Summary: Unmet Mental Health
Addressing the unmet mental health needs of cancer patients in the England.
Introduction:
1.8million people are currently living with cancer in England. This is set to grow to 3million by 2030 (UK Department of Health, Macmillan Cancer Support & NHS Improvement, 2013). This can be largely attributed to an increased prevalence of unhealthy lifestyles. Advancements in treatment and early diagnosis means that 40% are not expected to die from the disease (Macmillan Cancer Support, 2013). 50% are expected to live beyond five years compared to only 28% in the early 1970s (Gordon-Dseagu, 2006).
Whilst many will return to their normal lives many will suffer the consequences of treatment or continue …show more content…
to live with cancer, further one in four will suffer two or more comorbidities. Cancer can now be considered a long-term disease (Macmillan Cancer Support, 2013).
Government issued a mandate to the NHS Commissioning Board in 2012 expecting progress in support for those surviving cancer to live a better quality (UK Department of Health, 2013). This is reflected in domain two of the NHS outcomes framework.
Public health concern:
The physical long-term consequences of treatment include chronic fatigue, sexual difficulties, moderate to severe pain, incontinence, gastrointestinal problems and lymphedema. People can also suffer psychological problems as a consequence of their cancer diagnosis and treatment. These can last for many years.
49% say they experience depression as a result of their cancer diagnosis (Cardy et al., 2006). Depression, anxiety and post-traumatic stress disorder (PTSD) are also common. It is estimated that 240,000 cancer patients have a mental health problem (Macmillan Cancer Support, 2013). Singer et al (2013) found that 30% of those with cancer were also diagnosed with a mental health condition and few received care early enough. Naylor et al (2012) suggests that identification of depression amongst people with a long-term condition largely goes undetected and untreated. Hobbie et al (2000) found that 20.5% of young adults that had been diagnosed with a childhood cancer suffered from PSTD at some point from the end of their treatment. Care received is unlikely to be relevant to the needs of the patient.
‘Chemo brain’ is a side effect of chemotherapy treatment. The American Cancer Society has identified a link between ‘chemo brain’ and depression. Radiation treatment has also been shown to cause depression (American Cancer Society, 2014).
“Depression and/or anxiety disorders may decrease adherence to medical treatment; increase unhealthy behaviour such as smoking, substance misuse, and poor diet; and lead to poorer outcomes for those suffering with chronic diseases.” Department of Health (2008, p. 3).
The link between cancer and mental health is not new however, Finlay et al (2011, cited in Naylor, 2012) suggests that a decrease in generalism and increases in specialisms and sub specialisms has led to an oversight in the multiple needs from multiple morbidities in patients. Care can be fragmented due to the split between specialist commissioning and local community care. There is a need for collaboration across disciplines.
Tacking mental health conditions will improve quality of life of those with cancer and improve survival rates (Spiegal, 2014).
Cost burden:
Failing to meet this challenge will increased the use of health resources, reduced economic activity and increase dependency on benefits resulting in significant cost implications for NHS England and the wider economy. Whilst figures are not available for the impact of those with a cancer diagnosis, Naylor et al (2012) suggests that the burden of poor mental health linked to long-term conditions is a cost to the NHS of between £8billion and £13billion. Layard (2006) suggests that £9billion per year is lost in tax receipts and benefit payments. Changing the way we support cancer survivors is therefore a financial as well as an outcomes priority.
Health Inequalities:
Gordon-Dseagu (2009) suggests an inversely correlated relationship between social economic status and cancer mortality and morbidity suggesting differing rates of cancers amongst black and minority ethnic communities and other hard to reach populations.
Those who live in deprived areas are 17% more likely to be diagnosed with cancer and 33% less likely to be alive between five and 10 years post diagnosis than those form more affluent areas (Macmillan, 2010).
The prevalence of mental health conditions in those suffering multiple long-term conditions is greater in those living in deprivation. Prevalence of depression and anxiety is also not evenly distributed across the population. Positive correlations have been found between these conditions and poor education, low income and low socio economic status (Mercer and Watt, 2007 cited in Naylor et al, 2012).
