In a preliminary analysis of a study of more than 800 patients
with early-stage cancer, researchers found that those who gave
a negative self-appraisal of their situation and their ability
to cope were more likely to develop affective disorders during
the course of their treatment. Peter Maguire, MD, reported the
results in his keynote lecture at the annual American Society
for 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 questionnaire
within 8 weeks of their diagnosis in an effort to identify current
concerns, learn what coping strategies are used, and learn to
what extent patients have resolved concerns. A standardized psychiatric
assessment is then administered. A repeat assessment at 1 year
determines whether that patient's coping process was predictive
of 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 had
resolved them were highly predictive of which patients later became
anxious and depressed, Dr. Maguire said.
Those patients most likely to develop affective disorders warranting
psychiatric intervention appraised their illness and its effects
as more severe than other patients, and responded with a greater
sense of hopelessness and anergy.
Dr. Maguire said that the study will be expanded to look at early
intervention based on patients' negative appraisals and coping
Outside the study setting, cancer patients may fail to disclose
their distress to anyone, thus preventing early intervention.
Dr. Maguire's research suggests that the problem is due equally
to patient and physician behaviors.
Patient attitudes that contribute to failure to disclose include
the belief that psychological problems are to be expected and
cannot be relieved; patients' desire not to bother their physicians,
whom they perceive as having limited time to listen; and their
desire to be seen as good copers and to avoid being judged as
psychologically inadequate to handle their illness.
Patients also note that their physicians often do not ask open-ended
questions that might help them reveal an emotional state. For
example, questions such as "How have you coped with the loss
of your breast?" encourage the patient to express feelings
as well as problems related to breast cancer surgery.
Patients also say that doctors often give cues that they don't
want to hear about emotions. Physicians sometimes use such "distancing
strategies" unconsciously to brush aside issues that they
do not wish to address.
Common distancing tactics include premature reassurance, premature
advice, false reassurance, passing the buck, switching the subject,
and "jollying along" as Dr. Maguire described it. Premature
reassurance, for example, may be given to try to soften the reality
of bad news. But such distancing tactics often lead patients not
to express concerns that could be discussed and dealt with directly.
When physicians were asked why they might have used a distancing
strategy, they responded with three reasons, Dr. Maguire said.
First was fear of several issues. They had concerns about becoming
emotionally upset, of burning out, of psychologically damaging
the patient, of becoming too close emotionally to the patient,
and of taking up too much clinic time by "opening Pandora's
A second reason for distancing was the feeling that they were
inadequately trained to assess psychological issues. The physicians
were concerned about their ability to explore patients' feelings
and to handle painful communication, particularly breaking bad
A third reason physicians gave for distancing was the absence
of opportunity to discuss their own personal emotions, leaving
them to deal alone with difficult patient situations. Dr. Maguire's
research has shown that physicians need the most help in three
situations: breaking bad news, dealing with an angry patient,
and working with patients who deny their illness and the need
Dr. Maguire has identified the types of questions most likely
to 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 physical
By contrast, disclosure is promoted by questions that are open
and direct, have a psychological focus, request clarification
of psychological issues, summarize information, show empathy,
and reflect the physician's educated guess about what is important
to the patient.
He emphasized that these techniques can be used successfully without
lengthening the time taken with the visit. In fact, he said, psychological
aspects of illness can be integrated into the ordinary process
of taking patient histories, and physicians who are trained to
ask questions that promote disclosure are more easily able to
Workshops Provide Training
Training in how to reduce distancing behaviors, improve communication
skills, and manage difficult situations can be helpful, Dr. Maguire
said, pointing to his own workshops.
In these workshops, video demonstrations, role playing, and group
discussion are used to teach communication skills to doctors in
small groups. Individual feedback is given, and handbooks provide
descriptions of the interview process and successful strategies
used in working with patients.
The initial workshops are held for 3 consecutive days. Participants
then meet again, 3 months later, for 2 days of consolidation workshops.
Because the course content varies with the needs of those who
attend, individuals have an opportunity to address issues that
concern them most.
Topics that have been covered in the workshops include assessing
patients' problems and emotions, breaking bad news, handling a
patient who denies illness, promoting openness when collusion
is present, handling guilt, confronting a colleague about undesirable
behavior, and dealing with an angry relative or patient.