By Maria Woods, clinical nurse specialist
Special to NurseZone
People with cancer often have problems that are associated with their diagnosis, treatment and prognosis (Bottomley, 1997). According to Maguire et al (1978), up to 30 percent of women receiving treatment for breast cancer will develop anxiety or depressive illness within a year of diagnosis. In addition, psychiatric morbidity further increases when chemotherapy and/or radiotherapy is used (Hughson et al, 1986; 1987).
Women in Teesside who had breast cancer and were experiencing related mental health problems were not routinely being offered access to mental health services. Recognizing this gap in service provision, a senior sister in liaison psychiatry and a clinical nurse specialist in breast care joined forces in late 1999 to discuss the development of a system of assessment and rapid referral.
This article reports on a study carried out to investigate the feasibility of developing a nurse-to-nurse referral system to fast-track women who are experiencing such difficulties into mental health services. The aim was to ensure that those in need of support to deal with the emotional and psychological impact of breast cancer had access to appropriate services.
Liaison psychiatry is a branch of psychiatry that is devoted to dealing with mental health problems in acute hospitals. It developed in response to the increasingly specialist nature of medicine, which created a division between mental and physical health care, and the prevalence of mental ill health among patients treated in general hospitals.
The specialist breast care nurse is in an ideal position to monitor patients' adjustment to their diagnosis and treatment, identify those who need help and refer them to mental health services.
We devised a flowchart that identified the patient pathway, from initial referral and diagnosis through to two years after treatment. We chose Snaith and Zigmond's (1986) Hospital Anxiety and Depression (HAD) Scale as a tool to screen women at risk of developing mental health problems. The HAD scale is a self-report questionnaire developed to detect adverse anxiety and depressive states.
In the six months between March and August 2000, the breast care nurse used the HAD scale to assess all of the 48 women admitted for breast cancer surgery at one and six weeks after their surgery. If their HAD score was borderline (eight or more), they were offered a mental health assessment by the psychiatric liaison nurse. However, if their level of anxiety or distress was so high that it caused their functioning to diminish they were offered an earlier assessment.
Of the 48 women in the trial, 16 received a full mental health assessment. However, some women who fulfilled the criteria refused a mental health assessment. The reasons given for refusal included:
- They had already been prescribed treatment for anxiety/depression by their general practitioner and were showing signs of improvement;
- They were experiencing pressure from relatives who wanted to support their loved ones without 'outside help';
- They could not cope with involvement from another service and preferred to 'wait and see' how they felt in a few weeks or months;
- They refused because of the stigma associated with mental health problems.
The women who received a mental health assessment were given a Global Assessment of Functioning (GAF) score (American Psychiatric Association, 1994) by the psychiatric liaison nurse during the initial assessment and at the time of discharge. GAF scores are used to measure the effectiveness of mental health involvement and include the patient's social, psychological and occupational functioning on a hypothetical continuum of mental illness.
The psychiatric liaison nurse discussed each assessment with the liaison consultant psychiatrist or the specialist registrar to enable a formal World Health Organization ICD-10 (International Statistical Classification of Diseases and Related Health Problems) diagnosis (WHO, 2001) and for advice on medication.
The information was fed back to each patient's general practitioner, who remained her responsible medical officer. Equally, all professionals involved in the patient's care were kept regularly informed of her progress.
A variety of input was required to help and support those women who had anxiety and depression. Interventions included:
- Weekly contact time with the psychiatric liaison nurse, as required;
- Risk assessment;
- Monitoring of mental state;
- Monitoring of medication;
- Offering supportive therapy/cognitive interventions;
- Bereavement counseling;
- Liaising with the patient's employers and occupational health departments.
Three women are still in regular contact with the psychiatric liaison nurse. Twelve were referred back to the primary health care team and one was referred to the secondary mental health team. Throughout the period of the project there was ongoing and continual support from the breast cancer team.
Looking to the future
We were able to carry out this project because a bursary was granted to the psychiatric liaison nurse from the education sub-group of the Cancer Care Alliance of Teesside, South Durham and North Yorkshire. The project successfully identified women with breast cancer who were at risk of developing a mental health problem.
However, the challenge for us now is to develop a nurse-to-nurse service that is ongoing and supported. We aim to raise awareness of the mental health needs of cancer patients by presenting our work both locally and nationally and recognize the need for further research. In the short term we are devising a joint-documentation care pathway for breast cancer patients.
Source: Reproduced by kind permission of Nursing Times. Copyright Emap Healthcare, 2002. Nursing Times, VOL 98, NO 32, August 6, 2002.
Maria Woods, BSc, DipN, RM, SRN, is clinical nurse specialist, breast care, James Cook University Hospital, South Tees Acute Hospitals NHS Trust; Lyn Williams, DipHE, RMN, is senior sister in liaison psychiatry, St Luke's Hospital, Tees and North East Yorkshire NHS Trust.