At present, it is not possible to segment those living with cancer based upon their mental health needs making the targeting of interventions difficult. Whilst it can be hypothesised who these people are, further insight into this area is required.
NICE Guidance:
Five sets of NICE guidance are relevant: -
Post-traumatic stress disorder (PSTD) (NICE, 2005)
Depression in adult (NICE, 2009a)
Depression in adults with a chronic physical health problem (NICE, 2009b)
Generalised anxiety disorder and panic disorder in adults (NICE, 2011a)
Common mental health disorders (NICE, 2011b)
NICE (2011b) recommends asking two specific questions: -
“During the last month, have you often been bothered by feeling down, depressed or hopeless?”
“During the last month, have you often been bothered by having little interest or pleasure in doing things?”
Answering ‘yes’ to either requires further assessment.
This assessment could use the 9-item Patient Health Questionnaire, the Hospital Anxiety Scale, the 7-item Generalised Anxiety Disorder Scale or the Increased Access to Psychological Therapies tool (NICE, 2011b).
NICE 2011a and NICE 2009 both recommend the DSM-IV classification to make a formal diagnosis however, the ICD-10 classification system, that makes a diagnosis based on counting symptoms, is also considered.
There are several limitations that should be addressed. The assessment tools do not take into account the presences of symptoms from physical illness that could result in the incorrect ‘counting’ of symptoms leading to an incorrect diagnosis. None have been validated for use on those living with cancer. With six potential measures identified, it might be confusing for health professionals.
DSM-IV is recommended as the majority of the research uses this measure. It provides definitions for seasonal variations and symptoms that are uncommon, however, as this is not specific to cancer or long-term conditions it could lead to false positive results. More research is required.
Patient Centred …show more content…
Care:
The patient should be involved in all decisions where they have the mental capacity to do so. This provides the patient with the opportunity to take back control of the major decisions about their care and indeed their lives.
Communication between health professions is vital to ensure a coordinated approach is taken toward patient care. Treatment typically only focuses on the long-term condition rather than the mental health condition (Department of Health, 2012 cited in Hadert, 2013).
Interventions:
Patients will need to be monitored throughout their cancer journey as mental health concerns could present at anytime. Selection of the intervention will depend on the nature and severity of the mental health condition not the stage of the cancer journey.
NICE (2009a, 2009b, 2011a, 2011b) recommend a step care approach for treatment and management. NICE (2011b) summarised the treatments used in steps one, two and three. Those presenting at step four would need to receive high intensity interventions and are not included.
Step: Intervention:
Step 3: Persistent sub threshold depressive symptoms or mild to moderate depression that has not responded to a low-intensity intervention; initial presentation of moderate or severe depression.
Generalized Anxiety Disorder (GAD) with marked functional impairment or that has not responded to a low-intensity intervention.
PTSD.
Depression: CBT, Interpersonal Therapy (IPT), behavioural activation, behavioural couples therapy, counseling (effectiveness unclear), short-term psychodynamic psychotherapy (effectiveness unclear), antidepressants, combined interventions, collaborative care, self-help groups.
GAD: CBT, applied relaxation, drug treatment, combined interventions, self-help groups.
PTSD: Trauma-focused CBT, Eye Movement Desensitisation and Reprocessing therapy (EMDR), drug treatment (effectiveness is unclear).
All disorders: Support groups, befriending, rehabilitation programmes, educational and employment support; referral for further assessment.
Step 2:
Persistent sub threshold depressive symptoms or mild to moderate depression.
GAD; mild to moderate.
PTSD.
Depression: Individual facilitated self-help, computerised CBT, structured physical activity, peer support programmes, non-directive Counseling, antidepressants, self-help groups.
GAD: Individual non-facilitated and facilitated self-help, psychoeducational groups, self-help groups.
PTSD: Trauma-focused CBT or EMDR.
