hello, i'm norman swan. welcome to this programon maintaining wellbeing, depression and anxiety in men withprostate cancer, and their partners. prostate cancer is the most commoncancer in australian men apart from non-melanotic skin cancer. one in nine will develop the illnessin their lifetime. men with prostate cancerreport higher levels of depression than the general community, but the rate of depression and anxietyin their partners is even greater -
more than double the incidenceof the australian community. psychological distress and depressionin men with prostate cancer, and their partners, is often overlookedand underdiagnosed. there's a fair bit of evidencethat cancer-associated depression has its own issues,and that's what we'll explore. you'll find useful resources available on the rural health educationfoundation's website: you're can't go there yetbecause you've got to meet our panel. suzanne chambers is director of researchof the cancer council queensland
and professor of psycho-oncologyat griffith university. - welcome, suzanne.- thank you, norman. suzanne is a member of theaustralian cancer network working party for the developmentof clinical practice guidelines for the managementof advanced prostate cancer. as you'll hear, that's associated withsignificant psychological morbidity. caroline johnsonis a general practitioner and lecturerat the university of melbourne. - welcome, caroline.- thanks.
caroline is about to complete her phd on monitoring depressionin general practice. peter strange is a nurse practitionerspecialising in men’s health within the rural bendigo area. - welcome, peter.- good evening. norman: you do mobile clinics?- we go to workplaces and areas where there aren't doctors. what sort of things do you do? health assessments for men.
in particular,we look at preventative medicine, getting to the guysthat won't come and see their doctors. norman: you're involved inthe men's shed movement? yeah. anywhere we can get to menfor preventative-type health. norman:getting close to too much information. colin bartlettis a prostate cancer survivor, and also suffered depressionthrough his illness, as you'll hear. he's facilitator for the westmeadhospital prostate cancer support group in sydney, and is heavily involvedin the prostate cancer foundation.
- welcome, colin.- good evening. welcome to you all. colin, tell me your story. i was asked to have a psa testby my doctor, under protest, i was. had it done. four days later, he says,we have a problem - i had the problem. go to a urologist. i was given a dre, and promptly told,there's an irregularity. we're going to have togo to another stage.
at that time, it didn't reallycome home, but the next bit did. norman: you didn't realise you wereon a truck hurtling towards the wall? no, i didn't. i then went to have a biopsy done. it was after the biopsythat the world crashed. that was when trish was with me,my wife, and andrew just told us straightaway,you have cancer. what are you going to do about it? shock, horror.
i think she was more devastatedthan i was. the mind just goes into freefall -what am i going to do? do you remember the emotionattached to that? the emotion is one of disbelief -why me? why is this happening to me? a little bit of faith came into it,because i turned to him and said, i'm going to make sure other men don't fall into the same trapthat i've fallen into. that's all i could say at that stage. so you were offered a series of options?
yes, i was given three options,just given them straight out - a radical prostatectomy,radiation therapy or we could possibly go onto some therapy if it suited. it was just left at that,and i was to make the choice. norman: how did you make the choice? seeing as the urologistwasn't much help, i did get a piece of paper that indicated a prostate cancersupport group at westmead hospital. i found the guy who was the facilitator,who still is, by the way.
he gave me some informationabout choices. i went to see him,and we talked about it. we decided really there was no optionbut a radical prostatectomy because the gleason score was high - 7. the psa was 20. it meanti really had nowhere else to go. when did the depression hit? that, norman, is an unknown factor. i don't really know when it really hit,
but it's been an insidious thing that'sbeen growing and growing and growing. possibly, it really came homeprobably three to four months after everything, i thought,had settled down. it hadn't. so you had the operation.how did it leave you? i felt pretty good, actually.i wasn't particularly worried. i didn't have any pain or anything. i was still in this freefall -what am i going to do? i didn't really knowwhat i was going to do. didn't know what to expect either.
were you feeling anxiety? i was anxious, of course i was, very anxious abouthow trish was feeling. she was my main concern. norman: how was it going between you? then? very good. we were pretty good. we'd suffered a few other problems whichhad brought us a bit closer together. so we were in a fortunate positionat that stage, but it unwound later on.
norman: unwound? i'm afraid i was the onewho was the problem because i virtually shut off. what you feel is pain,and it's a mental pain. how do you run away from it,get away from it? i found solace in getting on my bicycle and going off and doing three or fourhours' ride and coming home. norman: the male thingof riding off into the sunset? virtually, yes.
into the sunrise, actually,at that time of day when i'm around. you sort of get yourselfinto your own little sphere, into your own little bubble. she wasn't ableto make contact with you? we didn't talk much about it, no. i had a lot of men come to talk to me. i had a lot of supportfrom the support group itself. it more or less put her out on a limb. she really didn't do muchin that course at all.
