: CRD42018104720.

Search strategy
We searched Pubmed Central, Cochrane Register of Con-
trolled Trials, the Clinical Trial Registry and Google Scholar
from the time of inception to August 2018 for Randomised
Controlled Trials (RCTs) meeting our inclusion criteria and
without any language restrictions. The reference list of re-
ceived full articles were also searched. The following keywords
were searched in the aforementioned databases: (‘Caudal’
OR ‘Caudal analgesia’ OR ‘Caudal Block’) AND (‘Mor-
phine’[Mesh] AND (‘Clonidine’[Mesh] OR ‘Randomised
Control Trial’ OR ‘Trial’) (Figure 1). The titles and abstracts
of articles retrieved from this search strategy were examined
by two independent authors and those deemed not relevant
were excluded. In the cases of abstracts and titles that did not
clarify eligibility, we attempted to retrieve full length articles.
Full texts of articles identified as potentially relevant were re-
viewed. Articles fulfilling the inclusion criterion were assessed
independently by two authors (SG and AS). Any discrepancy
was resolved by communication with a third author (DG).

Our search focused on RCTs which included direct compari-
sons between clonidine and morphine as adjuvants in caudal
anaesthesia for prolonging postoperative pain relief in paedi-

Main Points:

• In this systematic review and meta-analysis, Morphine and Cloni-
dine were compared as adjuvants in caudal anaesthesia.

• Four randomised controlled trials including 166 patients were
pooled for various outcomes.

• We found that Clonidine is as effective as Morphine when used an
adjuvant to local anaesthetic for caudal block.

• Clonidine has a more desirable side effect profile, particularly with
respect to postoperative nausea and vomiting.

• There were no statistically significant differences between these 2
groups for urinary retention, pain scores or need for rescue analge-
sia at 24 hours. Figure 1. PRISMA flow diagram

13 of records after
duplicates removed

13 of records screened

4 of studies included
in qualitative synthesis

4 of studies included
in quantitative

synthesis
(meta-analysis)

9 of records excluded
(2 Non RCT: 7 Not

eligible)

21 of records
identified

through database
searching

No additional
records identified

through other
sources

Turk J Anaesthesiol Reanim 2020; 48(4): 265-72Goyal et al. Clonidine and Morphine in Caudal Analgesia

266

atric patients. We excluded non-paediatric patients (age>18
years) and studies that did not measure ‘duration of analgesia’
as a primary outcome. We also excluded data from review
articles, case reports, letter to editors, comments on published
articles and data from animal studies (Figure 1).

Primary and secondary outcomes
The primary outcome was duration of analgesia. This out-
come was measured as the time from administration of cau-
dal block to the time at which rescue analgesia was needed.
As expected, there was substantial heterogeneity in reporting
of outcomes and in assessing of pain in paediatric patients; as
in Vetter et al. (10), the time to administration of first rescue
analgesia was accepted as a useful outcome measure. The sec-
ondary outcomes were postoperative pain scores and adverse
effects including PONV and urinary retention.

Collection of data
The data were collected from the selected studies by three
independent authors (SG, AS and NK); all findings were
cross-checked. If the data included in a publication was not
sufficiently detailed for our needs, we attempted to contact
the authors by e-mail. The data extracted from the select-
ed studies included all the basic information as well as the

pre-specified outcomes of the RCTs. In order to simplify the
meta-analysis, we approximated medians and interquartile
ranges into means and corresponding standard deviations us-
ing methods as described in Cochrane library (9).

Assessment of risk of bias in independent studies
Two authors (SG and AS) independently assessed the risk of
bias in the individual selected studies. In the case of any dis-
crepancy, a common consensus was reached with the third
author (DG).Trials with one or more domains of unclear or
high risk of bias were designated as such.

Assessment of quality of evidence
We used Grading of Recommendations Assessment, Devel-
opment and Evaluation (GRADEpro) methodology for as-
sessing the overall quality of evidence for each outcome (11).
The quality of evidence for each primary or secondary out-
come was graded as high, moderate, low or very low.

Results

A summary of the four clinical trials included in this me-
ta-analysis are listed in Table 1. The selected clinical trials
include a total of 166 patients. GRADE summary of findings

Table 1. Characteristics of studies included in this meta-analysis

Definition
Number Amount of the
of patients LA used of Scoring duration Dose of Dose of
Authors/ (clonidine/ for caudal LA used tool of Clonidine Morphine
S.No Year Age morphine) Surgery block (ml kg−1) for pain analgesia (mcs kg-1) (mcs kg-1)
1 Luz (12) 6 months 18/18 Orchidopexy, 0.18% 1.5 OPS Time from 1 30
1999 to 6 years Hernia repair, bupivacaine caudal block
Circumcision to first need
of systemic
analgesia
2 Vetter (10) 6 months 20/20 Ureteric re- 0.2% 1 FLACC Time from 2 50
2007 to 6 years implantation ropivacaine PACU
admission to
first
postoperative
FLACC
pain score of
4 or more
3 Singh (3) 1–6 25/25 Upper 0.2% 1.25 FLACC Time from 2 30
2011 years abdominal bupivacaine caudal block
surgery to first need
for systemic
analgesia
4 Fernandez 1–10 20/20 Infraumbili- 0.166% 1 FLACC Time from 1 20
(5) 2011 years calurological bupivacaine caudal block
and genital with to first need
procedures epinephrine for systemic
(1:600000) analgesia
LA: local anaesthetic drug; OPS: objective pain scale; FLACC: face, legs, activity, cry, consolability scale; PACU: post-anaesthesia care unit

Turk J Anaesthesiol Reanim 2020; 48(4): 265-72 Goyal et al. Clonidine and Morphine in Caudal Analgesia

267

in which the use of clonidine versus morphine is compared
are included in Table 2.

Duration of analgesia
Two of the selected studies (3, 12) reported on the duration of
analgesia; the other two studies (5, 10) included data that were
not suitable for meta-analysis. Taken together, the two suitable
studies included a total of 66 participants, 32 in the group that
received clonidine with local anaesthetic and 34 in the group
that were treated with morphine with local anaesthetic. The
pooled estimate demonstrated no statistically significant dif-

ferences between the two groups (MD=2.90, 95% CI 4.05 to
9.85, i2 93%, very low certainty evidence; Figure 2). The true
observed heterogeneity between these studies was 94%; this
finding indicates that results are significantly different among
the studies. Variability between the studies was incorporated in
the analysis by using a random effect rather than a fixed effect
model. The data available were not sufficient for subgroup anal-
ysis. These results overall were graded as low certainty evidence.

Postoperative nausea and vomiting: All four studies
(3, 5, 10, 12) provided data addressing PONV. In the cloni-
dine group, 17/83 patients (20.5%) and the morphine group
30/83 patients (36.1%) reported this outcome. There were
significantly fewer reports of PONV among the patients
receiving clonidine group than among those receiving mor-
phine (RR-0.57, 95% CI −0.36 to −0.90, i2, 26%, low cer-
tainty evidence; Figure 3a).

Urinary retention: The incidence of urinary retention was
reported in only two (5, 12) of RCTs (total 76 patients). There
were no statistically significant differences between the two

Table 2. Summary of findings
Clonidine compared to morphine in caudal analgesia in children: a systematic review and meta-analysis of
randomised controlled trials
Patient or population: caudal analgesia in children: a systematic review and meta-analysis of randomised controlled trials
Intervention: Clonidine
Comparison: Morphine
Anticipated absolute № of Certainty of
effects* (95% CI) Relative effect participants the evidence
Outcomes Risk with Morphine Risk with Clonidine (95% CI) (studies) (GRADE) Comments
Duration of The mean duration The mean duration of – 66 ⨁◯◯◯
analgesia of analgesia was 0 analgesia in the intervention (2 RCTs) VERY LOW
group was 2.9 higher (4.05
lower to 9.85 higher)
PONV 361 per 1,000 220 per 1,000 RR 0.57 166 ⨁⨁◯◯
(112 to 427) (0.36 to 0.90) (4 RCTs) LOW
Urinary 53 per 1,000 11 per 1,000 RR 0.20 76 ⨁⨁◯◯
Retention (1 to 206) (0.01 to 3.92) (2 RCTs) LOW
Rescue 379 per 1,000 607 per 1,000 RR 1.60 116 ⨁◯◯◯
Analgesia (288 to 1,000) (0.76 to 3.36) (3 RCTs) VERY LOW
Pain Scores – – – 116 ⨁⨁◯◯
(3 RCTs) LOW
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the
intervention (and its 95% CI).
CI: Confidence interval; MD: Mean difference; RR: Risk ratio; SMD: Standardised mean difference, RCT: randomised controlled trial, PONV:
Postoperative nausea vomiting
GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a
possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Figure 2. Forest plot for the primary outcome of
duration of analgesia

Turk J Anaesthesiol Reanim 2020; 48(4): 265-72Goyal et al. Clonidine and Morphine in Caudal Analgesia

268

treatment groups (RR0.20, 95% CI −0.01 to 3.92, heteroge-
neity, not applicable, low certainty evidence; Figure 3b).

Need for rescue analgesia: Three studies (5, 10, 12) with
a total 116 participants contributed findings that addressed

the need for rescue analgesia. We found no statistically signif-
icant differences regarding the need for rescue analgesia at 24
hours after surgery in the group that received clonidine com-
pared to group that received morphine (RR 1.60, 95% CI
0.76 to 3.36, i2, 67%, very low certainty evidence) (Figure 4a).

Pain scores: Pain was measured using various scoring tools;
as such, we analysed the data using standardised mean differ-
ence (SMD) methods. Results from three studies (5, 10, 12)
with 116 participants were consistent with one another; no
statistically significant differences were observed between the
treatment groups (SMD 0.22, 95% CI −0.14 to 0.59, i2 0%,
low certainty evidence (Figure 4b). Of note, there were no
pain scores included in the trial reported by Singh et al. (3).
Objective Pain Scale (OPS) was used for pain assessment in
Luz et al. (12) In the other two studies (5, 10) the paediatric
Faces Legs Activity Cry Consolability (FLACC) pain scale
was used to assess the need for rescue analgesia.

Risk of Bias: A tool from the Cochrane Collaboration was
used to assess the risk of bias in each study. Risk of bias relat-
ed to randomisation, allocation concealment, attrition and se-
lective reporting, performance and detection bias was found
to be low for most of the trials (Figure 5).

Publication bias: Publication bias is low. The current re-
view includes only randomised trials and does not take into
account any pilot or cohort studies; this was as per the inclu-
sion criteria listed in the Methods.

Discussion

The mechanisms by which clonidine and morphine promote
caudal anaesthesia are unique and distinct. Several mecha-
nisms have been postulated for analgesic action of clonidine
in this setting. Clonidine crosses the blood-brain barrier and
combines with α2 adrenoceptors at spinal and supraspinal
sites, thereby producing analgesia. Clonidine also elicits di-
rect suppression of the spinal cord nociceptive neurons and
suppresses peripheral sensory Aδ and C nerve fibre neuro-
transmission. Likewise, the pharmacokinetics of clonidine
suggests that it may also function by inducing vasoconstric-
tion through α 2b adrenoceptors which are located at the pe-
ripheral vascular smooth muscles (13).

Caudal clonidine in combination with bupivacaine has been
used at different doses; increasing the dose of clonidine from
1 μg kg−1 to 2 μg kg−1 had no impact on its efficacy. Lee et al.
(14) compared 0.25% bupivacaine at 1 mL kg−1 combined
with either normal saline or clonidine at 2 μg kg−1; mean du-
ration of caudal analgesia was 5.2±1.2 hours and 9.8±2.1
hours, respectively (p<0.0001). Similarly, Singh et al. (15) reported that the mean duration of caudal analgesia with

Figure 4. a, b. Analysis of the pooled data for (a) numbers
of patients requiring postoperative rescue analgesia (b)
postoperative pain scores

Figure 5. Risk of bias of the included trials

Figure 3. a, b. Analysis of the pooled data for (a)
postoperative nausea and vomiting and (b) urinary
retention

Turk J Anaesthesiol Reanim 2020; 48(4): 265-72 Goyal et al. Clonidine and Morphine in Caudal Analgesia

269

0.75 mL kg−1 of 0.25% bupivacaine combined with 1 μg kg−1
of clonidine was significantly longer (629.06±286.32 min)
than observed in response to any of the other study groups.

