Journal of Preventive Medicine

Introduction
Cancer is the second most common cause of death after cardiovascular diseases in global and in developed countries and the third cause of death after cardiovascular diseases and road accidents in less developed countries [2]. Most patients with cancer suffer from high stress, depression and anxiety in the first weeks or months after being diagnosed with the disease. The continuation of these negative feelings is a sign of low adaptation and can lead to a decrease in the acceptance of treatments and the deterioration of the disease [3]. Today, due to the presence of psychological symptoms in people with cancer, experts in cancer treatment use either medical treatments or psychological interventions that play a decisive role in controlling and reducing psychological symptoms [6]. One of the psychological interventions is the Intensive Short-Term Dynamic Psychotherapy (ISTDP) which is designed to overcome and solve problems caused by emotional distress. In this approach, the patient finds more satisfactory ways to overcome problems by solving his unconscious conflicts [7]. On the other hand, Cognitive Behavioral Therapy (CBT) has been effective in reducing catastrophizing and perceived pain and increasing pain acceptance and self-efficacy in patients with chronic pain [10]. Considering the studies on ISTDP in various chronic diseases, this study aims to compare the effectiveness of ISTDP and CBT in reducing the death anxiety of women with breast cancer.

Methods
This is a quasi-experimental study with a pre-test/post-test design. The study population includes all women with breast cancer covered by the Imam Khomeini Relief Foundation in Gorgan, Iran. Using a convenience sampling method, 45 women were selected. After the initial interview and not having an acute disorder and taking other drugs, 30 women who met the inclusion criteria were selected and randomly assigned in three groups including two intervention groups and one control group with the same size. The inclusion criteria were: having cancer, not taking psychiatric drugs, consent to participate in the study, educational level above diploma, and age >20 years. Exclusion criteria were: absence from more than two intervention sessions, having another psychiatric disorder, and participation in other psychological interventions. After obtaining informed consent from the participants, eleven 90-minute ISTDP sessions were performed in the experimental group 1, and eleven 90-minute sessions of CBT were performed in the experimental group 2. Finally, the data was analyzed in SPSS software, version 26 using analysis of covariance.

Results
There was no statistically significant difference in death anxiety between the two experimental groups in the raw model (p=0.631, Mean Difference=-3.80) and adjusted model (p=0.072, Mean Difference=-4.32). The Cohen’s d, as the effect size index, also indicated that the effect of the two interventions on death anxiety was not statistically significant.
There was a statistically significant difference in death anxiety between the ISTDP and control groups in the raw model (p<0.001, Mean Difference=-15.40) and adjusted model (p< 0.001, Mean Difference=-15.49). The values of Cohen’s d, which were -2.30 and -3.06 in raw and adjusted models, respectively, also indicated that ISTDP had a very strong effect on reducing the death anxiety.
There was a statistically significant difference in death anxiety between the CBT and control groups in the raw model (p=0.002, Mean Difference=-11.60) and adjusted model (p<0.001, Mean Difference=-11.17). The values of Cohen’s d, which were -1.52 and -2.22 in raw and adjusted models, respectively, also indicated that CBT had a very strong effect on reducing the death anxiety.

Discussion
In a chronic disease like breast cancer, death anxiety is one of the factors that affect women. This type of anxiety is in the field of psychiatry, which includes thoughts, fears and emotions related to death. Death anxiety may affect a person’s sleep and daily functioning in various ways, such as avoiding seeing friends and even the treatment process, or reducing self-confidence, impairment of motor activities, and other clinical issues. CBT with adjustment of beliefs and exposing the person to cognitive traps causes higher acceptance of problems and reduction of anxiety and negative feelings. On the other hand, mindfulness and daily exercises help go through the treatment period with minimal anxiety. By adjusting beliefs and reducing anxiety, a person finds more quality in her daily life. The CBT can affect the quality of life of women with breast cancer. Challenging distorted beliefs helps these women develop resilience, experience less anxiety, and become more determined to heal and challenge the disease. The CBT can reduce the distress and psychological stubbornness of patients with cancer.

Ethical Considerations

Compliance with ethical guidelines
This study was reviewed in the Islamic Azad University of Bojnourd Branch (Code: IR.IAU.BOJNOURD.REC.1400.015).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors consider it necessary to appreciate all the people who participated in the current research and all the medical centers that fully cooperated for the implementation of the research.

 

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