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ONLINE EXCLUSIVE
Depression in Internet and Face-to-Face
Cancer Support Groups: A Pilot Study
Paula Klemm, DNSc, RN, OCN, and Thomas Hardie, EdD, RN, CS, NP
Key Points . . .
Purpose/Objectives: To examine depression in Internet
cancer support groups as compared to traditional (face-
to-face) cancer support groups and to explore the rela-
A scarcity of research is available to support the efficacy of
tionship between Internet use and levels of depression.
Internet support groups in achieving positive coping outcomes
Design: Exploratory, descriptive.
and reducing depression.
Setting: Traditional (face-to-face) and Internet cancer
support groups.
The vast majority (92%) of those in the Internet group suf-
Sample: Convenience sample of 40 patients with can-
fered from major depressive disorders, as compared to none in
cer, 14 from traditional face-to-face groups and 26 from an
the face-to-face group.
Internet support group, with different cancer diagnoses.
The data, on the surface, provide credence for the notion that
Methods: Traditional paper or Internet surveys consisting
the Internet as support may be related to depression in patients
of an investigator-developed questionnaire including de-
with cancer.
mographic information, brief medical history, support
group history, and the Center for Epidemiologic Studies
Depression Scale (CES-D).
Main Research Variable: Depression scores on the CES-D.
lmost 1.29 million people will be diagnosed with can-
A
Findings: Participants in the face-to-face groups were
cer in the United States in 2002, and 555,500 will die
100% male. The online group was 56% male and 44% fe-
of the disease (Jemal, Thomas, Murray, & Thun,
male. Groups did not differ significantly by income, health
2002). The psychological effects of cancer are well docu-
insurance status, or days since initial diagnosis. Groups dif-
mented. A diagnosis of cancer may initiate a period of crisis
fered significantly on level of depression. The traditional
accompanied by anxiety and fear. Spiegel and Classen (2000)
(face-to-face) group had a CES-D mean score of 1.86
indicated that a cancer diagnosis fostered great uncertainty
(SD = 2.69), and the online group had a mean score of
and unleashed strong intrapsychic and interpersonal forces.
29.27 (SD = 11.89, p < 0.000). A comparison of CES-D scores
Patients with cancer often feel anger, emotional distress, un-
of men in the face-to-face and Internet groups revealed
certainty about the future, and depression and have psycho-
that they differed significantly on level of depression. Men
in the traditional group had a mean score of 1.86 (SD =
sexual concerns (Bottomley, 1997; Chernecky, 1999; Ferrell,
2.69), and men in the online group had a mean score of
Grant, Funk, Otis-Green, & Garcia, 1998; Galloway & Gray-
27.42 (SD = 112.69, p < 0.000).
don, 1996; Gaston-Johansson, Ohly, Fall-Dickson, Nanda, &
Conclusions: These data suggest that more depressed
Kennedy, 1999; Zabalegui, 1999).
patients with cancer use Internet support groups instead of
Nearly 50% of people receiving treatment for a malignancy
face-to-face support. Before online interventions can be
will experience cancer-related depression (Carroll, Kathol,
implemented effectively, their efficacy needs to be evalu-
Noyes, Walk, & Clamon, 1993; Derogatis et al., 1983; De
ated.
Walden-Galuszko, 1996; Leopold et al., 1998). Thus, this is a
Implications for Nursing: Patients with cancer are at in-
creased risk for developing depression. This should be a
consideration during nursing assessments. Traditional can-
Paula Klemm, DNSc, RN, OCN  , and Thomas Hardie, EdD, RN,
cer support groups can help people cope with their can-
CS, NP, are associate professors in the Department of Nursing at the
cer, but the efficacy of Internet cancer support groups in
University of Delaware in Newark. (Submitted June 2001. Accepted
providing psychoeducation and psychotherapeutic inter-
for publication October 3, 2001.)
vention remains to be proven.