The analgesic effect of morphine can be attributed to its local
action on opioid receptors at the spinal cord (16). Morphine
is rapidly transferred from the epidural space to peripheral
circulation and reaches a maximum concentration in plasma
within 10 min after caudal block. Once in plasma, its half-
life is approximately 2 hours, and the major pathway for its
elimination is conjugation with glucuronic acid, forming
morphine-6-glucuronide and morphine-3-glucuronide. The
former metabolite is a potent analgesic compound in animal
models (17). In humans, morphine-6-glucuronide produces
similar pain relief, dysphoria and sedation with less respiratory
depression than the parent morphine; morphine-3-glucuron-
ide lacks significant activity (18). In children, adding morphine
at 0.05 mg kg−1 to 0.125% bupivacaine improves the quality
and prolongs postoperative analgesia after orchidopexy (3).
However, in a retrospective study, 138 children received 0.07
mg kg−1 of morphine in a caudal block, with 11 patients (near-
ly 8%) reporting clinically significant hypoventilation (4).

Fernandes et al. (5) emphasised that the use of opioids in cau-
dal epidurals in children has been questioned due to side ef-
fects, patient discomfort, delayed patient discharge and mar-
ginal efficacy. Use of morphine in caudal anaesthesia does
not seem to be justified for minor procedures including those
that are performed as day-case surgery; pain control for these
procedures can typically be achieved with non-opioid agents.
Use of morphine as a caudal adjuvant might be reserved for
those procedures that require intensive postoperative analge-
sia with intravenous opioids.

Our meta-analysis included two randomised trials that fo-
cused on postoperative analgesia; the findings presented in
the other two studies were not fully suitable for meta-analysis.
Overall, the results revealed no statistically significant differ-
ences between the clonidine group vs. the morphine group
for postoperative analgesia (MD=2.90, 95% CI 4.05 to 9.85,
i2 93%, very low certainty evidence).The heterogeneity was
93%; the difference in the magnitude of the effects observed
may be the result of different volumes and doses of local an-
aesthetic and drugs used. We inferred from this analysis that
morphine as an adjuvant provided an equivalent duration of
analgesia when compared to clonidine.

There was also no significant difference in need for rescue
analgesia, as assessed by pain scores in three randomised trials
(5, 10, 12). The report of Singh et al. (3) made no mention of
pain scores or the need for rescue analgesia; the authors did
not reply to our e-mail queries, and as such, we excluded this
study from the assessment of these two criteria (Table 2). Luz

et al. (12) used OPS as the pain score; rescue analgesia was
administered when the value was greater than 4. The remain-
ing trials (5, 10, 11) used FLACC for pain assessment; patients
were given rescue analgesia when score was ≥4.

PONV was reported more frequently and with higher inci-
dence in the group receiving morphine than in the clonidine
group (p=0.02). Neuraxial opioids have been previously asso-
ciated with a higher risk of PONV (19, 20); the 5-HT3 antag-
onist, ondansetron, is effective at reducing PONV secondary
to epidural morphine (21). In the study presented by Fernan-
dez et al. (5), the incidence of PONV was higher in morphine
group (20 mcg kg−1) and likewise in a comparable study by
Wolf et al. (22), in which morphine was used at a dose of
50 mcg kg−1. No prophylactic antiemetic therapy was used
in these studies, which permits a better assessment of the risk
of PONV. Vetter et al. (10) reported that a significantly larger
number of children experienced PONV in response to mor-
phine than in response to clonidine (80% vs. 50%; p=0.01),
and noted the larger need for antiemetics in in the former
group.

Urinary retention was comparable in the two groups. Fer-
nandez et al. (5) reported urinary retention in two patients in
morphine group and none in clonidine group. Urinary reten-
tion was relieved by simple measures.

Fernandez et al. (5) also reported that two patients in the mor-
phine group developed pruritis but not treatment was neces-
sary. Singh et al. (3) reported pruritis in 16% of the children
in the morphine group vs. none in clonidine group, a finding
that was statistically significant (p=0.03).

Vetter et al. (10) reported a higher incidence of pruritis in
the morphine group as compared to clonidine group and was
statistically significant (p=0.007).

Fernandez et al. (5) also reported no significant changes in
hemodynamic parameters. This result was consistent with
those reported in other studies (15, 23, 24). Luz et al. (12) also
observed a slight decrease in mean arterial pressure, together
with changes in heart and respiratory rates that were similar
in both the groups. Singh et al. (3) observed no incidence of
bradycardia or hypotension in either group.

Caudal morphine has been associated with respiratory de-
pression, a finding that has been reported primarily in chil-
dren less than 3 months of age and that has been associated
with doses of caudal morphine varying from 40 to 70 µg kg1.
The study of Fernandez et al. (5) included no mention of re-
spiratory depression, although the study was not sufficiently
powered to detect this as a side effect. Similarly, Luz et al.
(12) reported no evidence of respiratory depression after 30

Turk J Anaesthesiol Reanim 2020; 48(4): 265-72Goyal et al. Clonidine and Morphine in Caudal Analgesia

270

µg kg−1 of morphine. Although this side effect is known to be
dose dependent (4, 25), epidural morphine at doses as low as
40 µg kg−1 has resulted in respiratory depression (26, 27). Attia
et al. (28) recommended continuous, mandatory respiratory
monitoring for at least 22 hours in children who were treated
with 50 µg kg−1 morphine as this has been associated with
a decreased ventilatory response to CO2. A literature search
suggested that epidural clonidine, given in low dose (1–5 µg
kg−1) had no impact on respiratory function in children (23-
25). Singh et al. (3) reported no incidence of respiratory de-
pression in either group.

The report of Fernandez et al. (5) did not include sedation as
a side effect. The time to emergence from anaesthesia was not
prolonged in either the morphine or clonidine groups, results
that suggest that the doses used in this study had no signifi-
cant impact on sedation. Luz et al. (12) compared the analgesic
efficacy, anaesthetic requirements and operation time and all
outcomes were comparable in the two groups, although they
noted that the longer recovery time observed among those in
the clonidine group might be related to increased sedation (24,
29). Singh et al. (3) observed that the duration of sedation was
significantly higher among those in the clonidine group as com-
pared to the morphine group (p<0.01). Other studies suggest that there are no differences in the incidence of sedation in comparisons among agents used for caudal analgesia (15, 25).

Conclusion

Clonidine is equivalent to morphine as an analgesic when
each is used as an adjuvant to local anaesthetic for caudal
block. Clonidine has a more desirable side effect profile, par-
ticularly in terms of PONV.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – S.G., A.S.; Design – S.G., A.S.;
Supervision – N.K., V.V.; Resources – D.G.; Materials – A.G., R.S.;
Data Collection and/or Processing – S.G., A.S.; Analysis and/or
Interpretation – R.K., S.S.; Literature Search – A.S., V.V.; Writing
Manuscript – S.G., A.S., V.V.; Critical Review – A.G., V.V., R.S.;
Other – N.K., D.G., A.G., R.S.

Conflict of Interest: The authors have no conflicts of interest to
declare.

Financial Disclosure: The authors declared that this study has
received no financial support.

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Article Analysis 1

Article Citation and Permalink (APA format)

Article 1

Article

Article 3

Point

Description

Broad Topic Area/Title

Identify Independent and Dependent Variables and Type of Data for the Variables

Population of Interest for the Study

Sample

Sampling Method

Descriptive Statistics (Mean, Median, Mode; Standard Deviation)

Identify examples of descriptive statistics in the article.

Inferential Statistics

Identify examples of inferential statistics in the article.

Article Analysis: Example 1

Article Citation

Utens, C. M. A., Goossens, L. M. A., van Schayck, O. C. P., Rutten-van Mölken, M. P. M. H., van Litsenburg, W., Janssen, A., … Smeenk, F. W. J. M. (

013). Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial. International Journal of Nursing Studies, 50, 1537–1549. doi.org/10.1016/j.ijnurstu.2013.03.006

Link: https://www.ncbi.nlm.nih.gov/pubmed/23582671

(Include permalink for articles from GCU Library.)

Category

Description

Broad Topic Area/Title

The differences in preference and satisfaction based upon hospital care location for COPD exacerbations

Variables and Type of Data for the Variables

Treatment Location-categorical -“home treatment” and “hospital treatment”

Satisfaction – Ordinal Scale (1-5)

Preference – categorical “home treatment” and “hospital treatment”

Population of Interest for the Study

COPD exacerbation patients from five hospitals and three home care organizations

Sample

139 patients

69 from the usual hospital care group

70 from the early assisted discharge care group

Sampling Method

A randomized sampling method was used to select the patients who met the criteria for the study (p. 1540)

Descriptive Statistics (mean, median, mode; standard deviation)

Identify examples of descriptive statistics in the article.

Example descriptive statistics:

Usual hospital Age:

Mean: 67.8 Standard deviation: 11.30

Early assisted discharge Age:

Mean: 68.31 Standard deviation: 10.34 (p. 1540)

Inferential Statistics

Identify examples of inferential statistics in the article.

Example of inferential statistics:

Overall satisfaction score: Tested difference between HC and EAD p-value .863 (p. 1543)

REVIEW ARTICLE

Effectiveness of self-help psychological interventions for treating
and preventing postpartum depression: a meta-analysis

Ping-Zhen Lin1 & Jiao-Mei Xue2 & Bei Yang1 & Meng Li1 & Feng-Lin Cao1

Received: 19 October 2017 /Accepted: 21 March 2018 /Published online: 4 April 2018
# Springer-Verlag GmbH Austria, part of Springer Nature 2018

Abstract
Previous studies have reported different effect sizes for self-help interventions designed to reduce postpartum depression symp-
toms; therefore, a comprehensive quantitative review of the research was required. A meta-analysis was conducted to examine
the effectiveness of self-help interventions designed to treat and prevent postpartum depression, and identified nine relevant
randomized controlled trials. Differences in depressive symptoms between self-help interventions and control conditions, chang-
es in depressive symptoms following self-help interventions, and differences in postintervention recovery and improvement rates
between self-help interventions and control conditions were assessed in separate analyses. In treatment trials, depression scores
continued to decrease from baseline to posttreatment and follow-up assessment in treatment subgroups. Changes in treatment
subgroups’ depression scores from baseline to postintervention assessment were greater relative to those observed in prevention
subgroups. Self-help interventions produced larger overall effects on postpartum depression, relative to those observed in control
conditions, in posttreatment (Hedges’ g = 0.51) and follow-up (Hedges’ g = 0.32) assessments; and self-help interventions were
significantly more effective, relative to control conditions, in promoting recovery from postpartum depression. Effectiveness in
preventing depression did not differ significantly between self-help interventions and control conditions.The findings suggested
that self-help interventions designed to treat postpartum depression reduced levels of depressive symptoms effectively and
decreased the risk of postpartum depression.

Keywords Self-help . Depression . Postpartum . Meta-analysis . Randomized controlled trial

Introduction

Postpartum depression refers to major and minor depressive
episodes that occur within 12 months of parturition (Gavin
et al. 2005). It is a common mental illness in women, with high
prevalence rates ranging from 6.5 to 12.9% (Gavin et al. 2005).
Postpartum depression exerts negative effects including in-
creased obstetric complications in depressed mothers (Leung
& Kaplan 2009), compromised mother-child relationships,
and disturbed neurobiological, social, and cognitive develop-
ment in infants (Brummelte & Galea 2016). Consequently, the
development and validation of effective interventions and pre-
ventative programs are crucial.

Despite observation of positive effects and improvements
in depressive symptomatology with traditional treatments,
such as antidepressant medication and individual psychother-
apy, research has shown that low participation rates (5–14%)
(Andersson et al. 2003; Andersson et al. 2006; Kelly et al.
2001) limit these interventions (Bijl & Ravelli, 2000).

