Defining anxiety, depression and distress

There are variable meanings in the literature for both anxiety and depression. Anxiety is ‘a chronic state of tension, which affects both mind and body’ (p. 28)Reference Weller¹ and depression is explained as ‘a mental state characterised by excessive sadness, activity can be agitated and restless or slow and retarded. Behaviour is governed by pessimistic or despairing beliefs, and sleep, appetite and concentration are disturbed’ (p. 186)Reference Martin². Frequently co-existing with each other, the U.S. National Co-Morbidity Survey suggests that 51% of patients with depression are diagnosed with an additional anxiety disorder within a 1-year periodReference Massie³.

Studies should be reviewed with caution, as general terms such as distress and worry are commonly used, however, psychosocial distress is usually associated with depression and anxietyReference Sellick and Edwardson⁴. Generally, the literature describes distress as a multifactorial, unpleasant emotional experienceReference Greer⁵ impacting on psychosocial and spiritual wellness affecting an individual’s ability to cope with treatmentReference Pascoe, Neal, Allgar, Selby and Wright⁶, thus requiring some form of intervention. For the purpose of this article, distress will be defined as an emotional disturbance, significant enough to warrant professional, psychological or medical attention.

Prevalence of distress in oncology

Unsurprisingly, all cancer patients experience at least some level of distressReference Greer^5,Reference Pascoe, Neal, Allgar, Selby and Wright⁶, which is not just limited to the patient as the partner often suffers as wellReference Birnie, Garland and Carlson⁷. Following diagnosis, the typical sequence of emotions is initial shock/disbelief, anxiety, anger, guilt and depressionReference Boulton, Boudioni and Mossman⁸. The cancer trajectory can evoke constant, prolonged stress more apparent at the following significant times: awareness of symptoms, diagnosis, surgical intervention, treatment, follow-up and fear of recurrenceReference Gilbar and Neuman⁹.

Although researchers have measured anxiety and depression in oncology since the 1960s, the wide variation of reported prevalence is due to varying conceptualizations. Distress has been measured using a range of assessment methods, from brief self-report questionnaires to structured clinical interviews, with a range of classifications of distress used to assess different populations of patientsReference Massie³. Clinical depression is the most common psychiatric disorder in oncologyReference Hopko, Bell and Armento¹⁰, and clinical levels are estimated between 35 and 45%Reference Hopko, Bell and Armento^10,Reference Foley, Baillie, Huxter, Price and Sinclair¹¹, although Sellick and Edwardson (2007)Reference Sellick and Edwardson⁴ state one third of all cancer patients experience prolonged increased distress levels. Progress in the treatment of cancer has led to reduced mortality, making the understanding of psychological morbidity essential, with more patients surviving the disease and living with the consequencesReference Mystakidou, Tsilika, Parpa, Galanos and Vlahos¹².

Although a cancer diagnosis can generate an immense burden of fears, uncertainties, distress and psychological problemsReference Sellick and Edwardson^4,Reference Foley, Baillie, Huxter, Price and Sinclair^11,Reference Merckaert, Libert and Messin¹³ some studies claim the prevalence in oncology to be equal to that of the general populationReference Spiegel and Giese-Davis¹⁴; however, according to a meta-analysis of 58 studies, cancer patients develop significantly higher anxiety and depressionReference Massie³. Another meta-analysis suggests that depression and anxiety in oncology has decreased over the past two decades. This, in part, may be due to earlier diagnosis, improved treatments such as lumpectomy versus mastectomy, better medical outcomes and enhanced social supportReference Spiegel and Giese-Davis¹⁴.

There are some studies of the prevalence of psychological distress in paediatrics and adolescents with cancer, and it is widely accepted that they are no more depressed than that of the general populationReference Massie^3,Reference Grootenhuis and Last¹⁵. The results from this study demonstrate that this patient group are resilient in coping with their illness with positive emotional adjustment expected to facilitate in part the establishment of teenage cancer units; therefore, it will not be addressed within this article. However, as two thirds of children and adolescents now survive cancer, further research is indicated to establish how they can be best supported in the wider oncology settingReference Grootenhuis and Last¹⁵. The prevalence of distress in oncology patients will be discussed further.

