Nursing Assessment of Depression Among Palliative Care Cancer Patients:

Specialist palliative care nurses' management of the needs of patients with depression

BACKGROUND

Depression is an important condition to consider if we are to optimise the care outcomes for patients with palliative care needs. Depression has a high incidence in palliative patients, with up to 15% diagnosed with major depression and 37% expressing some form of depressive symptoms ( O'Connor et al, 2010 ). The challenge is to ensure that palliative care patients with depression are identified in a timely manner and that their depression is effectively managed.

AIM

To examine how Australian specialist inpatient palliative care nurses perceive, assess and respond to depression in a patient case study.

METHOD

This descriptive pilot study is a replication of a United States study by Little et al (2005) , exploring contemporary Australian specialist palliative care nurses' screening, assessment and management of depression in people with a progressive life-limiting illness. A survey titled 'Specialist palliative care nurses managing patients with complex care needs' questioned the nursing assessment, knowledge and clinical care priorities related to a case vignette of a patient demonstrating signs of depression.

RESULTS

A total of 33 nurses completed this survey. Less than half (39.4%) of the participants identified depression as a major issue arising from the case vignette. Depression screening tools were not widely known. Functionality assessments measuring activities of daily living were the most recognised and widely used tools by participants.

CONCLUSION

This small sample pilot study demonstrated that specialist palliative care nurses are still not confident in their screening and responding to a patient with depression. The available evidenced based depression screening tools were unfamiliar to these nurses and not widely used which can result in depression remaining undetected and undermanaged. The connections between physical health and mental health need stronger recognition and response within nursing care of palliative patients.

Nurses' perceptions of depression in patients with cancer

OBJECTIVE

Our study aimed at examining nurses' perceptions of depression in cancer patients and their role in its management.

METHOD

We employed questionnaire-based semi-directed interviews. Participants were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as "very important," "important," "less important," or "not important" for the diagnosis of depression in cancer patients at two different timepoints (baseline and after a video education program). They were also asked to complete a questionnaire exploring their perceptions about depression and of their role in its systematic screening. We recruited nurses caring for cancer patients from four different departments (palliative care unit, hematology, medical oncology, and thoracic oncology) at an academic medical center.

RESULTS

We interviewed 18 nurses and found that they had a good general knowledge of depression in cancer patients, with the majority of them being able to distinguish specific and important symptoms from nonspecific symptoms. Some nurses considered depression as a second-line symptom, and most did not employ a screening tool in their daily practice. All considered that they had a role to play in the management of depression, even as they acknowledged lacking specific training for that task.

SIGNIFICANCE OF RESULTS

Our results suggest that limited resources—especially lack of training—affects nurses' ability to correctly manage depression in their cancer patients.

[Depression and advanced cancer: agreement between different screening strategies]

Depression is a frequent problem in advanced cancer patients. However, there is no systematic screening for depression in the majority of cancer center resulting in underdiagnosed depression among cancer patients. The main objective of this study was to assess the level of agreement between self-reported depression by the patient and the physician and nurse assessment using the same tools. One of the secondary objectives was to estimate the possibility of a systematic and repeated (at one month) assessment. We used two scales for depression screening: the Brief Edinburg Depression Scale (BEDS) and the depression item of the Edmonton Symptom Assessment System (ESAS). Twenty-nine patients were included and eight of them (28%) had a BEDS score >6 and benefited from the initiation or modification of their antidepressant treatment. At visit 2, 15 patients were seen again and BEDS score was found ≤6 for all of them. A moderate concordance was found between assessment using the BEDS by patient and physician's (κ=0.519) and low agreement was found between physician and nurse regardless of the tool used (κ from 0.071 to 0.313). Researches with larger cohorts are now needed to confirm the benefits of depression's screening in this frail population and also to assess available strategies.

Depression assessment by oncologists and palliative care physicians

Objective:

Depression is a frequent problem in cancer patients, which is known to reduce quality of life; however, many cancer patients with depression are not treated because of the difficulties in assessing depression in this population. Our aim was to evaluate and improve the depression assessment strategies of palliative care (PC) physicians and oncologists.

Method:

We invited all medical oncologists and PC physicians from three cancer centers to participate in this multicenter prospective study. They were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as “very important,” “important,” “less important,” or “not important” for the diagnosis of depression in cancer patients, at three different time points (at baseline, after a video education program, and after 4 weeks). They were also asked to complete a questionnaire exploring physicians' perceptions of depression and of their role in its systematic screening.

Results:

All 34 eligible physicians participated. Baseline performance was good, with >70% of participants correctly classifying at least seven of nine related and specific symptoms. We found no significant improvement in scores in the immediate and 4-week follow-up tests. Additionally, 24 (83%) and 23 (79%) participants expressed support for systematic depression screening and a role for oncologists in screening, respectively.

Significance of results:

Oncologists had good baseline knowledge about depression's main symptoms in cancer patients and a positive attitude toward being involved in screening. Underdiagnosis of depression is probably related to problems associated with the oncology working environment rather than the physicians' knowledge.

A brief guided self-help intervention for psychological distress in palliative care patients: a randomised controlled trial

BACKGROUND

Previous findings implicated rumination (recurrent dwelling on abstract concerns) in elevated psychological distress in palliative patients. We hypothesised that reducing rumination may be important in addressing psychological distress in palliative care.

AIM

This study tested the prediction that a brief guided self-help technique targeting abstract rumination would reduce psychological distress in palliative patients.