how did it get better? i think it got better once we hadgot rid of the continence problem. i suffered a post-operative hernia,and we had that fixed. after that, things startedto get back into a normal operation but for one thing - i had continencetroubles. i had incontinence. it wasn't bad, but it was enoughto cause us some concern. and erectional function had also gone. did anybody recognise the depression? no.
that's the terrible thing about it. i never talked to anyone, andi didn't see what was happening to me. i didn't know what was happening to me. how did the depressionshow itself in you? the depression showed probablyafter about three to four years. i was starting to get very snappy,very irritable, and being a bit picky with trish. i look back at it, i'm ashamedof some of the things i said to her, like,i don't have to drive with you, do i?
i started to get very criticalabout her driving the car. i didn't notice it.i was just picked up as a grumpy old man who'd had a prostate operation. norman: were you sleeping? no, not very well at all. norman: had you lost interestin things around you? yes, completely. had you thought of killing yourself? no, that didn't come into it.
there's no self-harm in me. i'm very firm about that.there's no self-harm. but you ended upnot getting treated for it? quite a long time. as a matter of fact, it's only aftersix years of going through this that i finally was recognisedas having a problem. that was going to a men's shed function and listening to somebodytalk about depression. his recommendation was then,go and talk to your gp.
you do have a good one? yes, i do.i've known him for 20 years. he said, he will be the best personto see. he knows a lot about you. when i did go to jim, he said, more orless, i've been waiting for you to come. norman: but hadn't asked?- but hadn't asked. in a way, that's a bit disappointing,but i won't hold it against him. obviously, we're on the right track now.we have found the way through. we're having a good life. there's been a spin-off. i've been ontomedication, and it's quite a new story. the medication,i started in september '09
and by december '09,i'm beginning to say, where's this continence problem gone? norman:things have been fixed in one hit? it's just gone.i'm the same as you would be, the same as any manwho has not had a prostatectomy. which is quite surprising. asking then a beyondblue personwhat had happened, she said straightaway,what medication are you on? it's a serotonin type of medication.
she said,are you thinking about it anymore? and i said, no.really, i hadn't thought about it. she said, stress continence. it's gone. peter, you're nodding sagely there. this is obviously not an unusual storyfor you. no. i'm very interested in your story, particularly connecting withthe act of discovery for early diagnosis of depressionwas at men in sheds. well, it wasn't early - five, six years.
- true.- the first diagnosis. it's interesting that community groupsand support groups and people you just have a chat tooften will pick up these things. it's really important,a point to get across from the word go, that clinicians need to ask how people are travelling,if it's as simple as that. that's probably what you needed, colin,for someone to put their nose in and give him an opportunity to listen. you'll see menwith psychological issues,
particularly depression and anxiety,a lot. is it different when men have cancer, and is it differentwhen men have prostate cancer? i think it is. perhaps the more extreme the morbidityor the condition... sometimes i think men bury it moreso it's even harder to get out. it does become more extreme. norman: when you say more extreme,you mean what? the cause of the depression.
the medical condition and how theyperceive it will determine that. that's important.if we can help them through, give them education and explanation,perhaps we can lessen that. the waiting game - waiting for tests. also, it interferes with your senseof your own masculinity. absolutely. men will race ahead. we might start,as medical professionals, saying, we're having a psa test.this may not mean anything. some men will automatically race aheadright to - i'm going to have cancer,
erectile dysfunction, marriage problemsand all those things. as clinicians, we need to think aboutthat and help where we can. - it may not be unrealistic.peter: i agree. caroline, a familiar storyfrom your point of view as a general practitionerinterested in depression? it is indeed. one of the biggest tricks for gpsis getting this balance between the physicaland the psychological. if someone comes inwith a cancer diagnosis,
we assume, probably rightly, that the biggest thing on their mind is,is this going to kill me? so we focus on the physical. we often will say,how are you travelling? how's it going? how are you coping? we think that's usscreening for depression, but patients often think we're saying,how are you coping with the cancer? you're right, we have to bemore specific with questions. norman: more systematic?- that's an interesting point.
there aren't many research trialsthat show that by introducingsystematic screening... you might pick up more casesof depression but whether you'll get better outcomesis controversial unless you actually do something. hard to get better outcomes unless youfind out somebody who's got depression. in the late '90s,there were lots of studies that showed that if you ask people,are you depressed, and they say yes, it doesn't necessarily meananything will get done.
