Alex Mitchell      Consultant in Liaison Psychiatry and Hon SnR Lecturer in          Psycho-oncology, University Hospitals...
Most commonly diagnosed cancers worldwide                             Males                                            UK ...
5 Year Survival in US Cancers (2008 American Cancer Society, Atlanta)1009080                                              ...
10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases
Total prevalence                = 13.8raw 000S in 2010                                                               milli...
What is the prevalence of depression?      Levine PM, Silberfarb PM, Lipowski ZJ. Mental disorders in cancer         patie...
Prevalence of depression in Oncology settings             Plumb & Holland (1981)                                          ...
Prevalence of depression in Palliative settings24 studies involving 4007 individuals16.9% (95% CI = 13.2% to 20.3%)       ...
3500                                      Total prevalence Dep = 2 million in 20103000                                    ...
…but is the prevalence of depression high in long term  survivors? (3+ years)
Meta regression using the random effects model on raw porportions                   Estimated slope = - 0.02 % per month (...
12mo Service Use (NIH, 2002)40                      34.635                        32.7                                    ...
Two likely reasons…..
94.2%                               37.4%        P Wang Harvard8 yrs                    N= 9282 NCS‐R                     ...
100.0                                                                                  5.9                                ...
Illness Pathways           Many syndromes are easily overlooked by health professionals leading to unnecessary delays in t...
Illness Pathways – Oncology Studies           Many syndromes are easily overlooked by health professionals leading to unne...
Cancer in UKIncident Cancer Cases:  300,000+Prevalent Cancer Survivors  1-2 million estPrevalent Cancer Survivors with sig...
Depression              Three   D’sDysfunction                            Distress
Of the 293 Non-Nil                                       DepT                                                          23%...
100%   0.02                  0.00       0.00    0.00                 0.00           0.00                                  ...
Cancer #s in LeicesterIncident Cancer Cases:  3000Prevalent Cancer Survivors  12,500 estPrevalent Cancer Survivors with si...
Meeting Psychological Needs in Leicester FTE in Psycho-oncology   ?
Psycho-oncology in LeicesterFTE in Psycho-oncology  3.0CNS in UHL  35UHL Ward Nurses, Chemo Nurses and Rx Radiographers  1...
Psychological DistressPool x Prev  10,000 x 50% => 5000 (distress/anxiety)  10,000 x 20% => 2000 (depression)Depression / ...
DepT DT                                                               23%37%                        4%                    ...
What is the Aim of Psycho-Oncology?1. Reduce distress & emotional disorders   =>Desensitization by direct intervention2. P...
0                                       10                                                       20                       ...
Top 10 patient concerns     1 Anxiety             312     2 Family concerns     157     3 Independence/Role   122     4 Ap...
Help SeekingDo patients always ask for help when needed?
% Receiving Any treatment for Depression  20                                                                              ...
% Receiving Any treatment for Mental Health       Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Can...
1093 (100%) Population                                           462 needs                462 (42%)                  322 D...
Illness InformationAre we providing necessary information promptly and appropriately?
Information DeliveryIn 196190% of US doctors indicated a preference for not  telling a diagnosis of cancer.In 197997% indi...
Trusted Sources of Information
Women’s Information PreferencesCheck with me that I understand what he/she is saying   99   1Give me an opportunity to ask...
Disclosure of DiagnosisFamily wishesPalliative vs curative treatmentOverall prognosisNeed for compliancePatient “emotional...
Psychiatric DisordersWhat are the common psychiatric complications of cancer?
Brief Reactive Psychosis                                             Psychosis         Schizophrenia                      ...
DepressionCan we better understand depression in the context of cancer?
Two+ Key symptoms:• persistent sadness or low mood; and/or• loss of interests or pleasure• fatigue or low energy.Two+ asso...
Core Symptoms                      ICD10        DSMIVPersistent sadness or low mood   Yes (core)   Yes (core)Loss of inter...
Lung            (43%)BrainHodgkin’s diseasepancreaslymphomaliverhead and neckBreast          (35%)leukaemiamelanomacolonpr...
Cancer Related   Poor Quality of Life = Strong   Pain = Moderate - Strong   Later stage disease / poorer prognosis = moder...
Help!
2x2 Help Table                    Clinician thinks:   Clinician thinks:                    Help Needed         Help Not Ne...