Digital Object Identifier: 10.1188/02.ONF.E45-E51
KLEMM VOL 29, NO 4, 2002
E45
significant problem for patients with cancer. Twenty-five per-
Samarel et al. (1998) studied 70 women with early-stage
cent of patients with cancer may be suffering from depression at
breast cancer who attended a support group for eight weeks.
diagnosis (Hann, Winter, & Jacobsen, 1999; Lovejoy, Tabor, &
The women reported that the group helped them feel less
Deloney, 2000; Mermelstein & Lesko, 1992). In a study of 809
alone, gain helpful information, and take advantage of oppor-
women with cancer, Carroll et al. found that almost 50% exhib-
tunities to verbalize their feelings. These findings were sup-
ited symptoms related to depression and anxiety. Other research
ported by McLeod's (1999) study of women with secondary
indicates that depression rates increased when patients had recur-
breast cancer. The author reported that support group mem-
rent or metastatic disease, were within one month of diagnosis,
bers were less isolated and better able to communicate what
or were in pain (Aasa, Fossa, Dahl, & Moe, 1997; Breitbart,
they felt about their cancer experience. Coward (1998) de-
1995; Massie & Holland, 1990). Newport and Nemeroff (1999)
signed an eight-week cancer support group for women with
summarized by tumor site the prevalence of major depressive
breast cancer. The results indicated that functional perfor-
disorders in patients with cancer. They reported that malignan-
mance, mood state, and satisfaction improved significantly by
cies of the pancreas, oropharynx, breast, and colon were asso-
the end of the study. In another study, 56 women with breast
ciated with higher depression rates than other sites.
cancer were evaluated for coping patterns and side effects of
Pasacreta (1997) determined that women with breast cancer
treatment (Shapiro et al., 1997). The authors suggested that
who were depressed reported more physical symptoms and
the women's willingness to discuss and think about their ill-
more impaired functioning than women who were not de-
ness was an important factor for optimal coping.
pressed. Depression in patients with cancer has been reported
Stanton et al. (2000) explored emotional expressive coping
to increase length of hospitalization, interfere with treatment,
in 92 women with stage I or II breast cancer 20 weeks after they
and adversely affect quality of life (Gaston-Johansson et al.,
completed primary treatment. Women who used emotional
1999; Sellick & Crooks, 1999). Watson, Haviland, Greer,
expression as a coping mechanism reported decreased distress
Davidson, and Bliss (1999) found high depression scores were
and needed fewer medical appointments to address cancer-re-
linked to survival rates in women with breast cancer. The inves-
lated morbidity. Spiegel, Bloom, Kraemer, and Gottheil (1989)
tigators reported that women age 1875 with early stage breast
studied the effect of psychosocial treatment and survival time
cancer and high depression scores had a significantly increased
in women with metastatic breast cancer. A one-year interven-
risk of death from all causes over a five-year period.
tion consisting of weekly support-group therapy and self-hyp-
Adjuvant chemotherapy has been shown to improve both dis-
nosis for pain was conducted. Women were assigned randomly
ease-free survival and overall survival in patients with early-
to either an intervention group (i.e., group support and self-
stage breast cancer. Colleoni et al. (2000) reported that depressed
hypnosis) or a control group (i.e., treatment as usual). Ten-year
women were less likely to accept adjuvant therapy as part of their
follow-up of the participants revealed that the women in the
treatment for breast cancer. The researchers stressed the impor-
treatment group survived almost 18 months longer than those
tance of treating depression as a means to increase acceptance of
in the treatment-as-usual group (36.6 months versus 18.9
adjuvant chemotherapy and possibly improve prognosis.
months). Kogan, Biswas, Pearl, Carlson, and Spiegel (1997)
Advances in technology (e.g., the Internet) may offer effec-
conducted a follow-up study to determine whether the survival
tive methods of providing psychoeducation and psychothera-
effect in these women could be explained by differences in
peutic interventions to those not able or willing to receive help
medical treatment. Researchers reviewed the medical charts of
in more traditional face-to-face methods. Providing an eviden-
61 women and the death certificates of 83 women and con-
tiary basis for use of these technologies is the overarching aim
cluded that survival differences were independent of differ-
of this exploratory research. The specific purposes of this pilot
ences in medical treatment.
