0 1997 Martin Dunitz Ltd InternationalJournal of Psychiatry in Clinical Practice 1997 Volume 1 Pages 189- 195 189

Psycho-oncology and the role of the psychiatrist in cancer patient care

JENNIFER E BARRACLOUGH Consultant in Psychological Medicine, Oxford Radclfle NHS Trust

Correspondence Address Dr JE Barraclough, Sobell House, Churchill Hospital, Oxford OX3 7LJ, UK Tel: 01865 225860f62193 Fax: 01 865 225599

Received 14 March 1997; accepted for publication 29 April 1997

Cancer and its treatment lead to emotional distress for most patients and their families, and to psychiatric illness for some. Psychiatrists can contribute to the prevention, recognition and treatment of these problems. Educational and supportive group work, for both patients and stafl, complements the assessment and management of individually referred cases. Psychiatrists in this setting require a good understanding of medical matters, and good working relationships with colleagues both in cancer services and mental health services. The nature of the clinical work will be illustrated by case vignettes. (Int J Psych Clin Prac 1997; 1: 189- 195)

Keywords neoplasms

INTRODUCTION

sycho-oncology is concerned with relationships P between cancer and the mind.’ The subject may be considered as having two separate but intertwining branches:

The prevention, recognition and management of emo- tional distress, psychological symptoms and psychiatric disorder secondary to the diagnosis and treatment of cancer. This aspect, with its direct relevance to clinical practice, will form the main subject matter of this article. Similar principles apply to serious medical illnesses other than cancer. Investigation into whether the onset or outcome of cancer is influenced by psychological factors such as personality characteristics, attitude towards illness and coping style. This interesting and important aspect is complex, and research findings are conflicting;* it will not be considered in detail here. The prevalence of psychiatric disorder in cancer

patient populations is between 23% and 47Oh.l The main diagnostic groupings are adjustment disorders, anxiety, depression and organic mental disorders. Most cases appear reactive to stresses caused by the cancer (Table 1). These stresses are likely to be most numerous and severe for patients with advanced and terminal disease, but can also be prominent for some early-stage cases under radical treatment regimes.

Most cancer patients are able to cope through their own personality resources and social networks but benefit from information and professional support. Many (about 50%) at

psychiatry psychology

some stage experience emotional adjustment reactions which can be helped by skilled counselling, individually or in groups. Some (at least 10%) have more persistent and/or severe disorders meriting psychiatric referral. Problems may also affect relatives and healthcare staff.

Recent national reports have affirmed the need for psychosocial support for cancer patients and their carer^,^ and liaison psychiatry services for those with established d i~orde r .~ Although several authors have described service

there remains scope for discussion about how the contribution of psychiatrists and other mental health professionals - the ‘specialist psycho-oncologists’ - can best

Table 1 Stresses associated with cancer and its treatment

0 Diagnosis of a life-threatening condition in which long-term prognosis is frequently uncertain

0 Physical symptoms such as pain and nausea 0 Unwanted effects of treatment with surgery,

0 Loss of functional capacity; loss of independence,

0 Practical issues: finance, work, housing 0 Relationship changes; concern for dependents 0 Body image changes 0 Sexual dysfunction; infertility 0 Biological impairments of brain function (e.g. effects

radiotherapy, chemotherapy

enforced changes in role

of brain tumours, corticosteroids, metabolic derangement)

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190 JE Barraclough

be integrated with that of general hospital staff in oncology and palliative care units, the primary healthcare team, complementary practitioners, self-help groups and volun- teers. Whatever exact model is chosen, the nature of this work demands a multiprofessional approach in which the overlapping contributions of different disciplines, including psychiatry, are well co-ordinated so that they complement each other rather than lead to duplication or rivalry. As in all fields of healthcare, there is a need to plan services so that they will be effective, and in accordance with patients’ own views.