it's important to emphasise thatif you ask the question, you need some kind of planof what to do next. suzanne,how could it have been different? the first thing i would say is thatthe story we heard is very typical of how men often present whenthey're distressed and have depression, for example, after cancer -being withdrawn, angry, a strain on the relationship. it does get put down to beinga cranky old man, which is quite untrue. we know there's a range of risk factorspredictive of someone
more likely to suffer distress. - what are they?- things like lower levels of education, being poor,having a previous psychiatric or history of depression is important. stage of disease and symptomatologycan be important as well. but the one thing, if you measureat diagnosis the level of distress, that's the biggest predictorof subsequent distress. if someone had kept a close eye on yourlevels of distress from the beginning, they probably would have picked upthat they were high, and got in early.
in essence, you had a prolonged periodof suffering that was unnecessary. those are years you can't get back. - yes.- you've done well, and that's great, but it's not a good thing thatthat went on for so long. the other thing is,if you think about it, there are three main components to thinkabout with a cancer-specific distress. there's the psychological aspect - the distress the man exhibitswhether he's depressed or anxious, having intrusive thoughts.
then there's the social context - what'shis relationship like with his partner? is that a supportive relationship?has it been there for a long time? is it a well of resource for him? the third is,what's happened with the cancer? how has the treatment worked?what's the symptom profile like? when treating a cancer-related distress,you've got to treat all those. very important that you also treat side effects and symptomsof the cancer treatment. otherwise, the interventiondoesn't look relevant to the man,
who's primarily identifying - i've gotcancer - as his presenting problem. one of the greatest problemsthat we face within the support group is one of continence. incontinence is a big problem. to a degree, a lot of people don'tnotice or recognise it. we're focusing on it at the moment to bring a little bit of awarenessto the guys in the support group to know that there is something thereto help them. a lot of them suffer greatlywith continence problems.
- and it's pretty depressing.colin: very much. - which is your point.- exactly right. you can't divorce those physical thingsfrom the psychological impact. when they do unmet supportive caresurveys of men with prostate cancer, the big ones areunmet psychological needs with regards tofear of cancer occurrence, and unmet sexuality needs. if i were going to pick something,i'd focus on those two aspects for men who are surviving prostate cancer.
do you think you've got the equipmentto ask the questions, caroline? for psychological things? norman: to explore this. everybody has a different style. if you make it part of your routinepractice to raise the issue... we know that whenyou have a serious illness, it can be psychologically distressing. these are questions i'm going to ask,is it ok with you? so people knowyou're not running through a checklist.
so give us the script that you... it's often useful for gpsto hear the script that experts use. what are some of the questionsyou might feel awkward about? the screening toolsthat we use as psychologists are a little different to what worksin general practice. i'll say what i would do,then i'll defer to caroline. we typically usethe distress thermometer, a single item. i'll say, i'm going to ask youa question that sounds a little strange to check that i understand whereyou're at and i'm not missing anything.
on a scale from 0 to 10, where 10 is really high distressand 0 is - i'm fine... norman: you use the word 'distress?'- i use the word 'distress.' ..where would you see yourself? they'll give me a number. if it's lessthan 4, i think they're doing ok. if it's over 4 or 5, there's a good chancethey've got anxiety or depression. if it's over 7 or 8,i'm very concerned about them. that helps guide how muchi will go in-depth with that person
about their psychological condition. what i always do is let a personset their agenda first with me by saying,tell me what's been happening to you, why you've come to meand what you'd like help with. then weave it into the conversation. norman: that's in referral situation,whereas a gp is in the first situation. i heard that technique just tonight,and i think it's great. we do it all the time with pain. we say, on a scale of 0 to 10,where would you rate this pain?
it makes perfect sense to do that. it is a non-labelled wayof raising distress. norman: and it's a psychic thing.- right. if we're talking specifically aboutdepression, i still think questions are good - in the last two weeks or month, have youbeen feeling down most of the the time? have you lost interest in pleasure? researchers in new zealand did a trialwhere they added the question - would you like help with that?no, yes or yes but not today.
they found that extra questionwas a good way of picking up on people that might have been a false positive. if you ask people, would you like help,and they say yes, it should ring a bellthat you should focus on them. could something have been doneat the diagnostic stage? for example,one of the better predictors of whether or notyou'll regain erectile function is how much erectile functionyou had before, regardless of your age. could things have been donewith colin earlier?
is there any evidence of preventability? there is evidence of preventability. what's important is that at the outsetpeople understand this is going to bepsychologically tough. it validates them. if you start feelingdistressed, you're not saying, i'm weak. it's saying, this is a tough experience.let me give you some tips about things to do to help yourself. ideally, you work with the manand his partner. the best thing to do isget them working as a team
and pre-empt relationship issues, which are not uncommonafter a diagnosis of prostate cancer. research in south australia showed that much as men don't likeexpressing their distress, women don't like expressing it either 'cause they feel they have tobe the rock in this time of turbulence. women are often the emotional spongein a relationship. they take responsibilityfor maintaining emotional balance, and they suck it all up.
