Effects of behavioural activation on psychological distress among people with cancer: A systematic review and meta-analysis

Background: Cancer is a life-threatening disease that can have a significant impact on patients' psychological well-being. Behavioural activation is an emerging psychological therapy that has been suggested effective in improving depression and anxiety. However, no review has yet summarised its effects on psychological distress among people with cancer. Objective: To identify studies of behavioural activation designed for people with cancer and examine the effects on psychological distress, including depression and anxiety. Design: Systematic review and meta-analysis. Methods: A systematic search of PubMed/MEDLINE, CINAHL, EMBASE, PsycINFO, and the Cochrane Library was performed from the inception to 6 April 2024. Randomised controlled trials reporting on the effects of behavioural activation on psychological distress among cancer patients were included. Two authors independently screened the eligible studies, assessed the quality of studies, and extracted data. The risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). The meta-analysis was performed by Review Manager 5.4, and narrative synthesis was employed when the meta-analysis was inappropriate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the certainty of the evidence. Results: A total of nine studies were included in this systematic review, with 1811 participants. The pooled analysis showed that behavioural activation could improve depression (SMD = -0.24, 95 % CI -0.44 - -0.03, p = 0.020; moderate quality of evidence), and anxiety (SMD = -0.56, 95 % CI -1.01 - -0.10, p = 0.020; low quality of evidence) among people with cancer. The effects were robust in sensitivity analysis and yielded consistent results in studies that were not pooled due to insufficient data. Subgroup analyses suggested that face-to-face and group administration were more effective, whereas the effects of different dosages were uncertain. Besides, the effects of behavioural activation at different follow-up periods were not identified There was no consensus on the optimal components of intervention. Conclusions: The evidence for behavioural activation as an effective treatment of psychological distress among people with cancer is promising. However, it should be noted that the quality of evidence was moderate and low, thus emphasising the need for caution when applying these findings. In order to explore which components may be most effective in improving psychological outcomes, more rigorous study designs and more detailed descriptions of interventions are necessary. Registration: The protocol was registered on PROSPERO (Registration number: CRD42024533171).