Detection

The detection of anxiety and depression in oncology is a controversial subject, widely debated in the literature. Diagnosing clinically significant distress amongst cancer patients requires sensitivity as many symptoms of depression are very similar to those of some cancers themselves and may be treated differentlyReference Hopko, Bell and Armento^10,Reference Ciaramella and Poli¹⁶. For example, Cancer Research UK (2010)¹⁷ report that tumours positioned in the frontal lobe of the brain can cause personality changes including apathy, aggression and loss of inhibitions, whereas pituitary tumours are known to induce mood swings. Diagnostic assessment raises difficulties on both etiological and phenomenological groundsReference Newport and Nemeroff¹⁸. A subjective approach is vital when assessing both psychological and physical symptoms, for example, the level of pain or distress may only be measured based on what the patient says.

The two detection methods discussed in the literature are self-report questionnaires (i.e., HADS) and diagnostic clinical interviews. The Hospital Anxiety and Depression Scale (HADS) is the most widely accepted and commonly used instrument worldwide for screening clinically significant anxiety and depressionReference Massie^3,Reference Sellick and Edwardson^4,Reference Zenger, Brix, Borowski, Stolzenburg and Hinz¹⁹. HADS is a 4-point, 14-item self-report instrument, assessing depression (seven items) and anxiety (seven items)Reference Merckaert, Libert and Messin^13,Reference Zenger, Brix, Borowski, Stolzenburg and Hinz¹⁹. There are a number of other tools developed specifically for oncology, but this article will compare the two approaches, using HADS as an example of a commonly used assessment tool.

An easy-to-use, reliable and sensitive tool for assessing large numbers of cancer patients for psychological distress, HADS is described as an optimum balance between sensitivity and specificity. It appears to be patient friendly with one study of 3,548 patients reporting 97.7% returned and 85.5% completed.Reference Sellick and Edwardson⁴ HADS therefore has to be considered as a useful way of identifying distress. However, as with any screening tool, results may be influenced by reporting behaviour and may not always display an accurate reflection of actual sufferingReference Sellick and Edwardson⁴.

There are a number of screening tools used in oncology, that is, checklists that can highlight individuals’ problems, and these are often developed locally to be administered in the clinic and may be more appropriate than HADS, which is normally used by specialists. The interview allows a more subjective and personal assessment of each individual and can be combined with a tool such as to provide a comprehensive and meaningful assessment by a specialist.

Interventions to reduce anxiety and depression

There are several intervention techniques described in the literature that have shown to be effective in reducing anxiety and depression in oncologyReference Birnie, Garland and Carlson^7,Reference Boulton, Boudioni and Mossman^8,Reference Foley, Baillie, Huxter, Price and Sinclair^11,Reference Newport and Nemeroff^17,Reference Mathews, Ridgeway, Warren and Britton¹⁹, and patients who undergo any type of intervention generally cope better than those who receive none at allReference Spiegel and Giese-Davis^14,Reference Ramsay, Ramsay and Main²¹. These can be broken down into four main categories: cognitive behavioural therapy (CBT), counselling, drug therapy and complementary therapies. Greer (2008)Reference Greer⁵ emphasises the importance of establishing a rapport with patients, whichever intervention is used.

CBT is the dominant approach for treatment of a wide range of psychological disorders. Patients are taught to identify the negative automatic thoughts underlying their emotionsReference Boulton, Boudioni and Mossman^8,Reference Edelman and Kidman²², and therapy focuses on helping the patient reframe their thinking. In oncology, it is based on the premise that a patient’s psychological response to cancer will be dependant upon how well the patient appraises their disease (i.e., personal meaning) as well as the consequential physical effectsReference Greer⁵. The connection between thinking, behaviour and experience can be explored to promote more positive outcomes. Although CBT has not been widely tested in oncologyReference Boulton, Boudioni and Mossman^8,Reference Edelman and Kidman²², it has already demonstrated significant benefits in reducing emotional distress in some patientsReference Greer⁵.