so, while you're getting cranky,she's sucking it up, feeling worse. often, men and women havedifferent communication patterns about dealing with difficulties. if you can help them negotiate a wayto help them do that, that helps each person feel validated. it's important that people knowtough times are ahead, and that they give a hint of, if you start feeling this wayand it goes on... it's normal to feel distress,but if this goes on for some time,
no badges for bravery. go back and see your gp or call someone,and get help early. norman: peter? we may need to ask more than once. we may be asking someone like colinhow he's going, how he's feeling, and at that stage of the process - and this is stretched out over fiveor six years - he may be doing well, so we need to keep asking himhow he's travelling and asking those important questions.
there will be periodswhen he goes up and down. how important do you think settingexpectations is at the beginning so people know the journey they're on? we need to be very honest. we need to keep it very simplebecause men that are having stresses won't be ableto take in a lot of information. so we need to be very honest. we can't predict what's going to happen,but these are the possibilities. colin, in retrospect, what do you thinkcould have been done for you
at that diagnostic stage, before anyonehad laid a hand or knife on you, that would have made a difference? one of the thingsthat would make a difference is having what we call a road maplaid down of what's going to be,what the expectations are, what's going to happen. norman: physically and psychologically?- yes. the psychological onewould have been very important because i didn't realisethat was going to happen.
that's been the most devastating part,is the psychological part. we're sort of out of it, but it's stilldevastating, the psychological bit. in country towns, it is going tobe the gp who will carry the burden. that's true. there are more opportunities nowfor gps to get support, but it is harder in the rural setting because there are lesshealth professionals. it's great that there arenurse practitioners now. some practices have mental-health nursesthat can help,
particularly people withmore serious psychiatric illness. there's also telephone support for gpsthrough gp psych support. but, ultimately, the gp is often seeingboth partners in a relationship, so they often get the warning signsearlier. knowing how to act on thatis the challenge. suzanne, as the journey progresses? things like hormone treatmentcan be pretty rough psychologically. that's right. it's importantto recognise it is a journey. stress is typically very highat diagnosis,
usually quite rapidly diminishes, thencan spike when critical events happen, for example, a cancer occurrence, where distress can be higherthan at initial diagnosis. if a man is diagnosed withrecurrent cancer, he's at some point going to be put ontohormone treatment. hormone treatmentshave serious side effects such as mood disturbance, cognitivechanges, changes in muscle mass, central adiposity, osteoporosis. norman: libido disappearing.- libido goes, erectile dysfunction.
there's good work being done in westernaustralia using high-intensity exercise to help with that. there are things that can be donethat are complimentary therapies. serious exercise, physiology work,and there's medicare rebates for that - exercise physiology under certain plans. again, for the gp, it's being awarethat things change over time for men. every time you see themis an opportunity to check how things arewith the prostate cancer. let's go to our case studyand work through some of these issues.
don is a 52-year-old farmer. he comes to you, caroline, with urinary symptoms. when you do a digital examination, it feels a bit odd, and his psa comes back at 7. you refer him for a biopsy because his brother was diagnosed with prostate cancer, which is why
you did the psa and dre. he was widowed four years ago, and got a bit depressed. his wife died of breast cancer after many years of illness. luckily, he's recently repartnered. caroline, what's your approach going to be towards don? he's got the risk factors.
he does. first of all,any time you do a test for cancer, you should try and discusswith the person before you do the test what the possible outcomes would be, because you don't want to read someoneand say, the test is abnormal, and them getting very distressedand panicking before they hear what it really means. i try and tell people beforehandthe possible outcomes without going into detail.
then when the test comes back andthere is concern this could be cancer, taking into account his risk factors,past history. he's also had experience of cancerthrough his brother and his wife. that might alter his perceptionof what that might mean. he has existing knowledge,but it may be helpful or unhelpful. you might want to knowwhat happened to his brother to see what framing he's got. absolutely. it will be significant. the bell should be ringing straightaway
when you're presented withthat sort of history. start asking questions about his brotherand how he feels and how much that's affected him. that's going to drive him intothat condition, perhaps, of depression. suzanne, is there anything you can doat this point to steel-belt him, apart from improvinghis psychological reserves? the things i've already mentionedare appropriate for this person. i guess, close surveillance. like peter said,find out what picture he has in his head
about whatprostate cancer diagnosis means. it may be he's more focused onwhat happened to his wife - she died a difficult death,and that might happen to me. or it could be focused onwhat happened to his brother. you don't knowuntil you ask those questions. if he's got lay beliefs about cancerthat are unhelpful or untrue, you can try and correct those. just keep a close track on him. he's in a new relationship,so he doesn't have a 25-year history
of coping together through adversity. that couple, i would anticipatethey would need support and perhapssome relationship counselling. this is going to be a tough experience.it happens to you as a couple. talk about things you can doto support each other through it. the fact that he's gotthe history of depression, it rings bells thathe's more at risk of depression again. you can use that to your advantage -what was it like last time? what were the symptoms you experienced?
