Characteristics and Effectiveness of Individual Psychotherapy for Palliative and End-of-Life Care: A Literature Review for Randomized Controlled Trials

Article information

Psychiatry Investig. 2024;21(5):433-448
Publication date (electronic) : 2024 May 23
doi :
1Department of Psychiatry, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
2Department of Psychiatry, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
3Department of Psychiatry, Kyungpook National University Hospital, Daegu, Republic of Korea
Correspondence: Jungmin Woo, MD, PhD Department of Psychiatry, School of Medicine, Kyungpook National University, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea Tel: +82-53-200-5747, Fax: +82-53-426-5361, E-mail:
Received 2023 October 12; Revised 2024 February 1; Accepted 2024 March 3.



The introduction of psychotherapy in palliative and end-of-life care settings has become increasingly common and is effective in decreasing many psychological problems. This review reports the characteristics and effectiveness of individual psychotherapeutic interventions for patients receiving palliative and end-of-life care. In addition, the review reports the effectiveness of psychotherapies considering the expected life expectancy.


The PubMed, Google Scholar, and Cochrane Library databases were searched for English-language articles published between January 2000 to May 2023.


Twenty-six studies were included and classified into a total of nine types of psychotherapies, namely, dignity therapy (DT), life review therapy, narrative therapy, managing cancer and living meaningfully (CALM), individual meaning-centered psychotherapy, meaning and purpose therapy, meaning-making therapy, meaning-of-life therapy, and cognitive therapy.


Most of the psychotherapies provided to patients receiving palliative and end-of-life care showed effectiveness in the reduction of negative emotions and positive factors related to end-of-life issues. Most studies targeted patients with advanced cancer; however, studies on DT did not limit the target group to patients with cancer. Considering the expected life expectancy, CALM was found to be suitable for patients receiving early palliative care.


Advances in medical treatments have not only prolonged life expectancy over the past century but have also changed illness trajectories, particularly in economically developed countries. As a result of these illness trajectory changes, individuals experience physical, psychological, and spiritual difficulties ranging from days to years before death [1,2]. These difficulties have brought to the fore the need for palliative care, and a previous study showed that 38%–74% of the population needed end-of-life palliative care worldwide [3]. Among many dimensions, providing psychosocial support is a core component of palliative care [4]. Patients receiving palliative care suffer from high psychological distress, which can affect physical symptoms and poor social functioning [5]. These patients also suffer from depression, anxiety, and hopelessness, which also can negatively affect their overall quality of life [6]. However, the psychological problems among patients receiving end-of-life care can be treated by appropriate psychosocial interventions.

Since the 21 century, the introduction of psychotherapy in palliative and end-of-life care settings has become increasingly common, and its effectiveness has been confirmed. For individuals receiving palliative care, including those with advanced cancer, psychotherapy is effective in decreasing psychological symptoms and increasing existential happiness and overall quality of life [7,8].

Several review articles have focused on psychotherapy among patients receiving palliative and end-of-life care including group therapy [7-9]. Owing to tests, procedures, and treatments related to their physical diseases, patients may feel burdened, and participating in group therapy for a fixed time may be difficult. In addition, if patients are struggling to overcome their suffering, they may find it difficult to absorb the suffering of other patients in the group. Thus, patients undergoing palliative care may receive treatment in a more personal space [10]. By emphasizing the suitability of individual therapy rather than group therapy in the palliative care setting, in this review, we would like to exclude group therapy and explore the effectiveness and characteristics of individual psychotherapy more deeply. Most of the treatments were indicated for patients with advanced cancer; however, patients with other diseases receiving palliative and end-of-life care were also included. In addition, we would like to consider whether applying different psychotherapies according to the expected life expectancy of the patient group is effective. To focus on the effect of treatments on patients, articles including partners, caregivers, families, or medical staff were excluded.


PubMed, Google Scholar, and Cochrane Library were searched for studies published between January 2000 to May 2023 using the following terms in the title: “Palliative” or “End-of-life care” cross-referenced with “psychotherapy,” excluding the term “Group.” Papers published between January 2000 to May 2023 were included to determine trends in therapy over the past 20 years.

The eligibility criteria for study selection were as follows: 1) studies with randomized controlled trials (RCTs), clinical controlled trials, or waitlist controlled trials, 2) studies that investigated the effects of psychotherapy conducted in patients receiving palliative or end-of-life care, and 3) studies that were available in English.

The exclusion criteria were as follows: 1) studies of complementary therapies including physical (yoga and physiotherapy), art, music, and aromatherapy, 2) studies including the effects of medication treatment together, 3) studies that also enrolled partners, caregivers, and family-delivered therapies, 4) group therapies, 5) review articles including meta-analysis, abstracts, posters, editorials, protocols, gray literature, conference proceedings, and studies with unavailable full texts, and 6) studies that report only qualitative results.

If a phase 3 RCT was conducted after a phase 2 RCT, the preceding study was not included in the review if the study analyzed the same outcome as the latter study. However, if the outcomes to be confirmed were different, both papers were included in the review.


A total of 198 articles were identified through the title search. After screening of the titles and abstracts, the full texts of 42 articles were extensively reviewed by two reviewers. In addition, 8 studies were included through the related reference search by reviewers. Finally, 26 studies were included in the review. Figure 1 shows the flow diagram of the review process.

Figure 1.

Flow diagram for study selection.