Other methods of counselling can be employed, and through the skilled and principled use of relationships to facilitate self-knowledge, it can assist emotional acceptance, growth and the optimal development of personal resourcesReference Boulton, Boudioni and Mossman⁸. The increase in demand for counselling has resulted in many studies evaluating its effectiveness, demonstrating evidence of positive benefits for clients, including reduction in pain, psychological morbidity, physical symptoms and maladaptive coping responsesReference Boulton, Boudioni and Mossman⁸. However, it should be stated that counselling is not a panacea for all patients showing signs of depression and anxiety and in fact may not be helpful for some.

Many cancer patients are increasingly exploring the use of complementary therapies to ease symptoms and reduce anxiety. The World Health Organization (WHO) defines complementary and alternative medicine (CAM) as a comprehensive term used to refer both to traditional medicine and to various forms of indigenous medicineReference Hyodo, Amano and Eguchi²³. CAM therapies include either medication therapies involving the use of herbs, animal parts or minerals, or non-medication therapies, for example, acupuncture or manual therapy. CAM is increasingly being used in parallel to orthodox medicine, for the treatment of chronic diseases. One recent U.S. study of 3,461 patients suggests that it is used by more than 50%, with 24.3% reporting positive resultsReference Hyodo, Amano and Eguchi²³.

Drug therapy is used for the treatment of clinical depression in the general population, but its use is often viewed with caution in cancer patients. In fact, the National Institute for Health and Clinical Excellence (NICE, 2009) states that the use of drugs, that is, antidepressants should never be used routinely for the treatment of depressive symptoms or mild depression. Drugs should be considered as a last resort after psychosocial interventions, unless there is a previous history of moderate/severe depression, depression that complicates the care of a physical health problem or when depressive symptoms are present for at least 2 years. It is advised that only the newer antidepressants should be administered due to favourable side-effectsReference Newport and Nemeroff¹⁸. This is a conservative stance when one considers that the prognosis for many patients is less than 2 years.

We know that clinical depression is the most prevalent psychiatric disorder amongst cancer patients and is associated with significant functional impairment. Therefore, it is surprising that it remains an often under-diagnosed and untreated ‘side-effect’. In one small study consisting of 33 patients, only 6% of patients with clinical depression were identified by their oncologistsReference Hopko, Bell and Armento¹⁰.

Predicting psychological distress

The diagnosis of cancer is distressing for most patients, although after the initial shock some adjust surprisingly well. It would be useful to be able to predict which patients were most likely to worry, so scarce psychological intervention resources could be best utilizedReference Mathews, Ridgeway, Warren and Britton²⁰. There is a notion that some level of psychiatric distress is normal for patients with a serious illnessReference Massie^3,Reference Sellick and Edwardson^4,Reference Hopko, Bell and Armento^10,Reference Foley, Baillie, Huxter, Price and Sinclair^11,Reference Spiegel and Giese-Davis^14,Reference Lichtenthal, Nilsson and Zhang²⁴. Although many clinicians working in palliative care have speculated that the chance of a mental disorder increases as death approaches, this was not found to be the caseReference Lichtenthal, Nilsson and Zhang²⁴. In one study; 43 out of 100 clinicians (43%) admitted they often use disease severity to anticipate any likely distress; however, the prognostic category of cancer was not found to be significantly relatedReference Mathews, Ridgeway, Warren and Britton²⁰. These findings begin to address outstanding questions regarding the course of depression and anxiety disorders near the end of life, which challenge the assumption that mental health problems are exacerbatedReference Lichtenthal, Nilsson and Zhang²⁴.

