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Introduction

A diagnosis of cancer affects every aspect of a person's life. It can be like a bomb going off, damaging not only the area affected, but everything around it: from physical health to psychological well-being; from social functioning to financial stability. Like a bomb, some effects are immediate but others may not appear for some time. It is the immediate effects that are treated in the first instance, but the other damage can harm the foundations of lives and relationships. The effect is not limited to the person with the disease but also spreads to those around them.

It was suggested by Dr Adam Glaser at the Kings Fund conference in 2013 on patient-reported outcome measures1 that patients have three questions: Will I survive? Will I be well looked after? What will I be like? Immediately after diagnosis, most patients' main concern is with the first question, 'Will I survive?' Frequently, this is the first time a patient will have had to contemplate his or her mortality. Typically, patients experience shock and a period of turmoil which affect their sleep, appetite and day-to-day functioning. This usually diminishes over time, and the focus moves to treatment, which can be gruelling and consumes most of the patient's physical and emotional energy. It is often only when treatment is finished that there is the emotional energy to think about the last question, 'What will I be like?', which is when thoughts develop about what a diagnosis of cancer means to them, to their family and to their future.

Prevalence of psychological distress and psychiatric disorder

'Psychological distress' is a term which includes symptoms such as worry, intrusive thoughts, low mood, poor concentration, sleep difficulties and appetite changes, but which may be below the threshold for a diagnosable psychiatric condition. Psychological distress becomes clinically significant when it begins to impact a person's life: in patients with cancer the prevalence of mental disorder has been shown to be between 30% and 40%.2 The most common mental disorders are adjustment, depression and anxiety disorders.2 Studies examining the prevalence of major depressive illness show figures varying from 8%3 to around 25%,4 and the prevalence of anxiety disorder to be about 25%.4 In 2013 a systematic review of the prevalence of depression in adults with cancer concluded that rates are imprecise due to differences in study design; however, it is clear that psychological morbidity is a significant part of the cancer diagnosis for many people.5

Current recommendations for psychological support

In 2004 NICE issued guidance on improving supportive and palliative care for adults with cancer.6 It recommended that psychological support should be provided in a stepped care approach which addresses the needs of patients with few psychological needs through to those needing specific intervention (Table 3.1). It recommended that every member of the ...

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