All disorders: Support groups, educational and employment support; referral for further assessment.
Step 1:
All disorders – known and suspected presentations of common mental health disorders.
All disorders: Identification, assessment, psychoeducation, active monitoring; referral for further assessment and interventions.
Hadert (2013) suggests a gap in the literature in adapting mental health interventions for people with long-term conditions. Insight is needed into whether delivery of psychological mental health interventions within mental health services is appropriate for people with long-term conditions.
Evidence is lacking in the use of interventions in people with cancer. Only one paper was reviewed on the treatment of depression in cancer patients by NICE (2009b) in their guidance on depression in adults with a chronic physical condition.
The House of Care:
Coulter, Roberts and Dixon (2013) have developed the ‘House of Care model’ to tackle the growing burden of long-term conditions. NHS England has adopted this model to enhance the quality of life for people with long-term conditions as outlined in domain two of the NHS outcomes framework.
Person centred care is at the core with empowered better-informed patients who can self-manage their conditions coupled with health professionals who provide the skills and knowledge in a collaborative way (the walls of the house). This is in keeping with the fully engaged scenario (Wanless et al., 2004).
Local high quality services delivered in the community and commissioned based upon the needs of the local population form the foundations. The roof represents updated and fit-for-purpose systems.
There are multiple opportunities to intervene during cancer, at diagnosis, during treatment and recovery, living with cancer or at the end of life. Cancer care is made up of a multidisciplinary team and each has the opportunity to identify mental health problems and intervene. Early detection, referral and treatment will improve patient outcomes.
There is a need for an integrated holistic needs assessment and care plan rather than just combining treatments for mental health conditions with cancer treatments. Many treatments have contra-indications to other areas of care therefore an integrated approach is needed.
Supported and supervised case management is required coupled with close working relationships between cancer care and mental health teams ensuring consistency of care and follow up.
Recommendations:
Recommendations are deemed achievable, scalable and cost effective. Recommendations should be developed further using the Medical Research Council (Craig et al., 2008) guidance for developing and evaluating complex interventions.
Personnel:
Case management, possibly from a Cancer Nurse Specialist
Training, skills and resource development to allow cancer care teams to identify, assess and monitor mental health conditions
Develop relationships between mental health service teams and cancer care teams
Regular high-quality supervision linking cancer care with mental health teams
Training for mental health teams on understanding cancer
Interventions:
Provide up to date information on mental health conditions to the patient
High quality physical activities opportunities
Facilitated peer support groups
Group based CBT for those presenting with moderate depression, anxiety or PTSD (six weeks, two hours per session, up to 12 participants - robustly evaluate for PTSD as evidenced is lacking)
Computer based CBT (nine weeks with professional online support)
Cancer specific non-facilitated self-help materials based upon CBT (six weeks with occasional telephone follow-up and support)
Cancer specific guided self-help materials based upon CBT (seven weekly or fortnightly face to face telephone sessions lasting 20-30minutes)
Modify mental health interventions for cancer patients
Delivery:
Take a proactive approach to those most at risk e.g. those from a lower socioeconomic group. Consider the social determinants impacting upon this and deliver interventions universally but proportionate to the prevalence across groups
Ensure interventions are accessible, delivered by a trainer that can relate to the group and uses materials and language that are appropriate
Ensure referral routes are well defined and that the cancer care workforce are properly informed of the process.
Local Government support:
Adopt the House of Care model locally with support from the Clinical Commissioning Group and the Health and Wellbeing board
Improve IT systems to share data
Joined up commissioning of services ensuring collaborative patient centred care
Evaluation:
Robustly evaluate all interventions identifying cost effective solutions to ensure sustainability of future services
Ensure that the fidelity of the interventions are consistently delivered
Measure patient reported outcome measures
Use the Medical Research Councils (Craig et al., 2008) guide to developing and evaluating complex interventions.
Conclusion:
Cancer is considered a long-term condition. Many experience depression, anxiety and PTSD.