what would you do if you did a screeningand found he was depressed? i would askwhat worked for him last time. if he had antidepressantsand they were very effective and he had similar symptoms this time, i'd have no hesitationthat he try it again. suzanne, the evidence is that antidepressantsdon't make a lot of difference at the mild to moderateend of the scale and that cognitive behavioural therapywill improve their resilience.
the only thingthat improves your resilience in terms of reducing recurrenceis psychotherapy. i don't knowthat i would agree with that. a combined approach is appropriateand individually tailored. you can look at studies,then you look at individuals. i'm with caroline -what did he do that worked last time? i think that trying to help peopledevelop adaptive coping strategies if their predominant coping strategieshave been unhelpful is part of it as well.
maybe that's partof building their resilience. coming back to colin's pointof information being important, what evidence is there that informationhas an antidepressive effect? i don't know of evidencethat information alone has an antidepressive effect. it's just a basic thing that you needinformation you understand so you can make difficult decisionsand live with the consequences. it's just basic good care. the difficulty for peoplediagnosed with prostate cancer is,
no-one with cancer expects a choice. i don't know how many timesi've had men say to me, what's this business of, i've got achoice, and one is, i don't do anything? don comes back to the gp because he'shad the bad news from the urologist. the urologist says, there's no rush,go and think about it. you can have a radical,you can have two types of radiation or we can watch and waitfor a couple of years and see what happens to your psa levels. it's only 7 at the moment.
you're not going to dieif we wait for a year or so. he goes home, he's miserable, angry, and he's dragged in by his partnerto see you, caroline. she says,he needs help to make a decision. sit down, don, and listen to the doctor. in his situation, it is hard. as gps, we draw on experiencefrom previous patients or stories we've heard. we have to empower the patientto make a decision
using information they're given. one thing tested in general practiceis to use problem-solving therapy. norman: how does that work?- you work with the patient to generate a list of the problems. in this case it might be as simple aschoosing which therapy. you work with the patientto generate as many problems associated with that as possible. there's still cognitive restructuringinvolved? no, no. it's a very structured approach.
you can download structuredproblem-solving worksheets off the internet if you're so inclined. it's not a difficult technique to learn. it's just guiding the patientthrough that decision-making process, generating as many solutionsas possible, then listing them and looking atthe pros and cons of each. it is quite an effective therapy,but probably a hard case to start with. if you want to have a goat problem-solving therapy, you might not choose a distressed manwith prostate cancer
as your first subject. try it on yourselfor on a more simple case, then if it works,try it with someone like this man. if there's more than one clinicianinvolved, we need to get our stories together. that can cause more confusionfor the patient if we're giving different stories. we need to do thaton behalf of the patient, otherwise it becomes confusing.
a nurse in northern queensland asks, 'are there anyantidepressant medications contraindicatedwith prostate cancer?' i'd start with the antidepressantsi'm used to using. i'd use ones that don't interferewith urinary function. i don't know if there'sa strong evidence base for that. i'd start with ssrisrather than tricyclics, 'cause tricyclics have urine symptoms. obvious ssris,the message i get from the experts is,
they're pretty muchall in the same bunch. some have slightly different advantages. they do have sexual side effects. that's true, but that's going to be aproblem with all of the antidepressants. you have to make a decisionof how severe the symptoms are. again, if someone has had thesetreatments and they've worked, that's a reliable indicatorthat they'll work again, or are at least worth trying. the same nurse in queensland asks,'should all men on hormone treatment
be automatically prescribedantidepressant medication?' i wouldn't do that.i can't see any reason why you would. if they weren't having those specificside effects, i don't think you would. you'd do it based on the severityof their symptoms and their preference. it's been awhile since we hada question from western australia. also a nurse. 'is there any informationon suicide rates in patientsdiagnosed with prostate cancer?' there was a paper published recently,i've got a feeling it was european data, which showed an increasein the relative risk of suicide
in men with advanced prostate cancer. i've certainly had experience of men with advanced prostate cancercommitting suicide. it's somethingyou certainly never forget. i don't have exact data on that. and i guess, though,the main point is it's more about - anybody who's got depressionneeds to be screened for suicidality. norman:you've just got to ask the question? you've got to ask that question.
norman: do you ask the question, peter?peter: i certainly do. it's not the first question, but if i think they've got mildto moderate depression, i always ask whether there's self-harm. given that you're seeing menin men's situations, how do you involve the partner? norman: they've got to be involved. sometimes men come in becauseof the partner in the first place. so the partner may be involvedfrom the word go.