These studies were classified into a total of nine types of psychotherapies, namely, dignity therapy (DT), life review (LR) therapy, narrative therapy, managing cancer and living meaningfully (CALM), individual meaning-centered psychotherapy (IMCP), meaning and purpose (MaP) therapy, meaning-making therapy, meaning-of-life therapy, and cognitive therapy. In cognitive therapy, the treatment used in the studies was heterogeneous; however, they were classified and reviewed in the same category as cognitive or cognitive behavioral therapy (CBT). The overview of the reviewed studies is shown in Table 1.

Overview of studies

Characteristics of each psychotherapy and their treatment outcomes


DT is a brief, individualized psychotherapy developed to alleviate distress in patients with terminal illnesses and improve their end-of-life experiences. This treatment provides patients the opportunity to reflect on things that are important to them or other things they want to remember or convey to others. The treatment protocol shows the nine basic questions to begin this psychotherapy, reflecting the empirical model of dignity in patients.

Chochinov et al. [11] developed the DT, and their research team published their findings of the RCT study in 2011. They did not find significant differences in the distress levels estimated by standardized scales including the functional assessment of chronic illness therapy (FACIT), hospital anxiety and depression scale (HADS), and modified Edmonton symptom assessment scale (ESAS) between the groups receiving DT, client-centered care, and standard palliative care. However, in the self-report of end-of-life experiences, DT was significantly more likely than other therapies to improve the quality of life and sense of dignity and help patients and families. In addition, it was better than client-centered care in improving spiritual wellbeing and standard palliative care in reducing sadness or depression.

Scarton et al. [12] conducted another RCT analysis using previous research data. Their reanalysis included 326 participants with ≤6 months of life expectancy who completed the original study [11]. This study showed a higher rating on the Dignity Impact Scale (DIS) in the DT group than in the usual care or client-centered intervention group. The DIS was used to measure the dignity effect, which can assess spiritual issues associated with the end of life.

Hall et al. [13] performed an RCT with 45 participants who received DT plus standard care or standard care alone. They showed no significant differences in dignity-related distress between the groups. However, the intervention group reported more hope than the standard care group at the 4-week follow-up.

Julião et al. [14] conducted a phase 2 RCT with 80 participants receiving end-of-life care and reported that the DT group had a beneficial effect on depression and anxiety symptoms. Another study published in 2017 by the same research team [15] measured the effect of DT on demoralization, desire for death, and sense of dignity. Results showed that all of the three domains mentioned above were associated with the therapeutic effects of DT.

Rudilla et al. [16] conducted an RCT, which enrolled 70 participants from a home care unit, who had more than 2 weeks of predicted survival. The study found that the DT or counseling group showed improvements in the perception of the meaning of life, quality of life, and spiritual well-being among the patients. However, the results for anxiety were better in the counseling group than in the DT group. This study showed that among RCTs for various conditions, DT does not show a comparative superior treatment effect to counseling.

Vuksanovic et al. [17] compared the DT group with LR therapy and waitlist control groups. DT was suggested to improve generativity and ego integrity in individuals with advanced diseases and a life expectancy of <12 months. No significant differences were found for dignity-related distress or physical, social, emotional, and functional well-being among the three study groups.

Weru et al. [18] used ESAS to measure the quality of life of 144 participants with advanced cancers. No statistically significant improvements were found in the overall quality of life of the DT group when compared with the usual care group. In the DT group, the symptom scale showed a trend toward statistical significance in anxiety.

Iani et al. [19] conducted an RCT to determine whether DT is efficacious on spiritual well-being, demoralization, and dignity-related distress. Results showed that the DT group exhibited similar levels of peace in 15–20 days of follow-up, whereas the standard palliative care group showed decreased peace during the same period. The study did not show significant differences in meaning, faith, loss of meaning, purpose, or distress among the participants.

Taken together, eight of nine studies reviewed reported that DT was more effective than usual care or other therapies, including counseling or LR. The therapeutic effects of DT have been reviewed in various aspects such as lowering depression, anxiety, demoralization, desire for death, and dignity-related distress. Moreover, enhanced sense of dignity, sense of hope and meaning of life, generativity, and ego integrity were also reported as effects of DT. Only one study did not confirm the effectiveness of DT compared with counseling [16].

LR therapy

Ando et al. [20] developed short-term LR therapy consisting of two sessions over 1 week. Before this study, the research team explored the 4-week therapy for patients with terminal cancer [21]; however, approximately 30% of the participants could not complete the study because of the rapid deterioration of their physical condition. In the first session of short-term LR, patients reviewed their lives with an interviewer to recollect and integrate their lives. In this process, the therapist records the patient’s words, draws keywords from the verbatim, and makes an album with related photos and pictures. In the second session, patients review this album with the therapist to feel the continuity of self and accept life completion. The result of the RCT of this intervention showed that the meaning-of-life subscale from FACIT-Spiritual (FACIT-Sp) scale and the hope, life completion, and preparation scores were significantly improved in the intervention group compared with those in the general support group. Moreover, depression, anxiety, burden, and suffering were alleviated to a higher degree in the intervention group than in the control group.

Xiao et al. [22] conducted a study with 80 patients receiving home-based hospice care and three sessions of LR intervention. This study suggested that the LR intervention offered improvements in psychospiritual well-being including the feeling of support, value of life, and decreased negative emotions, sense of alienation, and existential distress.

Kleijn et al. [23] showed the effectiveness of an intervention combining LR and memory specificity training in patients with cancer receiving palliative care with an expected prognosis of >3 months. This RCT suggested that the course of ego integrity improved over time in the intervention group compared with the waitlist group but had no effect on despair, psychological distress, or quality of life.

