International Journal of Behavioral Medicine

, Volume 26, Issue 4, pp 380–390 | Cite as

Moderators of Cognitive Therapy and Bright Light Therapy Effects on Depressive Symptoms in Patients with Breast Cancer

  • Caroline Desautels
  • Josée SavardEmail author
  • Hans Ivers



Cognitive therapy (CT) and bright light therapy (BLT) have been found to be effective to treat depressive symptoms in breast cancer patients. No study has investigated the baseline patients’ characteristics that are associated with better outcomes with CT vs. BLT in this population. This study aimed to assess, in breast cancer patients, the moderating role of eight clinical variables on the effects of CT and BLT on depressive symptoms.


This is a secondary analysis of a randomized controlled trial conducted in 59 women who received an 8-week CT or BLT and completed questionnaires evaluating depression and possible moderating variables.


Patients benefited more from BLT when they had no prior history of major depressive disorder, higher depression scores on the Hospital Anxiety and Depression Scale (HADS-D) at baseline, a greater initial preference for BLT, and when they received BLT during spring or summer. Patients benefited more from CT when they had a lower initial preference for receiving CT, higher depression scores on the HADS-D, and seasonal depressive symptoms.


Although replication is needed, findings of this study suggest the existence of different profiles of patients more likely to benefit from CT and BLT.


Breast cancer Cognitive therapy Bright light therapy Depressive symptoms Moderator 



We sincerely thank the patients for their participation in this study, Fred Sengmueller for his assistance in the revision of the manuscript, as well as Virginie Audet-Croteau, Emmanuelle Bastille-Denis, Marie Solange Bernatchez, Aude Caplette-Gingras, Joanne Castonguay, Émilie Fortin-Gagnon, William Gilbert, Anne-Josée Guimond, Stéphanie Hamel, Jessica Julien, Louis-Philippe Marion, Camille Martineau-Côté, Véronique Massicotte, Joanie Mercier, Véronique Roy, Sophie Ruel, Eugénie Simard, Vincent-Philippe Tremblay, and Claudia Trudel-Fitzgerald for their contribution to the project. This research was supported by training awards from the Canadian Institutes of Health Research, the Psychosocial Oncology Research Training program, and the CHU de Québec – Université Laval Research Center, held by the first author.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.