* Feng-Lin Cao
caofenglin2008@126.com

Ping-Zhen Lin
lpz385675123@163.com

Jiao-Mei Xue
xuejiaomeiyan@163.com

Bei Yang
yangbeilucky@126.com

Meng Li
gflemon11@163.com

1 School of Nursing, Shandong University, No. 44 Wenhua Xi Road,
Jinan 250012, Shandong, People’s Republic of China

2 Society and Law School, Shandong Women’s University,
Jinan, Shandong, People’s Republic of China

Archives of Women’s Mental Health (2018) 21:491–503
https://doi.org/10.1007/s00737-018-0835-0

http://crossmark.crossref.org/dialog/?doi=10.1007/s00737-018-0835-0&domain=pdf

Antidepressant medication is associated with adverse preg-
nancy and neonatal outcomes. Antidepressants could exert
adverse effects during pregnancy and breastfeeding on both
mother and child, such as preterm birth, reduction in maternal
weight gain and infant birth weight, and poor neonatal out-
comes (Wisner et al. 2009). Moreover, there are other disad-
vantages, such as time inflexibility, the need for health profes-
sionals’ participation, and unaffordability for many women
(Cowpertwait & Clarke 2013; Roness et al. 2005).
Therefore, self-help interventions, which involve little burden
on clinical resources, few time constraints, and accessibility
for a broad range of users (Beatty & Binnion 2016), have
attracted increased attention.

Self-help interventions refer to psychological interventions
that patients largely complete independently at home, in ac-
cordance with a standardized protocol, using written material
(e.g., books, booklets), CD-ROMs, DVDs, computerized soft-
ware packages, and websites (Cuijpers & Schuurmans 2007).
Cowpertwait & Clarke (2013) conducted a systematic review
examining web-based psychological interventions for depres-
sion and showed such interventions exerted a statistically sig-
nificant and moderately large effect, relative to that observed
in the control condition (placebo or treatment-as-usual or
waitlist), and led to a significant reduction in depressive symp-
toms. Moreover, another systematic review that evaluated the
clinical effectiveness of cognitive behavioral therapy (CBT)-
based, guided self-help interventions for anxiety and depres-
sive disorders demonstrated the effectiveness of guided self-
help at posttreatment assessment; however, this effectiveness
was considerably diminished at follow-up and in clinically
representative samples (Coull & Morris 2011). Furthermore,
self-help interventions may be more effective for treatment
rather than prevention of depression in the general population
(Gellatly et al. 2007).

The effectiveness of a wide range of self-help interventions
for postpartum depression has been demonstrated in random-
ized controlled trials (RCTs). For example, behavioral activa-
tion (BA) is an effective method for reducing depressive
symptoms when compared to treatment as usual (TAU)
(O’Mahen, 2013, O’Mahen et al. 2014). Symptoms of post-
partum depression decreased more for participants in the CBT
group compared to those participants in the waitlist control
group (Pugh et al. 2016). In addition, self-help exercise inter-
vention was more effective than wellness/support contact con-
trol condition in alleviating symptoms of postpartum depres-
sion (Lewis et al. 2014). However, some studies failed to
demonstrate that self-help interventions were superior to usual
care in the treatment or prevention of postpartum depression
(Costa et al. 2009; Daley et al. 2015a; Mohammadi et al.
2015). Moreover, with the exception of a study conducted
by Milgrom et al. (2016), research has consistently shown that
intervention effects were not sustained during follow-up pe-
riods of various durations (Costa et al. 2009; Daley et al.

2015a; Mohammadi et al. 2015; O’Mahen et al. 2014). Most
studies reported that depressive symptoms decreased signifi-
cantly from baseline to postintervention assessment (Costa
et al. 2009; Daley et al. 2015a; King 2009; O’Mahen et al.
2014; O’Mahen et al. 2014; Pugh et al. 2016), while some
others reported that symptoms decreased significantly from
postintervention to follow-up assessment (O’Mahen et al.
2014; Pugh et al. 2016). In the only published RCT to com-
pare the effectiveness of an Internet-based self-help interven-
tion with a face-to-face control intervention in the prevention
of postpartum depression, King (2009) demonstrated that re-
duction of depression from pretest to posttest of the Internet-
based program was equivalent to that of the face-to-face
intervention.

Given that different effect sizes have been observed for
various types of self-help interventions designed to reduce
postpartum depression symptoms, comprehensive and quan-
titative reviews of potential outcomes are required. Therefore,
the primary aim of the current meta-analysis was to assess the
effectiveness of a range of self-help interventions in the treat-
ment and prevention of postpartum depression observed in
RCTs.

We compared depressive symptom severity between a self-
help intervention condition and a control condition and exam-
ined the overall effect of these interventions on depressive
symptoms over time. In addition, the difference in postinter-
vention recovery and improvement rates between the two con-
ditions was also examined.

Materials and methods

Data sources and search strategy

We conducted a meta-analysis in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(2015) statement (Moher et al. 2015) to examine the impact of
self-help psychological interventions on postpartum depression.
Systematic literature searches of the PubMed, Scopus, Web of
Science, Cochrane Central Register of Controlled Trials,
MEDLINE databases, and ProQuest Dissertation and Theses
were performed to identify relevant RCTs. There were no re-
strictions regarding publication date. Searches were last updated
in September 31, 2017. Searches were conducted within the
domains of title, abstract, and keywords. A string was used
within each database: (Bself-help^ OR BInternet^ OR Bweb^
OR Bonline^ OR Bcomputer^ OR Bhome^ OR Btelephone^)
AND (Bpostpartum depress*^ OR Bpostnatal depress*^ OR
Bmaternal depress*^) AND (Btreatment^ OR Btherapy^ OR
Bintervention^ OR Btrial^ OR Banalysis^). In addition, we per-
formed manual searches of the reference lists in the identified
articles and publications that cited them.

492 P.-Z. Lin et al.

Literature selection and data extraction

The eligibility criteria for study selection were as follows:
Study design: Studies were eligible for inclusion if they

reported RCTs that examined self-help interventions for at
least 4 weeks that involved one of the following four factors:
routine clinical care/treatment-as-usual (TAU), receive no
treatment, join a waiting list (WL), or participate in a face-
to-face psychological intervention. Where studies reported
multiple self-help intervention groups with a control group,
they were recoded as multiple subgroups, and effect sizes
were calculated between each intervention group and control
group separately.

Participants: Included studies were based solely on women
during pregnancy or the postpartum period (defined as the
12 months following the birth of a child), regardless of gender,
race, nationality, or depressive status.

Interventions: Self-help interventions, as a type of psycho-
logical interventions (interventions which could exert influ-
ence on the mental activity, personality characteristics, or psy-
chological problems of objects under the guidance of psycho-
logical theory), are defined as an individual’s access to self-
help materials (e.g., written material and websites) in the treat-
ment of mood disorders. Maximum professional input for self-
help interventions equals to half of that for the lower range in
conventional therapy, in accordance with the recommenda-
tions of a recent systematic review examining self-help inter-
ventions for depression (Gellatly et al. 2007).

Outcomes: Measurement and reporting of postpartum de-
pression scores using a validated self-report or clinician-
administered measure at postintervention and follow-up as-
sessment. The manuscript reported that sufficient outcome
data for the calculation of effect sizes was included. When
studies did not report sufficient outcome data for the compu-
tation of effect sizes, authors were contacted to request addi-
tional data, and this information was used to calculate effect
sizes when provided.

Studies in which all female participants were classified as
depressed using diagnostic criteria or symptom severity at
baseline were eligible for inclusion in the meta-analysis of
studies involving treatment; and studies in which not all par-
ticipants fulfilled the criteria for a depressive episode or ex-
hibited clinically significant depressive symptoms at baseline
were eligible for inclusion in the meta-analysis of studies in-
volving prevention subgroups.

Search results were not limited with respect to language,
but all of the identified articles were in English. The exclusion
criteria were as follows: (1) absence of a control group, (2)
examination of methods other than self-help interventions, (3)
irretrievable intervention results, and (4) total overlap of sam-
ple and results reported in a different publication.

The data extracted from all studies were as follows: First
Author, publication date, age (mean), education (%), race (%),

employment (%), marital status (%), months since postpar-
tum, depression at entry, intervention type (exercise vs. stress
management program vs. CBT vs. BA), control type (TAU vs.
WL vs. face-to-face psychological intervention), outcome
measure (the Edinburgh Postnatal Depression Scale, EPDS
vs. the Beck Depression Inventory-II, BDI-II), intervention
approaches (Internet-based vs. telephone-based), intervention
duration (months or weeks), follow-up duration (months or
weeks), and the mean and standard deviation from each
study’s depressive symptomatology scale scores.

The systematic search and data extraction were performed
independently by two of the researchers. The risk of bias was
assessed using the Cochrane Risk of Bias Tool (Peters et al.
2015), and a third researcher checked for consistency of bias.
Divergence of opinions was resolved through consultation.

Statistical analysis

Statistical analyses were performed using Stata Version 14.0.
Pooled mean effect sizes were calculated (Hedges’ g) with
95% confidence intervals (CIs), using random effects models
based on the assumption that included studies represented the
true distribution of intervention data, to compare outcomes
between self-help interventions and control conditions and
assess changes in depressive symptoms for self-help interven-
tions. Hedges’ g values of 0.2, 0.5, and 0.8 represent small,
moderate, and large effect sizes, respectively (Cohen 1988).
Odds ratios (ORs) were calculated to compare postinterven-
tion recovery and improvement rates between the intervention
and control conditions.

Q and I2 statistics were used to assess heterogeneity, and P
values of < .100 for the Q statistic indicated high heterogene- ity levels. For the I2 statistic, scores of 25, 50, and 75% indi- cated low, moderate, and high heterogeneity levels, respec- tively (Higgins et al. 2003). As fewer than 10 studies were included in the review, we did not perform a meta-regression.

Subgroups classified according to intervention purpose,
control type, intervention type, and depression measure were
analyzed. Except for intervention purpose and intervention
type, all the other subgroup analyses did not show significant
results, which would not be displayed in the result.

In each of these analyses, outliers were identified using the
sample-adjusted meta-analytic deviance (SAMD) statistic
(Huffcutt & Arthur 1995). If the SAMD value was ≥ 2.58
and the scree plot suggested that the SAMD did not differ
from the overall distribution, the study was retained.

Publication bias was assessed via visual examination of
funnel plots, Duval and Tweedie’s (2000) trim-and-fill proce-
dure, and classic fail-safe N values (Rosenthal 1979).
According to Rosenthal’s (1991) recommendation, a value
of 5K + 10, where K is the number of observed studies, was
used as the cutoff point for an unlikely number of nonsignif-
icant studies. Given the small number of studies in the meta-

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 493

analysis, these tests demonstrated low sensitivity in detecting
publication bias.

Assessment of study quality

The methodological quality of each study was assessed via the
Delphi List Criteria (Verhagen et al. 2017). The criteria in-
clude nine standard items for RCTs. Two of the nine list
criteria (i.e., BWas the intervention provider blinded?^ and
BWas the participant blinded?^) were not considered, as it is
difficult to conduct self-help intervention trials in which par-
ticipants and the intervention provider are blind to the inter-
vention (Daley et al. 2015b). Therefore, we evaluated the de-
sign of each study using seven criteria. One point was
assigned for each criterion, providing a maximum score of 7.

Results

Study characteristics

Figure 1 shows the literature search flow chart. Of the 1921
potentially eligible articles identified via the electronic
search, nine met all of the review criteria and were included
in the analysis (Costa et al. 2009; Daley et al. 2015a; King
2009; Lewis et al. 2014; Milgrom et al. 2016; Mohammadi
et al. 2015; O’Mahen et al. 2014; O’Mahen et al. 2014; Pugh
et al. 2016) after removal of duplicates, title and abstract
screening, and full-text article assessment. Most studies
were journal articles, with only one doctoral thesis included
(King 2009).

