Monday 21st December 2015
Mac Voice, the magazine for Macmillan professionals: Winter 2015
There is strong evidence demonstrating the benefits of interventions with people who experience psychological distress, writes Janice Rees, in the second part of this Sharing Good Practice issue on psychological support.
Prevalence of psychological distress
Psychological distress occurs on a spectrum from mild to severe, the latter of which is known to have significant consequences. Neurobiological research is adding to knowledge that cancer and its treatment affect neuroimmune functioning, which can trigger emotional consequences – depression in particular – and thus altered mood. Whether the cause is biological or psychological, mood disturbance can be effectively treated once identified. The observation that for up to 73% of cancer patients with clinical depression, the depression goes untreated, should raise serious doubt that screening for distress is routinely undertaken in some services.
As already noted, the 2004 NICE guidance states that 25% of patients require targeted professional intervention to support distress associated with initial diagnosis. For the year following diagnosis, prevalence of symptoms requiring specialist interventions is 10%, and it is up to 15% in those suffering advanced disease.
NICE guidelines are supported by two key meta-analyses [4,5] showing a need for such targeted treatment of distress in up to 38.2% of patients. In a large cross-sectional study, 20,000 patients in a Scottish specialist cancer service were routinely screened for clinical depression.  This robust study indicated higher prevalence of depression than in the general population: 13.1% for lung cancer, 10.9% for gynaecological cancer, 9.3% for breast, 7% for colorectal, and 5.6% for genitor-urinary cancers.
Greater vulnerability to depression was observed for younger patients, those in greater social deprivation, and women. Despair, depression, feelings of hopelessness, lack of social support, and anxiety all suggest a higher vulnerability to suicidal feelings and actual self-harm. Cancer patients are at an increased risk of taking their own lives compared to the general population.
A US study suggests cancer is the only health condition significantly associated with suicide: between 8.5% and 12% of patients experienced thoughts of self-harm or desire for death. An effective psychological care pathway is essential to enable good screening and multi-disciplinary management of self-harm risk, requiring advanced communication skills in staff, and including a crisis response process which guides the care of patients at risk of self-harm and suicide.
Consequences and costs of distress
A recent Macmillan report into developing adult psychological services in cancer care provides an excellent summary of research in this area, suggesting that additional costs to the NHS for all long-term conditions including cancer fall between £8 and £13 billion.
Emotional distress and mood disorders have implicit or knock-on financial costs as well as direct costs. These include poorer treatment adherence, reduced pain and symptom tolerance, higher mortality, reduced immunity through the effect of psychological stress, poorer levels of functioning, amplification of physical symptoms, and impact on carers. Without appropriate psychological intervention, these can result in increased use of healthcare resources such as contacts with CNSs, and GP and emergency visits.[8,9]
Examples include conditions such as needle phobia, or eating phobias, which may occur during treatment for head and neck cancer or when suffering nausea during other treatments.
Although rare, these difficulties may result in treatment refusal and enormous distress. They can interfere significantly with recovery and morbidity, and thus result in more complicated treatment with associated costs.
Economic benefits of psychological services at all levels of the NICE guidance Estimates of cost benefits suggest savings up to 20% when psychological services and holistic psychologically-informed care pathways exist within cancer care.
In addition to the benefits of direct psychological interventions with individuals or groups of patients, some benefit also derives from enhanced staff skills as a result of psychological consultation and training, and the positive effects on patient care when staff feel fully emotionally and psychologically supported.
Clinical effectiveness of interventions at levels one and two
There is growing evidence of effectiveness of interventions at all levels which include a range of types of interventions, delivered by staff with varying specialist skills. A recent Cochrane review looked at psychological interventions, mainly at levels one and two. No changes in depression or anxiety were observed, but small improvements in general psychological distress levels were noted for newly-diagnosed people. Participants were not screened for distress and were thus a mixed group. For patients with haematological malignancies, stem cell transplantation is a particularly burdensome treatment with considerable psychological consequences, including post-traumatic symptoms in up to 25% of patients.