DESIGN

A randomised controlled trial evaluated 4 weeks of guided self-help that involved patients practising thinking more concretely by recalling specific and vivid memories of when they were completely absorbed in an activity or scene. Participants completed a combination of standardised questionnaires to assess anxiety, depression, and quality of life.

SETTING/PARTICIPANTS

Palliative care patients who were reporting clinically significant psychological distress, whilst also physically well enough to take part in the trial were recruited from hospices in Devon and Somerset and randomised to either a treatment condition (n = 19) receiving 4 weeks of guided self-help, or a waiting-list control condition (n = 15) receiving treatment as usual.

RESULTS

As predicted, the palliative patients receiving the intervention reported significantly greater reductions in anxiety than the waiting-list controls (F(1,23) = 20.55, p < 0.001, partial η (2) = 0.47). However, no significant effect was found on depression or quality of life.

CONCLUSION

The findings suggest that a brief guided self-help intervention based on concreteness training can be effective in addressing anxiety in palliative care.

Depression and anxiety in palliative care inpatients compared with those receiving palliative care at home

OBJECTIVE

This study compared the prevalence of anxiety and depression as measured on the Hospital Anxiety and Depression Scale (HADS) in palliative care patients being treated at home with those being treated as inpatients.

METHOD

The participants were palliative care patients being treated at home (n = 46) and palliative care inpatients (n = 46). Subjects were assessed for functionality on the Karnofsky Performance Status Scale (KPS) and anxiety and depression were measured on the HADS.

RESULTS

The results showed that ~20% of all patients were depressed and anxious as measured on the HADS, regardless of the cutoff criteria. There was no significant difference in depression and anxiety between the two groups when socioeconomic status and functionality were controlled for. Functionality, as measured on the KPS, was uniquely a predictor of depression, and younger patients were shown to have greater anxiety.

SIGNIFICANCE OF RESULTS

The results suggest that home-based palliative care patients and palliative care inpatients should receive equal psychological support, and that clinicians need to be aware of the psychological vulnerability of younger and less-functional patients. The prevalence of depression and anxiety indicates that all palliative care patients should be screened for psychological distress, to identify those who need further assessment and treatment.

Association between patient-reported symptoms and nurses' clinical impressions in cancer patients admitted to an acute palliative care unit

BACKGROUND

Clinicians typically rely on their own or the nurses' clinical impression (NI) of symptoms rather than patient self-reports. It is unclear whether these means of assessment yield similar results.

OBJECTIVE

To prospectively compare patient-reported symptoms on a modified Edmonton Symptom Assessment System (ESAS) with NI scores.

METHODS

Consecutive patients with advanced cancer admitted to our acute palliative care unit between April and July 2010 were studied. We collected the results of the ESAS on the day of admission (D1) to the unit and 2 days later (D3). We also collected the NI of each patient's physical and psychological distress on D1 and D3.

RESULTS

One hundred eighteen patients completed the ESAS on D1 and 116 on D3. On D1 there was no significant association between NI score and ESAS assessment except for dyspnea, which was weakly correlated with NI score for physical distress (r=0.22, p=0.02). The median ESAS physical and psychosocial scores were 31 and 12 in patients with NI of low or no physical distress, versus 34 (p=0.07) and 15 (p=0.18) in patients with NI of moderate or severe distress, respectively. On D3, we found a significant association between ESAS and NI only for pain (r=0.32, p<0.001) and anxiety (r=0.30, p=0.001). Sensitivity and specificity of the NIs for ESAS scores were low on both days.

CONCLUSION

The clinical impression of highly trained palliative care nurses showed poor association with patient-reported symptom intensity. Validated symptom assessment tools are needed for bedside clinical assessment.

Palliative care nurses' experiences of training in cognitive behaviour therapy and taking part in a randomized controlled trial

BACKGROUND

This article describes the experiences of clinical nurse specialists in a palliative homecare team who took part in a cluster randomized controlled study. The study aimed to determine whether palliative care nurses given basic training in cognitive behavioural therapy (CBT) were able to use core components of this training when treating advanced cancer patients with anxiety or depression.

METHOD

Fifteen nurses were randomly allocated to either receive training in cognitive behavioural techniques or to continue their practice as usual. Nurses were interviewed following the CBT training and after the research study.

RESULTS

The CBT group reported a positive change in their approach to patients. Nurses felt empowered, more skilled and effective not only to assess and support patients with symptoms of anxiety and depression but also to facilitate change. In addition, nurses placed considerable value on being given a psychological model and set of interventions.

CONCLUSIONS

Nurses found taking part in the study demanding in terms of time and commitment; however, the authors conclude that research in the community palliative care setting is feasible.

A qualitative study assessing mental health issues in two hospices in the UK

This study is a qualitative investigation into the experiences of assessing mental health issues by members of staff from two hospices in the UK. Nine individual interviews were held with doctors and nurses from the two hospices using semi-structured interviews. The research method used was grounded theory and the emerging data were analysed using the computer software Atlas.ti. The analysis was conducted around the four main research questions: 'How is mental health assessed in the hospices?', 'What are the staff members' feelings about doing these assessments?', 'How does assessment information inform clinical practice?' and 'What are the perceived training needs of staff?' The findings show that mental health is, to some extent, being assessed within these two hospices; however, no formal assessment strategy is in place. The majority of staff interviewed had very limited experience and/or training in the field of mental health and expressed a lack of confidence when dealing with mental health-related issues. A list of training needs has been identified. On the basis of these findings, recommendations have been made to improve the assessment procedures currently used within these two hospices.