while cancer causing physical problems for patients, also causes many social and psychological problems. Crisis resulting from cancer causes disturbance in balance and psychological coordination, including sense of despair and depression. The aim of this study was to investigate the effectiveness of meta-cognitive therapy on depression and resilience of cancer patients in selected hospitals of Shahid Beheshti University of Medical Sciences.

1. Clinics of Oncology
Research Article ISSN: 2640-1037 Volume 4
The Effect of Metacognitive Therapy on Depression and Resilience of Cancer Patients
in Selected Hospitals of Shahid Beheshti University of Medical Sciences
Zahedi A1
, Mohtashami J2*
and Nasrabadi T3
1
Department of Nursing & Midwifery, Islamic Azad University of Medical Sciences, M.Sc. Student of Psychiatric Nursing, Iran
2
Shahid Beheshti University of Medical Sciences, and Islamic Azad University, Medical Sciences of Tehran branch, Iran
3
Department of Nursing & Midwifery Medical Sciences of Tehran branch, Islamic Azad University, Iran
*
Corresponding author:
Mohtashami J,
Shahid Beheshti University of Medical Sciences,
and Islamic Azad University, Medical Sciences of
Tehran branch, Tehran, Iran,
E-mail: j_mohtashami@sbmu.ac.ir
Received: 25 Feb 2021
Accepted: 12 Mar 2021
Published: 17 Mar 2021
Copyright:
©2021 Mohtashami J, et al. This is an open access article
distributed under the terms of the Creative Commons Attri-
bution License, which permits unrestricted use, distribution,
and build upon your work non-commercially.
Citation:
Mohtashami J, The Effect of Metacognitive Therapy on De-
pression and Resilience of Cancer Patients in Selected Hos-
pitals of Shahid Beheshti University of Medical Sciences.
Clin Onco. 2021; 4(3): 1-7
Keywords:
Metacognitive therapy; Depression; Resilience; cancer
1. Abstract
1.1. Background and Aim: while cancer causing physical prob-
lems for patients, also causes many social and psychological prob-
lems. Crisis resulting from cancer causes disturbance in balance
and psychological coordination, including sense of despair and de-
pression. The aim of this study was to investigate the effectiveness
of meta-cognitive therapy on depression and resilience of cancer
patients in selected hospitals of Shahid Beheshti University of
Medical Sciences.
1.2. Materials and Methods: This research was a semi-experi-
mental study and population included 40 patients with cancer in
Taleghani hospital in 2018. Patients were randomly divided into
intervention and control groups. The intervention group received
treatment for 4 weeks and the control group received routine treat-
ment. Participants completed demographic questionnaire, Beck
Depression Inventory (BDI), Connor- Davidson resilience Scale
(CD-RISC) before the first session, the end and one month after
intervention. To analysis data, descriptive statistics, and inferential
analysis of data to determine differences and paired t-test before
and after training were used.
1.3. Results: The highest difference between depression and re-
silience between the group before and one month after the inter-
vention was 13.75, 18.95 respectively, which showed a significant
reduction in depression and increased resilience of the patients (p
<0.0001).
1.4. Conclusion: The results showed that meta-cognitive therapy
was effective in depression and resilience of cancer patients imme-
diately and one month after intervention. Therefore, it is advisable
to help the patient recovery process by establishing and promoting
counseling and psychotherapy centers in hospitals and health cen-
ters.
2. Introduction
Cancer is characterized by abnormal cell deformation and loss of
cellular differentiation which causes cells proliferate abnormally
and grow in the environment irregularly [1]. Cancer is one of the
most prevalent diseases in the modern civilized world, with the
number of people affected by that day increasing [2]. Cancer after
cardiovascular disease is the second cause of death [3]. General-
ly, about two-thirds of the cancers occur in developing countries,
where only 5% of cancer control tools are available [4]. According
to the World Health Organization (WHO) in 2015, non-commu-
nicable diseases with a death rate of about 2166000 people ev-
ery year more than double the deaths from infectious and nutri-
tional diseases, which represent almost 60% of total mortality In
the Mediterranean region of the East. Among these, 15% will be
because of malignancies and cancers, while more than a third of
cancers can be prevented [5].
Cancer causes interaction between cells and tissues. Patients di-
agnosed with cancer are one of the most shocking and influential
events in their lives. Despite of the prognosis of the disease, this
clinicsofoncology.com 1

2. diagnosis changes the mental image of the patient and changes the
role of the home or work environment [3]. Because of the chronic
nature of the cancer, the patient should accept long-term treatment
with chemotherapy drugs. The treatment lasts weeks or months
and its side effects can be nausea, hair loss, fatigue, muscle aches,
skin burns, weight changes, and psychological problems [6].