  1. 1.
    Kim SH, Son BH, Hwang SY, et al. Fatigue and depression in disease-free breast cancer survivors: prevalence, correlates, and association with quality of life. J Pain Symptom Manag. 2008;35(6):644–55.Google Scholar
  2. 2.
    Krebber AM, Buffart LM, Kleijn G, et al. Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments. Psycho-oncology. 2014;23(2):121–30.Google Scholar
  3. 3.
    Linden W, Vodermaier A. Mismatch of desired versus perceived social support and associated levels of anxiety and depression in newly diagnosed cancer patients. Support Care Cancer. 2012;20(7):1449–56.Google Scholar
  4. 4.
    Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004;32:57–71.Google Scholar
  5. 5.
    Stafford L, Judd F, Gibson P, Komiti A, Mann GB, Quinn M. Anxiety and depression symptoms in the 2 years following diagnosis of breast or gynaecologic cancer: prevalence, course and determinants of outcome. Support Care Cancer. 2015;23(8):2215–24.Google Scholar
  6. 6.
    Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A. Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ. 2005;330(7493):702.Google Scholar
  7. 7.
    Robson A, Scrutton F, Wilkinson L, Macleod F. The risk of suicide in cancer patients: a review of the literature. Psycho-oncology. 2010.Google Scholar
  8. 8.
    Somerset W, Stout SC, Miller AH, Musselman D. Breast cancer and depression. Oncology (Williston Park, NY). 2004;18(8):1021–34.Google Scholar
  9. 9.
    Donohue JM, Pincus HA. Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment. PharmacoEconomics. 2007;25(1):7–24.Google Scholar
  10. 10.
    Pirl WF, Roth AJ. Diagnosis and treatment of depression in cancer patients. Oncology (Williston Park, NY). 1999;13(9):1293–301 discussion 301–2, 305–6.Google Scholar
  11. 11.
    Williams S, Dale J. The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review. Br J Cancer. 2006;94(3):372–90.Google Scholar
  12. 12.
    Beck AT, Dozois DJ. Cognitive therapy: current status and future directions. Annu Rev Med. 2011;62:397–409.Google Scholar
  13. 13.
    Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. J Consult Clin Psychol. 2008;76(3):468–77.Google Scholar
  14. 14.
    Hollon SD, DeRubeis RJ, Shelton RC, et al. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch Gen Psychiatry. 2005;62(4):417–22.Google Scholar
  15. 15.
    Jacobsen PB, Hann DM. Cognitive-behavioral interventions. In: Holland JC, editor. Psycho-Oncology. 1st ed. New York, NY: Oxford University Press; 1998. p. 717–29.Google Scholar
  16. 16.
    Moyer A, Sohl SJ, Knapp-Oliver SK, Schneider S. Characteristics and methodological quality of 25 years of research investigating psychosocial interventions for cancer patients. Cancer Treat Rev. 2009;35(5):475–84.Google Scholar
  17. 17.
    Evans RL, Connis RT. Comparison of brief group therapies for depressed cancer patients receiving radiation treatment. Public Health Rep. 1995;110(3):306–11.Google Scholar
  18. 18.
    Edelman S, Bell DR, Kidman AD. A group cognitive behaviour therapy programme with metastatic breast cancer patients. Psycho-oncology. 1999;8(4):295–305.Google Scholar
  19. 19.
    Greer S, Moorey S, Baruch JD, et al. Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ. 1992;304(6828):675–80.Google Scholar
  20. 20.
    Hopko DR, Bell JL, Armento M, et al. Cognitive-behavior therapy for depressed cancer patients in a medical care setting. Behav Ther. 2008;39(2):126–36.Google Scholar
  21. 21.
    Moorey S, Greer S, Watson M, et al. Adjuvant psychological therapy for patients with cancer: outcome at one year. Psycho-oncology. 1994;3(1):39–46.Google Scholar
  22. 22.
    Qiu J, Chen W, Gao X, et al. A randomized controlled trial of group cognitive behavioral therapy for Chinese breast cancer patients with major depression. J Psychosom Obstet Gynaecol. 2013;34(2):60–7.Google Scholar
  23. 23.