Narrative intervention

Narratives can change beliefs and motivate action and are useful for cancer communication. It can also provide opportunities to express emotions in a safe place for individuals to explore the meaning of their experience and promote coping strategies [24].

Wise et al. [25] conducted an RCT of patients with advanced cancer who received a narrative intervention, named “miLivingStory.” The three components of this intervention were storytelling, telephone interviews, and recording of the participant’s life, sharing the story on a website with support groups, and inviting guests and uploading the story in social media. Comparing the effectiveness with the control group, the intervention group showed a positive effect on peace, reduced depression in the 4-month follow-up, and protected against reduced wellbeing at the 2- and 4-month follow-ups.

Lloyd-Williams et al. [26] conducted an RCT involving patients with depression who scored ≥10 points in the Patient Health Questionnaire-9 and showed that after receiving a focused narrative intervention to usual care, the score of the group with moderate-to-severe depression reduced compared with that of the usual care group. They also suggested that the group receiving this intervention appeared to have longer survival than the control group.


Breitbart et al. [27] developed the IMCP, which was originally designed as an eight-session group-based intervention. The intervention focuses on encouraging patients with advanced cancer to share concerns related to their illness, express their emotions, and increase a sense of meaning in their lives. In their RCT for IMCP [28] compared with enhanced usual care, IMCP showed significant treatment effects on the quality of life, sense of meaning, spiritual well-being, anxiety, and desire for hastened death. In addition, compared with the supportive psychotherapy group, the IMCP intervention group showed enhanced effects on the quality of life and sense of meaning.

Fraguell-Hernando et al. [29] conducted IMCP in patients receiving home palliative care. IMCP demonstrated effectiveness in decreased levels of demoralization, depression, anxiety, and emotional distress, whereas the counseling group showed only decreased demoralization.


Rodin et al. [30] developed the brief, semi-structured psychotherapy called CALM for patients with advanced cancer to prevent depression and end-of-life distress. This therapy is compromised with 3–6 individual sessions of 45–60 min, which provide therapeutic relationship and reflective space, with attention to the four domains, namely, symptom management and communication with healthcare providers, changes in self and relations with others, spiritual well-being and sense of MaP, and mortality and future concerns. An RCT with 305 patients with advanced cancer showed that the CALM group reported less severe depression at the 3- and 6-month follow-ups and better end-of-life preparation at the 6-month follow-up than the usual care group.

Mehnert et al. [31] conducted an RCT with 206 patients with cancer to compare the effectiveness of CALM with supportive psycho-oncological counseling. The study showed that both interventions reduced depressive symptoms; however, no significant difference was found between the two groups.

MaP therapy

Kissane et al. [32] developed a therapy to enhance meaning-based coping through LR for patients with advanced cancer whose prognosis was ≤12 months and who received six manual sessions. To conduct each session, meaning-centered questions are used, which are illustrated in the MaP manual. Each session focused on cancer history and personal life, personalized therapy goals, enhancing MaP, connection with others, defining priorities with strengths and values, and consolidating the direction for the totality of life. The results of the RCT revealed that MaP therapy showed effectiveness in posttraumatic growth and positive life attitude compared with the waitlist control.

Meaning-making intervention (MMi)

MMi is a brief intervention conducted within four sessions of 30–90 min each and focuses on existential meaning. Each session is structured to deal with three tasks, namely, 1) reviewing the effect and meaning of the cancer diagnosis, 2) exploring important life events and ways of coping, related to the present cancer experience, and 3) prioritizing life and goal changes that give meaning to one’s life [33,34].

Henry et al. [35] conducted a pilot RCT with participants newly diagnosed with advanced ovarian cancer. Compared with the waitlist usual care group, the intervention group was suggested to influence the sense of meaning. The study used FACITSp-12 meaning subscale and captured the effect of MMi at 1 and 3 months post intervention. No significant effects on other measures including anxiety, depression, and self-efficacy were found following the intervention.

Meaning-of-life therapy

Mok et al. [36] developed the meaning-of-life intervention, a brief intervention to help patients receiving palliative care to reflect on their lives based on the sources of the meaning of life suggested in logotherapy. Intervention is composed of two sessions. The first session lasts for 30–60 min, which focuses on facilitating individuals about their lives with five core questions. The facilitator summarized the tape-recorded session and formulated a generalized meaning in the interview. In the second session, which continues after 2–3 days, participants verify the written summary, and this summary can be modified as needed. The results of this study revealed that the intervention demonstrated statistically significant effects on the overall quality of life score and existential distress subscale compared with the control intervention.


CBT helps individuals not only overcome fear and avoidance by being gradually exposed to situations that cause anxiety but also reconstruct irrational thoughts and beliefs that exacerbate anxiety [37]. Several research teams have developed CBT suitable for application to patients receiving palliative care and researched on its effectiveness.

Individual cognitive therapy (CT), which is composed of 8 weekly sessions and three booster sessions for women with depression and metastatic breast cancer, was conducted by Savard et al. [38] In their study, the intervention group showed significantly fewer symptoms including depression using the Hamilton depression rating scale measures than the control group. Moreover, they found that by using a pooled dataset, the effects were observed as a reduction in symptoms including depression, anxiety, fatigue, and insomnia and were sustained well at the 3- and 6-month follow-ups.

Moorey et al. [39] conducted an RCT involving patients receiving palliative home care. Home care nurses received training in CBT or continued the usual care. The trial enrolled patients who had anxiety and depression symptoms based on HADS and showed that the CBT group had significantly decreased anxiety levels but not depression.

