Peter Maguire

Doctor-patient communication: the Toronto consensus statement.

This report was compiled on behalf of the staff at the Northern General Hospital, Sheffield, the staff at the Royal Hallamshire Hospital, Sheffield, and the many people who helped at the scene. The efforts of hundreds of professionals and volunteers were vital and greatly appreciated. We thank Neil Appleyard, David Edbrooke, David Dawson, Stuart Yates, Ian Winston, John Duncan, G A Baker, Charlie Cooper, Kath Sherry, Tim Shaw, and A Moss for access to the neuropsychological reports on some of the survivors.

The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses

SummaryThe findings of two meta-analyses of trials of psychological interventions in patients with cancer are presented: the first using anxiety and the second depression, as a main outcome measure. The majority of the trials were preventative, selecting subjects on the basis of a cancer diagnosis rather than on psychological criteria. For anxiety, 25 trials were identified and six were excluded because of missing data. The remaining 19 trials (including five unpublished) had a combined effect size of 0.42 standard deviations in favour of treatment against no-treatment controls (95% confidence interval (CI) 0.08–0.74, total sample size 1023). A most robust estimate is 0.36 which is based on a subset of trials which were randomized, scored well on a rating of study quality, had a sample size > 40 and in which the effect of trials with very large effects were cancelled out. For depression, 30 trials were identified, but ten were excluded because of missing data. The remaining 20 trials (including six unpublished) had a combined effect size of 0.36 standard deviations in favour of treatment against no-treatment controls (95% CI 0.06–0.66, sample size 1101). This estimate was robust for publication bias, but not study quality, and was inflated by three trials with very large effects. A more robust estimate of mean effect is the clinically weak to negligible value of 0.19. Group therapy is at least as effective as individual. Only four trials targeted interventions at those identified as at risk of, or suffering significant psychological distress, these were associated with clinically powerful effects (trend) relative to unscreened subjects. The findings suggest that preventative psychological interventions in cancer patients may have a moderate clinical effect upon anxiety but not depression. There are indications that interventions targeted at those at risk of or suffering significant psychological distress have strong clinical effects. Evidence on the effectiveness of such targeted interventions and of the feasibility and effects of group therapy in a European context is required.

The psychological impact of cancer on patients’ partners and other key relatives: a review

Partners and other family members are key supports for cancer patients. Most cope well with the caregiving role, but an important minority become highly distressed or develop an affective disorder. Female carers and those with a history of psychiatric morbidity are more vulnerable, as are those who take a more negative view of the patients illness and its impact on their lives. Carers are likely to become more distressed and develop psychiatric morbidity as the illness advances and treatment is palliative. Carers are also more at risk when they lack a support network of their own and when there are relationship difficulties with the patient. The review discusses why, given this evidence, carers fail to take advantage of interventions designed to help them and those who participate derive only limited psychological benefits.

Screening for anxiety and depression in cancer patients: the effects of disease and treatment

The General Health Questionnaire 28 (GHQ 28), Hospital Anxiety and Depression Scale (HADS), and Rotterdam Symptom Checklist (RSCL) seemed promising in their ability to detect anxiety and depression in cancer patients. To compare their screening performance, 513 patients were recruited from four cancer centres, and visited at home by a trained interviewer. Paired combinations of questionnaires (GHQ 28 + HADS, GHQ 28 + RSCL or RSCL+HADS) were used, and then the Psychiatric Assessment Schedule was administered to enable a psychiatric diagnosis to be made using DSM III diagnostic criteria. A receiver operating characteristics curve was drawn by plotting the true positive rate (sensitivity) against the false positive rate (1-specificity) for each possible score on each questionnaire. In the overall sample, the HADS and RSCL performed well comparably. The HADS did best in those free of disease and when the disease was judged to be stable. Only the RSCL performed well in those with progressive disease. Both the HADS and RSCL were effective in those on treatment. The GHQ was superior to the RSCL in those off treatment. The choice of questionnaire and threshold score should take disease and treatment status into account, but all three questionnaires have a definite role in screening out anxiety and depression.

Improving communication with cancer patients

If doctors and nurses involved in cancer care are to help patients and their families achieve an optimal level of quality of life and psychological adjustment they must be able to carry out key communication tasks successfully. Yet, objective scrutiny of their consultations confirms that deficiencies in their ability to conduct these tasks remain. The reasons for this are discussed before important innovations in training and their impact are described.

