When individuals face life-threatening or chronic illnesses, they often experience a wide range of psychological reactions. These reactions can be influenced by the nature of the illness, personal coping strategies, social support, and previous mental health conditions. The most common psychological reactions include depression and anxiety disorders. A number of research projects at EPoS have focused on identifying the prevalence of and risk factors for these issues, as well as developing and evaluating the effectiveness of various psychological treatments. 

For example, researchers at EPoS have established a nationwide cohort of Danish women treated for breast cancer and have followed this cohort over several years. The results have shown an increased prevalence of depression [1] and post-traumatic stress reactions [2], as well as a significant fear of recurrence, even several years after the completion of primary treatment (contact: Robert (Bobby) Zachariae; Søren Christensen; Maja O’Connor). Since such psychological reactions can affect both physical health and overall quality of life, researchers at EPoS have, for several years, worked to identify and test effective and potentially cost-efficient treatments. 

We have, for example, investigated the effect of the so-called "expressive writing intervention" (EWI) on anxiety and depression among women treated for breast cancer, in collaboration with researchers from institutions such as Mount Sinai School of Medicine in New York [3]. EWI is a brief intervention where participants are asked to write about their thoughts and feelings regarding a stressful experience, such as a cancer diagnosis (contact: Robert (Bobby) Zachariae). In other projects, we have examined the effect of mindfulness-based cognitive therapy (MBCT) on anxiety and depression among individuals treated for both breast cancer and prostate cancer. In this project, the treatment was delivered via an internet-based program that we developed in collaboration with the Internet Psychiatry Unit at Karolinska Institute in Stockholm [4] (contact: Eva Nissen). 

A particularly challenging issue for many former cancer patients is the fear of cancer recurrence, which can have a considerably negative impact on a person’s quality of life and daily functioning. In collaboration with colleagues from the University of Sydney, Australia, we developed and tested a group-based version of ConquerFear, a brief psychological treatment specifically aimed at fear of cancer recurrence [5] (contact: Mia O’Toole; Robert (Bobby) Zachariae). The positive results have led this treatment program to be implemented at several of the Danish Cancer Society's counseling centers. 

When a person is affected by a serious illness, it is not only the patient who experiences stress, but also their closest relatives – especially those with caregiving responsibilities. At EPoS, we have examined the effect of emotion regulation therapy on psychological symptoms among relatives of patients undergoing treatment for lung and gastrointestinal cancers, among others. In addition to the expected direct positive effects on the well-being of the relatives, the results showed an indirect positive effect on the quality of life of the cancer patients [6] (contact: Mia O’Toole; Robert (Bobby) Zachariae). 

In addition to individual projects, we have conducted a number of systematic reviews with meta-analysis, where we assess the overall evidence for various treatments. For instance, we have identified which types of psychological treatments are most effective in treating fear of cancer recurrence [7] (contact: Mia O’Toole; Robert (Bobby) Zachariae). In another meta-study, we reviewed all studies that directly compared the effectiveness of traditional cognitive behavioral therapy and mindfulness-based therapy for depression, and found that the effects of the two forms of therapy were equivalent [8] (contact: Robert (Bobby) Zachariae; Eva Nissen). 

While the research thus indicates that there are several effective treatments available, a key challenge remains in identifying individuals who need help and ensuring they receive the appropriate treatment. EPoS collaborates with the Danish Center for Late Effects after Breast Cancer (DCCL) (www.brystkraeftsenfoelger.dk) to monitor individuals treated for breast cancer using a mobile app aimed at screening breast cancer survivors for psychological and physical late effects, and providing feedback and advice to the cancer survivors. Together with DCCL and two other Danish national late effects centers, researchers at EPoS are working to develop national clinical guidelines for the diagnosis and treatment of anxiety and depression among individuals treated for cancer (contact: Robert (Bobby) Zachariae). 

All of the projects described above have been carried out with support from external foundations, primarily the Danish Cancer Society. 

