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 pilot study of cognitive behavioural therapy and relaxation for migraine headache: a randomised controlled trial.

Headache is being viewed more commonly in a biopsychosocial framework, which introduces the possible utilisation of psychological treatment options, such as cognitive behavioural therapy and relaxation. No such treatments have been trialled in the UK. We conducted a randomised controlled pilot trial, comparing a brief guided self-help CBT and relaxation treatment with standard medical care (SMC), in a UK NHS setting. Participants were recruited from specialist headache clinics across London. Participants were randomised to receive either treatment or standard medical care. Our objective was to provide design information necessary for a future definitive trial of the SHE treatment, including, recruitment/retention rates, acceptability of randomisation, treatment fidelity and estimations of mean and variances of outcome measures. From the initial 275 patients identified, 73 were randomised. There was no difference in drop-out rates between SMC and treatment groups. Of the 36 participants randomised to receive treatment, 72% attended all sessions. Findings show that a future definitive trial of the SHE treatment is feasible, with small modifications of protocol, within a UK NHS context.

Adjuvant psychological therapy for patients with cancer.

Cancer-related psychosocial morbidity has been documented in a substantial minority of patients. In some patients, such morbidity persists for many years even when they are free of disease. Consequently, methods of reducing psychosocial morbidity by psychological treatment should be investigated. We describe Adjuvant Psychological Therapy (APT)--a brief treatment programme designed specifically for patients with cancer. APT is currently being evaluated in a randomized, controlled study at The Royal Marsden Hospital.

Patients' adjustment to cancer: the Mental Adjustment to Cancer (MAC) scale vs clinical ratings.

Broad categories of adjustment to cancer were originally identified clinically. Subsequently, a self-rating questionnaire--the MAC (Mental Adjustment to Cancer) scale--was developed to measure these categories of adjustment. We report here a validation study of the MAC scale. Fifty-four consecutively referred patients with various cancers were given the MAC scale. The patients' adjustment to cancer was also rated clinically by two psychiatrists who had no knowledge of the MAC scale scores. Statistical comparisons between these scores and the clinical ratings are reported. The level of agreement obtained was 79%--Kappa 0.72.

Women who experience domestic violence and women survivors of childhood sexual abuse: a survey of health professionals' attitudes and clinical practice.

Health professionals do not wish to routinely screen women for a history of domestic violence or childhood sexual abuse. However, over 80% believe that these are significant health care issues. Routine screening should not be prioritised until evidence of benefit has been established.

Adjuvant psychological therapy for patients with cancer: a prospective randomised trial.

OBJECTIVE: To determine the effect of adjuvant psychological therapy on the quality of life of patients with cancer. DESIGN: Prospective randomised controlled trial comparing the quality of life of patients receiving psychological therapy with that of patients receiving no therapy, measured before therapy, at eight weeks, and at four months of follow up. SETTING: CRC Psychological Medicine Group of Royal Marsden Hospital. PATIENTS: 174 patients aged 18-74 attending hospital with a confirmed diagnosis of malignant disease, a life expectancy of at least 12 months, or scores on various measures of psychological morbidity above previously defined cut off points. INTERVENTION: Adjuvant psychological therapy, a brief, problem focused, cognitive-behavioural treatment programme specifically designed for the needs of individual cancer patients. MAIN OUTCOME MEASURES: Hospital anxiety and depression scale, mental adjustment to cancer scale, Rotterdam symptom checklist, psychosocial adjustment to illness scale. RESULTS: 156 (90%) patients completed the eight week trial; follow up data at four months were obtained for 137 patients (79%). At eight weeks, patients receiving therapy had significantly higher scores than control patients on fighting spirit and significantly lower scores on helplessness, anxious preoccupation, and fatalism; anxiety; psychological symptoms; and on orientation towards health care. These differences indicated improvement in each case. At four months, patients receiving therapy had significantly lower scores than controls on anxiety; psychological symptoms; and psychological distress. Clinically, the proportion of severely anxious patients dropped from 46% at baseline to 20% at eight weeks and 20% at four months in the therapy group and from 48% to 41% and to 43% respectively among controls. The proportion of patients with depression was 40% at baseline, 13% at eight weeks, and 18% at four months in the therapy group and 30%, 29%, and 23% respectively in controls. CONCLUSIONS: Adjuvant psychological therapy produces significant improvement in various measures of psychological distress among cancer patients. The effect of therapy observed at eight weeks persists in some but not all measures at four month follow up.

A cluster randomized controlled trial of cognitive behaviour therapy for common mental disorders in patients with advanced cancer.

BACKGROUND: Cognitive behaviour therapy (CBT) has been shown to reduce psychological morbidity in people with cancer, but no randomized controlled trial (RCT) exists in palliative care. We aimed to determine whether home care nurses could be taught to deliver basic cognitive behavioural techniques and so reduce symptoms of anxiety and depression. METHOD: Clinical nurse specialists (CNSs) at St Christopher's Hospice were randomly allocated to receive training in CBT or continue their usual practice. At the end of the trial, nurses were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Home care patients who scored as possible cases on the Hospital Anxiety and Depression Scale (HADS) entered the trial. Participants received home care nursing visits. Assessments were carried out at baseline, 6, 10 and 16 weeks. RESULTS: Eight nurses received CBT training and seven continued practice as usual. The mean CTFARS scores were 35.9 for the CBT nurses and 19.0 for the controls (p=0.02). A total of 328 patients (54%) were possible cases and 80 entered the trial; most of those excluded were too ill to participate. There was an interaction between group and time: individuals receiving CBT had lower anxiety scores over time [coefficient -0.20, 95% confidence interval (CI) -0.35 to -0.05, p=0.01]. No effect of the training was found for depression. CONCLUSIONS: It is possible to conduct a randomized trial of psychological interventions in palliative care but there is considerable attrition from physical morbidity and mortality. Nurses can learn to integrate basic CBT methods into their clinical practice. This training may be associated with better outcomes for symptoms of anxiety.

