{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,5]],"date-time":"2026-11-05T19:28:54Z","timestamp":1793906934090,"version":"4.8.0"},"reference-count":40,"publisher":"Wiley","issue":"9","license":[{"start":{"date-parts":[[2021,5,3]],"date-time":"2021-05-03T00:00:00Z","timestamp":1620000000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100013421","name":"Pink Ribbon Foundation","doi-asserted-by":"publisher","award":["2012.WO26.C139"],"award-info":[{"award-number":["2012.WO26.C139"]}],"id":[{"id":"10.13039\/100013421","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Psycho-Oncology"],"published-print":{"date-parts":[[2021,9]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objective<\/jats:title><jats:p>Fatigue is a common symptom among cancer survivors that can be successfully treated with cognitive\u2010behavioral therapy (CBT). Insights into the working mechanisms of CBT are currently limited. The aim of this study was to investigate whether improvements in targeted cognitive\u2010behavioral variables and reduced depressive symptoms mediate the fatigue\u2010reducing effect of CBT.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>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 pre\u2010treatment and 6 months later. Classical mediation analysis testing a pre\u2010specified model was conducted and its results compared to those of causal discovery, an explorative data\u2010driven approach testing all possible causal associations and retaining the most likely model.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Data from 250 cancer survivors (<jats:italic>n<\/jats:italic>\u00a0=\u00a0129 CBT, <jats:italic>n<\/jats:italic>\u00a0=\u00a0121 waitlist) were analyzed. Classical mediation analysis suggests that increased self\u2010efficacy 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 post\u2010hoc analyses indicate that fatigue acts as mediator, not outcome, of changes in cognitions, sleep disturbance and depressive symptoms.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Cognitions, sleep disturbance and depressive symptoms improve during CBT. When assessed pre\u2010 and post\u2010treatment, fatigue acts as a mediator, not outcome, of these improvements. It seems likely that the working mechanism of CBT is not a one\u2010way causal effect but a dynamic reciprocal process. Trials integrating intermittent assessments are needed to shed light on these mechanisms and inform optimization of CBT.<\/jats:p><\/jats:sec>","DOI":"10.1002\/pon.5710","type":"journal-article","created":{"date-parts":[[2021,4,26]],"date-time":"2021-04-26T10:44:06Z","timestamp":1619433846000},"page":"1476-1484","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":21,"title":["Potential mechanisms of the fatigue\u2010reducing effect of cognitive\u2010behavioral therapy in cancer survivors: Three randomized controlled trials"],"prefix":"10.1002","volume":"30","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0412-7469","authenticated-orcid":false,"given":"Fabiola","family":"M\u00fcller","sequence":"first","affiliation":[{"name":"Department of Medical Psychology Amsterdam University Medical Centers University of Amsterdam Amsterdam Public Health Research Institute  Amsterdam The Netherlands"},{"name":"Department of Health Psychology University of Groningen University Medical Center Groningen  Groningen The Netherlands"},{"name":"Faculty of Science, School of Psychology The University of Sydney  Sydney Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Feri","family":"Wijayanto","sequence":"additional","affiliation":[{"name":"Institute for Computing and Information Sciences Radboud University  Nijmegen The Netherlands"},{"name":"Department of Informatics Universitas Islam Indonesia  Yogyakarta Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9581-088X","authenticated-orcid":false,"given":"Harri\u00ebt","family":"Abrahams","sequence":"additional","affiliation":[{"name":"Department of Medical Psychology Amsterdam University Medical Centers University of Amsterdam Amsterdam Public Health Research Institute  Amsterdam The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marieke","family":"Gielissen","sequence":"additional","affiliation":[{"name":"Academy Het Dorp  Arnhem The Netherlands"},{"name":"Siza (disability service) Arnhem  Arnhem The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hetty","family":"Prinsen","sequence":"additional","affiliation":[{"name":"Department of Medical Oncology Radboud University  Nijmegen The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annemarie","family":"Braamse","sequence":"additional","affiliation":[{"name":"Department of Medical Psychology Amsterdam University Medical Centers University of Amsterdam Amsterdam Public Health Research Institute  Amsterdam The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanneke W.M.","family":"van Laarhoven","sequence":"additional","affiliation":[{"name":"Department of Medical Oncology Cancer Center Amsterdam Amsterdam University Medical Centers University of Amsterdam  Amsterdam The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Perry","family":"Groot","sequence":"additional","affiliation":[{"name":"Institute for Computing and Information Sciences Radboud University  Nijmegen The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom","family":"Heskes","sequence":"additional","affiliation":[{"name":"Institute for Computing and Information Sciences Radboud University  Nijmegen The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hans","family":"Knoop","sequence":"additional","affiliation":[{"name":"Department of Medical Psychology Amsterdam University Medical Centers University of Amsterdam Amsterdam Public Health Research Institute  Amsterdam The Netherlands"},{"name":"Department of Medical Psychology Amsterdam University Medical Centers Expert Center for Chronic Fatigue Vrije Universiteit Amsterdam  Amsterdam The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2021,5,3]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1093\/annonc\/mdw099"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11764-015-0450-2"},{"key":"e_1_2_11_4_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamaoncol.2016.6914"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1037\/0278-6133.26.4.464"},{"key":"e_1_2_11_6_1","article-title":"Fatigue perpetuating factors as mediators of change in a cognitive behavioral intervention for targeted therapy\u2010related fatigue in chronic myeloid leukemia: a pilot study","author":"Hyland KA","journal-title":"Ann Behav Med"},{"key":"e_1_2_11_7_1","doi-asserted-by":"crossref","volume-title":"\u201cCondition\u201d or \u201cCognition\u201d? 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