Moreover, it causes many social and psychological problems,
while causing physical problems for patients. Crisis caused by can-
cer causes disturbance in the balance and coordination of thought,
body and soul, but the most common in this period for the patient
is the sense of despair, despair and depression [7]. Depression is
very harmful to cancer patients because it needs submission to dis-
ease. Other depressed people do not try to survive, and they miss
better opportunities to live in the remainder of their lives [8]. The
components that affect the incidence and severity of depression
are Resilience. Resilience is one of the most significant positive
psychologists, which is defined as a dynamic process positive and
significant adaptation in dangerous conditions [9]. Resilience is
defined as an act of self-restoration and of the conformity of behav-
ior and actions in order to overcome the dangerous situations and
promote life [10]. Many treatments for depression have been used
in these patients. One of these treatments is metacognitive therapy
in group therapy. The use of metacognitive therapy is considered
as a group of several directions. First, in group therapy, patients
do not need to be put on long waiting lists and therapists can use
them better than their own time [11]. Second, the group environ-
ment offers other advantages to patients, such as the experience of
being the same, modeling peer and peer support [12]. Karami et al.
(2014) concluded that there was a negative significant relationship
between metacognitive beliefs and mental health, and there was a
positive significant relationship between metacognitive beliefs and
self-esteem [13]. Also, the results of Mohammad Pour et al (2016)
in the research on the effectiveness of the participating in the
metacognitive therapy group on meta-cognitive beliefs in women
with breast cancer revealed that metacognitive therapy with pre-
test control had a significant effect on the reduction of symptoms
associated with the meta-cognitive factors of positive beliefs in
concern, uncontrollability, risk and the need to control thoughts
in women with breast cancer [14]. But a review of the literature
suggests that rare studies have concentrated on the effectiveness of
meta-cognitive therapy on depression and the Resilience of cancer
patients. Thus, more investigation is required about the effect of
the treatment. The aim of this study was to examine the effective-
ness of meta-cognitive therapy on depression and the Resilience
of cancer patients.
3. Materials and Methods
A semi-experimental study with intervention and control group
was performed and research population was 40 persons with can-
cer who referred to Taleghani Hospital affiliated of Shahid Behesh-
ti University of Medical Sciences in 2018. Sampling was firstly
based on the objective and then simple random method. Inclusion
criteria were not having a known psychological disorder, insight
toward of their cancer, duration at least 6 months from the diagno-
sis of cancer, and obtaining a score of 11 up from Beck Depression
Inventory (BDI). The samples who did not participate more than
two sessions exited from study. The sample size in each group was
also confirmed based on the following assumptions: power = 0.80,
α= 0.05, and Ơ=0.65 (20 for each group). The patients were ran-
domly assigned into intervention and control groups. Data were
collected using a socio-demographic questionnaire (included age,
gender, education level, insurance type and promotion system, the
duration of cancer, and type of cancer), Beck Depression Invento-
ry (BDI), and Connor- Davidson resilience Scale (CD-RISC).
3.1. Beck Depression Inventory (BDI)
This scale is included 21 items. Items receive a rating of zero to
three to reflect their intensity and are summed linearly to create a
score which ranges from 0 to 63. The 21 items included reflect a
variety of symptoms and attitudes commonly found among clin-
ically depressed individuals. The BDI is interpreted through the
use of cut-off scores. Cut-off scores may be derived based on the
use of the instrument (i.e., if a clinician wishes to identify very se-
vere depression, then the cut-off score would be set high). Scores
from 0 through 9 indicate no or minimal depression; scores from
10 through 18 indicate mild to moderate depression; scores from
19 through 29 indicate moderate to severe depression; and scores
from 30 through 63 indicate severe depression [15].
3.2. Connor- Davidson resilience Scale (CD-RISC)
Conner -Davidson Resilience Scale is designed by Connor and
Davidson in 2003 in the United States, which has 25 items and 5
components; personal competence / solidity, trust in instincts / tol-
erance of negative emotions, positive acceptance of changes / re-
lationships, safety, inhibition, and spirituality. The CD-RISC con-
tains 25 items, all of which carry a 5-point range of responses, as
follows: not true at all (0), rarely true (1), sometimes true (2), often
true (3), and true nearly all of the time (4). The scale is rated based
on how the subject has felt over the past month. The total score
ranges from 0–100, with higher scores reflecting greater resilience.