Alternatively, as distress at the end of life is so often considered normal, it may result in health workers overlooking or under-treating symptoms. Some studies suggest clinicians underestimate the level of psychological morbidity amongst more severely depressed terminally ill cancer patientsReference Massie^3,Reference Sellick and Edwardson^4,Reference Hopko, Bell and Armento^10,Reference Merckaert, Libert and Messin^13,Reference Mathews, Ridgeway, Warren and Britton^20,Reference Lichtenthal, Nilsson and Zhang²⁴. In one study consisting of 585, depression was found to be a predictor of disease progression and mortality, with 58.5% of terminally ill patients openly discussing assisted suicideReference Spiegel and Giese-Davis¹⁴. However, the reliability of this statement is questionable, with the study failing to use a validated measure of depression.

Psychological distress may be a reaction to the unique challenges of cancer or may be instigated by underlying vulnerability to anxiety and depression disordersReference Foley, Baillie, Huxter, Price and Sinclair^11,Reference Spiegel and Giese-Davis^14,Reference Ciaramella and Poli^16,Reference Mathews, Ridgeway, Warren and Britton²⁰ with previous psychiatric diagnosis associated with poor emotional outcomeReference Spiegel and Giese-Davis^14,Reference Ciaramella and Poli^16,Reference Newport and Nemeroff^18,Reference Mathews, Ridgeway, Warren and Britton²⁰. Unsurprisingly, patients with a history of anxiety and depression at the time of admission were found to hold more psychological distress during the course of their treatment. Tumour stage, sex, depressive symptoms, openness to discussion, available support, disease symptoms and size of social network could be used to accurately predict the likeliness of depression 3 years after treatmentReference Massie³.

Social isolation, personal/family history of depression, drug abuse, socio-economic pressures, conforming personality style, pain and pre-morbid coping skills are all psychiatric risk factorsReference Newport and Nemeroff¹⁸. The presence of pain also increases the chance of depressionReference Spiegel and Giese-Davis^14,Reference Ciaramella and Poli^16,Reference Mathews, Ridgeway, Warren and Britton^20,Reference Wong-Kim and Bloom²⁵ although it could be argued that the depression itself enhances the intensity of the pain. Cancer treatment–related factors may also be a significant predictor with several chemotherapy agents, steroids and analgesics linked with increased psychological morbidityReference Ciaramella and Poli¹⁶. Invasive surgery and radiotherapy regimes also increase the likelihood of psychological distressReference Ciaramella and Poli^16,Reference Wong-Kim and Bloom²⁵, and clinical depression is particularly associated with oropharyngeal, pancreatic, breast and lung cancersReference Massie^3,Reference Ciaramella and Poli¹⁶. Although these predictors may be useful, the factors affecting the individual’s ability to cope should be considered rather than disease site.

Individual patient coping mechanisms

A person’s ability to cope with cancer can have a direct impact on levels of distress. In one study, the factor most associated with distress was found to be dwelling on the initial clinic visit, as attending the clinic reminded patients of having cancerReference Gilbar and Neuman⁹. At this point, more attention should be paid to the patient’s individual thoughts, and routine questioning could be used to alert staff when more formal psychosocial support is requiredReference Pascoe, Neal, Allgar, Selby and Wright^6,Reference Mathews, Ridgeway, Warren and Britton²⁰. The practise of routine psychological assessment could be introduced in all hospitals involved in the care of cancer patients, and general predictive categories such as cancer site or treatment should not be solely relied upon as indicator as all patients are individuals.

Patients are not always aware of the potential benefits of psychological interventions, and it is important to identify patients who may not desire psychological support as their reluctance may be explored. Regular screening for distress and desire for support would allow implementation of interventions tailored to both the patient’s needs and desiresReference Merckaert, Libert and Messin¹³. Furthermore, the patient’s reluctance to disclose their current mood is often a result of fear of being labelled as a burdenReference Sellick and Edwardson⁴, whereas the stigma of being associated with anything “mental” can be unappealingReference Gilbar and Neuman⁹. These findings highlight the need to inform patients about the psychological consequences of cancer, the available support and the potential benefits of such supportReference Merckaert, Libert and Messin¹³.