Greer et al. [40] developed a brief CBT for patients with terminal cancer who had anxiety scores of ≥14 based on the Hamilton anxiety rating scale. After six CBT sessions, the anxiety level of the intervention group reduced compared with that of the waitlist control group. Similar to the results of Moorey et al. [39], this study showed that CBT had no significant effect on depressive symptoms.

In the study of 12 sessions of manualized CBT for patients with advanced cancer who have depression and estimated survival of >4 months, Serfaty et al. [41] tried to find the therapeutic effects on mood symptoms. However, the intervention group did not show any clinical benefit with depression compared with the treatment-as-usual (TAU) group. Subgroup analysis including widowed, divorced, or separated participants showed that CBT exerted a significant effect on depressive symptoms.

In the study of patients with late-stage ovarian cancer, Rost et al. [42] used acceptance and commitment therapy (ACT) for the intervention group. ACT is a recent variant of CBTs, which explicitly targets avoidance by enhancing experiential acceptance [43]. After 12 face-to-face meetings and interventions following the ACT or TAU, the ACT group showed much more improvement in the quality of life and reduction in psychological distress than the TAU group. It had no significant direct effects on anxiety or depressive symptoms.

Although evaluating and synthesizing the effectiveness of CBT using different protocols, most studies have confirmed that CBT is effective in reducing anxiety among patients receiving end-of-life care. However, no results were consistent on whether depressive symptoms were reduced.

Application of psychotherapy by life expectancy

In 13 of the 26 studies, the life expectancy of the participants was considered in the inclusion or exclusion criteria when recruiting participants. These studies are presented in Figure 2, along with the number of participants receiving psychotherapy. Studies dealing with the therapeutic effect of DT limit the expected life expectancy of the participants to <6 months or <12 months [11,12,14,15,17,19]. Among studies dealing with other psychotherapies, studies specifying the expected life expectancy of the participants target patients with a life expectancy of <6 months for narrative intervention [26] and <12 months for MaP therapy [32]. Moreover, certain studies have specified the minimum life expectancy instead of the maximum life expectancy. Among the reviewed studies, only patients with a life expectancy of >1 month in the IMCP study [29], >2 months in the CT study [38], >3 months in the LRT-MST study [23], and >4 months in the ACT study were recruited [41]. In the CALM study, both minimum and maximum life expectancies were specified, and patients with a life expectancy of 12–18 months were included [30].

Figure 2.

Life expectancy and conducted psychotherapy. Circle diameter: number of participants with intervention.

In Figure 2, for each study, the diameter of the circle corresponds to the number of participants who received each psychotherapy. If the sample size is too small, obtaining adequate results can be difficult even in strictly executed studies [44]. The studies reviewed have produced specific results; however, some are preliminary studies considering the number of participants [45]. Therefore, we tried to compare the sample size of the study according to each psychotherapeutic method by indicating the number of participants. In this figure, the number of participants was compared only for studies with a specified expected survival period, and the number of participants for all studies can be confirmed in Table 1.

The remaining 13 studies did not mention the patient’s life expectancy, and classifying participants according to life expectancy was difficult because of the mixed use of terms such as “terminal diseases,” “terminal cancer,” or “advanced cancer.”


Most of the reviewed studies have targeted the reduction of negative emotions as outcomes of treatment including depression, anxiety, emotional distress, burden and suffering, desire for death, and demoralization. DT [11,14-16,18,19], LRT [20,22], narrative intervention [25,26], IMCP [28,29], CALM [30,31], meaning-of-life therapy [36], and most of the CBT [38-40,42] were found to reduce negative emotions among patients receiving palliative care. Studies have also noted that psychotherapies not only reduced negative emotional factors but also increased positive factors. These include the sense of dignity, sense of hope and peace, meaning and value of life, ego integrity, generativity, psychological or spiritual wellbeing, posttraumatic growth, positive life attitude, and life completion and preparation. Psychotherapies that enhance positive life factors include DT [11-13,15-19], LRT [20,22,23], narrative intervention [25], IMCP [28], CALM [30], MaP therapy [32], MMi [35], meaning-of-life therapy [36], and ACT in CBT, which improved the quality of life [42]. In other words, the results show an increase in positive factors for life in all types of psychotherapies reviewed but not in most of the CBT. In this review, treatments addressed other than CBT, commonly emphasize the meaning of life that individuals can feel at the end of their lives and focus on dealing with this meaning in a comfortable environment. The effect of these therapies can also be linked to finding the meaning of life, promoting positive views on life.

As for the participant group, most studies have targeted patients with metastatic or advanced cancer. However, in the case of DT, more than half of the reviewed studies did not limit the target group to patients with cancer [11,12,14-17,19]. The fact that DT does not limit the target group to these patients compared with other psychotherapies may mean that this treatment can be comprehensively applied regardless of the characteristic disease progression of patients with cancer. According to Chochinov et al. [11], the developer of this treatment method, DT targets patients who reach the end of their lives with an expected life expectancy of <6 months. The nine questions given during the psychotherapeutic process take the form of a will that they want to remember personally or to be remembered by their loved ones. This helps all patients who face imminent death regardless of the disease course to face death with dignity.