2x2 Clinician Help Table : ACTUAL HELP                   Clinician thinks:   Clinician thinks no                   Unmet N...
2x2 Clinician Help Table : ACTUAL HELP                  Clinician thinks:   Clinician thinks                  Unmet Needs ...
Help – Who Wants Help?20% said they wanted professional help for  psychosocial issues.Only 36% of those distressed on the ...
What Kind of Help is Wanted?19% wanted medication (eg antidepressants)31% want self help guidelines31% wanted group therap...
Help – Who From?Nurse specialists (54%)Family and friends (21%)Spiritual advisor (8%)Psychiatrist (4%).
Why Not Needed?“getting help elsewhere” (57%)“feel well” (41%)“coping on my own” (31%)“fear of stigma”, “fear of side effe...
Promoting recognition & treatment
Do Clinicians Look for Depression/Distress?                    Mitchell, Kaar, Coggan, Herdman (N=226)
A                                  Form al QQMitchell, Kaar, Coggan, Herdman      6%              N=226         Ultra-Shor...
Distress Thermometer – Pooled                                                                    Proportion20.0%          ...
100.0                                                                                  5.9                                ...
Phase II
Psychological aspects of cancer care for students 2011 (Apr11)
Psychological aspects of cancer care for students 2011 (Apr11)
Psychological aspects of cancer care for students 2011 (Apr11)
Psychological aspects of cancer care for students 2011 (Apr11)
Psychological aspects of cancer care for students 2011 (Apr11)
Psychological aspects of cancer care for students 2011 (Apr11)
Psychological aspects of cancer care for students 2011 (Apr11)
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Psychological aspects of cancer care for students 2011 (Apr11)

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This is an introductory talk from the undergraduate lecturers in yr 5 cancer block, university of Leicester

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Psychological aspects of cancer care for students 2011 (Apr11)

  1. 1. Alex Mitchell Consultant in Liaison Psychiatry and Hon SnR Lecturer in Psycho-oncology, University Hospitals Leicesteralex.mitchell@leicspart.nhs.ukalex.mitchell@leicspart.nhs.uk Undergraduates (Feb11) Undergraduates (Feb11)
  2. 2. Most commonly diagnosed cancers worldwide Males UK Rank Females UK Rank Lung 16 15 (2nd) Breast 23 31 (1st) Prostate 14 24 (1st) Colorectum 9 12 (2nd) Colorectum 10 14 (3rd) Cervix 9 2 (11th) Stomach 10 3 (8th) Lung (3rd) 9 12 Liver 8 1 (15th) Stomach 6 2 (13th) Oesophagus 5 3 (6th) Uterus 5 5 (4th) Bladder 4 5 (4th) (19th) Liver 4 1 NHL 3 4 (5th) Ovary 4 5 (5th) Leukaemia 3 3 (10th) Thyroid 3 1 (18th)Lip, oral cavity 3 2 (12th) NHL 3 3 (7th) All others 23 25 All others 27 27 world (%) uk (%) world(%) uk(%)
  3. 3. 5 Year Survival in US Cancers (2008 American Cancer Society, Atlanta)1009080 1975-197770 1984-1986 1996-200460 Change5040302010 0 a r us a ia te on ry e) s as m de om om i te em ta al va ch tu ol re ad ls ph m os ec an C O on nc uk bl (fe Al lym Pr R el br Pa Le yM ar st d in ea an rin gk Br U ng od Lu -H on N Annual report to the national of status of cancer 1975 – 2005 J Natl Cancer Inst 2008;100: 1672 – 1694