Adjuvant psychological therapy for cancer patients.

Adjuvant psychological therapy (APT), a brief, problem-focused, cognitive-behavioural treatment for patients with cancer, is described. A previously published randomized trial demonstrated a significant reduction in cancer-related emotional distress. APT is recommended for cancer patients suffering from such distress.

Evaluation of adjuvant psychological therapy for clinically referred cancer patients.

Adjuvant psychological therapy (APT) is a newly developed cognitive behavioural treatment which has been designed specifically to improve the quality of life of cancer patients by alleviating emotional distress and inducing a fighting spirit. We report a phase I/II study which evaluates APT in routine clinical practice. A consecutive series of 44 outpatients with various cancers referred for psychiatric consultation and receiving APT at the Royal Marsden Hospital was studied. Standardised self-report questionnaires were used to measure anxiety, depression and four principal categories of mental adjustment to cancer, namely, fighting spirit, helplessness, anxious preoccupation and fatalism. Statistical comparisons between pre-therapy scores and scores after an average of five APT sessions revealed significant improvement in anxiety, depression, fighting spirit, anxious preoccupation and helplessness. Fatalism scores showed the same trend, but the changes were smaller. Patients with advanced disease showed as much improvement as those with local or locoregional disease. Present results indicate improvement in both psychiatric symptoms and mental adjustment to cancer associated with APT. Whether this association is causal remains to be determined by randomised controlled trials. Such a trial is in progress.

Medical illness and the acceptance of suffering.

This article challenges the belief that depression and anxiety are the inevitable consequences of medical illness. The authors describe how cognitive behavioral therapy can help individuals accept their disabilities and modify the distorted thinking patterns which may compound their suffering. Three case studies demonstrate the successful application of cognitive techniques to feelings of depression and anxiety in two patients with Stage III ovarian carcinoma and one patient with multiple sclerosis.

A comparison of adjuvant psychological therapy and supportive counselling in patients with cancer.

This study compared the effectiveness of two psychological treatments in a group of 57 patients with various types of cancer attending the Royal Marsden Hospital. Patients referred for psychiatric assessment who met criteria for an abnormal adjustment reaction were randomly allocated to either 8 weeks of Adjuvant Psychological Therapy (APT), a problem-focused, cognitive behavioural treatment programme, or 8 weeks of a comparison treatment of supportive counselling. At 8 weeks from the baseline assessment, APT had produced a significantly greater change than the counselling intervention on fighting spirit, helplessness, coping with cancer, anxiety, and self-defined problems. At 4 months from baseline, APT had produced a significantly greater change than counselling on fighting spirit, coping with cancer, anxiety and self defined problems. It is concluded that APT produces greater change in anxiety, adjustment to cancer and use of coping strategies than a non-directive, supportive intervention over an 8 week period of treatment. This difference persists at follow up 4 months after baseline assessment.

Relation between childhood sexual and physical abuse and risk of revictimisation in women: a cross-sectional survey.

BACKGROUND: Women who are physically and sexually abused in childhood are at increased risk of victimisation in adulthood. Research has concentrated on sexual revictimisation, and has not included investigation of other abusive experiences, nor examination of prevalence and effects of abuse on adult revictimisation. We aimed to examine the relation between childhood trauma and adult revictimisation, and identify confounding factors. METHODS: We did a cross-sectional survey of 2592 women who were attending primary care practices in east London, UK, with self-administered anonymous questionnaires. We included questions on physical and sexual abuse in childhood; on domestic violence, rape, indecent assault, and other traumatic experiences in adulthood; and on alcohol and other drug abuse. We analysed associations between childhood and adulthood abuse with multiple logistic regression. FINDINGS: 1207 (55%) of 2192 eligible women were recruited and completed the questionnaire. Abusive experiences co-occurred in both childhood and adulthood. Repetition and severity of childhood abuse were independently associated with specific types of adult revictimisation. Unwanted sexual intercourse (<16 years) was associated with domestic violence in adulthood (odds ratio 3.54; 95% CI 1.52-8.25) and with rape (2.84; 1.09-7.35); and severe beatings by parents or carers with domestic violence (3.58; 2.06-6.20), rape (2.70; 1.27-5.74), and other trauma (3.85; 2.23-6.63). INTERPRETATION: Childhood abuse substantially increases risk of revictimisation in adulthood. Women who have experienced multiple childhood abuse are at most risk of adult revictimisation. Identification of women who have undergone childhood abuse is a prerequisite for prevention of further abuse.

The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer.

An exploratory factor analysis of the HAD was carried out in 568 cancer patients. Two distinct, but correlated, factors emerged which corresponded to the questionnaire's anxiety and depression subscales. The factor structure proved stable when subsamples of the total sample were investigated. The internal consistency of the two subscales was also high. These results provide support for the use of the separate subscales of the HAD in studies of emotional disturbance in cancer patients.