When psychotherapy was classified according to the expected life expectancy, psychotherapy was conducted on patients with a life expectancy of ≤6 months or ≤12 months in narrative intervention [26], MaP [32], and DT [11,12,14,15,17,19]. In studies that mentioned the minimum life expectancy of patients, the minimum life expectancy was at least 1–4 months for other psytchotherapies [23,29,38,41]. This shows that most therapies simply target patients who are about to die. However, CALM therapy targets patients with advanced cancer who cannot be treated but have an expected prognosis of at least 1 year [30]. In other words, it targets patients who are expected to die from diseases, but death is not imminent. Early palliative care performs well in many ways [46,47]; however, early palliative care for psychological problems has not been well-organized. CALM therapy aims to provide early psychological palliative care to patients who expect death but have to live with the disease; it is different from other psychotherapies dealing with impending death.

The studies reviewed included various sample sizes of patients who participated in the psychotherapeutic intervention of the control group; however, in most cases, recruiting more than 100 participants in each arm was challenging. There can be two main reasons for this difficulty in participant recruitment. First, patients may not be the priority participants of psychotherapy or associated research if they are in a confusing situation. Patients must adapt to complex medical systems and make important treatment decisions while enduring their pain in situations such as cancer progression, exacerbation, and recurrence. Owing to the unique characteristics of these patients, study participation may not be a priority for most patients [10]. Second, even if they agreed to participate in the study, there may be many situations in which continued participation in psychotherapy and related research is difficult because of their physical condition, and deaths before completing the study protocol may also be frequent. Thus, compared with other studies that have investigated treatment outcomes, patient enrollment was difficult. Despite these implications, a total of five studies that have reviewed therapies such as DT [11,12], IMCP [28], and CALM [30,31] were completed with more than 100 participants per arm, which can be seen as fairly large-scale studies. Considering the characteristics of these patient groups, research must be conducted with large patient groups, and appropriate training of therapists to perform psychotherapy is also essential.


Most psychotherapies provided to patients receiving palliative and end-of-life care showed effectiveness in reducing negative emotions including depression, anxiety, emotional distress, burden and suffering, desire for death, and demoralization. Moreover, psychotherapies improve positive factors at the end of life including dignity, sense of hope and peace, meaning and value of life, ego integrity, generativity, psychological or spiritual wellbeing, posttraumatic growth, positive life attitude, and life completion and preparation, although the effects on each variable varied or absent depending on the study. Most studies have targeted patients with advanced cancer. However, studies on DT did not limit the target group to patients with cancer. Considering the expected life expectancy, CALM was found to be suitable for patients receiving early palliative care compared with other psychotherapies.


Availability of Data and Material

The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Kyungmin Kim, Jungmin Woo. Data curation: Kyungmin Kim. Methodology: Kyungmin Kim, Jungmin Woo. Formal analysis: Kyungmin Kim, Jungmin Woo. Investigation: Kyungmin Kim, Jungmin Woo. Writing—original draft: Kyungmin Kim. Writing—review & editing: Kyungmin Kim, Jungmin Woo.

Funding Statement





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Article information Continued

Figure 1.

Flow diagram for study selection.

Figure 2.

Life expectancy and conducted psychotherapy. Circle diameter: number of participants with intervention.

Table 1.