  4. 4. 10.9million incident cases (1mi breast, lung colorectal); 25mi prevalent cases
  5. 5. Total prevalence = 13.8raw 000S in 2010 million3500 Projected = 18.2million in 2020300025002000 raw 000S15001000 500 0 in y er x ry ng t l ck h a s s as a te ia ta as ne vi gu om ru ac ra om va dd em ta Lu re ec ne er re te B id m ha os O la an nc ph or C nd B uk U K o B op Pr ol St Pa m el da Le C M Ly Es ea H Angela B. Mariotto J Natl Cancer Inst 2011;103:117–128
  6. 6. What is the prevalence of depression? Levine PM, Silberfarb PM, Lipowski ZJ. Mental disorders in cancer patients. Cancer 1978;42:1385–91. Dartmouth Medical School and the Norris Cotton Cancer Center, New Hampshire
  7. 7. Prevalence of depression in Oncology settings Plumb & Holland (1981) Proportion meta-analysis plot [random effects] 0.7750 (0.6679, 0.8609) Levine et al (1978) 0.5600 (0.4572, 0.6592) Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920) Massie et al (1979) 0.4850 (0.4303, 0.5401)70 studies involving 10,071 individuals;14 countries. Bukberg et al (1984) Passik et al (2001) 0.4194 (0.2951, 0.5515) 0.4167 (0.2907, 0.5512)16.3% (95% CI = 13.9% to 19.5%) Baile et al (1992) Morton et al (1984) Hall et al (1999) 0.4000 (0.2570, 0.5567) 0.3958 (0.2577, 0.5473) 0.3722 (0.3139, 0.4333) Burgess et al (2005) 0.3317 (0.2672, 0.4012) Jenkins et al (1991) 0.3182 (0.1386, 0.5487)Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3% Green et al (1998) 0.3125 (0.2417, 0.3904) Kathol et al (1990) 0.2961 (0.2248, 0.3754) Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249) Fallowfield et al (1990) 0.2565 (0.2054, 0.3131) Golden et al (1991) 0.2308 (0.1353, 0.3519) Spiegel et al (1984) 0.2292 (0.1495, 0.3261) Evans et al (1986) 0.2289 (0.1438, 0.3342) Grandi et al (1987) 0.2222 (0.0641, 0.4764) Maunsell et al (1992) 0.2146 (0.1605, 0.2772) Berard et al (1998) 0.2100 (0.1349, 0.3029) Joffe et al (1986) 0.1905 (0.0545, 0.4191) Berard et al (1998) 0.1900 (0.1184, 0.2807) Devlen et al (1987) 0.1889 (0.1141, 0.2851) Leopold et al (1998) 0.1887 (0.0944, 0.3197) Akizuki et al (2005) 0.1797 (0.1376, 0.2283) Razavi et al (1990) 0.1667 (0.1189, 0.2241) Gandubert et al (2009) 0.1597 (0.1040, 0.2300) Alexander et al (1993) 0.1333 (0.0594, 0.2459) Kugaya et al (1998) 0.1328 (0.0793, 0.2041) Payne et al (1999) 0.1290 (0.0363, 0.2983) Ibbotson et al (1994) 0.1242 (0.0776, 0.1853) Prieto et al (2002) 0.1227 (0.0825, 0.1735) Morasso et al (1996) 0.1121 (0.0593, 0.1877) Desai et al (1999) [early] 0.1111 (0.0371, 0.2405) Silberfarb et al (1980) 0.1027 (0.0587, 0.1638) Costantini et al (1999) 0.0985 (0.0535, 0.1625) Morasso et al (2001) 0.0985 (0.0535, 0.1625) Ozalp et al (2008) 0.0971 (0.0576, 0.1510) Love et al (2002) 0.0957 (0.0650, 0.1346) Alexander et al (2010) 0.0900 (0.0542, 0.1385) Coyne et al (2004) 0.0885 (0.0433, 0.1567) Kawase et al (2006) 0.0851 (0.0553, 0.1240) Walker et