In order to obtain the total score of the questionnaire, the total
score of all questions is calculated; the higher the score, the greater
the respondent's level of resilience will be, and vice versa, the cut-
off point of the questionnaire is 50 points. In other words, the score
above 50 will be for higher Resilience.
Partovi, 1974; Wahhabzadeh, 1972 and Chegini in 2002 reported
that the reliability of the questionnaire was high and the maximum
was 90% [16]. In the research of Basharat (2007), the validity and
reliability of the Conor and Davidson questionnaire was confirmed
[17]. In the research of Haghranjbar et al (2011) the reliability of
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3. Conor and Davidson questionnaire was tested using Cronbach's
alpha coefficient test, which obtained 0.84 for this questionnaire
[16].
In this study, the internal consistency reliability was performed
using Cronbach's alpha coefficient that was calculated for Beck
Depression Inventory (0.90) and Conor Davidson Questionnaire
(0.88).
3.3. Intervention Method
At first, 40 patients with cancer were selected based on inclusion
criteria. Then, the objectives and benefits of participating in the
study were explained to patients and, if agreeing, written informed
consent was obtained. Patients were assured that the company was
volunteering and their information would be kept confidential.
All participants were completed questionnaires and after that they
were randomly divided into two groups, intervention(n==20) and
control (n=20) group. The metacognitive therapy group comprised
9 women and 11 men, control group including 10 women and 10
men. At the beginning intervention group, a meta cognitive group
therapy based on Adrian Wells [18] eight sessions (two sessions
per week) was being held in hospital by first researcher. Each ses-
sion took 90 minutes. Table 1 presents the content of each treat-
ment session separately.
Immediately after the completion of the intervention and one
month later, the participants in both groups simultaneously com-
pleted the study’s questionnaire again. Participants in the control
group received the educational package too, but one month after
the end of the intervention.
The ethical considerations for this research have been done to
get the approval of the Ethics Committee of Islamic Azad Uni-
versity of Medical Sciences with ethics Code of IR.IAU.TMU.
REC.1396.143 and obtain the essential permissions and coordina-
tion with the authorities of the research community.
Table 1: Intervention Sessions Features
Session Subjects
1ST
Make Case Formulation. Introduction of model and preparation, identification and naming of rumination courses (increased knowledge).
Attenuation Training Technique Practice (ATT). Complete the ATT Training Summary. Homemade homework: Practicing attentive in-
struction technique (twice a day), daily recording of the practice of teaching attentive techniques
2ND Review homework and MDD-S scale, especially rumination and unbeliever beliefs. Introducing and rumination as a test for uncontrol-
lability Homemade homework: ATT instruction exercises, deployment A mind-boggling consciousness and postponement of rumination
3RD
Review homework and MDD-S scale, especially rumination and unbeliever beliefs. Challenging meta-cognitive impairment (for example,
modulation testing), Technician's practice, and the use of mind-boggling consciousness (DM) (counteracting active rumination by perform-
ing postponement of rumination in the treatment session). Attitudinal Education (ATT). Surveying the level of activity and avoidance of
homework: ATT training, the use of flaccid consciousness (DM), and postponement of rumination (in the case of all inducers) Increases
activity level
4TH
Review of homework and MDD-S scale, especially rumination time, uncontrollable belief, level of activity, and maladaptive check-up,
postponement of rumination about at least 75% of instigators and more than 2 minutes of non-period Rhymes (Enhanced Application)
Challenge with Positive Beliefs about Ruminating Attitude Training Technique Practice (ATT) Homework: Attention Training Technique
(ATT), Extending the Application of Fuzzy Mindfulness and Delaying Rhyming, Activity Planning
5TH
Review homework and MDD-S scale, especially rumination time, positive beliefs, level of activity and maladaptive coping, review of
widespread and sustainable use of Diffused Mind (DM) Continue the challenge with positive beliefs about rumination Assessing the level
of activity and providing recommendations for its improvement (examination and prohibition of other maladaptive coping methods such
as excessive sleep, alcohol consumption), Attention Training Technique (ATT) Homemade homework: ATT instruction exercises, delayed
rumination, increased activity levels
6TH
homework and MDD-S scale review, especially rumination time, positive beliefs, activity level Investigating and Challenging with Neg-
ative Beliefs on Excitement / Depression Practicing Attention Training Technique (ATT) (Increasing Difficulty) Homework: Practicing
Attention Training Technique
7TH
Review homework and MDD-S scale, especially rumination, misconceptions and coping.Work on the development of new programs
(completion of the summary sheet of the program and presentation of a copy to the patient) Investigating and changing the fear of return-
ing symptoms, ATT training practice homework: ATT instruction exercises, new program execution, Start work on developing a general
treatment plan
8TH homework and MDD-S scale review, prevent recurrence (complete the treatment plan) Work on meta-cognitive beliefs, anticipating future
stimuli and discussing how to use the new program of reinforcement session planning
3.4. Statistical Analysis
In order to analyze the data, descriptive statistics (central indica-
tors and dispersion) and inferential statistics used. To define the
quantitative data, the mean, standard deviation, percentage and
frequency were used. To determine the differences before and af-
ter education, t-test was used. All statistical tests were performed
at a significance level of 0.05 and data were analyzed using SPSS
software version 19.