Improvements in identification and early treatment of mental health conditions will improve quality of life and reduce pressure on the NHS. It is recommended that a collaborative patient centered, stepped approach is adopted using the ‘House of Care’.
Improvements in this area will help achieve domain two of the NHS framework, “Enhancing quality of life for people with long-term conditions”, and domain one, “Improving the wider determinants of health”, domain two “Health improvement” and domain four “Healthcare public health and preventing premature death” of the Public Health Outcomes framework.
Word count - 2180
References:
American Cancer Society. (2014). Chemo brain. [Online]. [Accessed 12 August 2014]. Available from: http://www.cancer.org.
Cardy, P., Corner, J., Evans, J., Jackson, N., Shearn, K. & Sparham, L. (2006). Worried sick. The emotional impact of cancer. London: Macmillan Cancer Support.
Coutler, A., Roberts, S. & Dixon, A. (2013). Delivering better services for people with long-term conditions – Building the house of care. London: The Kings Fund.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I. & Patticrew, M. (2008). Developing and evaluating complex interventions: New guidance. London: Medical Research Council.
Department of Health.
(2008). Long-term conditions positive practice guide. [Online]. London: Crown Publishing. [Accessed 1 August 2014]. Available from: http://www.iapt.nhs.uk/silo/files/longterm-conditions-positive-practice-guide.pdf.
Department of Health, Macmillan Cancer Support & NHS Improvement. (2013). Living with and beyond cancer: taking action to improve outcomes. London: Department of Health.
Gordon-Dseagu. (2006). Cancer and Health Inequalities: An Introduction to Current Evidence. London: Cancer Research UK.
Hadert, A. (2013). Adapting cognitive behavioural therapy interventions for anxiety or depression to meet the needs of people with long-term physical health conditions. Unpublished doctoral dissertation, University of Exeter, Exeter.
Hobbie, W. L., Stuber, M., Meeske, K., Wissler, K., Rourke, M. T., Ruccione, K. et al. (2000). Symptoms of Posttraumatic Stress in Young Adult. Journal of Clinical Oncology, 18 (24), 4060-4066.
Layard, R. (2006). The case for psychological treatment centres. London: RL447.
Macmillan Cancer Support. (2013). Cured – but at what cost? Long-term consequences of cancer and its treatment. London: Macmillan Cancer
Support.
Macmillan Cancer Support. (2010). Routes from diagnosis. London: Macmillan Cancer Support.
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M. & Galea, A. (2012). Long-term conditions and mental health. The cost of co-morbidities. London: The Kings Fund.
National Institute for Health and Care Excellence. (March, 2005). Post-traumatic stress disorder (PTSD). The management of PTSD in adults and children in primary and secondary care. Manchester: NICE.
National Institute for Health and Care Excellence. (May, 2011b). Common mental health disorders. Identification and pathways to care. Manchester: NICE.
National Institute for Health and Care Excellence. (October, 2009a). Depression in adults. The treatment and management of depression in adults. Manchester: NICE.
National Institute for Health and Care Excellence. (October, 2009b). Depression in adults with a chronic physical health problem. Treatment and management. Manchester: NICE.
National Institute for Health and Care Excellence. (January, 2011a). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. Management in primary, secondary and community care. Manchester: NICE.
Singer, S., Szalai, C., Briest, S., Brown, A., Dietz, A., Einenkel, J. et al. (2013). Co-morbid mental health conditions in cancer patients at working age – prevalence, risk profiles, and care uptake. Psycho-oncology, 22, 2291-2297.
Spiegal, D. (2013). Minding the body: psychotherapy and cancer survival. British Journal of Health Psychology, 19, 465-485.
United Kingdom. Department of Health. (2013). A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. London: Crown Publications.
Wanless, D. (2004). Securing good health for the whole population. London: Crown Publications.
Bibliography:
Department of Health. (2010). Healthy lives, healthy people: Our strategy for public health in England. London: Crown Publishing.