The way patients adjust along their cancer journey depends on their individual innate coping strategies/responses. A recent meta-analysis suggests that emotional repressiveness is a predictor of cancer incidence, and this repressive emotional trait has been termed the cancer personality Reference Spiegel and Giese-Davis¹⁴. They postulate that a tendency to over control has been associated with an elevated risk of cancer incidence and disease progression, and those patients who reported extreme suppression were at higher risk of cancer. These people had never or no more than twice, during their adult lives, openly shown anger, almost always concealing their feelings. Although the reliability of this statement is both questionable and unproven, the study shows that those who tend to consciously suppress such emotions are more likely to experience anxiety and depression. It could therefore be suggested that a patient’s handling and reporting of emotional distress may contribute to both depression and possibly disease progressionReference Spiegel and Giese-Davis¹⁴.

Based on the theory of cognitive adaptation; positive personality factors help people to cope with critical life events.Reference Zenger, Brix, Borowski, Stolzenburg and Hinz¹⁹ Optimism was found to co-occur with helpful coping strategies, like seeking out supportReference Greer^5,Reference Zenger, Brix, Borowski, Stolzenburg and Hinz^19,Reference Ramachandra, Booth, Pieters, Vrotsou and Huppert²⁶, and depression is three times more likely in terminally ill patients, who failed to acknowledge their prognosisReference Massie³. Over the last few decades, the influence of personality factors such as optimism has attracted growing interest. Pessimistic patients with low levels of optimism were at higher risk of developing anxiety and depression disorders, resulting in poorer quality of lifeReference Massie^3,Reference Foley, Baillie, Huxter, Price and Sinclair^11,Reference Zenger, Brix, Borowski, Stolzenburg and Hinz¹⁹.

Helplessness is a negative coping response associated with increased emotional distress, whereas positive psychological attributes such as fighting spirit and resilience are undervalued in the literatureReference Greer⁵. The definition, aetiology and measurement of personal attributes, variously referred to as resilience, hardness and fighting spirit, provide a more holistic consideration for the patientReference Sellick and Edwardson⁴ and therefore warrant further investigationReference Greer⁵. Indeed, patients are bound to have different traits in their personality, which contribute to their ability (or inability) to cope. Becoming familiar with a patient and taking certain aspects of their personality into consideration should give rise to more appropriate personalized management.

The benefits of psychological interventions

Oncology has traditionally focused on pathological outcomes, but the need for psychosocial support has become obvious, and it is important that health care professionals become informed about the psychological strategies available. Clinicians should, however, consider pharmaceutical therapy in addition to psychiatric interventions in more severe casesReference Gilbar and Neuman^9,Reference Newport and Nemeroff¹⁸.

One study that employed ‘humanistic counselling’ focused on the experiences of the individual or their own perceptions. Very positive attitudes were expressed; almost all patients believed they had benefited from the support whilst they confronted fears of deathReference Boulton, Boudioni and Mossman⁸. Counselling helped patients work through powerful thoughts and emotions, coming to terms with their disease and regaining a sense of control. Peer-group counselling has been successfully implemented in many areas and could potentially out-perform individual counselling, lending patients a sense of parity, equivalence and shared destiny, as well as helping and advising fellow sufferersReference Ramsay, Ramsay and Main²¹.

The high level of perceived benefits counselling offers could possibly be due to methodological issues, such as selection bias and social desirability, or even the characteristics of patients that seek out counselling. Patients are self-referred and perceived themselves to have a problem that could be helped by counselling, at a time during their journey when they were ready. However, one could argue counselling provides a wide range of benefits to patients who view their problems as amenable to this form of intervention and therefore is highly valuable in a self-selected patient population. However, for some patients, attending what they thought of as specialist cancer counselling created an expectation for medical advice. They described their experience as frustratingly Abstract and reflective; as one patient put it, ‘I felt like a parrot repeating things’ (p. 132).Reference Boulton, Boudioni and Mossman⁸ Nevertheless, although they themselves gained little benefit, these patients generally seemed to maintain confidence in counselling itselfReference Boulton, Boudioni and Mossman⁸.