study were to examine depression in Internet cancer support
Although much of the work regarding cancer support groups
groups as compared to traditional (face-to-face) cancer support
has been conducted on women with cancer, some studies have
groups and to explore the relationship between Internet use and
included men. Fife, Kennedy, and Robinson (1994) conducted
levels of depression.
a study of 125 men and 208 women that investigated the clini-
cal implications of gender and adjustment to cancer. Results in-
Cancer Support Groups
dicated that women used coping strategies more frequently and
more effectively than men and men were less likely to construct
a positive meaning about their cancer. The authors speculated
The role of support groups in helping people cope with
that women focused more on altering their emotional responses
cancer is well documented (Cella & Yellen, 1993; Fobair,
to cancer, whereas men were more likely to concentrate on
1997; Pillon & Joannides, 1991). Support groups offer infor-
solving the problem of having a malignancy.
mation on cancer and its treatment, help members cope with
Curn (1993) started a face-to-face support group for men
illness, provide emotional support, and facilitate psychosocial
with prostate cancer. Initially, the author believed that men
adjustment (Cella & Yellen; Fobair; Grassman, 1993).
would not express their feelings in a group. However, she
Leavitt, Lamb, and Voss (1996) argued that physicians did not
found that the men freely discussed the anger and frustra-
adequately meet the informational needs of patients who were
tions associated with their illness. In addition, the group pro-
being treated for brain tumors. The authors suggested that pa-
vided emotional support, suggestions, and advice to mem-
tients with cancer were better able to help other people with
bers. Gray, Fitch, Davis, and Phillips (1997) interviewed
cancer meet the physical and emotional problems associated
men in a prostate cancer group and noted that the primary
with their disease. According to Hurt, McQuellen, and Barrett
reason for joining was a need for information. Coreil and
(1994), patients with cancer often felt anxious and helpless
Behal (1999) surveyed face-to-face prostate cancer groups
after treatment and when medical surveillance was not as in-
in Florida. They reported that most group members (83%)
tense. Wellisch (1993) believed that social support after treat-
valued information and education about prostate cancer and
ment was essential in helping patients cope with their disease.
ONF VOL 29, NO 4, 2002
E46
only 5% percent valued receiving social and emotional sup-
hoods. The researchers found that 55% of total time use in the
port or sharing experiences with others. Bastecky, Tondlova,
group was devoted to social support issues, whereas 41% fo-
Vesela, Brizekova, and Boleloucky (1996) studied individu-
cused on information seeking and giving. In addition to the
als with breast and gastrointestinal cancers. They found no
psychosocial support the group offered, several barriers to
differences in psychopathology between the two groups.
participation (e.g., transportation, child care) were solved by
However, only 12 of 107 subjects were male.
the home-based computer system. In 1996, Weinberg,
Schmale, Uken, and Wessel reported on their use of a com-
Online Support Groups
puter-mediated support group for women with breast cancer.
Results suggested that the computer-mediated group provided
Historically, support groups were designed to meet the
the same therapeutic benefits of traditional support groups
needs of patients with cancer in a community setting (e.g.,
while in the comfort of the home. Sharf (1997) discovered
hospital, church, clinic) and were run by a professional facili-
three dimensions in communication (exchange of informa-
tator. In the past decade, online support groups have become
tion, social support, and empowerment) in a computer-based
a popular alternative to traditional groups. Similar to tradi-
support group for women with breast cancer.
tional groups, Internet groups offer social support, informa-
A few studies on Internet groups have included men.