al (2007) 0.0831 (0.0568, 0.1165) Grassi et al (1993) 0.0828 (0.0448, 0.1374) Grassi et al (2009) 0.0826 (0.0385, 0.1510) Reuter and Hart (2001) 0.0761 (0.0422, 0.1244) Lee et al (1992) 0.0660 (0.0356, 0.1102) Pasacreta et al (1997) 0.0633 (0.0209, 0.1416) Sneeuw et al (1994) 0.0540 (0.0367, 0.0761) Singer et al (2008) 0.0519 (0.0300, 0.0830) Katz et al (2004) 0.0500 (0.0104, 0.1392) Mehnert et al (2007) 0.0472 (0.0175, 0.1000) Lansky et al (1985) 0.0455 (0.0291, 0.0676) Derogatis et al (1983) 0.0372 (0.0162, 0.0720) Hardman et al (1989) 0.0317 (0.0087, 0.0793) Massie and Holland (1987) 0.0147 (0.0063, 0.0287) Colon et al (1991) 0.0100 (0.0003, 0.0545) combined 0.1730 (0.1375, 0.2116) 0.0 0.3 0.6 0.9 proportion (95% confidence interval)
  8. 8. Prevalence of depression in Palliative settings24 studies involving 4007 individuals16.9% (95% CI = 13.2% to 20.3%) Proportion meta-analysis plot [random effects] Lloyd-Williams et al (2007) 0.30 (0.24, 0.36)14% major 9% minor adj 15% anx 10% Jen et al (2006) 0.27 (0.19, 0.36) Lloyd-Williams et al (2003) 0.27 (0.17, 0.39) Payne et al (2007) 0.26 (0.19, 0.33) Desai et al (1999) [late] 0.25 (0.10, 0.47) Hopwood et al (1991) 0.25 (0.16, 0.36) Lloyd-Williams et al (2001) 0.22 (0.14, 0.31) Minagawa et al (1996) 0.20 (0.11, 0.34) Meyer et al (2003) 0.20 (0.10, 0.35) Breitbart et al (2000) 0.18 (0.11, 0.28) Le Fevre et al (1999) 0.18 (0.10, 0.28) Chochinov et al (1994) 0.17 (0.11, 0.24) Kelly et al (2004) 0.14 (0.06, 0.26) Wilson et al (2007) 0.13 (0.10, 0.17) Chochinov et al (1997) 0.12 (0.08, 0.18) Wilson et al (2004) 0.12 (0.05, 0.22) Love et al (2004) 0.07 (0.04, 0.11) Kadan-Lottich et al (2005) 0.07 (0.04, 0.11) Akechi et al (2004) 0.07 (0.04, 0.11) Maguire et al (1999) 0.05 (0.01, 0.14) combined 0.17 (0.13, 0.21) 0.0 0.2 0.4 0.6 proportion (95% confidence interval)
  9. 9. 3500 Total prevalence Dep = 2 million in 20103000 Projected depression = 2.7 million in 20202500 Popn Orange Country2000 raw 000S1500 DISTRESS DEPRESSION1000500 0 in y er x ry ng t l h ck a s s as a te ia ta as ne vi gu ac om ru ra om va dd em ta Lu re ec ne er re te B id m ha os O la nc an ph or C nd B uk U K o B op Pr ol St Pa m el da Le C M Ly Es ea H => Who is helped?
  10. 10. …but is the prevalence of depression high in long term survivors? (3+ years)
  11. 11. Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size. 0.4 0.3Proportion 0.2 0.1 0.0 0 20 40 60 80 100 Time (months)
  12. 12. 12mo Service Use (NIH, 2002)40 34.635 32.7 Cancer n=4878 No Cancer n=90,7373025 19.120 % Receiving Any treatment for Mental Health % Receiving Any treatment for Mental Health 16.1 1415 11.7 11 8.910 7.7 7.2 6.5 5.7 5.7 5 6.3 6.4 6.2 55 3.9 3.2 2.3 1.80 l th l th ons nt s ti o n s s 75+ rs rs rs ti o n ti o n H ea H ea y ea y ea y ea atie d iti n di n di n di l Il l l Il l con 44 64 74 l co P l co l co Al l n ta nt a 18- 45- 65- di ca cal di ca di ca Me Me edi me me me No cm nic nic nic o ni hr o hr o hr o c hr 1c 2c 3c Two explanations=> No Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590
  13. 13. Two likely reasons…..