Study quality and sensitivity analysis

Table 1 shows the results regarding the methodological quality
of the included studies. Eight studies were awarded 6 points,
which indicated high methodological quality. The remaining
study (King 2009) was awarded 4 points. All studies involved
random sampling, specified eligibility criteria, and presented
point estimates and measures of variability for the primary
outcome measures.

Elimination of the data from the study that was
awarded 4 points resulted in a reduction in heterogeneity
in the overall depressive symptomatology analysis, from
I2 = 63.2% to I2 = 57.9%. In addition, the effect sizes for
the psychological interventions were maintained (Hedges’
g = 0.42; 95% CI 0.20 to 0.64) following the exclusion of
this study, and the reduction in effect sizes did not reach
statistical significance (P = .098). This study (King 2009)
was remained in the following analysis.

Study designs and participants

The characteristics of each study are presented in Table 2. All
interventions were administered after parturition, with the ex-
ception of that in one study, which was implemented between
26 and 32 weeks of pregnancy (Mohammadi et al. 2015).
Intervention durations ranged from 4 weeks to 6 months,
and the follow-up period ranged from 3 weeks to 6 months,
with the exception that three studies did not have follow-up.
The study conducted by Mohammadi et al. (2015) involved
two self-help intervention groups and a control group, which
were recoded as two subgroups: Mohammadi 2015a (antenatal
exercise intervention versus TAU) and Mohammadi 2015b

(antenatal and postnatal exercise intervention versus TAU).
Effect sizes were calculated between each intervention group
and the control group separately.

Six and four of the intervention subgroups received
Internet- and telephone-based interventions, respectively.
Control groups included TAU, WL, and face-to-face psycho-
logical intervention. Intervention subgroups involved five ex-
ercise subgroups, one stress management program, two CBT
subgroups, and two BA subgroups. The studies included six
treatment subgroups and four prevention subgroups.

Sample sizes ranged from 17 to 165. The total numbers of
participants in self-help intervention and control groups were
513 and 438, respectively. Seven studies used EPDS, and two
used BDI-II.

Meta-analysis findings

Postintervention postpartum depressive symptoms following
self-help interventions

The pooled effect size for eight subgroups was − 1.08 (95% CI
− 1.61 to − 0.55, Fig. 2), suggesting that depressive symptoms
in the self-help intervention groups decreased following the
interventions, with large effect sizes. In addition, the effect
sizes were significantly heterogeneous (χ2 = 76.19,
P < .001), indicating that potential moderators existed. One study (O’Mahen et al. 2014) reported SAMD values exceed- ing 2.58. Visual inspection of the scree plot of rank-ordered SAMD scores indicated that the value for this study was con- sistent with the overall distribution of SAMD scores. Therefore, this study was excluded from further analyses.

Postintervention effect sizes were − 0.60 (95% CI − 1.16 to
− 0.05, P = .001, I2 = 80.7%) for exercise; − 0.84 (95% CI −
1.55 to − 0.14) for the stress management program; − 1.88
(95% CI: − 2.29 to − 1.46, P = .153, I2 = 51.0%) for BA; and
− 1.50 (95% CI − 2.18 to − 0.82) for CBT.

The difference in intervention purposes between subgroups
was significant (P = .013), and Hedges’ g value for the treat-
ment subgroups (− 1.51; 95% CI − 1.90 to − 1.12, P = .004,
I2 = 73.6%) was higher relative to that observed for the

494 P.-Z. Lin et al.

prevention subgroups (− 0.29; 95% CI − 0.70 to 0.12,
P = .151, I2 = 47.1%). Significant heterogeneity was observed
for the treatment and exercise subgroups.

In the treatment studies, the fail-safe N was 654, which
exceeded the tolerance level for an unlikely number of non-
significant studies (35). In the treatment and prevention stud-
ies, the funnel plot and trim-and-fill procedures indicated that
there was no publication bias (Fig. 3).

Comparison of postpartum depressive symptoms
between postintervention and follow-up assessments
for self-help interventions

The pooled effect size for six subgroups was − 0.32 (95% CI
− 0.52 to − 0.12, Fig. 4), indicating that depression symptoms
in the self-help intervention groups decreased between post-
intervention and follow-up assessments, with small-to-

Full-text articles assessed for eligibility

(n=36)
Full-text articles excluded:

No RCT (n=5)

Study design (n=1)

Population (n=1)

Non-self-help (n=11)

Insufficient data (n=9)

Studies included in

treatment

meta-analysis

(n=6)

Studies included in

prevention

meta-analysis

(n=3)

Records after duplicates removed

(n=991)

Records identified though database searchin

＆ reference review

Title and abstract screening

(n=79)

In
cl

u
d

E
li

gi
b

il
it

cr
ee

n
in

g
Id

en
ti

fi
ca

ti
on

S
cr
ee
n
in
g

(n=1921)

Fig. 1 Study selection flow
diagram

Table 1 Methodological quality of included studies

Quality characteristics Costa
2009

Daley
2015a

King
2009

Lewis
2014

Milgrom
2016

Mohammadi
2015

O’Mahen
2013

O’Mahen
2014

Pugh
2016

1. Was a method of randomization performed?

Y Y Y Y Y Y Y Y Y

2. Was the treatment allocation concealed? Y Y – Y Y Y Y Y Y

3. Were the groups similar at baseline regarding the most
important prognostic indicators?

Y Y Y Y Y Y Y Y Y

4. Were the eligibility criteria specified? Y Y Y Y Y Y Y Y Y

5. Was the outcome assessor blinded? – N – Y – N – –

–

6. Were point estimates and measures of variability
presented for the primary outcome measures?

Y Y Y Y Y Y Y Y Y

7. Did the analysis include an intention-to-treat analysis? Y Y N N Y Y Y Y Y

Total 6 6 4 6 6 6 6 6 6

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 495

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(2
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=
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496 P.-Z. Lin et al.

moderate effect sizes. There was no significant heterogeneity
observed for effect sizes (χ2 = 4.96, P = .421), and no studies
reported SAMD values exceeding 2.58 (range − 1.71 to 1.56).

Effect sizes for depression symptoms between follow-up
and postintervention assessments were − 0.21 (95% CI − 0.44
to 0.02, P = .923, I2 = 0.0%) for exercise, − 0.54 (95% CI −
1.03 to − 0.06) for BA, and − 0.93 (95% CI − 1.64 to − 0.21)
for CBT.

The difference in intervention purposes between subgroups
was nonsignificant (P = .510), with Hedges’ g values of −
0.38 (95% CI − 0.70 to − 0.07, P = .200, I2 = 35.4%) in treat-
ment subgroups and − 0.25 (95% CI − 0.58 to 0.07, P = .790,
I2 = 0.0%) in prevention subgroups. No significant heteroge-
neity was observed for the subgroups.

In the treatment studies, the fail-safe N was 12, which did
not exceed the tolerance level for an unlikely number of non-
significant studies (30). The funnel plot and trim-and-fill pro-
cedures suggested that there was no publication bias for treat-
ment or prevention studies (Fig. 3).

Comparison of postintervention postpartum depressive
symptoms between intervention and control conditions

A forest plot presenting the pooled between-group effect
sizes for postintervention depression scores is presented
in Fig. 5. The pooled postintervention between-group
effect size for nine subgroups was 0.32 (95% CI 0.09
to 0.56, P = .004), indicating that self-help interventions

produced stronger overall effects relative to those of
control interventions, which were small to moderate.
No studies reported SAMD values exceeding 2.58
(range − 2.22 to 2.24).

Postintervention between-group effect sizes for depressive
symptoms were 0.20 (95% CI − 0.06 to 0.46, P = .113, I2 =
46.4%) for exercise, − 0.35 (95% CI − 0.99 to 0.30) for stress
management programs, 0.56 (95% CI 0.37 to 0.76, P = .696,
I2 = 0.0%) for BA, and 1.06 (95% CI 0.42 to 1.70) for CBT.

The difference in intervention purposes between subgroups
was nonsignificant (P = .063), and Hedges’ g for treatment
subgroups (0.51; 95% CI 0.27 to 0.75, P = .146, I2 = 41.3%)
was higher relative to that observed for prevention subgroups
(0.05; 95% CI − 0.35 to 0.45, P = .032, I2 = 66.0%).
Significant heterogeneity was observed in the prevention
subgroups.

In the treatment studies, the fail-safe N was 64, which
exceeded the tolerance level for an unlikely number of non-
significant studies (35). In addition, the funnel plot was slight-
ly asymmetric (Fig. 3), and trim-and-fill procedures suggested
one missing study with a value to the left of the mean. The
overall effect size after trim-and-fill correction was 0.45 (95%
CI 0.19 to 0.70). This adjusted value suggested that if the
included studies reflected publication bias, it occurred in the
direction of overestimation of true effect sizes for the inter-
ventions. In the prevention studies, the funnel plot showed no
publication bias (Fig. 3), and trim-and-fill procedures sug-
gested no missing studies.

Fig. 2 Forest plot displaying
effect sizes of depression scores at
post-intervention versus at
baseline in self-help intervention
group. Note. Mohammadi
(2015)a: antenatal exercise
intervention versus treatment-as-
usual, Mohammadi (2015)b:
antenatal and postnatal exercise
intervention versus treatment-as-
usual.

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 497

Fig. 3 Funnel plots to assess for
publication bias by relating effect
sizes of the studies to standard
errors

498 P.-Z. Lin et al.

Comparison of postpartum depressive symptoms
between interventions and control conditions at follow-up

The pooled between-group effect size at follow-up in six sub-
groups was 0.19 (95% CI − 0.05 to 0.43, see Fig. 6),

indicating that self-help interventions produced larger overall
effects relative to those of control conditions, which were
small to moderate. In addition, the effect sizes were signifi-
cantly heterogeneous (χ2 = 7.24, P = .203). No studies report-
ed SAMD values exceeding 2.58 (range − 1.79 to 1.61).

Fig. 4 Effect sizes of depression
scores at follow-up versus at post-
intervention in self-help
intervention group. Note.
Mohammadi (2015)a: antenatal
exercise intervention versus
treatment-as-usual, Mohammadi
(2015)b: antenatal and postnatal
exercise intervention versus
treatment-as-usual.

Fig. 5 Forest plot displaying
effect sizes of depression scores at
post-intervention comparing self-
help interventions with control
conditions. Note. Mohammadi
(2015)a: antenatal exercise
intervention versus treatment-as-
usual, Mohammadi (2015)b:
antenatal and postnatal exercise
intervention versus treatment-as-
usual.

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 499

Between-group effect sizes for depressive symptoms at
follow-up were 0.03 (95% CI − 0.20 to 0.26, P = .981, I2 =
0.0%) for exercise; 0.48 (95% CI − 0.04 to 1.00) for BA; and
0.83 (95% CI 0.20 to 1.45) for CBT.

Treatment trials showed a trend toward larger overall ef-
fects for self-help treatment, relative to those in control con-
ditions, with a Hedges’ g value of 0.32 (95% CI − 0.01 to
0.65, P = .170, I2 = 40.3%). In prevention studies, the
Hedges’ g value was − 0.02 (95% CI − 0.34 to 0.31, P =
0.100, I2 = 0.0%), which was nonsignificant. Subgroup anal-
yses of intervention purposes showed no difference between
subgroups (P = .240). No heterogeneity was observed for the
subgroups.

In the treatment studies, the funnel plot showed no
publication bias (Fig. 3); and trim-and-fill procedures sug-
gested no missing studies. In the prevention studies, the
funnel plot showed no publication bias (Fig. 3), and trim-
and-fill procedures suggested that the overall effect size
did not change with one missing study (Hedges’ g = −
0.02, 95% CI − 0.28 to 0.25).

Postintervention recovery and improvement rates

A forest plot presenting the pooled between-group effect sizes
for postintervention recovery and improvement rates is shown
in Fig. 7. Participants in seven subgroups (n = 372) recovered
or showed significant improvement following self-help
interventions.