Interventions focusing on mental awareness and frequency of positive thoughts could have a better impact than interventions specifically targeting relief of symptoms, reducing psychiatric morbidity and improving quality of lifeReference Ramachandra, Booth, Pieters, Vrotsou and Huppert²⁶. Meditative practices, with the use of mindfulness techniques, to reduce anxiety and depression have been suggestedReference Foley, Baillie, Huxter, Price and Sinclair¹¹. Clinical trials have supported the use of mindfulness based stress reduction (MBSR), where patients are taught to pay more attention to their own thoughts, to become more aligned in their psychological adjustment during their cancer journey. MBSR is beneficial for both cancer patients and their partners for reducing mood disturbance as well as symptoms of distressReference Birnie, Garland and Carlson⁷.

Mindfulness-based cognitive therapy (MBCT) is a recent refinement of MBSR for depression, focusing more specifically on the rumination that frequently maintains recurrent depressive episodes. Ruminative processes have been identified as significant etiological factors for anxiety and depression; therefore, the effectiveness of MBCT for cancer patients needs to be established. From the first randomized controlled trial of MBCT in oncology, 3-month post-intervention feedback indicated that treatment gains were consistently positive and maintained. These results should be reviewed with caution, however, as the self-selecting patients could have been particularly motivated to engage in the programme and more extensive research is requiredReference Foley, Baillie, Huxter, Price and Sinclair¹¹.

Responsibilities of health professionals for detection and screening

There is a limited role played by general practitioners in primary care, with recognition of symptoms, investigation and referral. Identification and treatment of psychological problems are not formally recognized or integrated into existing primary care structures. This may be partially due to lack of communication between primary and secondary care, ‘only one in five general practitioners had received a report from their corresponding oncologist after initial consultation’Reference Pascoe, Neal, Allgar, Selby and Wright⁶. It is suggested that primary care resources are scarce, and with general practitioner’s limited knowledge of psychiatric symptoms and diagnosis inadequate to effectively assess mood disorders, this perhaps has lead to a less-than-optimum serviceReference Hopko, Bell and Armento¹⁰.

The detection and intervention of anxiety and depression in oncology is almost exclusively undertaken in secondary care and will remain this way until the role of primary care is more firmly establishedReference Pascoe, Neal, Allgar, Selby and Wright⁶. An overall management system for the detection and intervention for psychosocial problems, using community and primary care, may improve service to patients. If we consider the management of diabetes, for example, the role of primary care is well understood with general practitioners and nurses being able to provide emotional support and reassurance, tailored to the specific needs of the patient. Therefore, a range of interventions for psychological problems could be offered by primary care health professionals, and work is required to implement thisReference Pascoe, Neal, Allgar, Selby and Wright^6,Reference Ramsay, Ramsay and Main²¹.

All members of the multi-disciplinary team should take more responsibility not only for routine screening but also for placing a greater emphasis on their own duty to communicate the needs of patients directly with each other. Liaising with other allied health professionals about the care of individual patients provides opportunities for constructive advice, professional development and increased job satisfaction whilst contributing towards a forward thinking, patient-centred culture in our service.