Department of Health. (2011). No health without mental health. A cross-government mental health outcomes strategy for people of all ages. London: Crown Publishing.
Goodwin, N., Curry, N., Naylor, C., Ross, S. & Duldig, W. (2010). Managing people with long-term condition. London: The Kings Fund.
Hewitt, M. & Rowland, J. H. (2002). Mental Health Service Use Among Adult Cancer Survivors:
Analyses of the National Health Interview Survey. Journal of Clinical Oncology, 20 (23), 4581-4590.
Ipsos MORI & Macmillan Cancer Support. (2011). More than a million. Understanding the UK’s carers of people with cancer. London: Macmillan Cancer Support.
Mitchell, A, J., Ferguson, D,W., Gill, J., Paul, J., Symonds, P. (2013). Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis. Lancet Oncology, 14 (8), 721-732.
Introduction:
1.8million people are currently living with cancer in England. This is set to grow to 3million by 2030 (UK Department of Health, Macmillan Cancer Support & NHS Improvement, 2013). This can be largely attributed to an increased prevalence of unhealthy lifestyles. Advancements in treatment and early diagnosis means that 40% are not expected to die from the disease (Macmillan Cancer Support, 2013). 50% are expected to live beyond five years compared to only 28% in the early 1970s (Gordon-Dseagu, 2006).
Whilst many will return to their normal lives many will suffer the consequences of treatment or continue …show more content…
to live with cancer, further one in four will suffer two or more comorbidities. Cancer can now be considered a long-term disease (Macmillan Cancer Support, 2013).
Government issued a mandate to the NHS Commissioning Board in 2012 expecting progress in support for those surviving cancer to live a better quality (UK Department of Health, 2013). This is reflected in domain two of the NHS outcomes framework.
Public health concern:
The physical long-term consequences of treatment include chronic fatigue, sexual difficulties, moderate to severe pain, incontinence, gastrointestinal problems and lymphedema. People can also suffer psychological problems as a consequence of their cancer diagnosis and treatment. These can last for many years.
49% say they experience depression as a result of their cancer diagnosis (Cardy et al., 2006). Depression, anxiety and post-traumatic stress disorder (PTSD) are also common. It is estimated that 240,000 cancer patients have a mental health problem (Macmillan Cancer Support, 2013). Singer et al (2013) found that 30% of those with cancer were also diagnosed with a mental health condition and few received care early enough. Naylor et al (2012) suggests that identification of depression amongst people with a long-term condition largely goes undetected and untreated. Hobbie et al (2000) found that 20.5% of young adults that had been diagnosed with a childhood cancer suffered from PSTD at some point from the end of their treatment. Care received is unlikely to be relevant to the needs of the patient.
‘Chemo brain’ is a side effect of chemotherapy treatment. The American Cancer Society has identified a link between ‘chemo brain’ and depression. Radiation treatment has also been shown to cause depression (American Cancer Society, 2014).
“Depression and/or anxiety disorders may decrease adherence to medical treatment; increase unhealthy behaviour such as smoking, substance misuse, and poor diet; and lead to poorer outcomes for those suffering with chronic diseases.” Department of Health (2008, p. 3).
The link between cancer and mental health is not new however, Finlay et al (2011, cited in Naylor, 2012) suggests that a decrease in generalism and increases in specialisms and sub specialisms has led to an oversight in the multiple needs from multiple morbidities in patients. Care can be fragmented due to the split between specialist commissioning and local community care. There is a need for collaboration across disciplines.
Tacking mental health conditions will improve quality of life of those with cancer and improve survival rates (Spiegal, 2014).
Cost burden:
Failing to meet this challenge will increased the use of health resources, reduced economic activity and increase dependency on benefits resulting in significant cost implications for NHS England and the wider economy. Whilst figures are not available for the impact of those with a cancer diagnosis, Naylor et al (2012) suggests that the burden of poor mental health linked to long-term conditions is a cost to the NHS of between £8billion and £13billion. Layard (2006) suggests that £9billion per year is lost in tax receipts and benefit payments. Changing the way we support cancer survivors is therefore a financial as well as an outcomes priority.