One treatment study (Milgrom et al. 2016) reported SAMD
values exceeding 2.58 and was excluded from subsequent
analyses. Following exclusion of this outlier, the average ef-
fect size was 2.50 (95% CI 1.76 to 3.55, P = .772, I2 = 0.0%),
indicating that recovery rates following self-help interventions
were significantly higher relative to those observed in control
conditions. No significant heterogeneity was observed for the
treatment studies. The fail-safe N value was 35, which
exceeded the tolerance value of 30. While the funnel plot
was asymmetric (Fig. 3), trim-and-fill procedures showed
two missing studies with values to the left of the mean. The
overall effect size following trim-and-fill correction was 2.31
(95% CI 1.53 to 3.08). This adjusted value suggested that if
the included studies reflected publication bias, it occurred in
the direction of overestimation of the true effect size for the
interventions.

One of the prevention subgroups (Mohammadi 2015b) re-
ported SAMD values exceeding 2.58 and was excluded from
subsequent analyses. Excluding this outlier, the effect size for
the subgroups was 1.13 (95% CI: 0.31 to 4.08), indicating that
improvements in depression symptoms did not differ between
the self-help prevention and control conditions in nonde-
pressed women.

Discussion

This meta-analysis summarized the effects of self-help inter-
ventions in the prevention and treatment of postpartum

Fig. 6 Forest plot displaying
effect sizes of depression scores at
follow-up comparing self-help
interventions with control
conditions. Note. Mohammadi
(2015)a: antenatal exercise
intervention versus treatment-as-
usual, Mohammadi (2015)b:
antenatal and postnatal exercise
intervention versus treatment-as-
usual.

500 P.-Z. Lin et al.

depression. The meta-analysis showed that self-help interven-
tions constituted an effective method of treatment for postpar-
tum depression. Specifically, (1) depression symptoms contin-
ued to decrease from baseline to posttreatment and follow-up
assessments in treatment subgroups. Changes in depression
scores from baseline to postintervention assessment in treat-
ment subgroups were greater relative to those observed in
prevention subgroups. (2) Posttreatment and follow-up de-
pression symptoms showed greater reductions following
self-help interventions, relative to those observed in control
conditions; and (3) self-help interventions were significantly
more effective in aiding recovery from postpartum depression,
relative to control conditions. However, their effectiveness in
improvement of depression symptoms did not differ signifi-
cantly from that of control conditions in prevention studies.

Depression scores continued to decrease from baseline to
postintervention and follow-up assessment in treatment sub-
groups, which verified the effectiveness of self-help treatment
for postpartum depressive symptoms. In treatment studies,
self-help interventions produced larger overall effects on post-
partum depressive symptoms relative to those observed for
control conditions (Hedges’ g = 0.51). In addition, effect sizes
observed at follow-up assessment (Hedges’ g = 0.32) were
consistent with those observed in previously published re-
views examining treatments for perinatal depression, which
reported an average posttreatment effect size of 0.57 for post-
partum depressive symptoms (Sockol et al. 2011). Moreover,
the effectiveness of self-help interventions in aiding recovery
from postpartum depressive symptoms was significantly

greater relative to that observed for control conditions. As
stated by Cuijpers et al. (2010), guided self-help and face-to-
face treatments for depression exhibited comparable benefits
at follow-up of up to 1 year. This pattern of results suggested
that, similar to face-to-face treatments, self-help interventions
were more effective for postpartum depressive symptoms rel-
ative to TAU or WLs, and these benefits could be maintained
in the long term.

Treatment effects were stronger, relative to prevention ef-
fects, with respect to symptomatic improvement of postpar-
tum depression from baseline to postintervention assessment.
Similar results were observed in another meta-analysis exam-
ining self-help intervention for depression in the general pop-
ulation (Gellatly et al. 2007). Moreover, no advantages of self-
help interventions for postpartum depression were observed in
prevention trials. Furthermore, it is possible that depression
symptom severity could have influenced effect sizes. In other
words, self-help interventions could have produced a signifi-
cant effect size in the treatment of women who met the criteria
for depression or displayed depression scores above the cutoff
point for clinically significant depressive symptoms at base-
line. However, the effects of the interventions could have been
limited for women with low levels of depressive symptoms
(Bortolotti et al. 2008; Cuijpers, Smit, & Van 2007a).

Self-help CBTand BA produced stronger overall posttreat-
ment effects on postpartum depression relative to those ob-
served in control conditions. Moreover, these interventions
could provide steady symptomatic improvements in postpar-
tum depression from baseline to follow-up assessment. The

Fig. 7 Forest plot of the odds
ratio of patients recovered or
improved comparing self-help
psychological interventions with
control conditions. Note.
Mohammadi (2015)a: antenatal
exercise intervention versus
treatment-as-usual.

Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a… 501

results showed that self-help CBTand BAwere more effective
for postpartum depression, relative to control conditions. A
systematic review of the effectiveness of CBT in treating
and preventing perinatal depression reported an overall effect
size of 0.65 (95% CI 0.54 to 0.76, P < .001), indicating that participants who received CBT exhibited significantly greater reductions in depressive symptoms relative to those observed in control conditions (Sockol 2015). Another meta-analysis examining BA for depression in adults showed that BA was as effective as cognitive therapy and other psychological treat- ments for depression, with a large effect size of 0.87 (Cuijpers, Van & Warmerdam 2007b). There is strong evidence indicat- ing that dysfunctional patterns of cognition constitute a key risk factor for emotional distress (Beck & Haigh 2014). In addition, CBTwas an effective treatment, as it helped patients to identify, evaluate, challenge, and modify dysfunctional be- liefs. The current meta-analyses showed that while relatively few studies had examined each condition, the overall numbers of studies and participants provided sufficient power for the identification of differences in effectiveness between treatments.

The meta-analysis was subject to several limitations.
For example, the sample size was small; therefore, the
results should be interpreted with caution. In addition,
the body of existing research examining this topic is rel-
atively small, and all of the studies included in the review
focused on the effects of self-help interventions for post-
partum depression. Therefore, the homogeneity of the
sample limited generalization of the results and exposed
the shortage in existing research. Another limitation that
should be noted is the existence of publication bias in the
included studies. Trim-and-fill procedures suggested that
the publications showed significant positive intervention
effects. In addition, following correction for publication
bias, the overall effects of the interventions remained sig-
nificant, but null findings from well-designed studies are
required to enhance understanding of these interventions.

In summary, self-help interventions were more effec-
tive, relative to TAU and WLs, and as effective as face-
to-face psychological interventions in treating postpar-
tum depression. Considering the advantage of conve-
nience, self-help interventions, such as self-help, CBT,
and BA, have the potential to be effective therapy
methods for the treatment of postpartum depression.

Funding information This work was financially supported by grants
from the Science and Technology Major Project of Shandong
Province (grant number: 2015ZDXX0801A01).

Compliance with ethical standards

Conflict of interest The authors declare that there is no conflict of
interest.

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Effectiveness of self-help psychological interventions for treating and preventing postpartum depression: a meta-analysis

Abstract
Introduction
Materials and methods
Data sources and search strategy
Literature selection and data extraction
Statistical analysis
Assessment of study quality
Results
Study characteristics
Study quality and sensitivity analysis
Study designs and participants
Meta-analysis findings
Postintervention postpartum depressive symptoms following self-help interventions
Comparison of postpartum depressive symptoms between postintervention and follow-up assessments for self-help interventions
Comparison of postintervention postpartum depressive symptoms between intervention and control conditions
Comparison of postpartum depressive symptoms between interventions and control conditions at follow-up
Postintervention recovery and improvement rates

Discussion
References

RESEARCH ARTICLE Open Access

Breast cancer survivors’ recollection of their
illness and therapy seven years after
enrolment into a randomised controlled
clinical trial
Patricia Lindberg1*, Michael Koller2, Brunhilde Steinger1, Wilfried Lorenz1ˆ, Jeremy C. Wyatt3,
Elisabeth C. Inwald4 and Monika Klinkhammer-Schalke1

Abstract

Background

: Little is known about the subjective experience of breast cancer survivors after primary treatment.
However, these experiences are important because they shape their communication about their illness in everyday
life, usage and acceptance of healthcare, and expectations of new generations of patients. The present study
investigated this topic by combining qualitative and quantitative methods.

Methods

: Breast cancer survivors in Bavaria, Germany were mailed a questionnaire up to seven years after
enrolment into a randomised controlled clinical trial and start of their therapy. This enquired about their worst
experiences during the breast cancer episode, positive aspects of the illness and any advice they would give to
newly diagnosed patients. A category system for themes was systematically created and answers were categorised
by two independent raters. Frequencies of key categories were then quantitatively analysed using descriptive
statistics. In addition, local treating physicians gave their opinion on the response categories chosen by their
patients.

Results

: 133 (80 %) of 166 eligible patients who survived up to seven years returned the questionnaire. The most
prominent worst experience reported by survivors was psychological distress (i.e. anxiety, uncertainty; prevalence
38 %) followed by chemotherapy (25 %), and cancer diagnosis (18 %). Positive aspects of the illness were reported by
48 % with the most frequent including change in life priorities (50 %) and social support (22 %). The most frequent
advice survivors gave was fighting spirit (i.e. think positive, never give up; prevalence 42 %). Overall, physicians’
estimates of the frequency of these responses corresponded well with survivors’ answers.

Conclusions

: Although physicians’ understanding of breast cancer patients was good, psychological distress and
chemotherapy-related side effects were remembered as particularly burdensome by a substantial part of survivors.
On the one hand, patients’ quality of life needs to be assessed repeatedly during medical follow-up to identify such
specific complaints also including specific recommendations to the physician for targeted psychosocial and medical
support. On the other hand the advices and positive aspects of the disease, reported by the survivors, can be used
to promote positive ways of coping with the illness.

Keywords: Breast cancer, Survivorship, Qualitative analysis, Quality of life, Patient-physician agreement, Complex
intervention

* Correspondence: patricia.lindberg@ukr.de
ˆDeceased
1Tumor Center Regensburg e.V., An-Institute of the University of Regensburg,
Regensburg, Germany
Full list of author information is available at the end of the article

© 2015 Lindberg et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Lindberg et al. BMC Cancer (2015) 15:554
DOI 10.1186/s12885-015-1573-6

http://crossmark.crossref.org/dialog/?doi=10.1186/s12885-015-1573-6&domain=pdf

mailto:patricia.lindberg@ukr.de

http://creativecommons.org/licenses/by/4.0

http://creativecommons.org/publicdomain/zero/1.0/

Background
During the last years there has been growing interest re-
garding survivorship in breast cancer patients. One rea-
son is the increasing number of long-term survivors due
to improved screening and earlier treatment. A bulk of
studies has investigated quality of life in long-term
breast cancer survivors [1–5]. Overall it has been shown
that patients recover from most impairments during the
first year of illness [6–9] resulting in a long-term quality
of life that is comparable to the general female popula-
tion in most dimensions [1, 5]. Nonetheless, some per-
sistent specific complaints have been identified in breast
cancer survivors, such as arm symptoms, reduced sexual
functioning, or fatigue [3, 5, 10]. Besides, fear of recur-
rence is often prevalent and negatively affects well-being
[1, 10, 11]. A systematic review [12] of ten studies on
breast cancer survivors’ quality of life concluded that
good quality of life more than five years after diagnosis
was associated with the absence of chemotherapy or co-
morbidities, high income, and sufficient levels of social
support. However, many breast cancer survivors also ex-
perienced persistent specific complaints, such as arm
symptoms or sexual problems. Furthermore, numerous
more recent studies investigated various therapeutic ap-
proaches (stress reduction, exercise, counselling, spirit-
ual therapy) for improvement of quality of life in
randomised controlled trials [13–16].
These studies investigating long-term quality of life of

cancer survivors predominantly use standardised mea-
sures. To date, there exists no established questionnaire
that focuses specifically on the quality of life of survi-
vors. Therefore, most studies use instruments initially
developed for monitoring the course of diagnosis and
treatment, such as EORTC QLQ-C30 [17] or FACT-G
[18]. Although these instruments have their merits, it is
possible that they omit aspects of the cancer experience
that are important for survivors. Qualitative research is
one way to resolve this, as this allows us to explore the
survivor perspective and elicit a wider spectrum of an-
swers than closed-ended quality of life questions. Thus
issues can be detected that are omitted from standar-
dised questionnaires [19]. This may elicit new hypoth-
eses that can be analysed quantitatively. A good example
of this approach is the study by Lauver et al. [20] that
combined quantitative and qualitative measures to ex-
plore stressors after the end of primary therapies. By
using open-ended qualitative questions they identified
“dealing with uncertainties” as a stressor which would
have been otherwise overlooked.
Another relatively unexplored field is cancer survi-

vors’ personal evaluation of their illness course [21].
The meaning of the cancer experience to 58 long-
term survivors was investigated by Foley et al. [22]
using interviews more than five years post-diagnosis.