Much of the material in this paper is based on my own experience as Director of Psycho-oncology in the Cancer Clinical Centre of the Oxford Radcliffe NHS Trust. Before describing the activities of a specialized psycho-oncology service, I shall outline some general issues relevant to the psychological care of the cancer patient population as a whole.

PSYCHOLOGICAL ASPECTS OF THE MEDICAL MANAGEMENT OF CANCER Many aspects of psychological care can and should be integrated with medical care, and provided by the same staff. Certain basic requirements apply for all patients with cancer (Table 2). Some of the items listed might seem too obvious to need stating, and are clearly not within the direct province of the psychiatrist. Yet many cancer patients are unhappy about the way these matters were handled in the early stages of their illness, and it is not unusual for those referred to psycho-oncology to ascribe their problems to an unsatisfactory ‘bad news interview’ which has had enduring psychological ill-effects. In some specialized psycho-oncology units, formal educational programmes to enhance the psychological skills of general hospital staff have been developed and evaluated.’ Ways of approaching these tasks on a more modest scale will be discussed later in this paper.

In most parts of the country, even if there is no specialized psycho-oncology service, a number of different sources of psychosocial care are available to cancer patients and their families. 1. The primary healthcare team, having long-term knowl-

edge of and responsibility for both patient and family, plays a central role both in providing psychological care directly, and co-ordinating additional care from other sources.

2. Clinical staff within hospital-based cancer services all have some psychological aspect to their role, and this is especially so for certain professional groups such as clinical nurse specialists, social workers, occupational therapists and chaplains. Clinical nurse specialists, for example breast care nurses and Macmillan nurses, combine the psychological support of patients and families with advising on practical aspects of care, and their role has been well studied in psycho-oncology.’

Table 2 Basic principles of good psychological care

0 Prompt skilled diagnosis and treatment of the

0 Honest communication, empathic ‘breaking bad

0 Access to information in appropriate format and

0 Continuity of care 0 Being treated with dignity, courtesy, privacy

Opportunities to express feelings and concerns and

physical illness

news’

timing

ask questions

Clinical nurse specialist follow-up does not necessarily prevent psychiatric disorders from developing, but it can certainly permit their earlier recognition and referral for specialized treatment. Most patients are very willing to be referred to such nurses, and highly appreciative of the service they provide. Self-help groups, often meeting away from the hospital setting, offer peer support in a format which depends very much on the orientation of the local organizers. Such groups are obviously difficult to evaluate; only a minority of patients choose to attend them. Complementary and creative approaches such as aromatherapy, art therapy and music therapy are now widely used in NHS cancer treatment settings. They are popular with patients, and their psychological benefits are currently being researched. They are, of course, different from psycho-oncology as practised by mental health professionals; some of those who are planning and purchasing psychosocial suppport services for cancer patients need to be advised of this difference if they are not to consider the two interchangeable.

SPECIALIZED PSYCHOLOGICAL PROGRAMMES; PREVENTIVE COUNSELLING AND GROUPS Psychological interventions, offered on an individual or group basis as adjuncts to the medical care of recently- diagnosed cancer patients, have now been evaluated in many controlled Most research has focused on the prevention of distress and enhancement of coping, as opposed to the treatment of established psychological and psychiatric disorders, though this distinction is not always made clear-cut. There is evidence that psychological interventions can improve patients’ quality of life according to such measures as emotional adjustment, mood state, coping skills, functional status, and control of medical symptoms. A few studies have also reported longer physical survival for patients who attend groups; replication studies, with exploration of the mechanisms involved, are in progress.

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Psycho-oncology 191

There are few direct comparisons between group therapy and individual therapy, but for most patients group interventions can be recommended as being more cost-effective than individual ones, and in some respects more powerful. Cunningham,” writing about groups, distinguishes a hierarchy of five types of intervention, each demanding progressively more active involvement and commitment to change from those who attend. They are: 1. Providing information; 2. Emotional support (‘supportive-expressive’ model); 3. Training in coping skills; this might include stress

management, relaxation, visualization, and other beha- viouraVcognitive techniques;

4. Psychotherapy to promote increased self-understanding; 5. SpirituaVexistential therapy to promote discovery of

meaning in the illness and experience of a transcendent order. Other authors refer to ‘psycho-educational’ groups;

these would combine information-giving with training in coping skills. The psycho-educational model appears to achieve more measurable benefit than the supportive - expressive one alone. However, different types of groups suit different patients, depending on their personality characteristics and the stage of their disease.