Sleep is essential for both physical and mental health, supporting a wide range of processes important for well-being, including cognitive function, the immune system, and emotional regulation. Insufficient sleep in terms of quantity and quality can lead to problems such as fatigue, poor concentration, weakened immunity, and an increased risk of various chronic conditions like heart disease, diabetes, and depression. Several research projects at EPoS have therefore focused on sleep difficulties. 

Many current and former cancer patients experience sleep problems in the form of insomnia, i.e., difficulties falling asleep and maintaining sleep throughout the night, which affects their daily functioning and well-being. In a large cohort of women treated for breast cancer, we found that over half experienced significant sleep problems, not only immediately after treatment [1] but also several years after completing treatment [2] (Contact: Robert (Bobby) Zachariae). 

While sleep medications remain the most commonly offered treatment, long-term use is not recommended due to side effects and adverse long-term consequences. The recommended first-line treatment is cognitive behavioral therapy for insomnia (CBTI), which has been shown to be effective with durable effects. However, a challenge lies in reaching all those in need, especially due to the cost of personally delivered treatment and the lack of trained therapists. At EPoS, we are therefore investigating the use of digitally delivered CBTI. In this context, we have tested the effect of digital CBTI on sleep disturbances among Danish women treated for breast cancer, finding the intervention to be highly efficacious [3, 4]. In a systematic review with meta-analysis, we confirmed that CBTI is the best-documented treatment for sleep disturbances among cancer patients and survivors [5, 6]. In another meta-analysis, we documented that electronically and personally delivered CBTI have comparable effects, further supporting the efficacy of digital delivery  [7] (Contact: Robert (Bobby)Zachariae; Ali Amidi). 

Based on this work, we developed HVIL®, a mobile app for delivering CBTI, which we are currently testing with various collaborators in several projects with different target groups, including patients with chronic pain and sleep problems and patients seeking treatment from their general practitioners for sleep issues (Contact: Robert (Bobby) Zachariae; Morten Lopdrup). 

Research suggests that cancer and cancer treatment can disrupt the circadian rhythm, leading to fatigue and sleep problems. At EPoS, we are therefore exploring the role of circadian rhythm disruptions in the development of fatigue and other negative symptoms [8], particularly in relation to treatment with immunotherapy (Contact: Louise Strøm). The circadian rhythm is primarily regulated by the balance between light and darkness, and we have conducted several projects investigating the effect of light therapy on cancer-related fatigue and sleep [9]. Additionally, an upcoming project will explore the effect of circadian rhythm therapy (light, activity, meal timing) on fatigue among individuals treated for breast and prostate cancer (Contact: Ali Amidi; Lisa Wu; Louise Strøm). 

Pain is a frequent late effect among current and former cancer patients and can have a significant negative impact on their quality of life, work ability, and daily functioning. For many of these pain types, there is a lack of effective medical treatments, and at EPoS, we have therefore focused on research projects that explore the prevalence and risk factors for cancer-related pain, as well as how these pains can be alleviated through psychological treatment techniques. 

Research at EPoS indicates that pain among current and former cancer patients is an often overlooked problem in the healthcare system [1]. For example, results from our nationwide cohort of women treated for breast cancer show that one in five women continues to experience frequent pain even 7-9 years after completing primary treatment [2]. Another project with women treated for breast cancer also showed that such breast cancer-related pain is associated with an increased occurrence of other symptoms, primarily fatigue and sleep difficulties [3] (contact: Robert (Bobby) Zachariae). 