They demonstrated that most survivors reported ei-
ther little impact of cancer or even a positive long-
term influence on their lives, such as more inner
strength and a greater appreciation of life. This kind
of personal growth was associated with a better qual-
ity of life.
The starting point of this research was the patient per-

spective which is communicated in their everyday life to
family, friends, other patients, and physicians and might
influence women’s attitude toward the illness as well as
their use and acceptance of health services, support ser-
vices and alternative therapies. More specifically, the aim
of the present study was to examine the recollections of
breast cancer survivors seven years after diagnosis re-
garding their (1) worst experiences during the illness, (2)
potential positive aspects of the disease, and (3) the ad-
vice they would give to fellow patients. Another aim was
to investigate if these responses of patients correspond
with the opinion of their physicians regarding breast
cancer survivors’ worst and most positive experiences
and advices (4).

Methods
Sample
The study sample consisted of 200 female primary breast
cancer patients who had participated in a randomised
controlled clinical trial investigating the use of standar-
dised quality of life diagnostics and related therapies to
improve patients’ subjective recovery [23]. All partici-
pants had been surgically treated between 2004 and
2006 in one of five participating certified breast cancer
centres in Bavaria, Germany. To achieve high external
validity, the trial inclusion criteria had no restrictions re-
garding disease stage or age [24]. Details about the the-
oretical background, method, and results of this
complex intervention have been previously described
[23, 25–27].
Follow-up of survivors was conducted up to seven years

after breast cancer diagnosis in August and December
2012 (mean time since surgery 84 months; range 73–93
months). The term “survivor” is here used as five year sur-
vival of the cancer diagnosis, a criterion commonly ac-
cepted in cancer statistics [28, 29]. Therefore we supposed
that the chosen time point for follow-up was adequate to
investigate the perspective of “real” long-term survivors.

Design
A cross-sectional design was used for the present study.
This study constitutes Part IV (long-term implementa-
tion) of a large scale complex intervention project [30]
on the routine use of quality of life data in oncological
practice. Part I [26], II [27], and III [23] have already
been published. Ethical approval had been obtained from
the local university ethics committee (University of

Lindberg et al. BMC Cancer (2015) 15:554 Page 2 of 13

Regensburg, 03/197) and patients had given their in-
formed consent. In August 2012 all eligible women were
mailed a package of questionnaires supplemented by a
stamped return envelope and a cover letter informing
them about content and aims of the study. Patients who
did not respond within six weeks received one reminder
by telephone. Those who could not be contacted by
phone were mailed a reminder with the questionnaire
package [31]. There were no financial or other incentives
to respond.

Measures/instruments
Demographic and clinical variables
In this survey the following data were collected: age,
marital status, number of children, education level, and
employment status. Prognostic stage, type of surgical
procedure, and adjuvant/ neo-adjuvant therapy were ob-
tained from the original record of the randomised trial.

Qualitative questionnaire
The survivor questionnaire consisted of one page with
three qualitative, open-ended questions:

(1)“Which was the worst experience regarding your
cancer disease?”

(2)“Have there also been positive aspects according to
the illness?”

(3)“Which advice would you give newly diagnosed
breast cancer patients to cope with the disease?”

This questionnaire had been tested beforehand in a
pilot survey with breast cancer survivors who were not
part of the randomised trial cohort and thus did not take
part in the present survivorship study. Twelve women
with an earlier diagnosis of breast cancer participated in
the pilot study (mean time since diagnosis: 55.5 months,
range 11–84 months) with a mean age of 58 years (s.d. ±
7.5, range 45–69 years). Pilot participants evaluated the
qualitative questions as clearly formulated and easy to
understand. No woman perceived the content of the
qualitative questionnaire as unpleasant. Only one partici-
pant noted that the question asking for an advice for
newly diagnosed patients was difficult to answer. Over-
all, the qualitative questionnaire was highly accepted and
revealed useful insights into their illness so there was no
need for modification.

Developing a category system for qualitative answers
To analyse the qualitative data, categories were gener-
ated by inductive analysis encompassing all prominent
and relevant issues regarding the worst and positive ex-
periences and advice for fellow patients (see Fig. 1). Be-
cause little is known about the investigated research
field, candidate themes were derived from the data

instead of using a predefined category system [32]. This
was done independently by two investigators. Consensus
was reached by discussion.
To quantify the proportion of responders mention-

ing each finding, answers were transferred to an elec-
tronic database (Microsoft Access 2010). In the first
step, data were inspected using two different strat-
egies: (1) using a word-by-word analysis, frequency of
each word individually was counted using a computer
program. Through this, issues which were commonly

Fig. 1 Sequence of each step in the qualitative data analysis process
in the survivor study

Lindberg et al. BMC Cancer (2015) 15:554 Page 3 of 13

addressed by participants could be objectively identi-
fied, based on “Linguistic Inquiry and Word Count”
(LIWC) by Pennebaker et al. [33]); (2) using a more
holistic approach, the answers from all participants
were read to become familiar with the data and their
context. On the basis of (1) and (2) the most promin-
ent issues in women’s answers were identified and
transferred to a preliminary category system, consider-
ing the following criteria: each category should be
broad enough to include as much information as pos-
sible, so that a reasonable picture of women’s answers
could be given. At the same time categories were de-
signed to be as specific as possible, to include mean-
ingful information regarding content of the data.
Furthermore, categories were clearly circumscribed
and mutually exclusive so that data could be only
assigned to one category.
The final category system contained 11 different cat-

egories for worst experience, 6 categories for positive as-
pects and 13 categories for advice for fellow patients (see
Table 1). To facilitate the practical use of this coding
system, each category was illustrated with a short de-
scription and text examples that resembled but were not
identical to the patients’ original answers. Two raters (a
physician and a psychologist) were trained in this cat-
egory system and were then instructed to categorise all
patient responses independently [34]. Some answers
contained multiple statements belonging to more than
one category. Those had to be divided into single issues
and classified in different categories. Finally, both raters
met with the third independent expert (methodologist)
to discuss divergent ratings until consensus was achieved
[35].

Survey of coordinating practitioners
Following completion of data analysis of the patient sur-
vey, a survey was conducted with those physicians who
had taken care of the patients’ treatment and follow-up
during the randomised trial [23]. Thus, the physicians
were familiar with quality of life issues and would have
managed one or more patients who were participating in
the survivorship study. The aim of this survey was to
compare physicians’ opinions regarding worst and most
positive experiences of breast cancer survivors with the
survivors’ actual perspective. A total of 50 eligible physi-
cians were mailed a five-page questionnaire supple-
mented by a stamped return envelope and a letter
explaining the study aim. The questionnaire referred to
the three qualitative questions that were the focus of the
patient survey (worst experience, positive experience, ad-
vice to fellow patients). After presenting the five most
frequent categories from the patient survey for each of
the three qualitative questions, the physicians’ task was
to arrange the categories according to their expectation

of the survivors’ response frequency, from “1” (most
common answer) to “5” (less common answer). All the
categories and category descriptions were taken from
our analysis of the patient questionnaire data.

Statistical analysis
Agreement between the two raters of categories was
analysed using intercoder percent agreement and
Cohen’s kappa to account for random agreement. Re-
sponse categories were analysed quantitatively in a de-
scriptive manner and reported as frequencies and
proportions. For physicians’ ratings, means were calcu-
lated for each category as well as the percentage of each
category ranked as number “1”. All data were analysed
using SPSS software version 20.

Results
Participant characteristics
Of the 200 patients enrolled into the randomised study,
three patients refused further participation and 31 had
died at the time of the present study. Thus, 166 patients
were eligible and 133 returned the questionnaire, a re-
sponse rate of 80 % (Fig. 2).
The mean age of participants at long-term follow-up

was 64.2 years (s.d. ± 10.8) and average interval since
surgery was 84.8 months (s.d. ± 5.6). Further demo-
graphic and medical characteristics of participants are
reported in Table 2.
Respondents (n = 133) did not differ from non-

respondents (n = 33) regarding age, time since surgery,
stage, type of surgery, or recurrence of cancer.
133 respondents answered the questionnaire package

including both the quantitative quality of life question-
naire (not reported in this paper) and the qualitative
questions. Eight respondents missed this latter set of
questions. Thus, qualitative analysis was based on 125
participating survivors.

Qualitative analyses of worst and positive experiences
and advice for fellow patients
Analysis of response length and word frequency
The length in words of participants’ responses was
analysed: Women gave the longest answers when asked
for positive aspects of their disease with a median of
10.0 words per answer (range 1–24 words), while re-
sponses describing the worst experience during cancer
disease were shortest with a median of 5.0 words per
answer (range 1–43 words). In between was advice for
fellow patients (word length median 6.5, range 1–43
words).
In order to identify the most common issues in partic-

ipants’ answers, frequency of each single word was
counted electronically. The three most frequent nouns
addressing worst experience were “anxiety” (n = 25),

Lindberg et al. BMC Cancer (2015) 15:554 Page 4 of 13

Table 1 Final category system used for the qualitative and quantitative analysis

Category Description Sample characteristic statements by the women

Worst experience

Psychological
distress

Anxiety or uncertainty about the course or outcome of the
illness.

“uncertainty according to the outcome of surgery”; “uncertainty
about the future”; “anxiety”; “fear of recurrence”; “fear of dying”

Chemotherapy Chemotherapy or related side-effects. “chemotherapy”; “loss of hair”; “to look at myself due to the loss
of hair” “port implantation for chemotherapy”

Cancer diagnosis The shock of receiving cancer diagnosis and the fact of being
a cancer patient.

“communication of the diagnosis by the gynaecologist”; “Cancer
itself! I have always lived a healthy life”; “that you have cancer
and can’t forget it”

Mastectomy Removal of the breast and the affected body image. “removal of the breast, loss of self-esteem regarding sexuality”;
“losing my breast or dying”; “disfigurement of the body, consider-
able restrictions in dressing”

Social burden Fear of family or other conflicts in partnership or family caused
by the illness.

“to have to be strong for my family”; “the fear of my twin sister
and my daughter”; “that my husband couldn’t get along with the
changes of my body, what I never had expected”; “to see, how
my husband was suffering”;

Additional
illnesses

Additional diseases like comorbidities or recurrence during or
after breast cancer.

“I had a recurrence”; “cancer disease was accompanied by atrial
fibrillations – bad health status for a long time”; “arm pain
because my right upper arm was disabled by a fracture”

Radiotherapy Radiotherapy with related side-effects. “loss of energy because of radiation”; “after radiotherapy I had a
pneumonia for nearly five years after treatment with cortisone”

Endocrine
therapy

Endocrine therapy with related side-effects. “endocrine therapy with all side effects”; “the obligation to take
pills continuously despite circulatory complaints”; “my bones,
probably affected by the intake of medication”

Nothing No worst experience.

Other ”pain”; “fatigue”; “that life will never be the same!”; “Everything
happened at once. Diagnosis, divorce, driving test, moving
house”

Positive aspects

Change in life
priorities

Change of one’s own priorities in life in terms of living life
more consciously and relaxed, or changes in lifestyle.

“I think, you live more intensively and consciously”; “I have
reconsidered my life, changed several things”; “I see a lot of
things more relaxed”; “I have learnt to take more care of myself,
to say ‘no’ more often that makes me proud”

Social support Support by family, friends, or colleagues as well as unexpected
help from others.