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4. 4. Findings
Of the 40 participants in the study, 20 participants were placed in
the intervention or meta-cognitive therapy group (9 men and 11
women) and 20 participants in the control group (10 men and 10
women). Table 2 shows the mean and standard deviation of age of
the participations in two groups. According to findings the distri-
bution of cancer patients in the two groups of control and interven-
tion in terms of age variables were no significant differences. Also,
other variables are presented at Table 3. The distribution of cancer
patients in terms of sex, education level and type of insurance,
were also no significant differences between control and interven-
tion groups. In addition, the two groups were homogeneous.
Also, results showed that the mean of depression in the control,
immediately after and one month after therapy in the intervention
group was 18.25, 14.40 and 2.30 respectively. Moreover, the level
of resilience in the control group, immediately after and one month
after the intervention was 69.45, 74 and 88.35 respectively (Table
4).
According to Table 5 the highest mean difference between the
cases before intervention one month after the intervention was
13.75. So, the rate of depression has decreased significantly and
metacognitive therapy has been effective. Table 5 showed that the
highest mean difference between the case before intervention and
one month after the intervention 18.95, that shows an increase in
the doping of the subjects in the intervention group who have un-
dergone metacognitive treatment.
Table 2: the average age of patients in both intervention and control group
Age Number Average Standard deviation F Lewin Test( P-value) t P-value
Control
Intervention
20
20
39.94
40.45
13.95
10.88
2.562
(0.115)
0.125 0.901
Table 3: Distribution of education level, insurance type and gender in both control and intervention group
Control
Number /frequency
Intervention
Number / frequency
K 2 P-value
Education level
Illiterate
Less than diploma
Diploma
Bachelor
Higher education
1 5
9 45
4 20
5 25
1 5
1 5
7 35
9 45
2 10
1 5
3.459 0.484
Insurance type
Health
Social supply
Medical services
non
9 45
9 45
2 10
0 0
5 25
11 55
3 15
1 5
2.543 0.468
Gender
Male
female
10 50
10 50
11 55
9 45
0.100 0.500
Table 4: Depression and Resilience rate in control and intervention groups, before, immediately and one month after therapy
Variable Group Average Standard deviation t P –value
Depression Control 17.95 8.86 -6.836 0.0001
Before intervention Intervention 16.05 7.75 -8.916 0.0001
Depression Control 18.25 8.66 -6.84 0.0001
Intervention (Immediately after) 14.4 6.86 -11.144 0.0001
After intervention Intervention (One month after intervention) 2.3 2.03 -64.368 0.0001
Resilience Control 69.5 11.46 8.387 0.0001
Before intervention Intervention 69.4 14.23 6.724 0.0001
Resilience Control 69.45 11.37 8.144 0.0001
Intervention (Immediately after) 74 13.62 12.476 0.0001
After intervention Intervention (One month after intervention) 88.35 4.7 40.446 0.0001
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5. Table 5: Difference in average level of Depression and Resilience of intervention groups, before, immediately and one month after therapy
Variable Group Difference Average Standard deviation t P –value
Depression before intervention
immediately after intervention
1.65 5.60
-1.317 0.204
before intervention
one month after intervention
13.75 6.57 -9.362 0.0001
immediately after intervention
one month after intervention
12.10 5.65 -14.746 0.0001
Resilience before intervention
immediately after intervention
4.60 8.64 2.381 0.028
before intervention
one month after intervention
18.95 12.16 6.967 0.0001
immediately after intervention
one month after intervention
14.35 2.55 5.623 0.0001
5. Discussion
The aim of this study was to study the effectiveness of metacogni-
tive therapy on depression and resilience of cancer patients. In this
study, 40 cancer patients were studied in both experimental and
control groups, each of which was 20. The results of this study on
meta-cognitive therapy on the rate of depression in patients with
cancer indicated that there was a significant difference in depres-
sion in the control and control groups. Furthermore, meta-cogni-
tive therapy is effective in decreasing the incidence of depression
in cancer patients. Comparison of mean depression scores before
and after intervention in control group did not show statistically
significant difference.