A review of 11 studies with transplant patients showed a small but beneficial effect of interventions including cognitive behavioural therapy (CBT), with maintenance of this effect up to a year post-transplant. The most effective interventions were those with a substantial psychological component.
Clinical effectiveness of interventions at levels three and four
In order to deliver effective interventions targeted at those with high levels of distress, screening with tools such as a holistic needs assessment is crucial. When referred to clinical psychologists, patients are offered targeted psychological therapies which have a strong evidence base in mental health settings and for a range of other health conditions.
Psychological treatments for phobias have long been known to be particularly effective, and such treatments will have a major impact on patients whose anxieties and phobias interfere with completing treatment. Evidence of a positive effect on depression has been noted for CBT, relaxation and stress management, behavioural activation, couple and family systemic therapy, and a range of psychotherapies in palliative care.
Effects were observed at early, mid and palliative stages. The section on Acceptance and Commitment Therapy (ACT) will review the evidence for this particular therapy.
Documents published by the London Cancer Alliance  and Macmillan  give guidance for professionals seeking to establish these services where they do not already exist, and provide advice on how they can interface with multidisciplinary team work.
1 Musselman DL, Miller AH et al. Biology of Depression and Cytokines in Cancer. In Kissane DW et al (eds). Depression and Cancer. 2011. Wiley-Blackwell.
2 Walker J, Holm Hansen C et al. Prevalence, associations, and adequacy of treatment of major depression in patients with cancer. Lancet Psychiatry. 2014: 1(5), 343–350.
3 NICE. Improving Supportive and Palliative Care for Adults with Cancer, the Manual. 2004.
4 Mitchell AJ, Chan M et al. Prevalence of depression, anxiety and adjustment disorder in oncological, haematological and palliative-care settings. Lancet Oncology. 2011: 12: 160-74.
5 Walker J, Holm Hansen C, Martin P et al. Prevalence of depression in adults with cancer: a systematic review. Annals of Oncology 2013: 24 (4): 895-900.
6 Breitbart W, Pessin H and Kolva E. Suicide and desire for hastened death in people with cancer. In Depression and Cancer (see ref 1).
7 Schairer C, Morris Brown L et al. Suicide after Breast Cancer: an International Population-Based Study of 723,810 Women. Journal of the National Cancer Institute. 2006. 98 (19): 1416-1419.
8 Baliousis M, Rennoldson M, Snowden JA. Psychological interventions for distress in adults undergoing haematopoietic stem cell transplantation. Psycho-Oncology. 2015; Wiley online. DOI 10.1002/pon.3925.
9 DiMatteo MR, Haskard-Zolnierek KB. Impact of depression on treatment adherence and survival from cancer. In Depression and Cancer (see ref 1).
10 Highfield J. Developing adult professional psychology services for oncology. 2015. Macmillan Cancer Support.
11 Carlson LE and Bultz BD. Efficacy and medical cost offset of psychosocial interventions in cancer care: making the case for economic analyses. Psycho-Oncology 2004. 13: 837-849.
12 Galway K, Black A et al. Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients. Cochrane Database Systematic Review. Wiley. 2012.
13 Kissane DW, Levin T et al. Psychotherapy for depression in cancer and palliative care. In ref 1.
14 London Cancer Alliance. Developing a mental health and psychological support services pathway for adults. 2014
Email Janice Rees.
Continue reading Sharing Good Practice
Part 1: Psychological support - Dr Anne Johnson, Macmillan Consultant Clinical Psychologist, Velindre Cancer Centre.
Part 2: Evidence base - Janice Rees, Macmillan Consultant Clinical Psychologist, Cardiff and Vale University Health Board.
Part 3: Acceptance and Commitment Therapy - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 4: Helping parents with cancer support their children - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 5: How a clinical psychologist can support shared decision-making - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 6: Psychological supervision for staff - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 7: Extend your psychological support skills - Resources and training for professionals.