“the experience of intensive and also often unexpected support
and friendship”; “my friends never abandoned me”; “I experienced
a lot of attention, appreciation and support”; “I met wonderful
people”

Good course of
cancer

The good course and outcome of the illness. “tumour was very small”; “no metastases”; “disease was early
detected because of annual check-up”

Support by
physicians/
nurses

The good (medical) treatment by physicians or nurses. “the experience of caring physicians and nurses”; “advice and
reassurance”; “the good medical attendance”

Gratitude Being grateful to have survived. “I have developed a profound feeling of gratitude”; “that I’m still
alive”; “looking back on my life and thankfulness”; “regarding
every day as a gift from God”

Other “I could manage my disease very well”

Advice

Fighting spirit Think positive, fight, and never lose hope. “never give up and think positive all the time”; “always thinking
‘Yes, I can manage that!’”; “Never lose hope!”

Information Keep calm, get a second opinion, and inform yourself about
the illness.

“inform yourself about all treatment options”; “don’t believe just
one single physician”; “inform yourself intensively in the internet,
get a second opinion”

Confidence in
physicians

Trust your physician and follow his/ her instructions. “do everything the doctor says”; “confidence in physicians”;
“adherence to treatment”

Openness Confide in somebody and talk a lot about the illness. “positive conversations, share your experiences”; “talking a lot
about the illness”; ““don’t hide the disease”

Lindberg et al. BMC Cancer (2015) 15:554 Page 5 of 13

“chemotherapy” (n = 25), and “diagnosis” (n = 16). Asked
for positive aspects, women most frequently used words
like “life/ living” (n = 15), “illness” (n = 7), and “positive”
(n = 7). When giving advice for fellow patients, the most
frequent words were “positive” (n = 23), “illness” (n = 18),
and “physician/s” (n = 12).

Interrater agreement
The median interrater percent agreement between the
two raters was 98 % for categories regarding worst expe-
riences, 93 % for positive aspects, and 99 % for advice for
fellow patients. To account for random agreements
Cohen’s kappa was also calculated. The median kappa

Table 1 Final category system used for the qualitative and quantitative analysis (Continued)

No advice It is not possible to give any advice for fellow patients. “I can’t give any advice”; “none, every patient comes to terms
with it another way”

Business as
usual

Don’t think too much about the illness, live life in a normal
way.

“fade out disease of daily life, live for the moment”; “master
everyday life as usual, domestic work, sports, friends, theatre”;
“don’t think too much about disease, distract yourself, and remain
cheerful”

Cancer
screening

Have regular cancer screening. “go to the doctor in time”; “regular cancer screening”; “early
detection by screening”

Acceptance Accept the illness. “things you can’t change you have to accept”; “accepting disease”

Self-reflection Reconsider your life. “consider disease as a touchstone and if applicable as turning
point, which is not solely negative but also offers opportunities to
find oneself”; “attend to your own soul, find out, what makes you
happy”

Belief in God Strengthening in faith. “pray a lot”; “don’t lose courage, my trust in God helped me a lot”

Support group Visit a support group. “contact other patients or a support group”; “visit a support
group as soon as possible”

Secrecy Keep your illness as a secret. “Inform as few people as possible! Hardly anybody can help!”

Other “Go to rehab”; “to undergo surgery immediately”; “no
complementary medicine, take part in a trial”; “accept help”

Fig. 2 Patient recruitment in the survivor study. Breast cancer survivors, initially part of a randomised trial, enrolled onto long-term follow-up
respecting drop-outs. Response rate of eligible patients in the survivor study 80 %

Lindberg et al. BMC Cancer (2015) 15:554 Page 6 of 13

Table 2 Demographic and medical characteristics of patient participants (n = 133)

No. of patients % of patients

Age (Mean ± s.d. 64.2 ± 10.8, range 41–92)

<50 8 6

50–59 45 34

60–69 36 27

70–79 31 23

80+ 13 10

Months since surgery
(Mean ± s.d. 84.8 ± 5.6, range 74–96)

Marital status

Married 101 76

Unmarried 4 3

Divorced 14 11

Widowed 14 11

Children

Children 113 85

No children 10 8

Unknown 10 8

Employment status

Employed full time 20 15

Employed part time 27 20

Retired/ not employed 80 60

Unknown 4 3

Educational level

Did not finish school 2 2

Compulsory 61 46

Advanced vocational 56 50

University 10 8

Unknown 6 5

Cancer stage at diagnosis

UICC 0 2 2

UICC I 68 52

UICC II (II a and b) 39 29

UICC III (III a, b, c) 21 16

Unknown 3 2

Surgical procedure

Breast conserving therapy 106 80

Mastectomy 27 20

Treatment (first year after surgery)

Chemotherapy 94 71

Radiotherapy 118 89

Endocrine therapy 113 85

Anti-HER2 monoclonal antibody 11 8

Recurrent cancer 15 11

s.d. standard deviation

Lindberg et al. BMC Cancer (2015) 15:554 Page 7 of 13

was 0.83 for worst experiences (range 0.41–0.98), 0.75
for positive aspects (range 0.49–0.95), and 0.95 for advice
for fellow patients (range 0.58–1.00) (it should be men-
tioned that for all three categories the lowest kappa was
observed with respect to the response option “other”).

Worst experience regarding breast cancer
Of the 125 survivors answering the qualitative question-
naire, 118 (94 %) responded to the question asking for
their worst experience during breast cancer (Table 3). By
far the most prominent worst experience was psycho-
logical distress, reported by 38 %. The category included
answers like “uncertainty about the future”, “fear of

recurrence”, or “fear of dying”. This was followed by
chemotherapy with 25 % (e.g. “to look at myself due to
the loss of hair”, “port implantation for chemotherapy”),
and cancer diagnosis with 18 % (e.g. “communication of
the diagnosis by the gynaecologist”, “Cancer itself! I have
always lived a healthy life”). The other defined categor-
ies were mentioned by less than 10 % of respondents.
12 % of issues were categorised as other including “pain”
which was noted by only two survivors as one of their
worst experiences (Table 3). Further examples of an-
swers from individual patients are given in Table 1.

Positive aspects of cancer
When asked if there had been also positive aspects of the
disease, about half of the survivors affirmed this question
(positive aspects: “yes” 60/125 (48 %); “no”: 54/125
(43 %); “missing” 11/125 (9 %)). Of those 60, 58 women
gave written information about their most positive ex-
perience (Table 3). A change in life priorities was re-
ported by 50 %. For example a woman answered “I have
reconsidered my life, changed several things” and another
described “I have learnt to take more care of myself, to
say ‘no’ more often that makes me proud”. Furthermore
22 % of survivors mentioned the role of social support
by family, friends, and colleagues (e.g. “the experience of
intensive and also often unexpected friendship”, “my
friends never abandoned me”). 16 % named the good
course of cancer (e.g. “tumour was very small”, “no me-
tastases”) and 10 % emphasised (medical) support by
physicians and nurses (e.g. “the experience of caring phy-
sicians and nurses”, “the good medical attendance”). The
remaining categories gratitude and other were used by
less than 10 % (see Tables 1 and 3).

Advice for fellow patients
This question was answered by 110 out of 125
women (88 %, Table 3). By far the most frequent ad-
vice for newly diagnosed patients was fighting spirit
with 42 %. In this regard a woman recommended
“never give up and think positive all the time” and
another one advised “Never lose hope!”. Furthermore,
16 % of survivors suggested information, for example
“inform yourself intensively in the internet, get a sec-
ond opinion” or “don’t believe just one single phys-
ician”. Another 11 % advised confidence in physicians.
(e.g. “do everything the doctor says”). Other categories
were used by less than 10 % (see Tables 1 and 3).

Evaluation of physicians
Of the 50 physicians contacted for the survivor survey,
one was retired and could not be reached by mail. Of
the remaining 49 doctors, 29 participated in the survey
(59 %). Those had a mean age of 53.8 years (s.d. ± 9.0),
were predominantly female (62 %) and all but one

Table 3 Frequency of breast cancer survivors’ answers about
their worst experience during breast cancer, positive aspects of
the illness and advice for fellow patients

Worst experience (n = 118) No. of patients % of patients

Psychological distress 45 38

Chemotherapy 29 25

Cancer diagnosis 21 18

Mastectomy 9 8

Social burden 8 7

Additional illness 7 6

Radiotherapy 3 3

Endocrine therapy 3 3

Nothing 1 1

Other 14 12

Positive Aspects (n = 58) No. of patients % of patients

Change in life priorities 29 50

Social support 13 22

Good course of cancer 9 16

Support by physicians/ nurses 6 10

Gratitude 5 9

Other 3 5

Advice (n = 110) No. of patients % of patients

Fighting spirit 46 42

Information 17 16

Confidence in physicians 12 11

Openness 10 9

No advice 10 9

Business as usual 8 7

Cancer screening 7 6

Acceptance 6 6

Self-reflection 5 5

Belief in God 4 4

Support group 2 2

Discreteness 2 2

Other 9 8

Lindberg et al. BMC Cancer (2015) 15:554 Page 8 of 13

worked as gynecologist with length of professional ex-
perience in treating patients with breast cancer from 6
to 46 years (Median 23.5) (see Table 4). Four of the 29
participants did not fill in the questionnaire appropri-
ately so their answers could not be analysed.
Overall, physicians’ estimates of the frequency of

women’s experiences corresponded relatively well with
their patients’ actual answers (Table 5). Regarding
women’s worst experience during breast cancer, doctors
and survivors named the same three issues most fre-
quently (cancer diagnosis, chemotherapy, psychological
distress). However, physicians underestimated the role of
psychological distress. This was by far the most frequent
answer of survivors (38 %), but was rated as the most
common answer by only 16 % of physicians. Instead,
60 % of doctors thought that cancer diagnosis was the
worst experience for patients (true answer 18 %).

Regarding positive aspects of cancer disease, physicians
also showed a good correspondence with their patients,
naming the issues in nearly the same order as the survi-
vors (Table 5). They only underestimated the role of sup-
port by physicians and nurses. While 10 % of survivors
reported this issue as their most positive experience dur-
ing the illness, 52 % of doctors thought it would be the
rarest answer given by patients.
When asked which advice breast cancer survivors

might give to newly diagnosed patients, physicians
(44 %) and survivors (42 %) similarly named fighting
spirit most frequently. Seeking information about the ill-
ness was also frequently named by doctors (21 %) and
women (16 %), while the role of openness was overesti-
mated by physicians (28 %) compared with patients
(9 %).