Due to the difficulties in treating several types of cancer-related pain pharmacologically, especially so-called neuropathic pain, it is important to test the efficacy of other types of pain treatment, including psychological therapies. A systematic review and meta-analysis of various psychological treatments for breast cancer-related pain conducted at EPoS indicated, among other things, that newer psychological treatments such as mindfulness-based therapies could be relevant to explore further [4]. Researchers at EPoS have therefore investigated the effectiveness of so-called mindfulness-based cognitive therapy (MBCT) on pain after treatment for breast cancer [5]. The results not only indicated a good effect of the treatment but also that the treatment was cost-effective and was associated with a subsequent reduction in the use of healthcare services in the treatment group compared to the control group [6] (contact: Robert (Bobby) Zachariae; Mia O'Toole). While psychological treatment thus proved effective in treating pain in this patient group, it is not known exactly which treatment components are most effective, and whether the treatment can be optimized by excluding certain components. In a project at EPoS, we are therefore working to examine which combination of treatment elements from contemporary, so-called "third-wave" psychological treatments (e.g., mindfulness-based therapy and acceptance and commitment therapy (ACT)) is the most effective and least resource-intensive [7] (contact: Cecilie Buskbjerg, Mia O'Toole).

To develop effective psychological pain treatments, it is essential to uncover the underlying psychological mechanisms that contribute to maintaining pain. Researchers at EPoS have participated in various projects that investigate such mechanisms. It has, for example, been found that so-called catastrophizing cognitions about pain are associated with increased pain intensity [8], and that a significant part of the effect of mindfulness-based cognitive therapy on pain among women treated for breast cancer is associated with a reduction in such catastrophic thoughts [9]. Other projects explore how both negative and positive emotions affect pain [10] (contact: Mia O'Toole; Robert (Bobby) Zachariae). 

Based on their experiences from pain research, researchers at EPoS, together with the Danish Center for Late Effects of Breast Cancer (DCCL) (www.brystkraeftsenfoelger.dk) and other Danish cancer researchers and clinicians, are also involved in the development of national clinical guidelines for the diagnosis and treatment of various late effects after cancer, including cancer-related pain (contact: Robert (Bobby) Zachariae) 

Cognitive Difficulties After Cancer and Cancer Treatment 

The term "chemo brain" or chemo fog is often used by cancer patients and survivors and refers to the experience of cognitive difficulties, such as memory and concentration problems, during and after cancer treatment. Although this issue has been described in research literature since the 1970s, it has only been in the past decade that it has gained significant recognition. 

At EPoS, since 2009, we have conducted a large number of prospective observational studies aimed at identifying the prevalence and severity of cognitive difficulties following cancer and cancer treatment. These research studies have been conducted in various patient populations, including both CNS (patients with brain tumors) and non-CNS cancers, such as testicular, breast, and prostate cancer (contact: Ali Amidi, Cecilie Buskbjerg). Our research group has considerable expertise in neuropsychological assessment in a research context [1-11]. 

In several of the aforementioned studies, we have also used newer brain imaging methods, such as MRI, to investigate some of the underlying neurobiological factors that may potentially mediate cognitive difficulties. Specifically, we have used structural MRI to examine potential impacts of specific chemotherapy agents on brain structure. Our studies have shown, among other things, that some chemotherapy agents can cause changes in the brain's networks. Additionally, we have conducted several systematic reviews and meta-analyses in this area [10-12] (contact: Ali Amidi, Cecilie Buskbjerg, Robert (Bobby) Zachariae). 

One of the fundamental questions in this field of research concerns whether it is the cancer itself or the systemic treatment that causes cognitive difficulties, or whether it is more due to the psychological reactions often triggered by a cancer diagnosis. Overall, our research at EPoS has helped establish that both the cancer itself and its treatment are significant risk factors for cognitive disturbances. 

At EPoS, we also research how the cognitive difficulties experienced by many cancer survivors can be alleviated or treated. For instance, we have tested digital brain training tools among breast cancer patients, though they have shown relatively small effects as standalone treatments [13]. In ongoing projects, we are therefore investigating whether a holistic neurorehabilitation approach involving family members is a more effective method for treating cognitive difficulties [14] (contact: Lisa Wu, Cecilie Buskbjerg). 

