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 deficits.
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 box."
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 news.
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 for treatment.
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 illness.
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 do this.
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.