Discussion

The subject of survivorship is of increasing interest due
to the improved methods of cancer screening and ther-
apy that prolong survival. The present study investigated
how breast cancer patients remembered their illness epi-
sode about seven years after therapy onset. We are
aware that such retrospective reports are vulnerable to
distortions, such as recall and hindsight bias [36], re-
framing [37], and response shift [38, 39]. Different fac-
tors may contribute to recall bias [40] such as mood
[41], the kind of material to be remembered (i.e. infor-
mation in great detail) [42], or personal characteristics
(i.e. optimism [43]). So, we deliberately bypassed the
issue of “objectivity” and memory distortions, instead fo-
cusing on subjective recollections because these are the
kinds of opinions and experiences that are communi-
cated by survivors and shape the perceived stereotypes
of breast cancer via their families, friends, and the
media. These stories and stereotypes will in turn influ-
ence future generations of patients [21].
To our knowledge this is the only study investigating

the perspective of breast cancer survivors regarding their
course of illness which is also supplemented by the per-
spective of their physicians. The methodology we have
used can act as a paradigm for others to investigate
these issues. Open-ended, qualitative surveys go well be-
yond standardised assessment of quality of life and elicit
new information. In contrast a recent study by Hollen et
al. [44] investigated the importance of quality of life is-
sues that are listed by breast cancer patients in general
without assessing their subjective experiences in their
course of treatment and recovery.
Before discussing our results, the strengths and limita-

tions of the present study should be considered. The
study population was well-defined due to patients’ par-
ticipation in an earlier randomised trial [23]. The re-
sponse rate was high given that the study was conducted

Table 4 Characteristics of participating physicians (n = 29)

No. of
physicians

% of
physicians

Age (Mean ± s.d. 53.8 ± 9.0,
range 35–72)

<40 1 4

40–49 8 29

50–59 12 43

60–69 6 21

70+ 1 4

Sex

Female 18 62

Male 11 38

Specialisation

Gynaecologist 28 97

General practitioner 1 3

Professional experience

Breast cancer patients per year
(Median 30.0, range 10–700)

<20 8 28

20–50 13 45

51–100 2 7

101–199 4 14

200+ 2 7

Years treating breast cancer patients
(Median 23.5, range 6–46)

<10 2 7

10–19 8 29

20–29 11 39

30–39 6 21

40+ 1 4

s.d. standard deviation

Lindberg et al. BMC Cancer (2015) 15:554 Page 9 of 13

more than six years after diagnosis (80 %). Further-
more, this investigation has high external validity (no
exclusion according to age, stage, or recurrence, par-
ticipants from both urban and rural areas). Further
strengths are the emergent rather than predefined
categories and the use of duplicate assessors to de-
fine the categories from the data.
However, there are also some limitations: First, we used

a mailed survey instead of semi-structured interviews or
focus group meetings. Therefore, most of the qualitative
answers were short and enquiry for further explanation
was not possible. The reason to choose this method any-
how was that our participants were already familiar with
the questionnaire method. A mailed survey has also the
advantage that there is less likelihood of social desirability
than in interviews, no potential influence of the inter-
viewer, and the accessibility of a larger sample of partici-
pants. Another limitation is the response rate of only 59 %
in the physician survey. It is possible that only those doc-
tors who have a particularly close relationship with their
patients participated, so that the observed patient-
physician agreement might be overestimated. Third, al-
though this study can claim external validity for breast
cancer patients in Germany, future studies need to con-
firm results in other countries and healthcare settings.

In qualitative research each category will contain a
range of different perspectives. In order to address this
problem we tried to be as objective and data-driven as
possible when analysing patients’ qualitative statements.
We therefore used word counting to identify objectively
the most frequent issues in participants’ answers. In
addition, two raters categorised the data independently.
Nonetheless, we are aware that there is never a sole
truth [45].
Keeping these pros and cons in mind, one key result is

that the major part of our breast cancer survivors re-
membered psychological distress (such as fear of recur-
rence or uncertainty about the future) as their worst
experience. A possible explanation might be the high
prevalence of fear of recurrence which has been shown
in long-term breast cancer survivors [11]. Thus, uncer-
tainty and fear are still relevant to survivors so that these
psychological complaints are also remembered as par-
ticularly burdensome during the illness. This informa-
tion is directly relevant to physicians, who should
anticipate psychological distress in their patients during
the whole follow-up period and encourage patients to
express their fears so that these can be discussed. Good
patient-physician communication may help to reduce
these fears and uncertainties and improve patient satis-
faction [46] in order to prevent chronic psychological
distress in long-term survivors [47].
In addition, chemotherapy was reported by one out of

four women as particularly burdensome during the ill-
ness. These medical side effects have been already shown
to be common psychosocial concerns in women with a
recent diagnosis of breast cancer [48] and also remain
one of the most burdensome experiences remembered
by long-term survivors. Specific complaints of individual
breast cancer patients need to get more attention during
the time of medical treatment and follow-up. One solu-
tion to this problem is the regular assessment of the pa-
tient’s quality of life. These results need to be
communicated to the physician with recommendations
for tailored treatment of reduced quality of life [26]. This
kind of intervention has been demonstrated to be effect-
ive for breast cancer patients during the first year of
medical follow-up [23].
Another interesting result is that somatic symptoms

seemed to play little or no role in the patients’ recollec-
tion of their illness. In particular, the concern over
“pain” widely debated in oncology was almost never
mentioned by patients in our survivor study. This infor-
mation might help newly diagnosed breast cancer pa-
tients by taking away some of their fears.
Apart from this about half of the participants also re-

ported positive effects related to the illness. This is not-
ably lower than the percentage found by Sears et al. [49]
with 83 % of breast cancer patients reporting at least

Table 5 Physicians’ estimates of patients’ most frequent
answers (n = 25)

Physicians’responses Patients’
responses

Worst experience Mean % %a

Cancer diagnosis 1.8 60 18

Chemotherapy 2.5 24 25

Psychological distress 2.9 16 38

Social burden 3.4 – 7

Mastectomy 4.1 – 8

Positive aspects Mean % %a

Change in life priorities 2.1 52 50

Social support 2.5 24 22

Good course of cancer 3.0 16 16

Gratitude 3.2 8 9

Support by physicians 4.1 – 10

Advice Mean % %a

Fighting spirit 2.2 44 42

Openness 2.3 28 9

Information 2.8 21 16

Confidence in physicians/ nurses 3.3 8 11

Business as usual 4.1 4 7
apercentages based on raw counts of patients’ most frequent answers
(multiple answers were possible, see Table 3); Mean = mean of ranks on a
scale of 1–5; %: percentage of physicians rating the category as “most
frequent answer” (response category “1” on a scale of 1–5)

Lindberg et al. BMC Cancer (2015) 15:554 Page 10 of 13

one benefit in their disease. An explanation for these di-
vergent results might be that Sears et al. surveyed re-
cently diagnosed women whereas the present study
focused on the perspective of long-term survivors. Per-
haps finding benefit in the disease is especially important
during the time of diagnosis as a form of coping. But in
the long run it can be also maladaptive if expectations of
benefits are not realised [50]. Similarly, Foley et al. [22]
noticed that most cancer survivors experienced no im-
pact of the disease on their lives.
Of those women in our sample who reported positive

aspects most emphasised a change in life priorities. This
is closely related to the concept of ‘posttraumatic
growth’ – personally important changes as a result of a
life-threatening crisis – often described in relation to
cancer survivorship [51]. Similarly, a substantial number
of survivors in our sample mentioned that they are living
more intensively and consciously.
Furthermore, women evaluated the social support they

received during the illness as a positive aspect. Although
some survivors reported the social burden caused by
cancer (fear of family members, conflicts in partnership)
as their worst experience, a considerable number of the
women experienced positive social support by family,
friends, and colleagues. This seems to be an important
aspect of coping with the illness, as it has been demon-
strated that social support is a significant predictor for a
better long-term quality of life in breast cancer patients
[6]. Likewise, Sears et al. [49] identified the topic of so-
cial relationships as the most frequent benefit reported
by recently diagnosed breast cancer patients. Similarly,
social support was also relevant for survivors in the
present study but not as important as a change in life
priorities. Perhaps the meaning of positive experiences
changes during the course of the disease. Whereas social
support is most helpful in the acute phase of the illness
its role becomes less important during survivorship. In-
stead, personal changes are more relevant because they
are long-lasting and therefore can be still noticed as a
benefit in long-term survivors. This needs to be investi-
gated in future prospective studies.
Support by physicians and nurses was also stressed as a

positive aspect during cancer. Medical staff need to be
aware that they are an important aid for their patients in
coping with breast cancer. This information relates to
studies investigating patient-physician communication.
Those identified that breast cancer patients perceive a car-
ing attitude of the physician as more important than
information-giving [52]. Likewise, physician attentiveness
and empathy have been found to be associated with
greater patient satisfaction and reduced emotional distress
after the consultation in cancer patients [53]. In this sense
the present study supports the assumed high relevance of
patient-physician communication by demonstrating that a

positive relationship with physicians and nurses is still im-
portant in the recollection of long-term survivors.
Survivors who reported positive aspects of their dis-

ease were also more likely to give advice to fellow pa-
tients compared to those women who did not remember
any positive aspects. The vast majority recommended to
think positive, to fight, and to never give up. This kind
of fighting spirit has been found to be associated with
better psychological adjustment to advanced breast can-
cer [54, 55]. Additionally, previous studies identified a
positive relationship between trait optimism and well-
being in breast cancer patients during the course of
medical therapy [8, 56] and long-term follow-up [57].
The second most common advice was to inform oneself
intensively about the illness e.g. by using the internet or
by getting a second opinion. The specific information
needs of cancer patients have been described in a sys-
tematic review including 112 articles published between
1980 and 2003 [58]. Reasons why some cancer patients
do not want to get further information were qualitatively
analysed by Leydon et al. [59] conducting in depth inter-
views with 17 cancer patients. They identified three mo-
tivations: hope (keeping away fearful, contradictory, or
negative information to preserve hope), charity (con-
cerns about taking up too much time of the doctor to
the detriment of other patients), and faith (the doctor
knows best, medical knowledge is too complex to under-
stand). In agreement with the last explanation, some
women in our sample adopted a passive posture by
recommending confidence in physicians (do anything the
doctor says, faith in physicians and medical therapy).
The study also demonstrated good but not perfect cor-

respondence between physicians and patients. This is in
contrast to the bulk of previous studies [60, 61]. There
may be two explanations for this finding: (1) the meas-
urement method, asking for direct experiences instead
of standardised questionnaires and (2) the close relation-
ship of our physicians with their patients as a result of
regular follow-up, which might have been intensified by
the randomised trial [62]. Physicians realised the
affective dimension of the worst experience by choosing
cancer diagnosis first (60 %) and psychological distress
third (16 %). Patients had a similar opinion, although the
two issues were reversed in frequency. Patients and phy-
sicians agreed that psychological distress and cancer
diagnosis were particularly important elements of the
cancer experience in the follow-up. The important
lesson for physicians to learn is that distress caused by
fear of recurrence or uncertainty about the future prob-
ably plays a more important role in the follow-up phase
compared to the shock of diagnosis. So, in the medical
encounter patients’ fears need to be addressed repeat-
edly, also discussing prognosis and the risk of recur-
rence. Another finding was that doctors tended to

Lindberg et al. BMC Cancer (2015) 15:554 Page 11 of 13

underestimate the important role they played for their
patients: they need to be more aware of how much pa-
tients appreciate their medical and interpersonal support
as an important aid in coping with their disease.

Conclusions
This is the first study investigating the recollection of
breast cancer survivors regarding their course of illness
which is supplemented by the perspective of their physi-
cians. Results demonstrated that physicians had a good
overall understanding of the subjective experiences of
breast cancer patients. Most survivors remembered psy-
chological distress as their worst experience during
breast cancer, followed by chemotherapy. These issues
need to be considered even more in patient care. Physi-
cians should address patients’ fears repeatedly in the
medical encounter. Regular assessments of patients’
quality of life during medical follow-up can help to iden-
tify these specific complaints but should also include
recommendations for the physician for targeted psycho-
social and medical support. About half of the survivors
also reported positive aspects of the illness, such as a
change in life priorities. Their most frequent advice was
fighting spirit. These advices and positive aspects of the
disease should be further investigated to promote posi-
tive ways of coping with the illness.
Investigating the perspective of cancer survivors in this

way is important since subjective recollections of former
patients shape communication about the illness in every-
day life, usage and acceptance of health care and ultim-
ately, the expectations of new generations of patients.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors contributed to the conception of the study design. PL, BS, and
MKS have made substantial contribution to the acquisition of data. PL, MK,
BS, WL, JW, and MKS have made substantial contribution to the analysis and
interpretation of data. PL drafted the manuscript. MK, BS, WL, JW, EI, and
MKS have made substantial contributions to the revision of the manuscript
for important intellectual content. All authors have approved the submitted
manuscript and agreed to be accountable for all aspects of the work. Sadly,
WL died when working on this project.

Acknowledgements

This work was supported by the Deutsche Krebshilfe, Project number
109216. The authors would like to appreciate all women who participated in
the survivor study and took the time and effort to remember the course of
their breast cancer disease. Furthermore, we would like to thank the
physicians who took part in the survey.

Author details

1Tumor Center Regensburg e.V., An-Institute of the University of Regensburg,
Regensburg, Germany. 2Center for Clinical Trials, University Hospital
Regensburg, Regensburg, Germany. 3Leeds Institute of Health Sciences,
University of Leeds, Leeds, UK. 4Department of Gynecology and Obstetrics,
University Medical Center Regensburg, Regensburg, Germany.

Received: 30 October 2014 Accepted: 21 July 2015

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