  14. 14. 94.2% 37.4% P Wang Harvard8 yrs N= 9282 NCS‐R In cancer?=>
  15. 15. 100.0 5.9 11.1 14.3 90.0 Comment: Slide illustrates diagnostic 21.4 accuracy according to score on DT 11.8 25.9 80.0 38.7 38.1 43.5 22.2 14.3 46.7 70.0 59.6 21.4 72.4 60.0 Judgement = Non-distressed 33.3 Judgement = Unclear 19.4 19.0 Judgement = Distressed 50.0 26.1 24.4 82.4 40.0 71.4 66.7 30.0 25.0 57.1 41.9 42.9 40.7 20.0 15.8 30.4 28.9 10.0 15.4 11.8 0.0 Zero One Two Three Four Five Six Seven Eight Nine Ten
  16. 16. Illness Pathways Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatmentIllness Lag Lag Lag Illness Lag LagBegins time time time time time Resolves years months weeks weeks days Symptoms Help Symptoms Referral Symptoms Treatment Occur Seeking Recognized Occurs Validated Occurs
  17. 17. Illness Pathways – Oncology Studies Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatmentIllness Lag Lag Lag Illness Lag LagBegins time time time time time Resolves years months weeks weeks days Symptoms Help Symptoms Referral Symptoms Treatment Occur Seeking Recognized Occurs Validated Occurs Fabida09 – Physical Symptoms & distress Baker-Glenn08 – Need for help in cancer Karr07 – Detection by cancer specialists Mitchell10 – Detection by nurse specialists Todd10 – RCT of PACT in cancer
  18. 18. Cancer in UKIncident Cancer Cases: 300,000+Prevalent Cancer Survivors 1-2 million estPrevalent Cancer Survivors with sig. Burden /yr 1 millionPrevalent Cancer Survivors with sig. Distress 1 millionPrevalent Cancer Survivors with clinical Depression 350,000
  19. 19. Depression Three D’sDysfunction Distress
  20. 20. Of the 293 Non-Nil DepT 23% 0.3% DepT 3% 2% 18% Dysfunction Distress 28% 26% 22%Dysfunction Distress 76% 69%
  21. 21. 100% 0.02 0.00 0.00 0.00 0.00 0.00 0.03 0.04 0.03 0.01 0.06 0.08 0.09 0.07 0.1790% 0.20 0.18 0.11 0.19 0.28 0.31 0.1880% 0.31 0.4770% 0.20 0.48 0.4060% 0.50 0.40 0.5350% 0.4540% 0.80 0.40 0.69 0.6230% 0.50 3=Extremely Difficult” 0.43 0.4120% 2=Very Difficult 0.32 0.33 0.27 0.2510% 1=Somewhat Difficult 0.20 Unimpaired 0% Zero One Tw o Three Four Five Six Seven Eight Nine Ten
  22. 22. Cancer #s in LeicesterIncident Cancer Cases: 3000Prevalent Cancer Survivors 12,500 estPrevalent Cancer Survivors with sign. Burden /yr 6,000Prevalent Cancer Survivors with sig Depression 2,000
  23. 23. Meeting Psychological Needs in Leicester FTE in Psycho-oncology ?
  24. 24. Psycho-oncology in LeicesterFTE in Psycho-oncology 3.0CNS in UHL 35UHL Ward Nurses, Chemo Nurses and Rx Radiographers 100CNS+McMillan+LOROS 70Oncologists and Haematologists and Palliative Consultants 15
  25. 25. Psychological DistressPool x Prev 10,000 x 50% => 5000 (distress/anxiety) 10,000 x 20% => 2000 (depression)Depression / Staff 2000 / 200 => 10 cases per staff member
  26. 26. DepT DT 23%37% 4% 3% 3% DT DepT 7% 1% Non-Nil 8% 0% Nil 9% 59% 41% 4% 1% AnxT 2% AngT 15% 2%AnxT AngT47% 18%
  27. 27. What is the Aim of Psycho-Oncology?1. Reduce distress & emotional disorders =>Desensitization by direct intervention2. Promote detection & treatment by cancer staff =>Screening3. Treat less common psychiatric disorders => delirium, dementia, psychosis, mania4. Promote Quality of life ⇒ Regardless of stage, age, cancer type of prognosis5. Do we influence survival? => Observations vs interventional studies
  28. 28. 0 10 20 30 40 50 60 70 80 Fa tig ue La Pa ck in of en er We gy ak Ap ne pe ss tite Ne l os rv o s us ne We ss ig h t lo Dr ss De ym p re ou ss th ed mo Co od ns tip ati on Wo rry ing In s om n ia Dy sp ne a Na us ea An xie Irr ty ita bil ity Blo atiCo ng gn Co itiv ug es h ym pto Ea ms rl y Ta sa s te tie ty ch an ge So re s mo Dr uth ow / sin es Ur s i na Ed ry em sy a mp tom Diz s zin es Dy s sp ha g ia Co nfu si o Bl n ee Ne d in ur g o lo Ho g ic ars al en es Dy s Sk sp in ep sy sia mp tom Self-Reported Symptoms in Cancer by Frq Di s arr he a Pr ur itu s Very Common Hic Uncommon Quite Common cu p
  29. 29. Top 10 patient concerns 1 Anxiety 312 2 Family concerns 157 3 Independence/Role 122 4 Appearance 111 5 Pain 86 6 Sleep 76 7 Fatigue/Energy 71 8 Finances 63 9 Weight 52 10 Breathing 49
  30. 30. Help SeekingDo patients always ask for help when needed?