Some authorities recommend that psychological inter- ventions should form an integrated part of all cancer patients’ management.” Others consider that not all patients want or need such intervention, and have argued for a more selective approach which relies on early detection of cases or targetting those at high risk. However, it is not clear that the sensitivity and specificity of selective approaches are sufficient to justify the extra work involved, and these approaches tend to ignore the key factor of patient motivation. Many cancer patients claim to want more psychological support; there is research evidence for its benefits; and most of its recipients are appreciative. But it has been the experience in many centres that few patients come forward in response to leaflets and posters. Recruit- ment can be improved through personal recommendation from an oncology doctor or nurse.

These approaches are not, however, appropriate for everyone. Adverse effects may follow when patients have been persuaded to take part against their real wishes, or before they are ready to do so. Those who are either very anxious already, or had been keeping anxiety at bay through denial, may become upset if prematurely made to confront the realities of their plight.

The psychiatrist who takes some direct part in running preventive groups is brought into contact with a wider population of cancer patients than merely those referred for psychiatric care. This contact can prove most valuable in the planning and supervision of colleagues who are counselling individual patients or leading preventive groups. For example, the leader of an educational group discussing diet and cancer is unlikely to have any training in mental health issues, yet may well be faced with the undue dominance of one group member, scapegoating, or

breaching of confidentiality boundaries. Regarding indivi- dual counselling, most counsellors working in cancer treatment settings are now much better trained than in the past, but it may still be the case that some of them have had little specific preparation for their role, and are working in professional isolation. Problems which might arise if there is no adequate supervision include failure to recognize depressive illness or other mental disorders likely to require drug treatment; failure to recognize organic mental disorders; embarking on long-term in-depth therapy with a few selected patients rather than brief focused contacts with a larger number; and excessive personal involvement. Some patients attending for individual counselling or groups will be found to have problems meriting onward referral to the psychiatrist.

ASSESSMENT AND MANAGEMENT OF PATIENTS REFERRED TO PSYCHO- ONCOLOGY Some clinical problems which commonly prompt referral to the specialized psycho-oncology service are listed in Table 3. Diagnostic assessment needs to take account of both medical and psychiatric aspects and sometimes the two cannot be clearly disentangled, for example when depres- sive symptoms are indistinguishable from those of physical d’ isease.

The therapeutic function of the assessment interview, which can give patients an opportunity to review their illness in the wider context of their lives, to ventilate emotions and begin reframing problems, is particularly important in a setting where limited life expectancy sometimes precludes extended follow-up.

As regards specific treatments, controlled trials have demonstrated that antidepressant drugs for depre~sion’~ and cognitive-behavioural therapy for anxiety and depre~sion’~ are effective. In clinical practice, individual cases may be complex and often demand an eclectic approach to their management; psychotropic drug treatment and/or brief

Table 3 Problems which may present to the psycho-oncologist

0 Anxiety 0 Depression 0 Confused, excited, psychotic or paranoid states 0 Pain or other somatic symptoms which are difficult

0 Inability to accept or adapt to having cancer, often

0 Suicidal feelings and behaviour 0 Sexual disorders 0 Problems in relationships with relatives or staff 0 Complex bereavement reactions

to control

manifest as anger or denial

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192 JE Barraclough

psychotherapy can be combined with more general measures implemented in co-operation with the oncology team.

A comprehensive account of the management of individual psychiatric disorders co-existing with cancer is beyond the scope of this article, but case vignettes illustrating some different clinical scenarios are given in the Appendix.