norman: you just don't necessarilysee them straight off. it can be. that's a question we also ask - how are travelling,how is your partner travelling? i often go into the relationship and askhow he perceives the relationship is. if the discussion wants to go onfrom there, i offer whether it would be of benefitseeing them both together. that's a really positive move,particularly if he agrees to that. caroline, do we know to what extenttreating the man
helps the woman's depression? i don't think i could answer. i mainly see womenwho are worried about their partners. i find talking to them can help themdeal with their partner's depression. i can give them generic strategies. the risk factors suzanne spoke aboutfor men could apply to women too. if they've got a history of depression,they could be at major risk. that's right. making things betterin a relationship or a family situation makes things better for everybody,
but whether you can automatically assumethat treating the man will make the woman better, it dependson the severity of his depression and how it's impactingon their problems. if the thing that's worrying heris that he's going to die or be impotent forever, treatinghis depression might not help her. you have to have a conversationwith the individuals. if you only see one partnerand the man sees another doctor, it's easier if the doctoris in the same practice. i've had that conversation of -
would it be ok if told his doctoryou came to see me? so he's aware of your concerns. there's issues of confidentiality. but if you say,these are things we could do to help, often they're open to that. you have to respect people's wishes. norman: was your wife depressed?- yes. one thing we have learned, and willpass on as a testimony to other people, is that if the manis suffering depression,
look at your wife as well,or your carer, because they are dragged down as well.one affects the other. - did she receive treatment?- yes, she has. she was worse off then i was. norman: really?- yes. norman: how was it affecting her? withdrawal, drawing away from things,not wanting to go anywhere, not driving her car,not wanting to go shopping. it was quite a thing,to drag her out of herself.
she became very much a homebody,got into her garden. while you were off on your bikein the sunrise, she was in the garden, pottering around. i was burying myself inprostate cancer work. norman:you were living parallel existences? basically, yes, norman. it wasn't very good, it was very poor. it's the one thing to pass on to people. i don't think enough attention was paidon the problem
that would come of this businessof depression. it wasn't in our case. it's only when it was too latethat it was noticed in me because of my crankiness,then suddenly she came down too. i say it was too late. it should havebeen picked up way before. norman: suzanne?suzanne: i agree with all of that. carers,we need to particularly worry about. there's mixed results on whether carershave more distress than do patients, but there's enough that suggeststhat in many cases they do. in our experience in running trialsat cancer council queensland
into psychological interventionsfor people with cancer, we find carers are relatively difficult,comparatively, to recruit into trials because they thinkthey don't really count. i'm busy looking after my partnerwho's unwell, and i don't have cancer,so i don't deserve that support. they neglect themselves while tryingto support the person who has cancer. when you're looking after someonewith cancer, you have to be as concernedabout their partner as you do about that personwho has cancer.
don and his partner glenda come backto see you, caroline, a year later. he's had a radical. he's got erectiledysfunction. he's had it for a year. he's got a bit of incontinence. he's been dragged back by glenda, ratherthan volunteering to come and see you. she tells you he doesn't sleep,he's not eating well, doesn't want to get out and about. she's pretty distressed, too, and tells the sort of storythat colin tells. what are you going to do here?
obviously my relapse-prevention strategy from the first part of this casedidn't work so well. norman:you don't need to beat yourself up. i'll say to him, i told you ifthe symptoms came back, to talk to me. it's great that you're here now. clearly, that sounds likehe has the symptoms of depression, but i would completea more thorough assessment. norman: you'd go into full mode. ask all the questions.
there's a list of symptomsyou have to have to qualify for a dsm diagnosisof depression, but in general practice, we tend to think more dimensionallythan categorically. if people have got distressat a sufficient level, we start talking aboutmore proactive treatment. in his case,i'd come back to what's worked before. if he has symptoms of depression, treatments that have helped himin the past should help again, even though circumstanceshave changed.
these treatments work for the symptomseven if you've got another diagnosis. but you have to be aware thatmedications have side effects, which you'd revisitif he's had them in the past. suzanne, this notion of stepped care.you talk about the pyramid. certainly. we have developedin queensland a tiered model of care that's been widely usedacross the country. the essence of thisis to acknowledge the fact that, while we're talking tonight particularlyabout extreme depression or anxiety, most people will do well over timewithout deeper psychological care.
at the bottom of the pyramidis where most people are. what they need is effectivecommunication from their clinicians, access to support groupsand cancer helplines - cancer council australiaruns those sorts of things - to know there's a peter around ifthere is one, to have a supportive gp. that's what most people need. - you've got a booklet, haven't you?- we produce several. there's a beyondblue bookletwe've contributed to, a general wellness book,
a sexuality after prostate cancertreatment booklet that's on the andrology australiawebsite. there are lots of resources. beyondblue have a stack of themand cancer councils have them. there's an excellent array of resources,cancer helpline is a national service. if you've got someonewho's got mild to moderate distress, they're further up the pyramid.they're a smaller number. they need care with a deeperbut narrower focus. they might needa psychoeducational program.