Health Inequalities:
Gordon-Dseagu (2009) suggests an inversely correlated relationship between social economic status and cancer mortality and morbidity suggesting differing rates of cancers amongst black and minority ethnic communities and other hard to reach populations.
Those who live in deprived areas are 17% more likely to be diagnosed with cancer and 33% less likely to be alive between five and 10 years post diagnosis than those form more affluent areas (Macmillan, 2010).
The prevalence of mental health conditions in those suffering multiple long-term conditions is greater in those living in deprivation. Prevalence of depression and anxiety is also not evenly distributed across the population. Positive correlations have been found between these conditions and poor education, low income and low socio economic status (Mercer and Watt, 2007 cited in Naylor et al, 2012).
At present, it is not possible to segment those living with cancer based upon their mental health needs making the targeting of interventions difficult. Whilst it can be hypothesised who these people are, further insight into this area is required.
NICE Guidance:
Five sets of NICE guidance are relevant: -
Post-traumatic stress disorder (PSTD) (NICE, 2005)
Depression in adult (NICE, 2009a)
Depression in adults with a chronic physical health problem (NICE, 2009b)
Generalised anxiety disorder and panic disorder in adults (NICE, 2011a)
Common mental health disorders (NICE, 2011b)
NICE (2011b) recommends asking two specific questions: -
“During the last month, have you often been bothered by feeling down, depressed or hopeless?”
“During the last month, have you often been bothered by having little interest or pleasure in doing things?”
Answering ‘yes’ to either requires further assessment.
This assessment could use the 9-item Patient Health Questionnaire, the Hospital Anxiety Scale, the 7-item Generalised Anxiety Disorder Scale or the Increased Access to Psychological Therapies tool (NICE, 2011b).
NICE 2011a and NICE 2009 both recommend the DSM-IV classification to make a formal diagnosis however, the ICD-10 classification system, that makes a diagnosis based on counting symptoms, is also considered.
There are several limitations that should be addressed. The assessment tools do not take into account the presences of symptoms from physical illness that could result in the incorrect ‘counting’ of symptoms leading to an incorrect diagnosis. None have been validated for use on those living with cancer. With six potential measures identified, it might be confusing for health professionals.
DSM-IV is recommended as the majority of the research uses this measure. It provides definitions for seasonal variations and symptoms that are uncommon, however, as this is not specific to cancer or long-term conditions it could lead to false positive results. More research is required.
Patient Centred …show more content…
Care:
The patient should be involved in all decisions where they have the mental capacity to do so. This provides the patient with the opportunity to take back control of the major decisions about their care and indeed their lives.
Communication between health professions is vital to ensure a coordinated approach is taken toward patient care. Treatment typically only focuses on the long-term condition rather than the mental health condition (Department of Health, 2012 cited in Hadert, 2013).
Interventions:
Patients will need to be monitored throughout their cancer journey as mental health concerns could present at anytime. Selection of the intervention will depend on the nature and severity of the mental health condition not the stage of the cancer journey.
NICE (2009a, 2009b, 2011a, 2011b) recommend a step care approach for treatment and management. NICE (2011b) summarised the treatments used in steps one, two and three. Those presenting at step four would need to receive high intensity interventions and are not included.
Step: Intervention:
Step 3: Persistent sub threshold depressive symptoms or mild to moderate depression that has not responded to a low-intensity intervention; initial presentation of moderate or severe depression.
Generalized Anxiety Disorder (GAD) with marked functional impairment or that has not responded to a low-intensity intervention.
PTSD.
Depression: CBT, Interpersonal Therapy (IPT), behavioural activation, behavioural couples therapy, counseling (effectiveness unclear), short-term psychodynamic psychotherapy (effectiveness unclear), antidepressants, combined interventions, collaborative care, self-help groups.
GAD: CBT, applied relaxation, drug treatment, combined interventions, self-help groups.