    Savard J, Simard S, Giguere I, et al. Randomized clinical trial on cognitive therapy for depression in women with metastatic breast cancer: Psychological and immunological effects. Palliat Support Care. 2006;4(3):219–37.Google Scholar
  24. 24.
    Goel N, Terman M, Terman JS, Macchi MM, Stewart JW. Controlled trial of bright light and negative air ions for chronic depression. Psychol Med. 2005;35:945–55.Google Scholar
  25. 25.
    Loving RT, Kripke DF, Shuchter SR. Bright light augments antidepressant effects of medication and wake therapy. Depress Anxiety. 2002;16:1–3.Google Scholar
  26. 26.
    Martiny K, Lunde M, Unden M, Dam H, Bech P. Adjunctive bright light in non-seasonal major depression: results from clinicianrated depression scales. Acta Psychiatr Scand. 2005;112:117–25.Google Scholar
  27. 27.
    Avery DH, Eder DN, Bolte MA, Hellekson CJ, Dunner DL, Vitiello MV, et al. Dawn simulation and bright light in the treatment of SAD: a controlled study. Biol Psychiatry. 2001;50:205–16.Google Scholar
  28. 28.
    Lam RW, Tam EM. A clinician’s guide to using light therapy. 1st ed. New York, NY: Cambridge University Press; 2009.Google Scholar
  29. 29.
    Terman M, Terman JS. Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects. CNS Spectrums. 2005;10(8):647–63 quiz 72.Google Scholar
  30. 30.
    Jacobsen PB, Jim HS. Psychosocial interventions for anxiety and depression in adult cancer patients: achievements and challenges. CA Cancer J Clin. 2008;58(4):214–30.Google Scholar
  31. 31.
    Jeste N, Liu L, Rissling M, Trofimenko V, Natarajan L, Parker BA, et al. Prevention of quality-of-life deterioration with light therapy is associated with changes in fatigue in women with breast cancer undergoing chemotherapy. Qual Life Res. 2012.Google Scholar
  32. 32.
    Ancoli-Israel S, Rissling M, Neikrug A, Trofimenko V, Natarajan L, Parker BA, et al. Light treatment prevents fatigue in women undergoing chemotherapy for breast cancer. Support Care Cancer. 2011.Google Scholar
  33. 33.
    Neikrug AB, Rissling M, Trofimenko V, Liu L, Natarajan L, Lawton S, et al. Bright light therapy protects women from circadian rhythm desynchronization during chemotherapy for breast cancer. Behav Sleep Med. 2012;10(3):202–16.Google Scholar
  34. 34.
    Redd WH, Valdimarsdottir H, Wu LM, Winkel G, Byrne EE, Beltre MA, et al. Systematic light exposure in the treatment of cancer-related fatigue: a preliminary study. Psychooncology. 2014.Google Scholar
  35. 35.
    Wu LM, Amidi A, Valdimarsdottir H, et al. The effect of systematic light exposure on sleep in a mixed group of fatigued cancer survivors. J Clin Sleep Med. 2018;14(01):31–9.Google Scholar
  36. 36.
    Rohan KJ, Lindsey KT, Roecklein KA, Lacy TJ. Cognitive-behavioral therapy, light therapy, and their combination in treating seasonal affective disorder. J Affect Disord. 2004;80(2–3):273–83.Google Scholar
  37. 37.
    Rohan KJ, Roecklein KA, Lacy TJ, Vacek PM. Winter depression recurrence one year after cognitive-behavioral therapy, light therapy, or combination treatment. Behav Ther. 2009;40(3):225–38.Google Scholar
  38. 38.
    Rohan KJ, Roecklein KA, Tierney Lindsey K, Johnson LG, Lippy RD, Lacy TJ, et al. A randomized controlled trial of cognitive-behavioral therapy, light therapy, and their combination for seasonal affective disorder. J Consult Clin Psychol. 2007;75(3):489–500.Google Scholar
  39. 39.
    Desautels C, Savard J, Ivers H, Caplette-Gingras A. Treatment of depressive symptoms in patients with breast cancer: A randomized controlled trial comparing cognitive therapy and bright light therapy. Health Psychol. 2018;37(1):1-13.Google Scholar
  40. 40.
    Meyerhoff J, Rohan KJ. Treatment expectations for cognitive-behavioral therapy and light therapy for seasonal affective disorder: change across treatment and relation to outcome. J Consult Clin Psychol. 2016;84(10):898–906.Google Scholar
  41. 41.
    Kwan BM, Dimidjian S, Rizvi SL. Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression. Behav Res Ther. 2010;48(8):799–804.Google Scholar