norman: what do you meanby psychoeducational? teaching people in-depth aboutwhat a diagnosis of cancer means psychologically,and how to cope with that. stress-management skills,coping-skills training, things you can do easily in a group. moving up, you might wantto do relationship or family therapy. at the top of the pyramidare your vulnerable people who might be suicidal ordemonstrating high levels of distress. they might need a psychiatrist,a mental-health care team.
you don't muck around withpeople in trouble. you get them straight to serious care. if you're in a country townand referral sources are limited, what's your view of the self-help areas? st vincent's hospital in sydneynow has internet-based therapy, where they will offer a therapistonline. you're not just doing internet cbt, a psychologist willactually talk to you. there's moodgymat the australian national university.
swinburne has something. they seem to have good randomisedcontrol-trial evidence that they work. would you refer somebody with cancerto one? i think so, if it was a reputable oneand i knew about it. it's an emerging area,and important for australia because we havea decentralised population. remote-access therapiesare important for us to get population-based translationof psychological care, not just for cancer but in every area.
there is randomised-control evidence forthese therapies being able to deliver through the internetand on the telephone. for a gp,it's knowing what your arsenal is. wherever i live,i know these things are available on the internet and the telephone. this age group doesn't necessarilyhave access to the internet. that's an issue, but it also dependsupon the level of distress. we're doing a trial on this now. we're offering two types ofremote-access, telephone-based therapy.
our hypotheses are that people who areover 4 on the distress thermometer but not up around 8will probably do well with minimal telephone intervention, where the more distressed peoplewill need the higher level. that study hasn't been donein cancer before. is there evidencethat response to therapy is different when cancer underlies the depression? i'm familiar withcancer psycho-oncology literature, where there's good evidence to supporta range of cognitive-based therapies,
problem-solving therapy. one of the best studies was onproblem-solving therapy, where they targeted peoplewho already had anxiety and depression. it's also about health economics. you've got a limited numberof resources. let's get our in-depth resourcesand throw those at people in trouble. a lot of the others will do finewith good-standard care and access to self-management materials. because you feel disempowered,don't you, colin?
colin: yes, you do. you feel very disempowered. i feel sorry for the country people. they would be even more disempoweredthan we are because they have no accessto people like yourselves. they're locked away. for them to come in to the city,it takes them a week. who's going to do that? there's a lot of men we've heard ofwho have had recurrence
of their prostate cancerand it's metastasised. too late. if somebody had been in contact withthem regularly, probably their own gp, maybe that would not have happened. they don't have timeto go for a psa test. let's have a lookat our next case study, a film studyon a prostate cancer support group created some years agoby david and pam sandoe. it's based atthe sydney adventist hospital in the northern suburbs of sydney,and offers a unique support base
to men - and their partners -with prostate cancer. man: the effect of being diagnosedwith prostate cancer varies between individuals and couples. i opted for the radical prostatectomy. once i got over the original diagnosis,yes, i was anxious, but together as a couple,we've been able to handle it. there are other couples not so luckyas pam and i. they're the peoplewe're trying to look after. some guys are in tunnel vision for along time after getting their diagnosis.
they don't want to speak about what canhappen in their treatment options. it's usually the wifethat has this huge learning curve, and knows more about the diseasethan the partner does. we need to know if there's a situationwhere that woman needs extra assistance. she's probably got anxietyand depression herself, rather than just the malewith his recent diagnosis. it's easy to talk to peoplethat have been similarly diagnosed. through the support group, we can match people upwith whatever they're going through.
i can think of one couplewho came to us in some despair because they weren't communicatingwith one another. he didn't talk about it at work, and when he came homehe didn't talk about it. somehow, they came to our support groupand we gave them some facts. we gave them connections to medicalprofessionals that could help them. now they're a great couplethat help telephone-counsel people going through a similar situation. beyondblue information about anxietyand depression,
the women, you can see going through it.they'll take the fact sheets. as pam was suggesting, they're the ones that will workthrough things in a realistic way. mostly, they're the health managersof the family, we find. we get to the men through women. it's amazing how many times,and we were exactly the same when we found out - the prostate?what's that? where is it? what's it do? it's not like women, who know they've gotall the different sexual parts to them.
men think as long astheir penis is functioning correctly and they're having great sex, that's all there isto the anatomy of it. they need to speak to their partner and talk to other men,if they're brave enough, to find out howthey can best move forward. my erectile functionand urinary function are returning pretty well,i'd say to 90% to 100%. it's good to be able to express yourselfin front of people.