Overview of studies

Author (published year), country Study period Participants Intervention (N) Control (N) Outcomes Measures
Chochinov et al. (2011) [11] Canada, USA, and Australia April 2005–October 2008 - 18 years or older individuals DT (N=165) Client-centred care (N=140) or SPC (N=136) - No significant differences in reductions in various dimensions of distress - Palliative performance scale
- Terminal prognosis with expected life expectancy ≤6 months - FACIT
- Significant improvement in quality of life, sense of dignity in selfreported end of-life experiences - Spiritual Well-Being Scale
- Receiving palliative care in a hospital or community setting - PDI
- No cognitive impairments (hospice or home) - Structured interview for symptoms and concerns (items including dignity, desire for death, suffering, hopelessness, depression, suicidal idea and sense of burden to others)
- Quality of life scale (two-items)
- Modified ESAS
Scarton et al. (2018) [12] Canada, USA, and Australia April 2005–October 2008 - 18 years or older individuals DT (N=108) Client-centred care (N=107) or SPC (N=111) - Intervention group showed a higher Dignity impact ratings compared to both other groups - The 7-item of Dignity Impact Scale
- Terminal prognosis with expected life expectancy ≤6 months
- Receiving palliative care in a hospital or community setting (hospice or home)
- No cognitive impairments
Hall et al. (2011) [13] UK April 2009–June 2010 - No cognitive impairments DT (N=23) SPC (N=22) - No significant differences in dignity related distress - Primary outcome
- Patients with advanced cancer  - PDI (dignity-related distress)
- Aged 18 years or more - Intervention group showed higher levels of hope than the control group with medium effect size - Secondary outcomes
- Referred to hospital based palliative care teams  - Herth Hope Index (hope)
- Excluded if the palliative care team felt they were unable to take part in a protocol lasting 2 weeks - No difference in anxiety, depression, quality of life or palliative outcomes  - HADS (psychological distress)
- No cognitive impairments  - EQ-5D (quality of life)
 - Palliative care outcomes
Julião et al. (2014) [14] Portugal May 2010–May 2013 - Participants with 18 or more years of age DT (N=39) SPC (N=41) - DT had beneficial effect in depression and anxiety, sustained for 30 days follow up period - HADS; baseline (T1), day 4 (T2), day 15 (T3), day 30 (T4) of follow-up
- Having a life-threatening disease with a prognosis of 6 months or less
- Mini Mental State score 20 or more
Julião et al. (2017) [15] Portugal May 2010–May 2013 - Participants with 18 or more years of age DT (N=41) SPC (N=39) - DT was associated with significant decrease in DS and desire for death - DS
- Having a life-threatening disease with a prognosis of 6 months or less - DT participants showed significant decrease in 19 of 25 PDI questions (except cognitive capacity, meaningful life and healthcare support) - Desire for Death Rating Scale
- Mini Mental State score 20 or more - PDI
Rudilla et al. (2016) [16] Spain April 2013–June 2013 - 18 years or older patients DT (N=35) Counselling therapy (N=35) - Both DT and counseling group showed positive effect on perception of meaning in life, quality of life and spiritual well-being - PDI
- From a palliative care, home care unit with advanced/terminal illness - HADS
- Brief Resilient Coping Scale
- Less than 2 weeks of predicted survival were excluded - Significantly higher effect on anxiety in counseling group - GES Questionnaire; Spirituality
- No cognitive impairments - Duke–UNC-11 Functional Social Support Questionnaire
- No other significant differences were found in outcomes comparing two groups - Two items from the EORTC Quality of Life C30 Questionnaire (EORTC–QLQ–C30)
 - “ How would you rate your overall health during the past week?”
 - “ How would you rate your overall quality of life during the past week?”
Vuksanovic et al. (2017) [17] Australia March 2012–December 2015 - 18 years or older individuals DT (N=20) LR (N=18) - DT significantly improved generativity and ego integrity - Brief Generativity and Ego-Integrity
- Advanced disease with a life expectancy of less than 12 months based on clinical consensus WC (N=18) - No group differences for dignity related distress or physical, social, emotional and functional well-being among three groups - PDI
- Receiving specialist multidisciplinary palliative care either in a hospital or home setting - FACT-G, version 4: QOL
- No cognitive impairments - A treatment evaluation form
Weru et al. (2020) [18] Kenya August 2016–March 2017 - Adults aged between 18 and 65 years DT (N=72) UC (N=72) - No statistical effect on overall quality of life score, but improvement in summated symptom score in DT group compared to the control group - ESAS: quality of life
- Advanced cancers (stage 3 and 4)
- Recruited from the inpatient hospital setting and outpatient oncology clinics
- No cognitive impairments - Anxiety symptom score showed a trend toward significance (p=0.059)
Iani et al. (2020) [19] Italy February 2018–May 2020 from - Age over 18 DT (N=32) SPC (N=32) - Unlike control group, DT reported the effect of protecting the decline of peace - Primary outcomes
- Diagnosis of life-threatening disease with a prognosis ranging from 1 to 6 months (based on the evaluation of physicians who referred patients)  - FACIT-Spiritual Well-Being Scale (FACIT-Sp)
- No significant longitudinal changes measured of meaning, faith, loss of MaP, coping ability and distress - 2ndary outcome
- No cognitive impairments  - DS-II
 - PDI (dignity related distress)
Ando et al. (2010) [20] Japan April 2007–March 2008 - Terminally ill patients with incurable cancer Short-term LR interview (N=38) General support (N=39) - Short-term LR reported effectiveness in improving the spiritual well-being, hope, life completion and preparation than control group - Primary outcomes
- Over age 20 years  - FACIT-Sp scale; meaning of life domain
- Undergoing treatment in the PCU; duration in the PCU was between two and four weeks - Intervention showed decreased depression, anxiety, burden and suffering compared to control group - Secondary outcomes
- No cognitive impairments  - Good Death Inventory (hope, burden, life completion, and preparation)
 - A numeric scale for psychological suffering
Xiao et al. (2013) [22] China Not mentioned - Patients with advanced cancer LRT (N=40) Routine care through home visits and weekly telephone follow-up (N=40) - In the intervention group, significantly better outcomes were shown in overall quality of life, support and value of life - Overall QOL; single-item
- Aged 18 years or more - Quality-of-life concerns: 28-item quality of life concerns in the end-of-life questionnaire
- From a home-based hospice - Reduction in negative emotions, sense of alienation, existential distress were found compared to control group  - 8 subscales: physical discomfort, food-related concerns, healthcare concerns, support, negative emotions, sense of alienation, existential distress, and value of life
- Karnofsky Performance Status more than 40
- No cognitive impairment
Kleijn et al. (2018) [23] Netherlands June 2010–December 2013 - Adults over 19 years old LRT and memory specificity training (N=55) WC (N=52) - Ego-integrity improved over time in the intervention group compared to control group - Primary outcome
- All types of cancer receiving palliative care  - Ego-integrity and despair
- Expected prognosis more than 3 months - No significant difference in despair, psychological distress or quality of life - Secondary outcome
- No psychotic behavior or severe cognitive dysfunction  - HADS (psychological distress, anxiety and depression)
 - The European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire PAL 15 (EORTC QLQ-C15-PAL; quality of life)
 - Autobiographical Memory Test (specificity of the autobiographical memory)
Wise et al. (2018) [25] USA Not mentioned - Age 30 or older patients miLivingStory; a telephone-based LR and illness narrative intervention (N=49) miOwnResources; an active control group website with information and support but no story tips (N=37) - miLivingStory group had a positive effect for peace, and trend effect for lower depressed mood at four months follow up compared to control group - FACIT-Sp; peace and meaning
- Stage III or IV cancer - Profile of Mood States-Short Form; depressed, angry, and anxious moods
- Willingness to use internetenabled computer - Protection against control group’s declining wellbeing between two and four months follow up were shown
Lloyd-Williams et al. (2018) [26] UK May 2013–December 2015 - Age older than 18 Narrative intervention (N=33) UC (N=24) - Intervention group had greater reduction in PHQ-9 score at 6-week follow-up (p=0.04) - PHQ-9
- Advanced cancer patients attending hospice day care services - ESAS; pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath
- Eastern Cooperative Oncology Group one or two - Median survival was longer (157 days) for intervention and compared to control group (102 days, p=0.07)
- Life expectancy of 12 months or less
- No severe cognitive impairment
- Exclude prognosis of 6 weeks or less
- All participants were depression cases at baseline (PHQ-9≥10)