Finally, in current and future studies, we aim to investigate how different symptoms after a life-threatening illness like cancer can influence each other. For example, it is known that many patients, after their treatment, experience both sleep problems and cognitive difficulties. Therefore, it makes sense to explore whether targeted treatment of one symptom (e.g., sleep) might also have an effect on another (e.g., cognition) (contact: Ali Amidi). Other ongoing projects focus on possible changes in cognitive function in patients receiving immune therapy (contact: Josefine Danielsen) 

All the projects described above have been carried out with support from external funding, primarily from the Danish Cancer Society. 

• Amidi, A., et al., Changes in cognitive functions and cerebral grey matter and their associations with inflammatory markers, endocrine markers, and APOE genotypes in testicular cancer patients undergoing treatment. Brain Imaging Behav, 2017. LINK 
• Amidi, A., et al., Changes in Brain Structural Networks and Cognitive Functions in Testicular Cancer Patients Receiving Cisplatin-based Chemotherapy. Journal of the National Cancer Institute, 2017. 109(12). LINK 

In the field of cancer care and health psychology more broadly, we often interact with relatives to critically ill patients. Witnessing death, dying, and the grief following the death of a loved one can be difficult to navigate. Therefore, at EPoS, in collaboration with the Unit for Bereavement Research (UBR), we also study grief, including both natural and complicated grief reactions. 

Today, the grieving process is often understood through the dual-process model of coping with bereavement, which describes an oscillation between focusing on the loss (loss-oriented process) and adjusting to life without the deceased (restoration-oriented process). However, a research project that the dual-process model may not fully reflect the experience of the bereaved. The findings show, among other things, that there are no breaks from grief and that the grief processes overlap more than previously assumed. Additionally, the results highlight that grief can be understood as a learning process in which time also plays a crucial role [1]. (Contact Lene Larsen, Maja O’Connor) 

Bereaved individuals may also experience grief as more persistent, intense, and painful than what is seen in an adaptive, natural grieving process as described above. Our research estimates that approximately 5-10% of bereaved individuals show symptoms of prolonged grief disorder, which is included in the ICD-11 and DSM-5-TR diagnostic systems [2]. In connection with this, research projects at UBR and EPoS have developed and validated a questionnaire and a structured clinical interview to better identify bereaved individuals with prolonged grief disorder [3]. (Contact Maja O’Connor) 

When working with bereaved individuals, it is also essential to identify risk factors for prolonged grief disorder. Research at UBR and EPoS has therefore in a recent meta-analyses examined risk factors related to the loss situation, as well as personal and relational factors predicting later prolonged grief disorder [4, 5]. (Contact Christina Buur Steffensen) 

Knowledge of and tools to identify prolonged grief disorder in bereaved individuals are crucial to ensure that they receive the appropriate support. Research suggests that in particular cognitive behavioral therapy can be effective in treating prolonged grief [6]. (Contact Katrine B. Komischke-Konnerup) 

Read more about this research here: https://psy.au.dk/en/research/research-centres-and-units/unit-for-bereavement-research 

• Lene Holm Larsen, Lisbeth Hybholt & Maja O’Connor (31 May 2024): Lived experience and the dual process model of coping with bereavement: A participatory research study, Death Studies, https://doi.org/10.1080/07481187.2024.2355244

A user- or patient-centered approach to communication fosters trust, increases patient satisfaction, and improves treatment outcomes. By focusing on the patient's needs, concerns, and preferences, patients are motivated to actively participate in their treatment, leading to more accurate diagnoses and better adherence to treatment plans. This approach also involves an increased focus on the emotional and existential aspects of illness and health, contributing to the overall well-being of both the patient and their relatives. The importance of quality in communication between healthcare professionals and patients is thus a central theme in health psychology research and practice. 

For several years, staff at EPoS have been involved in efforts to increase the focus on the importance of communication in the healthcare system. Staff have, for example, been involved in policy-developmental work aimed at introducing communication as a central aspect of quality in the Danish healthcare system [1]. Researchers at EPoS have also initiated several research projects on communication in healthcare. In a large study of 454 consultations at an oncology outpatient clinic, we found that when patients experienced a higher degree of patient-centered communication from the oncologist, there were simultaneous positive changes in anxiety and depressive symptoms, as well as an increased level of cancer-related "self-efficacy," indicating greater confidence in their ability to handle the challenges of cancer and cancer treatment [2]. (contact: Robert (Bobby) Zachariae). 