DETECTION OF CASES AND MECHANISMS OF REFERRAL There are no simple answers to the questions of what should be the criteria for referral to psycho-oncology services, and how staff can tell which patients fulfil these.

In most units the trend is one of under-referral. Leaving aside the minority with an obvious severe disturbance, patients may not be recognized as having a psychiatric disorder because they conceal emotional complaints or present them as somatic symptoms, and because staff are too busy or too embarrassed to ask about emotional issues. Other cases are recognized but not referred, perhaps because emotional distress is assumed to be inevitable and untreatable, or, less often, because of a possessive attitude on the part of dedicated staff who are personally involved.

The opposite problem is that of over-referral, which cames the disadvantages of attaching a psychiatric label to normal adjustment processes, undermining patients’ own coping resources, and enabling medical staff who are not psychologically minded to avoid the basic counselling and communication which should be part of their own skills.

Self-rating questionnaires such as the HAD scale,’* administered to all patients at intervals, should theoreti- cally detect most psychiatric cases, but comprehensive screening programmes are difficult to sustain outside research settings. In clinical practice, training general hospital staff to recognise affected patients at interview is probably a better approach, and clinical nurse specialists are particularly well placed to monitor their patients for development of psychiatric symptoms.

In team-work settings where many staff members contribute to each patient’s care with some overlap of roles, there can be issues about who should initiate a referral to psycho-oncology and who else should be consulted first. Local guidelines can be developed in regular discussion with colleagues. Some patients will request a psycho-oncology consultation themselves if they know a service is available, but the articulate and psychologically-minded patients most likely to come forward may not be the ones in greatest need. Most referrals are in practice initiated by staff, although only in the most exceptional circumstances should a referral be made without the patient’s own knowledge and consent.

Feedback regarding individual referrals, besides being important for management of those particular cases, has a role in staff education and support, even though issues of

confidentiality may limit disclosure of detailed psychosocial information. For patients perceived as particularly difficult, meetings with staff enable them to ventilate their own feelings and agree on a consistent management plan, including realistic practical goals.

STAFF TRAINING AND SUPPORT Whereas only selected cancer patients will be seen personally by the psycho-oncology service, all cancer patients encounter the medical and nursing staff, and the psychological impact of these consultations is often profound even if not intended. To enhance the psycholo- gical skills of general hospital staff is therefore an important aim for a specialized psycho-oncology service.

Educational programmes can help both students and qualified staff to improve their skills, for example, in breaking bad news and communicating with patients and relatives, and in recognizing patients who could benefit from specialized referral. Such programmes are of course not the prerogative of psycho-oncology. Teaching and training should start at the undergraduate stage, and continue for qualified staff, including those at senior level. Formats might include talks or case presentations, small group seminars to discuss a particular patient or problem issue, and opportunities for individual supervision.

Individual discussions with colleagues may be consid- ered in certain cases-for example, if a patient seen for psychiatric consultation reports distress over the way the cancer diagnosis was given-but are not always feasible or helpful. Such situations clearly require sensitive handling, and it is certainly unwise and unproductive for the psycho- oncologist to collude with the patient in blaming medical staff, because the patient’s version of what happened may be coloured by projection of distress about the illness itself.

Informal interaction with colleagues, including those who do not come to training sessions, can best take place if psycho-oncologists become integrated with the rest of the cancer unit by sharing the same building, attending medical rounds or meetings, and talking to colleagues over lunch. Such practices facilitate mutual education and good working relationships, and help reduce stigma about psychological issues.