  42. 42.
    Mergl R, Henkel V, Allgaier AK, Kramer D, Hautzinger M, Kohnen R, et al. Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? Results from a randomized controlled trial including a patients’ choice arm. Psychother Psychosom. 2011;80(1):39–47.Google Scholar
  43. 43.
    De Graaf LE, Hollon SD, Huibers MJ. Predicting outcome in computerized cognitive behavioral therapy for depression in primary care: a randomized trial. J Consult Clin Psychol. 2010;78(2):184–9.Google Scholar
  44. 44.
    Driessen E, Cuijpers P, Hollon SD, Dekker JJ. Does pretreatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis. J Consult Clin Psychol. 2010;78(5):668–80.Google Scholar
  45. 45.
    Hoifodt RS, Mittner M, Lillevoll K, Katla SK, Kolstrup N, Eisemann M, et al. Predictors of response to web-based cognitive behavioral therapy with high-intensity face-to-face therapist guidance for depression: a Bayesian analysis. JMIR. 2015;17(9):e197.Google Scholar
  46. 46.
    Weitz ES, Hollon SD, Twisk J, van Straten A, Huibers MJ, David D, et al. Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: an individual patient data meta-analysis. JAMA Psychiatry. 2015;72(11):1102–9.Google Scholar
  47. 47.
    Golden RN, Gaynes BN, Ekstrom RD, Hamer RM, Jacobsen FM, Suppes T, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry. 2005;162(4):656–62.Google Scholar
  48. 48.
    Martensson B, Pettersson A, Berglund L, Ekselius L. Bright white light therapy in depression: a critical review of the evidence. J Affect Disord. 2015;182:1–7.Google Scholar
  49. 49.
    Rosenthal NE, Sack DA, Gillin JC, Lewy AJ, Goodwin FK, Davenport Y, et al. Seasonal affective disorder. A description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry. 1984;41(1):72–80.Google Scholar
  50. 50.
    Tuunainen A, Kripke DF, Endo T. Light therapy for non-seasonal depression. Cochrane Database Syst Rev (Online). 2004;2:CD004050.Google Scholar
  51. 51.
    Lam RW. Morning light therapy for winter depression: predictors of response. Acta Psychiatr Scand. 1994;89(2):97–101.Google Scholar
  52. 52.
    Privitera MR, Moynihan J, Tang W, Khan A. Light therapy for seasonal affective disorder in a clinical office setting. J Psychiatr Pract. 2010;16(6):387–93.Google Scholar
  53. 53.
    Naus T, Burger A, Malkoc A, Molendijk M, Haffmans J. Is there a difference in clinical efficacy of bright light therapy for different types of depression? A pilot study. J Affect Disord. 2013;151(3):1135–7.Google Scholar
  54. 54.
    Thalén BE, Kjellman BF, Mørkrid L, Wibom R, Wetterberg L. Light treatment in seasonal and nonseasonal depression. Acta Psychiatr Scand. 1995;91(5):352–60.Google Scholar
  55. 55.
    Even C, Schroder CM, Friedman S, Rouillon F. Efficacy of light therapy in nonseasonal depression: a systematic review. J Affect Disord. 2008;108(1–2):11–23.Google Scholar
  56. 56.
    Reichborn-Kjennerud T, Lingjaerde O. Response to light therapy in seasonal affective disorder: personality disorders and temperament as predictors of outcome. J Affect Disord. 1996;41(2):101–10.Google Scholar
  57. 57.
    Savard J, Laberge B, Gauthier JG, Ivers H, Bergeron MG. Evaluating anxiety and depression in HIV-infected patients. J Pers Assess. 1998;71:349–67.Google Scholar
  58. 58.
    Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation; 1996.Google Scholar
  59. 59.
    Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–98.Google Scholar
  60. 60.
    Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–70.Google Scholar
  61. 61.
    Roth AJ, Kornblith AB, Batel-Copel L, Peabody E, Scher HI, Holland JC. Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer. 1998;82(10):1904–8.Google Scholar
  62. 62.
    Borkovec TD, Nau SD. Credibility of analogue therapy rationales. J Behav Ther Exp Psychiatry. 1972;3:257–60.Google Scholar
  63. 63.
    First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV axis I disorders - patient edition (SCID-I/P, Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute; 1996.Google Scholar