Some clinicians consider psychological therapy for the cancer patient as a futile exercise, as emotional distress is simply a normal, appropriate response. This attitude needs eliminating from our service, as the benefits of therapy in reducing anxiety and depression are evidentReference Greer^5,Reference Spiegel and Giese-Davis^14,Reference Ramsay, Ramsay and Main²¹. It is imperative to differentiate anxiety and depression from the expected physical symptoms of the disease, and health care professionals need to be alert to suspected psychological morbidityReference Sellick and Edwardson^4,Reference Pascoe, Neal, Allgar, Selby and Wright^6,Reference Edelman and Kidman^22,Reference Lichtenthal, Nilsson and Zhang²⁴. An increased awareness and training amongst all health professionals in oncology is needed, as too often they fail to recognise distress, with their lack of knowledge, forcing them to rely on superficial signs.Reference Fukui, Ogawa, Ohtsuka and Fukui²⁷

Recommendations for clinical radiotherapy practice

Studies suggest only a small percentage of patients are diagnosed with psychological problems in radiotherapy, due to under-reporting of symptoms, lack of awareness or understanding of available services and under-recognition of symptoms by some health care professionalsReference Pascoe, Neal, Allgar, Selby and Wright⁶. There is a need for a multi-disciplinary screening approach and routine questioning by health care professionals; in particular, therapy radiographers could contribute to the holistic assessment of patients and refer appropriately when formal psychosocial support is requiredReference Mathews, Ridgeway, Warren and Britton²⁰. Problems usually remain undetected until their adverse impact on quality of life is severe; therefore, the service could undertake a more pro-active approach, meeting the needs of patients and families rather than waiting for a crisisReference Sellick and Edwardson⁴.

The time constraints placed on therapy radiographers (roughly 12 min per patient contact) mean additional duties such as referral could be difficult to implement. However, one of the primary roles of the therapy radiographer should be to provide the patient with the opportunity to disclose any psychological concerns. This could be facilitated via a simple questionnaire, that is, concerns checklist to identify those that require full psychological assessment. It is important to consider that whilst this may be deemed time-consuming for every patient, only a proportion of patients would need such a specialist referral thus enabling the prioritization of patients relative to the resources of the service.

Some therapy radiographers, although very competent, lack the ability and/or desire to empathise and emotionally reach out to patients. They are in a unique situation to be able to assess the patient’s emotional needs as a consequence of the familiarity and trust established during daily treatment sessions. This prime position should enable contribution towards timely referral to the appropriate specialist. In addition, more deliberate and routine communication across the radiotherapy multidisciplinary team, including counsellors and psychologists, is paramount to a more effective service.

Radiotherapy should not be a profession whereby success is judged solely on 5-year survival rates. The detection and intervention of psychological problems should be well integrated into the overall management of patients, and thus success is directly related to patient outcomes, including psychological adjustment. Where currently successful referral of a patient to psychological care by therapy radiographers is perceived as an ‘add-on’, there should be an expectation that all patients are competently assessed by this professional group, which arguably has more contact with the cancer patient than any other.

Areas for future research

Generally, the more narrowly depression and anxiety are defined, the lower the prevalence is reported. Symptoms occur on a broad spectrum, ranging between sadness and major affective disorder, making the study of anxiety and depression challengingReference Massie³. The methodology deployed is a significant variable responsible for the wide range of prevalenceReference Massie^3,Reference Hopko, Bell and Armento^10,Reference Merckaert, Libert and Messin^13,Reference Ciaramella and Poli^16,Reference Newport and Nemeroff^18,Reference Lichtenthal, Nilsson and Zhang²⁴, and rates can be measured between 3.7% and 58%Reference Sellick and Edwardson^4,Reference Hopko, Bell and Armento^10,Reference Merckaert, Libert and Messin^13,Reference Ciaramella and Poli^16,Reference Ramachandra, Booth, Pieters, Vrotsou and Huppert²⁶. The main variations amongst studies are diagnostic tool (interview vs. scale), definition of depression, clinical staging, time since diagnosis, previous cancer treatment, previous treatment for depression and hospitalization statusReference Newport and Nemeroff¹⁸. The lack of standardization, in terms of populations studied, assessment instruments, cut-off scores, type of interview/diagnostic criteria employed and disease site/stage also contribute to the wide variation in prevalence of psychological distressReference Massie³.