Working with cancer patients raises a number of psychological challenges and stresses for staff themselves (Table 4). Emotional distress and ‘bum-out’ affect some doctors and nurses working in oncology and palliative

though the problem is probably no more wide- spread than in many other healthcare settings. Attention to practical organizational issues - for example, reduction of excessive workloads - may be the most effective way to prevent and relieve staff stress, but the psycho-oncologist may be asked to advise regarding psychological aspects. Designated ‘staff support groups’ are no panacea for this purpose. Although some such groups prove very success- ful, others flounder because of low attendance, an absence

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Psycho-oncology 193

Table 4 Issues for staff working in oncology

0 Communicating with patients and carers: breaking bad news, explaining technical issues and management options

responses Eliciting patients’ concerns and offering appropriate

Responding to patients’karers’ sadness or anger 0 Prescribing medical treatments which may have

adverse effects or fail to work; decisions about continuation of treatment such as chemotherapy

0 Extent of personal involvement; dealing with own grief when patients deteriorate or die

0 Personal parallels; cancer in friend, relative or self 0 Colleagues; difficulties in communication, overlap of

clinical roles

of clear aims and boundaries, or being perceived as stressful in themselves. Other approaches may be less threatening and more helpful. The skills imparted through educational groups for staff, such as communication training work- shops, can enable those attending to reduce stress for themselves as well as for their patients. If a favourable group atmosphere can be achieved, much staff support can actually take place within the session itself.

CONCLUSION The existence of a psycho-oncology service may well bring benefits for staff morale and patient care even when it is not being used directly. Colleagues feel more confident in discussing psychological matters with their patients if they know that specialized advice can easily be obtained at short notice. Such observations highlight that the measurable activities of a psycho-oncology service, namely seeing individual patients and running groups, are part of a broader remit of enhancing psychological care in the medical setting.

APPENDIX: CASE EXAMPLES Some minor details have been altered to preserve confidentiality.

CASE 1 : DEPRESSION PRECIPITATED BY DIAGNOSIS OF EARLY BREAST CANCER

A woman in her 50s was referred 2 days after surgery for node-positive breast cancer. Ward staff had observed her to be agitated and tearful to an unusual degree. She had a history of one previous depressive episode which had responded to outpatient drug treatment. At the assessment interview she expressed much appropriate feeling, and

appeared to be showing an acute depressive adjustment reaction to the cancer diagnosis. Because such reactions often resolve within a few weeks, and the patient was well supported by her husband and the breast care nurses, arrangements were made to review her 10 days later rather than initiate antidepressant drug treatment immediately. However, when she next came her depression was worse, and her GP had prescribed fluoxetine 20 mg daily. She had also been recommended to start a course of adjuvant chemotherapy and, though dreading this treatment, ex- pressed determination to see it through; it was notable that though severely depressed, she was not hopeless or suicidal. The chemotherapy regime proved in her case to have marked unwanted effects of nausea and neutropenia. Over the next several weeks she remained unwell, with marked anorexia and weight loss, anergia and fears of leaving her home. It was hard to tell whether the depression or the chemotherapy was responsible for these symptoms: probably a mixture of both. She was managed by frequent review by the psychiatrist, the oncology team and the primary care team. Fluoxetine was increased to 40 mg daily. She was encouraged to follow a simple programme of scheduling pleasant activities every day. On this regime she began to improve and by the end of the 6-month chemotherapy course was fully recovered.

CASE 2: DEPRESSION ASSOCIATED WITH A BRAIN TUMOUR

A woman in her 40s had received a radical course of radiotherapy to her brain for treatment of a malignant glioma of the left temporal lobe. Four weeks later she presented with severe agitation and tearfulness, continually asking for ‘an injection to make me better’. She appeared severely depressed, and her poor cognitive function was confirmed by a low score on the Mini Mental State Examination. Several factors were thought to be contributing to her condition: pre-existing vulnerability to mood disorder as evidenced by a past history of post-natal depression, the psychological trauma of the medical diagnosis, biological effects of the brain tumour, after- effects of the radiotherapy, and corticosteroid medication (dexamethasone). Her family’s exhaustion promoted her admission to the palliative care ward for symptom control. Sertraline 50 mg daily had already been given for 4 weeks with no benefit, and her antidepressant was changed to amitripty- line 50 mg at night, with thioridazine 25 mg to relieve day- time agitation. Within a week she was well enough to be discharged home, with attendance at the palliative care day centre. Six months later, she continued to show marked impairment of short-term memory, but her mood was greatly improved and she was able to enjoy taking part in a wide range of supervised activities.