as you see today,you can talk about anything at all. i enjoy coming. it's fellowship. my wife has enjoyed coming alongas well. i like to spread the word. i swim every morning,and i have pamphlets in my bag. if i see a new guy in the dressing room,i say, would you like to read this? there's so many ignorant peopleabout prostate cancer. the advice i'd givemedical professionals giving information to their patientsabout mental health
is that they've got to be mindfulof the anxiety and state of depression that people get in when they don't,for instance, have full sexual rehabilitation. they've got to think beyondthe diagnosis and the treatment of the disease in its crudest form,and think more about getting the person backto normal of life, or as normal as possible. now more and more,people are being aware
of anxiety and depressionand how it affects the family. david and pam sandoeat the san in sydney. it's not for everybody though,is it, colin? - what, support groups?norman: yes. probably not. a lot of people prefer to haveone-to-one home treatment. that happens on a few occasions. generally, with a support group,it's the man and the woman who come in. you get the pair of them.
the man being draggedwith his heels skidding ground. just about. it's humorous, but yes. norman: how long does it take on averagefor the light to go on? what, in getting something done? realising that, i don't need to resistcoming. this is not for wimps. it's something that's good for me. some people, it's usually a year before they really get involvedwith a support group. norman: really?- yes, as long as that.
a lot don't come straightaway. some do. they come beforehand. norman: which is what you did?- yes. a lot of the guyswho are keen on themselves come before any procedure is done. that's where they gettheir road map from. peter, what are the benefits and limitsof support groups? the benefits are enormous. i've talked to a few support groups.
the first thing i didis see how many partners there were. there were 20 men and 20 womenat one in bendigo. it was a terrific social eventas well as education. but i agree, not every guywill want to turn up to that. which is not a problem, just a differentway of dealing with that man. that's a bloke, i suppose. men are like that. they can be withdrawn. particularly if they're depressed, theydon't want to go out and be in public.
we have to have our door open to giveconsults and give them time to talk. sometimes, i think they may benefit from talking to the guy on the bar stoolnext to them. it may not givegreat medical information, but they need somewhere to chat. that can grow through the clinicianif we give them more time. then maybe they will join thesupport group, even if it takes a year. norman: how do you find a support groupin your area, colin? it's reasonably active.
we've got something like 70 couplesregistered, and we get a floating attendance. that's in sydney. but if you'rein kalgoorlie or the northern territory, is there a network of support groups? the network of support groups is done from the prostate cancer foundationof australia. they have published a listof where support groups are. any evidence, suzanne, that they work,beyond the anecdotal? we've done research ourselves.
there are a lot of descriptive studiesthat are cross-sectional, looking at people who goto support groups, how are they doing and what are the aspectsof support groups they appreciate. they've been very positive studies. the important thing is that there area range of services available. different things suit different people. norman: a menu. which might be the cancer helpline,the cancer counselling service, the support groupor one of the volunteers from the group
who's available to talk on the phoneanonymously, your gp,your men's-health practitioner. people need to know that some thingsmight not suit, but don't give up. if it doesn't seem likeit's the right form of support for you, try something else. in bendigo, we run men's-health nights.we have for nine years. we get 1,500 men out in bendigo. bendigo's a 100,000 population. we'll go out into the sticksand run these nights,
towns that have 200 or 300 people,and you'll get 100 turn up. at those, even though it may not bespecifically on prostate cancer, we will get guys that comeand sneak in the back. we'll talk about things likemental health and sexual health, and those guys will absorbthat information. that's incredible. so much for blokesnot wanting to come forward. give them the right environment,they will. particularly if you put on a barbecueand a drink, they'll turn up, and you can talk frankly to them.
thank you all very much. what areyour take-away messages? colin? take-away message for people watching is to look at getting a proper road mapof where you're going with some of these things we'vementioned tonight included in that, of course, the big one being depression. for clinicians to ask the questionsto the patients, then to give them timeand to listen to them. i agree with that. to believethat you can make a difference
by helping people with psychologicalproblems as well as physical ones. norman: the evidence base is there.suzanne? cancer is a major life stress for boththe person with cancer and the carer. good psychosocial and psychological careis central to good care. thank you all very much, and thank you. i hope you've enjoy the programon maintaining wellbeing, depression and anxietyin men with prostate cancer. our thanks to beyondblue,the national depression initiative, and the prostate cancer foundationof australia
for making the program possible. our thanks to you for taking timeto attend and contribute. if you're interested in obtainingmore information, there are a number of resourcesavailable on the rural health education foundationwebsite: to register for cpd points, completeand send in your evaluation forms. i'm norman swan. i'll see you next time. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing,
community servicesand indigenous affairs�
No comments:
Post a Comment