Breitbart et al. (2018) [28] USA March 2011–March 2016 - Patients age 18 years or more IMCP (N=109) Supportive psychotherapy (N=108) or EUC - Significant treatment effects (small to medium in magnitude) were observed for IMCP, in comparison with EUC, in quality of life, sense of meaning, spiritual well-being, anxiety, and desire for hastened death - Primary outcomes; existential distress and overall quality of life
- Have a stage IV solid tumor cancer  - FACIT-Sp Well-Being Scale
- Have at least moderate distress (DT score of 4 or higher)  - Personal Meaning Index of the Life Attitude Profile–Revised
- No severe cognitive impairment or psychiatric disturbance (psychosis or suicidal ideation) - No significant improvement was observed for patients receiving SP  - MQOL
- Secondary outcomes; psychological distress
- The effect of IMCP was significantly greater than the effect of SP for quality of life and sense of meaning but not for the remaining study variables  - Hopelessness Assessment in Illness questionnaire
 - Schedule of Attitudes Toward Hastened Death
Fraguell-Hernando et al. (2020) [29] Spain May 2017–April 2018 - Age 18 years or more IMCP (N=24) Counselling (N=27) - Demoralization (despair), anxiety, depression, and emotional distress were reduced in intervention group - HADS
- Patients with advanced-stage cancer receiving palliative care at home - Detection of Emotional Distress
- Physician estimated life expectancy more than 1 month - Demoralization was the only variable that significantly improved in the counselling group - DS-II
- No psychiatric disturbance
Rodin et al. (2018) [30] Canada February 2012–March 2016 - Age 18 years or more patients CALM (N=151) UC (N=154) - Intervention group showed less-severe depression at 3 and 6 months follow up period - Primary outcome; PHQ-9
- Diagnosis of stage III or IV lung cancer, any-stage pancreatic cancer, unresectable cholangiocarcinoma, unresectable liver cancer, unresectable ampullary or peri-ampullary cancer or other stage IV gastrointestinal cancer, stage III or IV ovarian and fallopian tube cancers or other stage IV gynecologic cancer, stage IV breast cancer, genitourinary cancer, sarcoma, melanoma, or endocrine cancer - Secondary outcomes
- Better end of life preparation at 6 months follow up period compared to UC group  - GAD-7
 - FACIT-Sp Well-Being Scale (FACIT-Sp-12)
 - QUAL-EC Scale
- With an expected prognosis of 12 to 18 months  - 16-Item Experiences in Close Relationships Scale validated for use in advanced cancer (ECR-M16)
- Excluded cognitive impairment basis of SOMC score less than 20, current psychiatric or psychological treatment  - CCS
 - DS
Mehnert et al. (2020) [31] Germany August 2013–January 2017 - Age 18 years or more CALM (N=99) Non-manualized supportive psychooncological counselling intervention (SPI) (N=107) - Significantly less depressive symptoms at 6 months than at baseline but no group differences in depression severity - Primary outcome: depression
- Had a malignant solid tumor; Union for International Cancer Control III or IV stages  - BDI-revision (BDI-II)
 - PHQ-9
- Score of ≥9 on the PHQ-9, and/or ≥5 on the distress thermometer - No significant group differences on secondary outcomes either - Secondary outcomes
 - Psychological distress; distress thermometer
- Excluded  - Quality of life; QUAL-EC
- Severe cognitive impairment (≤20 on SOMC)  - Anxiety; GAD-7 Questionnaire
- High level of functional impairments (Karnofsky score ≤70)  - Demoralization; DS
 - Fatigue; Brief Fatigue Inventory
- If they reported suicidal ideation  - Symptom burden; Memorial Symptom Assessment Scale (MSAS-SF29)
- If they reported suicidal ideation  - Spiritual well-being; Functional Assessment of Chronic
 - Illness Therapy Spiritual Well-Being Scale (FACIT-Sp)
 - Death anxiety DADDS
 - Posttraumatic growth; PTGI
 - Attachment insecurity; Experiences in Close Relationships Scale (ECR-M16)
 - Couple communication; CCS
Kissane et al. (2019) [32] Australia 2015–2016 - Age >18 years MaP therapy (N=40) Wait list UC (N=17) - MaP therapy showed effectiveness in posttraumatic growth (new possibilities, appreciation of life, and personal strength) and life attitudes (choices and goal seeking) compared to control group - PTGI
- Advanced cancer - The Life Attitude Profile-Revised
- Whose prognosis was assessed at 12 months or less - Brief Symptom Inventory
- No cognitive or psychiatric impairments - DS-II
- Existential distress: FACIT-Sp-12 meaning subscale
- MQOLexistential subscale
Henry et al. (2010) [35] Canada Not mentioned - Age 18 years or older Meaning making interventioin (N=12) UC (N=12) - Intervention group had a better sense of meaning in life at one and three months post-intervention - HADS
- Stage III or IV ovarian cancer patients - General Self-Efficacy Scale; perception of his or her general ability to deal with new or difficult situations
- Diagnosed within the last two months - No significant effectiveness in anxiety, depression and self-efficacy compared to control group
- Physically and emotionally capable participating without burden (ECOG performance status 1 or 2)
Mok et al. (2012) [36] Hong Kong September 2010–March 2011 - 18 years or older aged Meaning of life intervention (N=44) UC (N=40) - Intervention group showed significant effects in the QOLC-E total score, and existential distress subscale. Single item scale on global quality of life also showed improvement - Quality-of-Life Concerns in the End-of-Life (QOLC-E) questionnaire
- Diagnosed advanced-stage cancer (refractory to established curative treatments or for which no established curative treatments existed) - Single-item scale on global quality of life
- Recruited from oncology inpatient ward
- Excluded if they had significant cognitive impairment or psychoses
Savard et al. (2006) [38] Canada May 1999–June 2003 - Women who diagnosed in metastatic breast cancer (stage IV) Cognitive therapy for advanced cancer (N=25) WC (N=20) - Significant lowering in depression using HDRS - HADS
- 7 or more on the HADS-D or of 15 or more on the BDI Score - Were found in intervention group compared to control - BDI
- Excluded criteria - Using a pooled data set, a significant effect in lower the symptoms including depression, anxiety, fatigue and insomnia were found - HDRS
- Life expectancy less than 2 months - Insomnia Severity Index
- Patients with DSM-IV criteria severe psychiatric disorder other than major depression - Multidimensional Fatigue Inventory
- Recent antidepressant start (with in 2 month) - No treatment effect was found on any of the immune variables - The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C33)
- Suicidal ideation/acting out using Scale for Suicide Ideation - EORTC Breast Cancer-Specific Quality of Life Questionnaire Module (QLQ-BR23)
- Currently receiving a psychological intervention for depression - Health Behaviors Questionnaire
- List of life events
- Secondary outcome: immune function
Moorey et al. (2009) [39] UK March 2004–December 2005 - Patients with palliative home care CBT, for palliative care (N=45) TAU (N=35) - Individuals receiving CBT had lower anxiety scores over time - HADS
- Who score 8 or more for anxiety or depression on the HADS on either subscale - The Mental Adjustment to Cancer Scale
- Excluded significant cognitive, communication difficulties - No significant effect was shown in depression - The Cancer Coping Questionnaire measure the coping strategies taught in CBT for cancer
- The Multi-dimensional Scale of Perceived Social Support 12-item self-report measure of perceived social support
- The Eastern Cooperative Oncology Group Performance Status Scale
Greer et al. (2012) [40] USA October 2007–June 2010 - Age 18 or more patients CBT (brief, 6 session or less) (N=20) WC (N=20) - Significant reduction in anxiety symptoms compared to control group - HAM-A
- With incurable solid tumor - Clinical Global Impression Scale
- The presence of clinically significant anxiety symptoms (HAM-A score 14 or more), at least 4 weeks after cancer diagnosis - No significant effects in depressive symptoms - Montgomery Asberg Depression Rating Scale
- Impact of Events Scale
- FACT-G Questionnaire; quality of life
Serfaty et al. (2019) [41] UK Not mentioned - Patients with advanced cancer and depression (a diagnosis of cancer not amenable to cure, a DSM-IV diagnosis of depressive disorder using the Mini-International Neuropsychiatric Interview) CBT (N=93) TAU (N=92) - CBT showed no significant clinical benefit in advanced cancer patients with depression - Primary outcome: BDI-II
- Secondary outcomes
- A subgroup analysis of those widowed, divorced or separated showed a significant effect of CBT on the BDI-II  - PHQ-9
- Excluded Clinician-estimated survival of <4 months, high suicide examined using the MINI, currently receiving or having received in the last 2 months, a psychological intervention  - Eastern Cooperative Oncology Group Performance Status satisfaction with care
 - EuroQol-5 Dimensions
 - Client Services Receipt Inventory
Rost et al. (2012) [42] USA Not mentioned - Women with late-stage ovarian cancer (stage III or IV) ACT (CBT) (N=25) TAU (N=22) - Significant effect improving quality of life, reduction in psychological distress in intervention group - BDI-II
- Beck Anxiety Inventory
- Profile of Mood States: distress
- No significant effect on anxiety or depressive symptoms compared to control group - Courtland Emotional Control Scale: emotional control
- White Bear Thought Suppression Inventory thought suppression inventory
- COPE: assesses general strategies of coping