These findings have been confirmed in later studies [3] and have led to investigations into whether systematic training of healthcare professionals in communication can result in greater patient satisfaction and fewer psychological and physical symptoms. In a project involving oncology nurses and 413 cancer patients recruited before and after the nurses participated in the Danish Medical Association's communication course, we found no clear effects of course participation [4]. Possible explanations could be that the nurses who participated were already skilled in communication, or that the content of the medical course did not fit nurses’ communicative skill needs (contact: Robert (Bobby) Zachariae). 

Current ongoing projects include a collaboration with Australian colleagues to investigate the effect of an e-learning program that trains oncologists in communicating with patients who experience fear of cancer recurrence (contact: Eva Nissen, Louise Strøm). Another project is investigating whether medical students' empathy can be increased through a series of communication exercises with patients or actors portraying patients. Empathy is an important aspect of patient-centered communication, and studies suggest there is a link between medical students' level of empathy and burnout [5]. 

Several staff members at EPoS have taught communication skills training courses to doctors and medical students, and to better assess changes in their perceived communication abilities, we have developed and validated a questionnaire instrument (SEPCQ) that measures a doctor’s or medical student’s self-efficacy, that is, confidence in their ability to interact with patients in a patient-centered manner [6]. The instrument has been translated into several languages, including English, French, and German, and has been adapted for other professional groups, e.g., nurses (contact: Robert (Bobby) Zachariae). 

• Amtsrådsforeningen, et al., Patientens møde med sundhedsvæsenet - De mellemmenneskelige relationer - anbefalinger for kommunikation, medinddragelse og kontinuitet. 2003, Århus: Kvalitetsafdelingen i Århus Amt.  
• Zachariae, R., et al., Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer, 2003. 88(5): p. 658-65. LINK 
• Cairns, P., A.E. Isham, and R. Zachariae, The association between empathy and burnout in medical students: a systematic review and meta-analysis. BMC Med Educ, 2024. 24(1): p. 640. LINK 
• Rask, M.T., et al., Effects of an intervention aimed at improving nurse-patient communication in an oncology outpatient clinic. Cancer Nurs, 2009. 32(1): p. E1-11. LINK 

Health Psychology focuses on the interaction between body and mind, such as the bodily causes of mental states, health and illness behavior, and psychological interventions for physical illness. 

Health psychology research spans a range of areas, from evaluating treatments to experimental and epidemiological research. Among the most important tasks of health psychology research is to investigate factors that are significant for people with physical conditions and their treatment. Periodically, we receive inquiries about entering into research collaborations based on challenges and questions from practice. 

Researchers from EPOS have conducted numerous projects with partners from actors in the healthcare system, where issues from clinical reality have formed the basis for a research project. 

 For example, we have conducted studies on pain during egg retrieval in fertility treatment, and later on whether the psychological intervention method "Expressive Writing" has an effect on psychological stress in couples undergoing fertility treatment [1, 2]. 

 In collaboration with the Committee for Health Education, we have evaluated the effectiveness of lay-led, group-based patient self-management programs for individuals with chronic pain [3], on long-term sick leave, and with anxiety and depression [4]. Subsequently, in collaboration with the Committee, we developed a program specifically aimed at cancer patients. 

 In other diverse projects, we have examined topics as varied as the effect of mindfulness treatment for COPD [5], the effects of so-called energy healing [6, 7], patient-controlled admissions in psychiatry [8], career shifts among nurses [9], mindfulness and nature therapy [10], and cancer patients’ perceptions of how the COVID-19 pandemic affected the quality of cancer treatment [11]. 

We are always open to collaboration on health psychology projects and have significant research expertise in a variety of areas (Contact Mimi Mehlsen; Bobby Zachariae).