Objective
Fatigue is a common symptom among cancer survivors that can be successfully treated with cognitiveābehavioral therapy (CBT). Insights into the working mechanisms of CBT are currently limited. The aim of this study was to investigate whether improvements in targeted cognitiveābehavioral variables and reduced depressive symptoms mediate the fatigueāreducing effect of CBT.
Methods
We pooled data from three randomized controlled trials that tested the efficacy of CBT to reduce severe fatigue. In all three trials, fatigue severity (checklist individual strength) decreased significantly following CBT. Assessments were conducted preātreatment and 6 months later. Classical mediation analysis testing a preāspecified model was conducted and its results compared to those of causal discovery, an explorative dataādriven approach testing all possible causal associations and retaining the most likely model.
Results
Data from 250 cancer survivors (nĀ =Ā 129 CBT, nĀ =Ā 121 waitlist) were analyzed. Classical mediation analysis suggests that increased selfāefficacy and decreased fatigue catastrophizing, focusing on symptoms, perceived problems with activity and depressive symptoms mediate the reduction of fatigue brought by CBT. Conversely, causal discovery and postāhoc analyses indicate that fatigue acts as mediator, not outcome, of changes in cognitions, sleep disturbance and depressive symptoms.
Conclusions
Cognitions, sleep disturbance and depressive symptoms improve during CBT. When assessed preā and postātreatment, fatigue acts as a mediator, not outcome, of these improvements. It seems likely that the working mechanism of CBT is not a oneāway causal effect but a dynamic reciprocal process. Trials integrating intermittent assessments are needed to shed light on these mechanisms and inform optimization of CBT.