1. The Christie NHS Foundation Trust Supporting the patient and accessing support services Suzanne Mc Keever Nurse Specialist Psycho-Oncology

2. The Christie NHS Foundation Trust Objectives Raise awareness of NICE guidance Raise awareness of incidence of psychological morbidity Consider risk factors for depression Responding appropriately

3. The Christie NHS Foundation Trust Emotional impact of diagnosis Fear Distress Uncertainty Loss of control Anger

4. The Christie NHS Foundation Trust NICE Guidelines 2004 Level groupassessmentintervention 1All health and social care professionals Recognition of psychological needs Effective information giving, compassionate communication and general psychological support 2 Health and social care professionals with additional expertise ( e.g. clinical nurse specialists, GPs) Screening for psychological distress Psychological techniques such as problem solving 3Trained and accredited professionals Assessment of psychological distress and diagnosis of some psychopathology Counselling and specific psychological interventions such as anxiety management and solution focused therapy, delivered according to a specific psychological framework 4Mental health specialists Diagnosis of psychopathology Specialist psychological and psychiatric interventions such as psychotherapy, including cognitive behavioural therapy

5. The Christie NHS Foundation Trust Psychological morbidity – prevalence and recognition in cancer 9-58% of cancer patients develop an affective disorder requiring intervention Fallowfield et al 2001, Massie et al 2004; Burgess et al 2005 Oncologists fail to identify majority (60-100%) of patients with probable psychiatric morbidity Sharpe et al 2004; Parle et al 2001 Less than half of those patients recognised as depressed are treated Fallowfield et al 2001; Lloyd-Williams and Freidman 2001; Passik et al 1998

6. The Christie NHS Foundation Trust Psychological Morbidity 1 in 10 patients will suffer psychological distress severe enough to warrant specialist psychological/ psychiatric services (level 4), as will 10 to 15% of patients with advanced/ terminal disease 15% of patients will require level 3 service Patients and relatives should be assessed at key points along the patient pathway

7. The Christie NHS Foundation Trust Can we tell who will get depressed ?

8. The Christie NHS Foundation Trust Illness-related Concerns Number and severity of patients’ concerns predicts High levels of emotional distress Affective disorder Weisman & Worden 1977, Harrison et al 1994 Parle et al 1996 Yet up to 60% of concerns remain undisclosed in hospice setting Heaven & Maguire 1996 80% concerns remain undisclosed in inpatient setting Farrell et al 2005

9. The Christie NHS Foundation Trust Tailoring information Patients who feel they are given inadequate information (too little or too much) at time of diagnosis are at greater risk of affective disorders Fallowfield et al 1990, Butow et al 1995 Schofield et al 2003 History of depression

10. The Christie NHS Foundation Trust Shared decision making Associated with increased compliance with treatment, more favourable outcomes and greater satisfaction Eisenthal et al1979; Schulman 1979; Brody et al 1989 Approx 33% newly diagnosed patients fail to achieve their desire level of involvement Gattellari et al 2001

11. The Christie NHS Foundation Trust What is depression? Definition A condition characterised by persistent low mood, the absence of a positive affect (loss of interest and enjoyment in ordinary things and experiences) and a range of associated, cognitive physical and behavioural symptoms. NHS Clinical Knowledge Summaries 2010

12. The Christie NHS Foundation Trust What is depression? Defining characteristics 1.Depressed mood 2.Loss of interest or pleasure 3.Significant weight loss/increased appetite 4.Insomnia or hypersomnia 5.Psychomotor agitation or retardation 6.Fatigue or loss of energy 7.Feelings of worthlessness or excessive or inappropriate guilt 8.Diminished ability to think or concentrate or indecisiveness 9.Recurrent thoughts of death

13. The Christie NHS Foundation Trust Making a diagnosis Symptoms 1 or 2 must be present 5 or more of the symptoms must be present Present for most of the day for at least 2 weeks Represents a change from previous functioning

14. The Christie NHS Foundation Trust How do we identify patients with depression During the last month have you often been bothered by: −feeling down, depressed or hopeless? −having little interest or pleasure in doing things?

15. The Christie NHS Foundation Trust How do we identify patients with depression If yes: Requires a mental health assessment If not competent in mental health assessment refer on to an appropriate professional consider GP, specialist mental health services.

16. The Christie NHS Foundation Trust How do we identify patients with depression Consider using a screening tool Hospital Anxiety and Depression Scale (HADS) PHQ-9

17. The Christie NHS Foundation Trust Suicide Risk Not asking is not an option Need to find out the extent of the suicidal thoughts If the patient presents a considerable immediate risk refer them urgently to specialist mental health services Get advice – GP, specialist mental health services

18. The Christie NHS Foundation Trust Why is it so difficult ?

19. The Christie NHS Foundation Trust Concerns about impact on patient Uncontrollably upset Angry and shout Run out of the room Refuse treatment Go silent Start asking difficult questions That we may make things worse

20. The Christie NHS Foundation Trust Concerns for ourselves… Taking up too much time Coping with our own emotions I won’t know what to do about the problems raised I may not be able to manage the emotions /problems expressed Wanting to avoid problems that I can’t change & focus on those I can help with I have no support for myself I have no-one to refer on to

21. The Christie NHS Foundation Trust Key messages Psychological care is everyone’s business ‘How might this person be feeling’ and how will that influence our interaction Ask about concerns Ask about previous history of depression Think ‘what can I do to help’? Be confident in suggesting support

22. The Christie NHS Foundation Trust