The effects of cancer treatment as well as non-cancer-related variables that affect mood are often not considered amongst the literature; for example, cytotoxic drug and hormone use are seldom presented in study data. Few studies note the time of onset of depression or correlated patient’s history of depression with current distress or functioning. Furthermore, a significant proportion of patients with a good psychiatric and emotional response to cancer may not be accounted for, as these patients could also be recruited into intervention studiesReference Massie³. Alternatively, many studies are orientated towards the patients who are fit enough to take part, with some clinicians omitting severely ill patientsReference Merckaert, Libert and Messin¹³. Thus, a clear picture of the prevalence of anxiety and depression in oncology patients has yet to be established.

Few studies have examined the predictive utility of psychological assessment tools for detecting distress in oncology, whereas the sparse studies that do exist have generally focused on cancer-specific sites (e.g., breast or head and neck). This may not have the same predictive value amongst a broader range of cancer types, limiting understanding of the phenomenology of depression experienced by the cancer patientReference Hopko, Bell and Armento¹⁰. Patients are often grouped into broad categories (i.e., palliative care/terminally ill), which do not capture the diversity of such samples, whereas comparing patients at various times in their own ‘cancer journey’ could enhance our understanding of the transition of psychiatric conditions over timeReference Lichtenthal, Nilsson and Zhang²⁴. However, the aim of capturing a more holistic view is complex as patients cannot be categorized like stamps in a collection; they should be acknowledged as individual people with a wide range of different psychosocial factors impacting their well-being, and this makes research problematical and ultimately contestable.

Longitudinal detection of psychological distress is rare, with the majority of studies assessing anxiety and depression with self-report questionnaires varying in quality, rather than using diagnostic interviewsReference Spiegel and Giese-Davis^14,Reference Mathews, Ridgeway, Warren and Britton²⁰. Regardless of which screening tool is used, they must be deemed valid and reliable, easily understood and completed and easily scored and interpretedReference Sellick and Edwardson⁴. A ‘biosocial model’ combining biological/clinical, psychological and social variables would more accurately describe depressive symptomsReference Wong-Kim and Bloom²⁵. A prospective, longitudinal investigation of an ethnically and geographically diverse sample of patients, at various points in time, would provide the best available data for baseline assessmentReference Lichtenthal, Nilsson and Zhang²⁴.

It is useless to employ more than one or two tools as many patients are not interested in completing long questionnaires. Self-assessment questionnaires are often compiled on a few items, are economical and easy to fill inReference Bonacchi, Rossi and Bellotti²⁸, whereas structured clinical interviews can be advantageous for the detection of anxiety and depression, allowing for adaptations to be made by the evaluating health professionalReference Lichtenthal, Nilsson and Zhang²⁴. From a clinical perspective, interviews have a pivotal role in the evaluation of practice and the ability to access psychological support, providing an opportunity for patients to ask for support. They are arguably the best method of screening clinical depression in cancer patientsReference Hopko, Bell and Armento^10,Reference Newport and Nemeroff^18,Reference Ramachandra, Booth, Pieters, Vrotsou and Huppert²⁶, A study of 285 patients demonstrated that 44.1% requested support during their interview yet failed to do so in their initial questionnairesReference Bonacchi, Rossi and Bellotti²⁸. It is, however, important to recognise that screening tools are not diagnostic tools and only with the help of specific instruments following referral to mental health services can a psychiatric diagnosis be confirmedReference Sellick and Edwardson⁴.

Outcomes of psychological interventions should be measured in a way which allows clinical effectiveness to be assessed. Within the literature, there is a preference for randomised controlled trials and most studies use standardized quantative instruments for measurement. However, these measures overlook an important dimension; the patient’s own perception of the benefits which they derive. For example, the benefits of counselling are not well captured by standard research instruments, but using client-defined outcomes may provide a sensitive way of gauging the true value of counselling in cancer patientsReference Boulton, Boudioni and Mossman⁸.