PTSD: Trauma-focused CBT, Eye Movement Desensitisation and Reprocessing therapy (EMDR), drug treatment (effectiveness is unclear).
All disorders: Support groups, befriending, rehabilitation programmes, educational and employment support; referral for further assessment.
Step 2:
Persistent sub threshold depressive symptoms or mild to moderate depression.
GAD; mild to moderate.
PTSD.
Depression: Individual facilitated self-help, computerised CBT, structured physical activity, peer support programmes, non-directive Counseling, antidepressants, self-help groups.
GAD: Individual non-facilitated and facilitated self-help, psychoeducational groups, self-help groups.
PTSD: Trauma-focused CBT or EMDR.
All disorders: Support groups, educational and employment support; referral for further assessment.
Step 1:
All disorders – known and suspected presentations of common mental health disorders.
All disorders: Identification, assessment, psychoeducation, active monitoring; referral for further assessment and interventions.
Hadert (2013) suggests a gap in the literature in adapting mental health interventions for people with long-term conditions. Insight is needed into whether delivery of psychological mental health interventions within mental health services is appropriate for people with long-term conditions.
Evidence is lacking in the use of interventions in people with cancer. Only one paper was reviewed on the treatment of depression in cancer patients by NICE (2009b) in their guidance on depression in adults with a chronic physical condition.
The House of Care:
Coulter, Roberts and Dixon (2013) have developed the ‘House of Care model’ to tackle the growing burden of long-term conditions. NHS England has adopted this model to enhance the quality of life for people with long-term conditions as outlined in domain two of the NHS outcomes framework.
Person centred care is at the core with empowered better-informed patients who can self-manage their conditions coupled with health professionals who provide the skills and knowledge in a collaborative way (the walls of the house). This is in keeping with the fully engaged scenario (Wanless et al., 2004).
Local high quality services delivered in the community and commissioned based upon the needs of the local population form the foundations. The roof represents updated and fit-for-purpose systems.
There are multiple opportunities to intervene during cancer, at diagnosis, during treatment and recovery, living with cancer or at the end of life. Cancer care is made up of a multidisciplinary team and each has the opportunity to identify mental health problems and intervene. Early detection, referral and treatment will improve patient outcomes.
There is a need for an integrated holistic needs assessment and care plan rather than just combining treatments for mental health conditions with cancer treatments. Many treatments have contra-indications to other areas of care therefore an integrated approach is needed.
Supported and supervised case management is required coupled with close working relationships between cancer care and mental health teams ensuring consistency of care and follow up.
Recommendations:
Recommendations are deemed achievable, scalable and cost effective. Recommendations should be developed further using the Medical Research Council (Craig et al., 2008) guidance for developing and evaluating complex interventions.
Personnel:
Case management, possibly from a Cancer Nurse Specialist
Training, skills and resource development to allow cancer care teams to identify, assess and monitor mental health conditions
Develop relationships between mental health service teams and cancer care teams
Regular high-quality supervision linking cancer care with mental health teams
Training for mental health teams on understanding cancer
Interventions:
Provide up to date information on mental health conditions to the patient
High quality physical activities opportunities
Facilitated peer support groups
Group based CBT for those presenting with moderate depression, anxiety or PTSD (six weeks, two hours per session, up to 12 participants - robustly evaluate for PTSD as evidenced is lacking)
Computer based CBT (nine weeks with professional online support)
Cancer specific non-facilitated self-help materials based upon CBT (six weeks with occasional telephone follow-up and support)
Cancer specific guided self-help materials based upon CBT (seven weekly or fortnightly face to face telephone sessions lasting 20-30minutes)
Modify mental health interventions for cancer patients
Delivery:
Take a proactive approach to those most at risk e.g. those from a lower socioeconomic group. Consider the social determinants impacting upon this and deliver interventions universally but proportionate to the prevalence across groups
Ensure interventions are accessible, delivered by a trainer that can relate to the group and uses materials and language that are appropriate
Ensure referral routes are well defined and that the cancer care workforce are properly informed of the process.
