Transcript How do we identify patients with depression

Supporting the patient and
accessing support services
Suzanne Mc Keever
Nurse Specialist
Psycho-Oncology
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
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Emotional impact of diagnosis
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Fear
Distress
Uncertainty
Loss of control
Anger
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NICE Guidelines 2004
Level
group
assessment
intervention
1
All 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
3
Trained 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
4
Mental health
specialists
Diagnosis of
psychopathology
Specialist psychological and
psychiatric interventions such as
psychotherapy, including
cognitive behavioural therapy
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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
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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
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Can we tell who will get
depressed ?
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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
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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
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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
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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
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What is depression?
Defining characteristics
1.
Depressed mood
2.
Loss of interest or pleasure
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Significant weight loss/increased appetite
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Insomnia or hypersomnia
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Psychomotor agitation or retardation
6.
Fatigue or loss of energy
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Feelings of worthlessness or excessive or inappropriate guilt
8.
Diminished ability to think or concentrate or indecisiveness
9.
Recurrent thoughts of death
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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
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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?
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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.
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How do we identify patients with
depression
• Consider using a screening tool
• Hospital Anxiety and Depression Scale (HADS)
• PHQ-9
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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
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Why is it so difficult ?
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Concerns about impact on patient
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Uncontrollably upset
Angry and shout
Run out of the room
Refuse treatment
Go silent
Start asking difficult questions
That we may make things
worse
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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
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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
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The Christie NHS Foundation Trust