INTRODUCTION
Major depression and adjustment disorders are the most prevalent and burdensome psychiatric disorders in patients with cancer (Derogatis et al., Reference Derogatis, Morrow and Fetting1983; Minagawa et al., Reference Minagawa, Uchitomi and Yamawaki1996; Kugaya et al., Reference Kugaya, Akechi and Okuyama2000; Okamura et al., Reference Okamura, Watanabe and Narabayashi2000; Akechi et al., Reference Akechi, Okamura and Nishiwaki2001, Reference Akechi, Okuyama and Sugawara2004; Uchitomi et al., Reference Uchitomim, Mikamim and Nagaim2003). Although there are effective means of treating these disorders (Gill & Hatcher, Reference Gill and Hatcher1999), these are often underrecognized by medical staff members (Fallowfield et al., Reference Fallowfield, Ratcliffe and Jenkins2001; McDonald et al., Reference McDonald, Passik and Dugan1999; Passik et al., Reference Passik, Dugan and McDonald1998), and National Comprehensive Cancer Network Clinical Practice Guideline recommends implementation of screening program.
We have developed and validated the Distress and Impact Thermometer (DIT) as a high-performance screening tool (Akizuki et al., Reference Akizuki, Yamawaki and Akechi2005), and then the nurse-assisted screening and psychiatric referral program (NASPRP) was instituted, which was a clinical screening program combining implementation of DIT and recommendation for psychiatric referral for all positively screened patients, by nurses. We previously showed that introduction of the NASPRP resulted in more distressed patients referred to psychiatric consultation than before, but we also noted the high refusal rate for psychiatric referral when nurses recommended psychiatric referral to all positively screened patients (Shimizu et al., Reference Shimizum, Akechim and Okamuram2005).
The recommendation of psychiatric referral for patients who are not willing to undergo consultation can be a burden to those patients, because the stigma still attached to psychiatric illnesses makes many patients reluctant to acknowledge to themselves or their physicians that they are experiencing emotional distress (Goldman et al., Reference Goldman, Nielsen and Champion1999). It is also time-consuming for nurses in a busy clinical setting. We determined that the continuation of the original NASPRP was not reasonable and decided to modify the terms of NASPRP. In the process of the original NASPRP, nurses had lectures about depression and also experienced assessment of psychological distress and recommendation for psychiatric referral (Shimizu et al., Reference Shimizum, Akechim and Okamuram2005). We assumed such an experience period gave nurses the ability to detect among their patients those who had psychological distress and were willing to consult mental health professionals. We therefore modified NASPRP to allow the nurses to judge the final eligible patients for psychiatric referral after screening.
The ability of the modified NASPRP to facilitate psychiatric referral for depressive patients was not clear, however, and the aim of this study was to clarify this point. We hypothesized that the use of the modified NASPRP would achieve a higher proportion of referral of cancer patients to the psychiatric service for treatment of major depression and adjustment disorders than usual care and would not be inferior to the original NASPRP.
METHOD
Study Sample
This study was conducted by means of a retrospective analysis, and charts of consecutive patients admitted to the Oncology/Hematology Unit of the National Cancer Center Hospital East (NCCH-E), Japan, were eligible for review during the usual care period before the original NASPRP was introduced (T1), the period during which the NASPRP was used (T2), and the period during which the modified NASPRP was used (T3 and T4). The T1 period was the 3-month period from August to October 2002, and the T2, T3 and T4 periods were same 3 months in 2003, 2004, and 2005, respectively. Patients with a noncancer diagnosis and who were under 18 years of age were excluded.
Because this study was a retrospective review for the purpose of comparing three clinical practices, written consent and institutional review board approval were not obtained.
Modified NASPRP
The original NASPRP was instituted from August until October, 2003, in the Oncology/Hematology Unit, a 42-bed unit of the NCCH-E (Shimizu et al., Reference Shimizum, Akechim and Okamuram2005). The modification of the NASPRP started gradually after the completion of the original NASPRP and reached its present form at the beginning of 2004. The details of the original NASPRP and modified NASPRP are described in Table 1.
Details of the original NASPRP and modified NASPRP
Analysis
The ability of the modified NASPRP to facilitate psychiatric referral for depressive patients was evaluated by calculating the referral proportion, which is the proportion of patients referred to the psychiatric service and treated for a diagnosis of major depression or adjustment disorders among all patients admitted. Intergroup comparisons of the proportion referred were performed between groups by the chi-squared test, respectively. All tests were two-tailed. All analyses were performed using SPSS 14.0 J for Windows statistical software (SPSS Japan Institute).
RESULTS
Patients' characteristics, number of patients referred to psychiatry, and referral proportion are shown in Table 2. The characteristics of the eligible patients in each period were comparable in terms of age and sex, but not about cancer sites. There existed significant differences concerning the proportion of primary unknown cancer patients.
Characteristic of patients and number of referred patients in each term
During the T3 period, 7 patients were referred to the psychiatry division and diagnosed as having an adjustment disorder among 160 admitted patients, and during the T4 period, 5 patients were referred with an adjustment disorder among 129 admitted patients. The referral proportion during the T3 period was 3.9%, and this was not significantly different from that in T1 (3.0%, 4/134; p = .53) when usual care was provided and significantly lower than that in T2 (11.5%, 18/157; p = .02) when the original NASPRP was used. The referral proportion during T4 period was 4.4%, and this was also not significantly different from that in T1 (p = .69) and significantly lower than that in T2 (p = .02). With regard to the difference concerning cancer sites, we also analyzed this with the exception of the primary unknown cancer patients, and the results were the same.
DISCUSSION
The result of this study demonstrated that the modified NASPRP was not useful compared to usual care and inferior to the original NASPRP regarding detection of major depression and adjustment disorders in cancer patients. With the nurses' experience of concentrated psychological care in the original NASPRP term, we assumed nurses could be a primary assessment team to decide eligibility to recommend psychiatric consultation, but our assumption was incorrect.
In this study, there were many limitations due to the study design, and we could evaluate only referral proportion and not for the process of the modified NASPRP. Why this modified program was not useful is not clear, but previous study demonstrates nurses tend to underestimate patients' depression (McDonald et al., Reference McDonald, Passik and Dugan1999), and this may have happened in this program also.
Empirical evidence showed that even though patients screened positively and were suggested as having severe psychological distress, many of them did not proceed to adequate treatment due to the refusal of the patients (Roth et al., Reference Roth, Kornblith, Batel-Copel and Pe et1998; McLachlan et al., Reference McLachlan, Allenby and Matthews2001; Shimizu et al., Reference Shimizum, Akechim and Okamuram2005). Very few studies have elucidated why patients refuse to proceed to treatment (Curry et al., Reference Curry, Cossich and Matthews2002), and we have no useful tactic to change their behavior so far. As it now stands, it is important to detect those patients who are distressed and willing to get consultation adequately and to treat them first. To compose an effective program, we should assess not only the patients' depressive symptoms but also the patients' need for consultation with a mental health professional. We expected the modified NASPRP could be such a strategy, but our assumption was not true, and we must pursue another way as the next step. In the primary care setting, adding a question regarding assistance to the questionnaire, which was, “Is this something with which you would like help?” improved the screening performance (Arroll et al., Reference Arroll, Goodyear-Smith and Kerse2005). Such a questionnaire may also give information about patients' needs, and adding a “help” question may be a clue to help us formulate our next step.
ACKNOWLEDGMENTS
This work was supported in part by a Grant-in-aid for Cancer Research, Clinical Cancer Research, and Third Term Comprehensive 10-year Strategy for Cancer Control, from the Japanese Ministry of Health, Labor and Welfare.