Local Government support:
Adopt the House of Care model locally with support from the Clinical Commissioning Group and the Health and Wellbeing board
Improve IT systems to share data
Joined up commissioning of services ensuring collaborative patient centred care
Evaluation:
Robustly evaluate all interventions identifying cost effective solutions to ensure sustainability of future services
Ensure that the fidelity of the interventions are consistently delivered
Measure patient reported outcome measures
Use the Medical Research Councils (Craig et al., 2008) guide to developing and evaluating complex interventions.
Conclusion:
Cancer is considered a long-term condition. Many experience depression, anxiety and PTSD.
Improvements in identification and early treatment of mental health conditions will improve quality of life and reduce pressure on the NHS. It is recommended that a collaborative patient centered, stepped approach is adopted using the ‘House of Care’.
Improvements in this area will help achieve domain two of the NHS framework, “Enhancing quality of life for people with long-term conditions”, and domain one, “Improving the wider determinants of health”, domain two “Health improvement” and domain four “Healthcare public health and preventing premature death” of the Public Health Outcomes framework.
Word count - 2180
References:
American Cancer Society. (2014). Chemo brain. [Online]. [Accessed 12 August 2014]. Available from: http://www.cancer.org.
Cardy, P., Corner, J., Evans, J., Jackson, N., Shearn, K. & Sparham, L. (2006). Worried sick. The emotional impact of cancer. London: Macmillan Cancer Support.
Coutler, A., Roberts, S. & Dixon, A. (2013). Delivering better services for people with long-term conditions – Building the house of care. London: The Kings Fund.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I. & Patticrew, M. (2008). Developing and evaluating complex interventions: New guidance. London: Medical Research Council.
Department of Health.
(2008). Long-term conditions positive practice guide. [Online]. London: Crown Publishing. [Accessed 1 August 2014]. Available from: http://www.iapt.nhs.uk/silo/files/longterm-conditions-positive-practice-guide.pdf.
Department of Health, Macmillan Cancer Support & NHS Improvement. (2013). Living with and beyond cancer: taking action to improve outcomes. London: Department of Health.
Gordon-Dseagu. (2006). Cancer and Health Inequalities: An Introduction to Current Evidence. London: Cancer Research UK.
Hadert, A. (2013). Adapting cognitive behavioural therapy interventions for anxiety or depression to meet the needs of people with long-term physical health conditions. Unpublished doctoral dissertation, University of Exeter, Exeter.
Hobbie, W. L., Stuber, M., Meeske, K., Wissler, K., Rourke, M. T., Ruccione, K. et al. (2000). Symptoms of Posttraumatic Stress in Young Adult. Journal of Clinical Oncology, 18 (24), 4060-4066.
Layard, R. (2006). The case for psychological treatment centres. London: RL447.
Macmillan Cancer Support. (2013). Cured – but at what cost? Long-term consequences of cancer and its treatment. London: Macmillan Cancer
Support.
Macmillan Cancer Support. (2010). Routes from diagnosis. London: Macmillan Cancer Support.
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M. & Galea, A. (2012). Long-term conditions and mental health. The cost of co-morbidities. London: The Kings Fund.
National Institute for Health and Care Excellence. (March, 2005). Post-traumatic stress disorder (PTSD). The management of PTSD in adults and children in primary and secondary care. Manchester: NICE.
National Institute for Health and Care Excellence. (May, 2011b). Common mental health disorders. Identification and pathways to care. Manchester: NICE.
National Institute for Health and Care Excellence. (October, 2009a). Depression in adults. The treatment and management of depression in adults. Manchester: NICE.
National Institute for Health and Care Excellence. (October, 2009b). Depression in adults with a chronic physical health problem. Treatment and management. Manchester: NICE.
National Institute for Health and Care Excellence. (January, 2011a). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. Management in primary, secondary and community care. Manchester: NICE.
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