tion, shared experience, positive role models, empowerment,
Klemm et al. (1998) identified eight response categories in 48
professional support, and patient advocacy (Madara & White,
men and 46 women with colorectal cancer who belonged to
1997). Internet support groups may be resistant to some of the
an online support group. Information giving and seeking
pitfalls of traditional groups, such as the ebb and flow of at-
(25%) and personal opinions (22%) accounted for the high-
tendance and inconvenient meeting times (Finfgeld, 2000;
est percentages of the messages posted. Encouragement and
Klemm, Reppert, & Visich, 1998; Oravec, 2000). People with
support (17%) and personal experiences (16%) also were
cancer use online support groups because they offer 24-hour
well represented. These four categories accounted for about
access, at-home availability, anonymity, information, support,
81% of all messages posted by group members. The remain-
and convenience (Fernsler & Manchester, 1997; Klemm,
ing categories of thanks, humor, prayer, and miscellaneous
Hurst, Dearholt, & Trone, 1999; Sharf, 1997). Madara and
made up almost 19% of responses. From this, the research-
White described online communication as an "equalizer,"
ers concluded that the Internet support groups provided psy-
lacking the visual distractions of age, gender, dress, and social
chosocial support to patients with cancer and caretakers. A
status seen in traditional support groups.
more recent study by Klemm et al. (1999) compared breast,
Several disadvantages to online support groups have been
prostate, and colorectal Internet support groups. The inves-
noted. These include the lack of a professional facilitator, no
tigators sorted 1,541 messages into the eight categories de-
visual cues or face-to-face interaction, posting of incorrect
scribed in their earlier study and found that men and women
information, and a risk of social isolation. Finfgeld (2000)
used the online groups differently. Men (n = 117) with pros-
indicated that natural leaders emerged on the Internet groups
tate cancer most often posted information giving and seeking
even without a trained facilitator. Klemm et al. (1998) noted
(36%) with information regarding personal experience (23%)
that members of the group quickly corrected inaccurate infor-
second. These categories were reversed for the women (n =
mation posted online.
126) in the breast cancer group (personal experience, 28%;
As early as 1995, Fawcett and Buhle (1995) suggested that
information giving and seeking, 23%). About 22% of mes-
the Internet was a viable method by which to collect data.
sages posted by the women in the breast cancer group offered
Fernsler and Manchester (1997) queried users of a computer-
encouragement and support, whereas only 8% of messages
based cancer support network and found that individuals joined
posted on the prostate cancer group site were placed in this
to learn from others who had similar experiences, garner infor-
category. When the messages for both the prostate and breast
mation, encourage others, and obtain psychological support.
groups were considered together, about 83% of the messages
Thomas, Leeseberg-Stamler, Lafreniere, and Dumala
posted were placed in the categories of information giving
(2000) described the use of the Internet to survey an interna-
and seeking, encouragement and support, personal opinions,
tional population of 593 women about breast cancer education
and personal experience.
and screening. Women from Canada, the United States, Aus-
Fernsler, Klemm, and Miller (1999) used the Internet to
tralia, Brazil, the Netherlands, and the United Kingdom par-
enlist 121 subjects (men = 68, women = 53) for a study inves-
ticipated in the study. The researchers concluded that the
tigating spiritual well-being and demands of illness in patients
Internet provided a cost-effective way to obtain, manage, and
with colorectal cancer. The participants were from 25 states
analyze research data.
and six countries other than the United States. Results indi-
Much of the research on computer-based groups has focused
cated that the greatest number of illness-related demands were
on women with breast cancer. Gustafson et al. (1993) developed
present in the youngest group of patients (aged 2645 years),
a computer-based support system to help women with breast
those with limited activity, and those who reported a terminal
cancer cope with their disease. The Comprehensive Health En-
stage of disease, regardless of gender.
hancement Support System (CHESS) allowed users to have
Kraut et al. (1998) indicated that the amount of time spent
questions answered, obtain help and support, tell their personal
on the Internet correlated positively with depression. The in-
stories, ask an expert, and participate in discussion groups. Age
vestigators tracked the Internet use of 169 participants from
and educational differences did not affect the women's use of
93 households over a two-year period and found that depres-
CHESS. Older and less-educated women used the system as
sion rates and feelings of loneliness increased as time spent on
frequently as younger and more-educated women.