  64. 64.
    Williams JBW, Link MJ, Rosenthal NE, Amira L, Terman M. Structured interview guide for the hamilton depression rating scale-seasonal affective disorder version (SIGH-SAD). New York: New York State Psychiatric Institute; 1992.Google Scholar
  65. 65.
    Donofry SD, Roecklein KA, Rohan KJ, Wildes JE, Kamarck ML. Prevalence and correlates of binge eating in seasonal affective disorder. Psychiatry Res. 2014;217(1–2):47–53.Google Scholar
  66. 66.
    Flory R, Ametepe J, Bowers B. A randomized, placebo-controlled trial of bright light and high-density negative air ions for treatment of Seasonal Affective Disorder. Psychiatry Res. 2010;177(1–2):101–8.Google Scholar
  67. 67.
    Roecklein K, Wong P, Ernecoff N, Miller M, Donofry S, Kamarck M, et al. The post illumination pupil response is reduced in seasonal affective disorder. Psychiatry Res. 2013;210(1):150–8.Google Scholar
  68. 68.
    Spoont MR, Depue RA, Krauss SS. Dimensional measurement of seasonal variation in mood and behavior. Psychiatry Res. 1991;39(3):269–84.Google Scholar
  69. 69.
    Williams JBW. A sructured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry. 1988;45:742–7.Google Scholar
  70. 70.
    Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979;47(2):343–52.Google Scholar
  71. 71.
    Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: The Guilford Press; 1979.Google Scholar
  72. 72.
    Blackburn I-M, James IA, Milne DL, Baker C, Standart S, Garland A, et al. The revised cognitive therapy scale (CTS-R): psychometric properties. Behav Cogn Psychother. 2001;29(4):431–46.Google Scholar
  73. 73.
    SPSS Inc. SPSS 13.0 Brief Guide. Chicago: SPSS Inc; 2004.Google Scholar
  74. 74.
    SAS Institute. SAS/STAT User’s guide, version 9.1.3. Cary, NC: SAS Institute; 2004.Google Scholar
  75. 75.
    Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G* Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149–60.Google Scholar
  76. 76.
    Frigon JY, Laurencelle L. Analysis of covariance: a proposed algorithm. Educ Psychol Meas. 1993;53(1):1–18.Google Scholar
  77. 77.
    Fillion L, Kohn P, Gagnon P, Wijk MV, Cunningham A. The inventory of recent life experiences for cancer patients (IRLE-C): a decontaminated measure of cancer-based hassles. Psychol Health. 2001;16(4):443–59.Google Scholar
  78. 78.
    Brugha TS, Cragg D. The list of threatening experiences: the reliability and validity of a brief life events questionnaire. Acta Psychiatr Scand. 1990;82(1):77–81.Google Scholar
  79. 79.
    Sun JL, Wu SC, Chang LI, Chiou JF, Chou PL, Lin CC. The relationship between light exposure and sleep, fatigue, and depression in cancer outpatients: test of the mediating effect. Cancer Nurs. 2014;37(5):382–90.Google Scholar
  80. 80.
    Oldham MA, Ciraulo DA. Bright light therapy for depression: a review of its effects on chronobiology and the autonomic nervous system. Chronobiol Int. 2014;31(3):305–19.Google Scholar
  81. 81.
    Pail G, Huf W, Pjrek E, et al. Bright-light therapy in the treatment of mood disorders. Neuropsychobiology. 2011;64(3):152–62.Google Scholar
  82. 82.
    Terman M, Amira L, Terman JS, Ross DC. Predictors of response and nonresponse to light treatment for winter depression. Am J Psychiatr. 1996;153(11):1423–9.Google Scholar
  83. 83.
    Rosenthal NE. Winter Blues: Everything you need to know to beat seasonal affective disorder. 4th ed. New York: The Guilford Press; 2013.Google Scholar

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© International Society of Behavioral Medicine 2019

Authors and Affiliations

  1. 1.School of PsychologyUniversité LavalQuébecCanada
  2. 2.CHU de Québec – Université Laval Research CenterQuébecCanada
  3. 3.Université Laval Cancer Research CenterQuébecCanada
  4. 4.Centre de recherche du CHU de Québec – L’Hôtel-Dieu de QuébecQuébecCanada

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