SPC, standard palliative care; FACIT, Functional Assessment of Chronic Illness Therapy; PDI, Patient Dignity Inventory; HADS, Hospital Anxiety and Depression Scale; ESAS, Edmonton Symptom Assessment Scale; DS, demoralization syndrome; LR, life-review; WC, waitlist control; UC, usual care; MaP, meaning and purpose; LRT, life review therapy; PHQ, Patient Health Questionnaire-9; EUC, enhanced usual care; MQOL, McGill Quality of Life Questionnaire; DS-II, Short Demoralization Scale; GAD-7, Generalized Anxiety Disorder-7; DADDS, Death and Dying Distress Scale; QUAL-EC, Quality of Life at the End of Life Cancer Scale; CCS, Couple Communication Scale; PTGI, Posttraumatic Growth Inventory; DS, Demoralization Scale; DT, dignity therapy; SOMC, Short Orientation-Memory-Concentration Test; BDI, Beck-Depressions-Inventory; TAU, treatment as usual; HDRS, Hamilton Depression Rating Scale; HAM-A, Hamilton Anxiety Rating Scale; FACT-G, Functional Assessment of Cancer Therapy-General; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; PCU, palliative care unit; IMCP, individual meaning-centered psychotherapy; CALM, cancer and living meaningfully; SP, supportive psychotherapy