the Internet increased. More recently, Nie and Lutz (2000)
McTavish et al. (1995) investigated an underserved popu-
surveyed 4,113 American adults and found that people who
lation of patients with breast cancer via CHESS. A pilot study
spent more than five hours per week online spent less time
included eight African American women from poor neighbor-
KLEMM VOL 29, NO 4, 2002
E47
with family and friends. Social withdrawal, lack of direct in-
tions about Internet support group history. The Internet form
terpersonal contact, and other reduction of interaction could
was completed online using Perseus Survey Solutions for the
be driving these findings. However, some people must reduce
Web 2.01 software. The software facilitates the development
their social contact for health reasons. The availability of
of a web-based survey and e-mails the responses to the re-
Internet communication seems to offer a wealth of potential
search team.
for these individuals.
Subjects were assessed for their level of depression using
Research studies have shown that face-to-face support
the Center for Epidemiologic Studies Depression Scale
groups help decrease psychological symptoms, enhance
(CES-D). The CES-D is a 20-item, self-report scale devel-
functional performance, decrease depression, and prolong
oped by Radloff (1977) that has been widely used in the as-
survival in patients with cancer. However, a scarcity of re-
sessment of depression. Each item is given a rating of 03,
search is available to support the efficacy of Internet support
with a potential range of 060 for the entire scale. Higher
groups in achieving positive coping outcomes and reducing
scores are associated with depression. The cutoff for the diag-
depression.
nosis of major depressive disorder on the CES-D is 16. The
instrument is a reliable measure (" > 0.85) of depression
Methods
(Hann et al., 1999; Radloff). In 1998, Beeber, Shea, and
McCorkle supported the reliability and validity of the CES-D
Design and Sample
in measuring depression in 453 newly diagnosed patients with
This exploratory descriptive study was comprised of a
cancer.
sample of 40 patients with cancer who participated in two
Data Analysis
support groups (i.e., face-to-face and Internet) selected by
convenience. Fourteen members of traditional face-to-face
Investigators completed a descriptive statistics and normal-
support groups for patients with prostate cancer and 26 mem-
ity screen to verify normality for the data. Contrasts between
bers of an Internet support group whose members had differ-
the two groups were determined using chi-square and inde-
ent cancer diagnoses participated. The selection of the face-
pendent group t tests. To examine the relationship between
to-face group was based on convenience and access; as such,
level of depression and time on the Internet, a Spearman cor-
local support groups were chosen. Selection of Internet dis-
relation was used. This statistic was chosen because the pilot
cussion groups was determined by access and a brief monitor-
survey used ordinal ranges to determine the amount of
ing period of traffic to ensure adequate volume. Initial consid-
Internet use.
eration about group selection assumed that men, based on
historic demographic data on Internet users, would overrep-
Results
resent the Internet group. Thus, researchers reasoned the se-
lection of a face-to-face group of patients with prostate can-
Forty patients with cancer participated. The sample con-
cer for the pilot would provide a pragmatic match. In fact, this
tained 14 men from traditional face-to-face support groups for
was not born out in the sample.
prostate cancer and 26 members of an Internet support group
Subjects were at least 21 years old, treated for cancer, and
with different cancer diagnoses. All members (n = 14) of the
belonged to either a face-to-face or Internet support group.
traditional face-to-face group were male, whereas the online
After receiving institutional approval for the protection of
group was 56% (n = 14) male and 44% (n = 12) female. Eighty-
human subjects, face-to-face participants were accessed via
three percent of the total sample (n = 33) were married, 10%
local support groups. The primary investigator attended two
(n = 4) were separated or divorced, and 7% (n = 3) were single
face-to-face meetings (with permission of the facilitator), ex-
or never married. The two groups did not differ by income,
plained the study, and asked for participants. The investigator
health insurance status, or mean number of days since initial di-
asked potential subjects to sign a written consent form and
agnosis. No members of the traditional face-to-face group rated
return the study instruments to the group facilitator at the end
themselves as "terminal" compared to four in the online group.
of the meeting. The facilitator then returned the instruments
This difference was not significant.
to the primary investigator.