  31. 31. % Receiving Any treatment for Depression 20 17.9 18 n=84,850 face-to-face interviews 16 15.4 13.8 14 12 11.3 10.9 10.9 10 8.8 8.1 8 7.2 6.8 6 5.6 5.5 4.3 4 3.4 2 0 SA in n ly na ca m l e a y ne ce e nd e s m bi pa an m It a a nd ra u hi i an U ai la Sp fr co om co gi Ja m Is C kr rla A a Fr el In er In Ze ol U h B he G w ut h C ew et ig Lo SoH N N Wang P et al (2007) Lancet 2007; 370: 841–50
  32. 32. % Receiving Any treatment for Mental Health Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-459040 34.635 32.7 Cancer n=4878 No Cancer n=90,7373025 19.120 16.1 1415 11.7 11 8.910 7.7 7.2 6.5 5.7 5.7 5 6.3 6.4 6.2 55 3.9 3.2 2.3 1.80 l th th ons n ns ns nt s 75+ rs rs rs diti o eal Hea diti o diti o y ea y ea y ea atie d iti Il l H con l Il l con con con 44 64 74 P l Al l n ta nt a 18- 45- 65- l di ca cal l l di ca di ca Me Me edi me me me No cm nic nic nic o ni hro hro hro c hr 1c 2c 3c No
  33. 33. 1093 (100%) Population 462 needs 462 (42%) 322 DSMIV Meetable Needs 17.3% 25% 388 (84%) Aware of Need 172 (44%) Requested Help 80 (47%) Needs Met
  34. 34. Illness InformationAre we providing necessary information promptly and appropriately?
  35. 35. Information DeliveryIn 196190% of US doctors indicated a preference for not telling a diagnosis of cancer.In 197997% indicated a preference for revealing a diagnosis of cancer. Novack DH, Plumer R, Smith RL, et al. Changes in physicians’ attitudes toward telling the cancer patient. JAMA 1979; 241: 897–900.
  36. 36. Trusted Sources of Information
  37. 37. Women’s Information PreferencesCheck with me that I understand what he/she is saying 99 1Give me an opportunity to ask questions 99 1Explain any medical terms 98 2Listen to my fears and concerns 97 3Summarize what he/she has told me 94 6Emphasize the good aspects of my prognosis 90 10Give me published information on my situation 88 12Tell me where I can go for additional emotional help 80 20Write down what he/she has told me 79 21Give me emotional support 79 21Talk to me about complementary therapies, 75 25Give me an audio tape of the discussion 28 72Check with me that I want to know my prognosis 63 37N=100 Early breast cancer Lobb et al (2000) Health Expectations, 4, pp.48±57
  38. 38. Disclosure of DiagnosisFamily wishesPalliative vs curative treatmentOverall prognosisNeed for compliancePatient “emotionally strong”Patient wishes to knowPatient is religiousPatient in youngerDiagnosis certain
  39. 39. Psychiatric DisordersWhat are the common psychiatric complications of cancer?
  40. 40. Brief Reactive Psychosis Psychosis Schizophrenia Mood Persistent Delusional DisorderUnipolar DepressionBipolar Affective Disorder Organic PsychosisAdjustment DisorderAnxiety DisordersPost-Partum Affective DisordersOrganic Affective Disorders Cognition Delirium Dementia Organic Amnesic Syndrome
  41. 41. DepressionCan we better understand depression in the context of cancer?