CASE 3: ANXIETY ASSOCIATED WITH RADIATION THERAPY

A man in his 40s was due to start a course of radical radiotherapy for prostate cancer. From a rational viewpoint he

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wanted to have this treatment, but doubted his ability to tolerate it because the idea of lying underneath the radio- therapy machine brought back traumatic memories of being trapped in a wrecked car some years earlier, following which he had been under psychiatric care with symptoms of post- traumatic stress disorder. A treatment plan was prepared in collaboration with the patient and a radiographer. This included gradual introduction to the radiotherapy machine with a mock treatment before the real course started, use of a relaxation tape to be played before and during each treatment, an agreement that one of a few familiar staff would treat him each time, and availability of 5 mg diazepam to take before each treatment if he wished. After 2 weeks’ delay in starting the course, he was able to complete it successfully, having needed the diazepam only twice.

CASE 4: SUICIDAL RISK WITH ANTICIPATED BEREAVEMENT A man in his 30s, husband of a young woman suffering from advanced cancer, was referred as an emergency through the ward where his wife was staying. He appeared acutely distressed and was talking about suicide. In his personal background there had been a number of significant previous losses, and he was alone at home. He had been using alcohol in an attempt to deal with his feelings of tension and anger, and often got involved in violent incidents when drunk. A diagnosis of depressive adjustment reaction, against a back- ground of personality and social problems, was made. His risk of impulsive suicidal behaviour was considered very real, but insufficient to justify psychiatric admission. He experienced marked relief from talking, and willingly agreed to approxi- mately twice-weekly follow-up, shared between the psychia- trist, the Macmillan nurse involved with his wife, and a community psychiatric nurse from his local mental health team. Psychotropic drugs did not seem indicated, especially in view of the danger of overdose. He attended regularly for the planned sessions, in which the opportunity to ventilate his feelings was combined with practical guidance, such as encouragement to resume an exercise programme rather than visiting the pub. Meanwhile his wife’s condition stabilized sufficiently for her to be discharged, both partners having expressed the wish that she should die at home. With support from the district nurse and the Macmillan nurse, this man fulfilled his undertaking to care for his wife until she died some 3 months later. Despite all his anticipatory grieving, he became acutely and deeply distressed for several weeks after her death. However he was no longer despairing or suicidal,

REFERENCES

and was soon able to return to work and make plans for the future.

CASE 5: THE HOLISTIC APPROACH TO CARE IN ADVANCED CANCER A woman in her 60s with advanced ovarian cancer was on the palliative care ward for 2 weeks’ respite care. She said that she had recently made a conscious decision to resign herself to dying, and therefore declined further chemotherapy, put all her affairs in order, sold her house and moved in with one of her children; now she felt ‘in limbo’. She presented as an articulate woman who was ambulant, well-nourished, and not clinically depressed. She agreed that she might have several weeks or even months still left to live, and would explore possible ways of making this time more worthwhile. Both medical and psychological contributors to fatigue were addressed during her admission. On the medical side, she was found to be anaemic and received a blood transfusion, and it proved possible to reduce her medication (including analgesic and antihypertensive drugs). On the psychological side, it transpired from the assessment interview that she had enjoyed writing in the past, and this discussion stimulated her to write a number of short poems during her inpatient stay. She also took advantage of various discussion groups and complementary therapies available through the day centre, and talked with the hospital chaplain on several occasions. These interventions were accompanied by a rapid improve- ment in her mood and energy and 2 weeks later, although continuing to show a realistic acceptance of her condition, she said “I’m no longer in dying mode”.

KEY POINTS 0 Between 2347% of cancer patients have some

form of comorbid psychiaric disorder 0 Psychological interventions can improve mood

status, coping skills and control of medical symptoms

0 Antidepressant drugs have proven value is the treatment of cancer patients with comorbid depression

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