The groups differed significantly by percent of patients re-
Once permission from the Internet support group "owner"
ceiving active treatment in the prior month (face-to-face: n =
2 [14%], Internet: n = 14 [54%]) (P2 [1, n = 40] = 4.95, p <
was obtained, a "call for participants" was posted for poten-
tial online subjects. If subjects wanted to participate or find
0.026), mean number of months in a support group (face-to-
out more about the study, investigators directed them to a
face: 34.2 months, Internet group: 11.8 months) (t [35] =
Web page designed for purposes of the study. The investiga-
3.282, p < 0.02), and level of depression (see Table 1). The
tors posted an electronic consent form along with directions
traditional face-to-face group had a mean score of 1.86 (SD =
on how to complete the study questionnaires online. Return of
2.69) on the CES-D whereas the online group had a mean
the survey by electronic mail was considered to be consent.
score of 29.27 (SD = 11.89) (t = 8.46, p < 0.000).
Study recruitment ran for approximately one month.
No significant difference occurred in the level of depression
between men and women in the online group. Twelve of 14
Instruments
men (86%) in the Internet group had mean scores on the CES-
The participants received one of two forms of the survey.
D above 16 (the cutoff score for major depressive disorder),
The patients in the face-to-face group received a paper survey
while all the women (n = 12) in the online group had scores
consisting of an investigator-developed questionnaire includ-
above 16. CES-D scores of the men in the Internet group
ing demographic information, a brief medical history, support
(27.42 [SD = 12.69]) and men in the face-to-face group (1.86
group history, and a depression measure. The Internet group
[SD = 2.69]) were significantly different (t = 7.37, p <
subjects received a similar instrument with additional ques-
0.000).
ONF VOL 29, NO 4, 2002
E48
Table 1. Selected Characteristics of the Face-to-Face
when gender was considered. Eighty-six percent of the men
and Internet Cancer Support Groups
and 100% of the women in the Internet group had CES-D
scores indicating major depressive disorder.
Face-to-Face
Internet
Research studies have indicated that depression is a major
(n = 14)
Characteristic
(n = 26)
p
problem for people receiving treatment for a malignancy
(Derogatis et al., 1983; De Walden-Galuszko, 1996; Leopold
Gender
NS
et al., 1998). In the current study, half of the subjects in the
14
Male
14
Internet support group were receiving treatment at the time
Female
12
they participated. Even so, active treatment alone does not
Prostate
Cancer type
NS
Mixed
account for the high depression scores in these subjects.
1,386
Mean days since diag-
1,123
NS
Colleoni et al. (2000) reported that depressed women were
nosis
2
Undergoing active treat-
14
< 0.026
less likely to accept adjuvant chemotherapy, an integral part
ment in prior month
of the treatment for early-stage breast cancer. Possibly, treat-
34.2
Number of months in
11.80
< 0.020
ment choices of the Internet respondents in the current study
support group
may be affected by their psychological state. Watson et al.
Depression scoresa
< 0.000
(1999) reported that survival was reduced in women with
1.86
Scores
29.27
breast cancer who were depressed. Possibly, the high depres-
2.69
SD
11.89
sion rates reported by the Internet support group members in
the current study will affect their survival, as well.
NS = not significant
Kraut et al. (1998) indicated that people became more de-
a
Cut-off score for major depressive disorder on Center for Epi-
pressed as they spent more time online. The subjects in the Kraut
demiologic Studies-Depression Scale is 16.
et al. study did not have cancer. Given that patients with cancer
have higher depression rates than the general population, per-
haps spending time online is associated with even greater de-
The scores indicated that the vast majority (92%) of those in
pression  rates.  On  the  other  hand,  self-
the Internet group suffered from major depressive disorder as
selection may have played a role in the findings of the current
compared to none of the participants in the face-to-face group.
study. Subjects who were depressed may have been more in-
Face-to-face group members reported that they did not belong
clined to participate in this study, therefore skewing the findings.