  42. 42. Two+ Key symptoms:• persistent sadness or low mood; and/or• loss of interests or pleasure• fatigue or low energy.Two+ associated symptoms:• disturbed sleep• poor concentration or indecisiveness• low self-confidence• poor or increased appetite• suicidal thoughts or acts• agitation or slowing of movements• guilt or self-blame.=> Mild 4/10 Moderate 6/10 Severe 8/10
  43. 43. Core Symptoms ICD10 DSMIVPersistent sadness or low mood Yes (core) Yes (core)Loss of interests or pleasure Yes (core) Yes (core)Fatigue or low energy Yes (core) YesDisturbed sleep Yes YesPoor concentration or Yes YesindecisivenessLow self-confidence Yes NoPoor or increased appetite Yes NoSuicidal thoughts or acts Yes YesAgitation or slowing of Yes YesmovementsGuilt or self-blame Yes YesSignificant change in weight No Yes
  44. 44. Lung (43%)BrainHodgkin’s diseasepancreaslymphomaliverhead and neckBreast (35%)leukaemiamelanomacolonprostategynaecological (29.6%) Zabora J, et al The prevalence of psychological distress by cancer site. Psycho-Oncology 2001;10(1):19 –28. n=4496,
  45. 45. Cancer Related Poor Quality of Life = Strong Pain = Moderate - Strong Later stage disease / poorer prognosis = moderate Greater uncertainty about the future = moderate greater disease burden / complications = weakNon-Cancer Related younger age = weak Lack social support = moderate Previous depression = moderate Additional difficulties = strong
  46. 46. Help!
  47. 47. 2x2 Help Table Clinician thinks: Clinician thinks: Help Needed Help Not Needed Patient Says: => Intervention => Refuse? Help Wanted Patient Says: => Delay =>Agree discharge Help Not Wanted
  48. 48. 2x2 Clinician Help Table : ACTUAL HELP Clinician thinks: Clinician thinks no Unmet Needs Unmet NeedsPatient Says: => Intervention => Low gradeHelp WantedPatient Distressed => Intervention =>??Patient Not => Monitor? => discharge?distressed orHelp Not Wanted
  49. 49. 2x2 Clinician Help Table : ACTUAL HELP Clinician thinks: Clinician thinks Unmet Needs no Unmet Needs Patient Says: Helped 1/3 Helped 1/2 Help Wanted Patient Helped 2/3 Helped 1/2 Distressed Patient Not Helped 1/4 Helped 1/6 distressed or Help Not Wanted
  50. 50. Help – Who Wants Help?20% said they wanted professional help for psychosocial issues.Only 36% of those distressed on the DT wanted help.
  51. 51. What Kind of Help is Wanted?19% wanted medication (eg antidepressants)31% want self help guidelines31% wanted group therapy56% wanted illness information.58% complementary therapies62% face-to-face psychological support
  52. 52. Help – Who From?Nurse specialists (54%)Family and friends (21%)Spiritual advisor (8%)Psychiatrist (4%).
  53. 53. Why Not Needed?“getting help elsewhere” (57%)“feel well” (41%)“coping on my own” (31%)“fear of stigma”, “fear of side effects”, “not likely to be effective for me”, and “don’t like to talk about problems” (all less than 10%)
  54. 54. Promoting recognition & treatment
  55. 55. Do Clinicians Look for Depression/Distress? Mitchell, Kaar, Coggan, Herdman (N=226)
  56. 56. A Form al QQMitchell, Kaar, Coggan, Herdman 6% N=226 Ultra-Short QQ 30% Refer to Specialist 1% Clinical Skills Alone 63%
  57. 57. Distress Thermometer – Pooled Proportion20.0% Insignificant Minim al Mild Moderate Severe18.0%16.0%14.0%12.0%10.0% 18 . 4 %8.0% 12 . 9 %6.0% 12 .3 % 11.9 % p124 11. 2 %4.0% 8 . 1% 7.7% 7.2 % 5.0 %2.0% 2 .8 % 2 .6 %0.0% Zero One Tw o Three Four Five Six Seven Eight Nine Ten 50%
  58. 58. 100.0 5.9 11.1 14.3 90.0 Comment: Slide illustrates diagnostic 21.4 accuracy according to score on DT 11.8 25.9 80.0 38.7 38.1 43.5 22.2 14.3 46.7 70.0 59.6 21.4 72.4 60.0 Judgement = Non-distressed 33.3 Judgement = Unclear 19.4 19.0 Judgement = Distressed 50.0 26.1 24.4 82.4 40.0 71.4 66.7 30.0 25.0 57.1 41.9 42.9 40.7 20.0 15.8 30.4 28.9 10.0 15.4 11.8 0.0 Zero One Two Three Four Five Six Seven Eight Nine Ten
  59. 59. Phase II

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