Psychological Distress Can Be Predicted Early in Cancer Patients

In a preliminary analysis of a study of more than 800 patientswith early-stage cancer, researchers found that those who gavea negative self-appraisal of their situation and their abilityto cope were more likely to develop affective disorders duringthe course of their treatment. Peter Maguire, MD, reported theresults in his keynote lecture at the annual American Societyfor Psychiatric Oncology/AIDS meeting.

Dr. Maguire, who has written extensively on doctor-patient communications,is Director, Cancer Research Campaign Psychological Medicine Group,and Honorary Consultant Psychiatrist, Christie Hospital, Manchester,UK. He said that, in this study, the prevalence of affective disorders,primarily depression and anxiety, was around 30%.

Patients in the study are interviewed initially by questionnairewithin 8 weeks of their diagnosis in an effort to identify currentconcerns, learn what coping strategies are used, and learn towhat extent patients have resolved concerns. A standardized psychiatricassessment is then administered. A repeat assessment at 1 yeardetermines whether that patient's coping process was predictiveof the development of an affective disorder.

In the current analysis, the number and severity of the patients'concerns and the extent to which they perceived that they hadresolved them were highly predictive of which patients later becameanxious and depressed, Dr. Maguire said.

Those patients most likely to develop affective disorders warrantingpsychiatric intervention appraised their illness and its effectsas more severe than other patients, and responded with a greatersense of hopelessness and anergy.

Dr. Maguire said that the study will be expanded to look at earlyintervention based on patients' negative appraisals and copingdeficits.

Outside the study setting, cancer patients may fail to disclosetheir distress to anyone, thus preventing early intervention.Dr. Maguire's research suggests that the problem is due equallyto patient and physician behaviors.

Patient attitudes that contribute to failure to disclose includethe belief that psychological problems are to be expected andcannot be relieved; patients' desire not to bother their physicians,whom they perceive as having limited time to listen; and theirdesire to be seen as good copers and to avoid being judged aspsychologically inadequate to handle their illness.

Patients also note that their physicians often do not ask open-endedquestions that might help them reveal an emotional state. Forexample, questions such as "How have you coped with the lossof your breast?" encourage the patient to express feelingsas well as problems related to breast cancer surgery.

Distancing Strategies

Patients also say that doctors often give cues that they don'twant to hear about emotions. Physicians sometimes use such "distancingstrategies" unconsciously to brush aside issues that theydo not wish to address.

Common distancing tactics include premature reassurance, prematureadvice, false reassurance, passing the buck, switching the subject,and "jollying along" as Dr. Maguire described it. Prematurereassurance, for example, may be given to try to soften the realityof bad news. But such distancing tactics often lead patients notto express concerns that could be discussed and dealt with directly.

When physicians were asked why they might have used a distancingstrategy, they responded with three reasons, Dr. Maguire said.First was fear of several issues. They had concerns about becomingemotionally upset, of burning out, of psychologically damagingthe patient, of becoming too close emotionally to the patient,and of taking up too much clinic time by "opening Pandora'sbox."

A second reason for distancing was the feeling that they wereinadequately trained to assess psychological issues. The physicianswere concerned about their ability to explore patients' feelingsand to handle painful communication, particularly breaking badnews.

A third reason physicians gave for distancing was the absenceof opportunity to discuss their own personal emotions, leavingthem to deal alone with difficult patient situations. Dr. Maguire'sresearch has shown that physicians need the most help in threesituations: breaking bad news, dealing with an angry patient,and working with patients who deny their illness and the needfor treatment.

Dr. Maguire has identified the types of questions most likelyto inhibit or promote patient disclosure of psychological problems.Inhibiting types include narrow or closed questions, leading questions,multiple questions, or questions that focus only on the physicalillness.

By contrast, disclosure is promoted by questions that are openand direct, have a psychological focus, request clarificationof psychological issues, summarize information, show empathy,and reflect the physician's educated guess about what is importantto the patient.

He emphasized that these techniques can be used successfully withoutlengthening the time taken with the visit. In fact, he said, psychologicalaspects of illness can be integrated into the ordinary processof taking patient histories, and physicians who are trained toask questions that promote disclosure are more easily able todo this.

Workshops Provide Training

Training in how to reduce distancing behaviors, improve communicationskills, and manage difficult situations can be helpful, Dr. Maguiresaid, pointing to his own workshops.

In these workshops, video demonstrations, role playing, and groupdiscussion are used to teach communication skills to doctors insmall groups. Individual feedback is given, and handbooks providedescriptions of the interview process and successful strategiesused in working with patients.

The initial workshops are held for 3 consecutive days. Participantsthen meet again, 3 months later, for 2 days of consolidation workshops.Because the course content varies with the needs of those whoattend, individuals have an opportunity to address issues thatconcern them most.

Topics that have been covered in the workshops include assessingpatients' problems and emotions, breaking bad news, handling apatient who denies illness, promoting openness when collusionis present, handling guilt, confronting a colleague about undesirablebehavior, and dealing with an angry relative or patient.