to an Internet support group or spend time online. The Internet
Secondary analysis of the online group suggests that among
group averaged 2.6 hours (range = 17) in the online support
the patients who were depressed, less time spent online was
group and 6.2 hours (range = 214) total time online each week.
associated with higher levels of depression. This is consis-
Investigators completed further analysis of the Internet
tent with clinical experience. Those with severe levels of de-
group to examine the Spearman correlation between total time
pression often have difficulty with simple activities of daily
on the Internet and level of depression. The correlation be-
living. They may be less likely to use the Internet for sup-
t w e e n these two variables approached significance
port. Conversely, the argument exists that the difference be-
(rs = 0.38, p = 0.064). Of the individuals in the Internet sup-
tween the face-to-face and Internet support groups is related
port group who were depressed, those with the highest scores
to the depressive effects of social isolation associated with
on the CES-D generally spent less time on the Internet than
time on the Internet.
depressed individuals with lower scores on the CES-D.
Limitations
Discussion
This pilot study had a small sample size, which limits gen-
The data, on the surface, provide credence for the notion
eralizing the results to the larger population. This sample of
that the Internet as support may be related to depression in
men and women could not be considered representative of all
patients with cancer. Investigators noted clear differences in
people who attend support groups. The findings in this study
depression scores between those in the face-to-face group and
might be explained by variance between the types of cancer,
those receiving support via the Internet. Although the Internet
gender, or the self-selection of subjects participating in both
subjects reported the amount of time they spent online per
groups. Other factors that may have affected the results are the
week, researchers could not determine if the high depression
inherent biases found when groups lack randomization.
rate of this group was related to the amount of time spent
Threats to the validity and reliability of the findings in this
online or to other factors as yet unknown.
pilot study are apparent. Only men with prostate cancer were
Newport and Nemeroff (1999) reported that people with
represented in the face-to-face support groups. Although the
pancreatic malignancies had the highest depression rates among
depression rate among these men was zero, these outcomes
patients with cancer, followed by malignancies of the orophar-
cannot be generalized to women or men with other types of
ynx, breast, and colon. Depression rates in the Newport and
cancers. In addition, it should not be assumed that the high
Nemeroff study did not rise above 50%. None of the patients in
depression rate found in the Internet support group is repre-
the current study comparing face-to-face and Internet support
sentative of other Internet groups.
groups had cancer of the pancreas, oropharynx, or breast; how-
Conclusions
ever, 92% of the online group had CES-D scores that indicated
major depression. Fife et al. (1994) reported women with can-
cer had better coping skills than men. In the current study,
Considering both the compelling natures of the data and
women were expected to have had a lower depression rate than
the identified weaknesses, this study provides impetus for
men. No significant differences were evident in CES-D scores
further exploration of the efficacy of Internet support. Ran-
KLEMM VOL 29, NO 4, 2002
E49
domized clinical trials comparing face-to-face, Internet, and
nursing assessments. Traditional support groups can help
treatment as usual (i.e., no intervention) groups should be
people with cancer function more effectively with their dis-
conducted to help determine the effectiveness of Internet
ease. Nurses should consider recommending face-to-face
support. The potential for providing life extension via an
groups to help people cope with their illness because they
Internet format to patients unable to tolerate face-to-face
have been shown to decrease depression and foster coping in
group support has significant appeal. Research should ex-
patients with cancer. However, the efficacy of Internet cancer
plore potential risks to better understand the limitation of
support groups in providing psychoeducation and psycho-
this treatment approach.
therapeutic interventions has not been proven. Although the
Internet support groups may offer many benefits, nurses
Implications for Nursing
should be aware of the potential pitfalls and monitor their
patients' responses accordingly.
Research has indicated that patients with cancer are at a
higher risk for developing depression (Aasa et al., 1997; Breit-
Author Contact: Paula Klemm, DNSc, RN, OCN, can be reached
bart, 1995; Hann et al., 1999; Newport & Nemeroff, 1999).
a t klemmpa@udel.edu, with copy to editor at rose_mary@
This should be a consideration during initial and subsequent
earthlink.net.
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