Major depression in outpatients attending a regional cancer centre: screening and unmet treatment needs

A screening programme designed to identify cases of Major Depressive Disorder (MDD) in patients attending a Regional Cancer Centre outpatient department was established. It comprised two stages: (1) The Hospital Anxiety and Depression Scale (HADS) self-rating questionnaire administered by a touch-screen computer; (2) we interviewed patients with high scores on the HADS (15 or more total score) over the telephone using the depression section of the Structured Clinical Interview for DSMIV (SCID). A large consecutive sample (5613) of oncology clinic attenders was screened, and practical difficulties in the screening process were identified. The estimated prevalence of major depressive disorder (MDD) in the sample surveyed was approximately 8% (7.8%; 95% confidence intervals 6.9–8.5%). We assessed a consecutive series of 150 patients identified as having MDD to determine how many had received evidence-based treatment for MDD. Only half had discussed their low mood with their general practitioner, only one-third had been prescribed any antidepressant medication, and very few had taken a therapeutic dose for an adequate period. Very few had received psychological treatment or had been referred to mental health services. Most were receiving no potentially effective therapy.

Confiding in crisis: gender differences in pattern of confiding among cancer patients.

Social support has been identified as a key predictor of psychological morbidity following adverse life-events. However, the majority of the research has focused exclusively on women, despite evidence of significant gender difference in the utilisation and role of social support. To examine gender differences in patterns of confiding crisis, 520 subjects were interviewed within 8 weeks of a cancer diagnosis. Men were as likely as women to have confided their main concern in others (61% mainly or fully confided vs 67% of women, P = 0.308) but were much more likely to have used only one confidante (45% vs 25% of women, P < 0.001) while women made use of a wider circle of family, friends and partner and used more confidantes overall. The results confirm marked gender differences in the utilisation of social support at times of crisis and call into question the extent to which support research using exclusively female samples can be generalized.

Maladaptive coping and affective disorders among cancer patients.

Coping has attracted much attention in research as a possible mediator of the psychological impact of cancer. Yet, conceptual ambiguity and methodological limitations have resulted in weak and contradictory findings. A major shortcoming has been the use of designs which do not represent adequately the complexity or the diversity of demands which arise from the diagnosis and treatment of cancer. The neglect of appraisal in the assessment of the relationship between coping and mental health is of particular concern, given the role it has been found to play in the onset and maintenance of affective disorders. In a prospective study 673 newly diagnosed cancer patients were interviewed 4 to 8 weeks and 1 year later to assess the effects of their appraisals, coping responses and resolution of any concerns on subsequent mental health. Logistic regression analyses, adjusted for possible confounding variables, were used to investigate the relationships between coping variables and affective disorders. When examined separately the degree of threat appraised, the reporting of a helpless response and perceived success of primary responses in resolving concerns all predicted subsequent effective disorder. However, in a multivariate model only appraisal and success of the response in resolving the concern were significant. No response was found to prevent affective disorders, however certain types of responses were associated with the resolution of specific concerns. The results highlight the importance of assessing the whole coping process and the need to address the complex and multifaceted characteristics of cancer demands. On the basis of our findings we describe a maladaptive cycle of coping, which we believe contributes to the later onset of affective disorders in cancer patients.

The recognition of psychiatric morbidity on a medical oncology ward.

The Generalised Health Questionnaire and Standardised Psychiatric Interview were used to determine psychiatric morbidity among 126 patients consecutively admitted to a medical oncology unit. Senior house officers and nurses also rated anxiety and depression. 36 (29%) patients were psychiatrically ill and affective disorders (29, 23%) predominated. Psychiatric morbidity was associated with feeling moderately or severely physically ill, and previous psychiatric illness, but not with awareness of having cancer or lack of a confiding tie. The General Health Questionnaire identified 79% of affective disorders at the cost of a 34% false positive rate. Doctors and nurses recognised only 49% of the depressed group; more of those with morbid anxiety (79%) were identified but only because they assumed most patients were anxious. Training in interviewing skills could substantially improve the identification and referral rates of patients with psychiatric morbidity.

The value of feedback in teaching interviewing skills to medical students

Forty-eight medical students took part in a study to assess the value of giving students some feedback about their interviewing skills. During the study they all received training from their clinical firms. In addition, 36 of the students received 1 of 3 types of feedback training. This was given by tutors who used television replays, audiotape replays or ratings of practice interviews conducted by the students. As in previous studies there was little improvement in the interviewing skills of those students who only received training from their clinical firms. In contrast, all 3 feedback groups improved their ability to elicit accurate and relevant information. However, only the television and audiotape groups also showed gains in techniques. While the differences between these 2 groups were not significant, they all favoured the television group.