But the mean comparison of this variable after meta-cognitive
therapy presented a significant difference in depression; telling in-
creased mental health and increasing the use of strategies to reduce
depression in the experimental group. In the follow up study, the
results after 1 month of metacognitive therapy, an improvement
in the rate of depression reduction were obtained. The finding
that metacognitive therapy reduces depression is similar to that of
study by Zhang et al [19] Kuyken et al [20], Bergersen [21], and
Parhoon et al [22]. Parhoon et al. in a similar explanation state that
metacognitive therapy leads to the control of the underlying mech-
anisms of cognitive, emotional and behavioral symptoms because
of the reduction of meta-cognitive beliefs involved in the continu-
ation of depression symptoms. Wells et al [23] presented that 75%
of depressed patients recovered after meta-cognitive therapy and
66% of them after a 6-month follow-up. In a study done by Gha-
hari et al [24], the effect of cognitive-behavioral intervention on
decreasing depression and anxiety in women with breast cancer
was not confirmed, which is not consistent with the results of this
study.
In a research by Sadeghi firoozabadi et al [25], supplementary psy-
chotherapy was effective in reducing the amount of anxiety and
depression in patients. Furthermore, in the follow up to a month,
the level of anxiety and depression remained constant. It can be
determined that the training techniques helped patients to manage
their thoughts and mental conditions when confronted with anxi-
ety events that were consistent with the present study. Only in one
study, supplementary psychotherapy did not affect anxiety and de-
pression in patients with prostate cancer [26], which did not match
the results of the present study.
The results of one-month follow-up also showed that there was a
significant difference between the persistency levels in the control
and control groups. Besides, meta-cognitive therapy is effective
on the Resilience of cancer patients. The study of Hosseini Ghomi
et al [27] indicated that survival education in mothers with a can-
cerous child who experienced a specified education has been re-
lated to increased survival and reduced stress compared to those
who did not have these training. They have made better progress
in controlling their mental conditions and their families and their
families, which is corresponding to the results of this study. Zami-
ri nejad and colleagues [28] indicated that the method of group
vibration training plus cognitive therapy causes girl students de-
pressed and is consistent with the results of this study.
Based on the findings of the study by Almasi et al [29], it has been
found that training coping skills with stress has a positive effect on
maternal relief and the degree of Resilience in them has increased
after training. So the maternal Resilience scores increased signifi-
cantly after 8 sessions of education (p <0.001), which is consistent
with the results of the present study. It appears that in clarifying the
significant relationship between vibration and emotional stresses
of depression and stress, it can be concluded that the focus of pro-
grams and psychological interventions on increasing the Resilience
of people with cancer can be a strategy infrastructure to decrease
the emotional distress of these patients. This research had several
limitations. Including time constraints, low sample sizes, tracking
results only in the four-week period can be mentioned. Because
of obstacles for further extensive research, it is recommended that
future research study the effect of this treatment on other variables,
such as adaptation to cancer. If there is a possibility to follow the
results of meta-cognitive therapy in the long term (3 months and 6
months), it is probable that the effectiveness of this type of treat-
clinicsofoncology.com 5
Volume 4 Issue 3 -2021 Research Article

6. ment for depressive disorder can be more persuasive.
6. Conclusion
The results indicate that metacognitive therapy has been effective
in depression and resilience of cancer patients after the interven-
tion and one month after the intervention. It is important to pre-
vent emotional disorders such as depression in people with cancer.
Therefore, according to the results, it can be said that the use of
metacognitive therapy is a useful intervention for r patients with
cancer. Because cancer has psychological dimensions and compli-
cations, metacognitive therapeutic behavior is not only effective in
curing many chronic diseases but also helps patients to minimize
the negative psychological effects of their disease. Therefore, re-
ducing psychological symptoms is not only effective in treatments
and future advances, but also in promoting supportive, coping, and
rehabilitation programs. Therefore, it is recommended that by es-
tablishing and upgrading counseling and psychotherapy centers in
hospitals and centers, effective assistance be provided in the im-
proving process of these patients.
This research has faced several limitations. For example, time
constraints, low sample size, follow-up of results only in the four-
week period can be mentioned. Due to the existence of barriers to
the wider implementation of research, it is suggested that in future
research, the effect of this treatment on other variables such as
adaptation to cancer will be investigated. If it is possible to follow
the results of metacognitive therapy in the long term (3 months
and 6 months), we can probably speak more effectively about the
effectiveness of this type of treatment for depressive disorder.
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Volume 4 Issue 3 -2021 Research Article