Psychosocial intervention

1. Psychosocial intervention Cherith Semple Macmillan Clinical Nurse Specialist Head & Neck Oncology Ulster Community & Hospitals Trust, N. Ireland Cherith.Semple@ucht.n-i.nhs.uk

2. Overview - W’s Why • Why is there a need for psychosocial intervention? What • What is meant by psychosocial intervention? • What is the aim of psychosocial intervention? • What approaches have been used in H&NC psychosocial interventions studies?

3. W’s covered in a recent study What? • What post-treatment problems were targeted? • What do we know about H&NC patients’ preferred mode of intervention delivery? • What was the duration of the psychosocial intervention? Who? • Who was the psychosocial intervention offered to? HoW? • How effective was the intervention?

4. Why is there a need for psychosocial intervention? • Increased awareness that cancer and its treatment often leads to psychosocial difficulties • Improving overall cancer survival rates • Quality of life and psychosocial well-being are important outcome criteria for treatment

5. What is meant by psychosocial intervention? • Definition is vague • Overt and subtle difference depending on theoretical perspective • Encompasses a myriad of interventions

6. What is meant by psychosocial intervention? Most basic level - psychosocial • Psycho – psychological aspect of our experience. Refers to our feelings, thoughts, desires, belief, values and how we perceive ourselves and others. • Social – refers to the our wider social experience i.e. our relationships, traditions and culture. • Both aspects are closely intertwined and influence each other.

7. Psychosocial intervention Psychosocial intervention is an approach aimed at improving people’s well-being. Acknowledges: • Psychological well-being of the individual • Knowledge and skills of the individual • Social support • Culture and values that influence individual’s experience

8. What is the aim of psychosocial intervention for patients with cancer? • Decrease physical sequelae (e.g. pain) • Decrease depression, anxiety • Enhance adjustment • Enhance acceptance • Enhance QOL

9. What approaches have been used in H&NC psychosocial intervention studies? • Fiegenbaum (1981) • Hammerlid et al. (1999) • Clarke (2001) • Peterson et al. (2003) • Allison et al. (2004) & Vilela et al. (2006) • Katz et al. (2004)

10. Fiegenbaum (1981)

11. Hammerlid et al. (1999)

12. Hammerlid et al. (1999)

13. Clarke (2001)

14. Peterson et al. (2003)

15. Allison et al. (2004)

16. Vilela et al. (2006)

17. Katz et al. (2004)

18. Overview of psychosocial intervention studies in H&NC • All but one demonstrated positive findings • Efficacious in terms of: • Reducing psychological morbidity • Improving coping skills • Improving social and functional adjustment

19. Post-treatment challenges for patients with head and neck cancer • Numerous • Span across physical, psychological and social domains • Problems are often inextricably linked

20. Post-treatment problems • Anxiety • Depression • Eating and drinking • Speech • Fatigue • Appearance • Financial concerns • Smoking cessation

21. Biopsychosocial framework • Combination of conceptual models -social psychology - cognitive and behavioural - learning theory Metatheoretical approach - no single theory could adequately underpin the intervention to treat a range of pertinent post-treatment problems

22. Aim of study Develop, deliver and evaluate the effectiveness of a problem-focused psychosocial intervention programme to reduce psychosocial distress and improve the quality of life for patients with head and neck cancer

23. Treatment approaches • Psychoeducation • CBT principles - Social skills training (behavioural experiments) • Cognitive restructuring • Problem-solving

24. What do we know about H&NC patients preferred mode of intervention delivery? Allison et al.(2004) 128 patients met inclusion criteria 50 patients completed intervention with outcome data 27 (54%) 20 (40%) 3 (6%) 1-1 format self-help group

25. Mode of intervention delivery • Pilot – descriptive survey • Convenience sample - 28 patients with H&NC (completed treatment 6-12mths earlier) - 19 CBT therapists • Data collection – postal survey • Data analysis - descriptive

26. Findings Preferred mode of intervention delivery

27. Mode of intervention delivery • Optimal mode - individualised + bibliotherapy as an adjunct • Consideration of patients and professionals views - responsive to patients’ needs but translatable into practice • Facilitates clinical judgement, collaborative discussion and reinforcement of information

28. Development of intervention programme • 9 bibliotherapeutic texts produced: - introductory text (introduction to managing cancer related concerns, relaxation strategies) - one text covering each problematic area identified

29. Should all post-treatment patients receive psychosocial intervention? • Drop-out rates is higher amongst patients with lower levels of psychosocial intervention • Not economically feasible for patients to engage in intervention without an identified need • Confound findings if patients do not have an identified need

30. Inclusion/exclusion criteria INCLUSION: • Informed of a head and neck cancer diagnosis • Completed treatment for head and neck cancer • Evidence of psychosocial dysfunction as determined by the cut-off points on the HAD scale ( ≥8) and, or the WASA scale (≥12) EXCLUSION: • Absence of gross psychopathology • Previous participation in a structured psychosocial post-treatment intervention • Evidence of recurrent disease

31. Duration of intervention Literature review – considerable variation • 1 short intervention(McArdle et al., 1996; Burton et al., 1995; Holland et al., 1991; Bridge et al., 1988) • 5 - 8 weekly sessions(Decker et al., 1992; Edgar et al., 1992; Greer et al., 1992; Cain et al., 1986) • ongoing support until death(Linn et al., 1982)

32. Duration of intervention • Each patient assessed individually – problem formulation • Offered between 2- 6 session • Maximum 90 minutes per session • Maximum time span of 2 weeks between sessions • Received bibliotherapeutic relevant to problems identified • Maximum of 3 problems treated in 1-1 sessions

33. Research design • Quasi-experimental • Ethical approval Completed treatment with psychosocial dysfunction Self selected Experimental Control Pre-test Pre-test Intervention No Intervention Post-test Post-test

34. Data collection Experimental group Pre-test – 6 months from diagnosis, prior to intervention Baseline data & outcome measures i.e. HADS, WASA and UWQOLv4 Post-test – 1-week post intervention Outcome measures (HADS, WASA, UWQOLv4) and patient satisfaction survey ) - 3-months follow-up Outcome measures (HADS, WASA and UWQOLv4) Control group Same standardised measure 6 months from diagnosis, 2 and 5 months later

35. Overview of participants who completed study Participants screened for Psychosocial dysfunction n=129 Above pre-determined cut-off scores On the HAD & WASA scale n=68 Eligible for study n=61 Refused Participation n=7 Experimental group n=25 Control group n=29 3 month follow-up n=24 3 month follow-up n=25

36. Data analysis • Homogeneity at baseline for • Sociodemographic characteristics • Disease characteristics • 4 psychosocial variables • Social support (SSQ6) • Optimism (LOT) • Disfigurement (Observer-rated disfigurement scale) • Coping strategies (COPE-SF)

37. Data analysis to evaluate the effectiveness of the intervention Baseline outcome measures • Experimental group higher levels of anxiety and depression than control group ANCOVA • Between-subject effects - changes on mean outcome measure scores between groups regardless of baseline scores • Within-subject effects – change sustained over time

38. Between-subject differences Outcome measure F score p value HADS – anxiety 12.23 0.001 HADS- depression 9.05 0.005 WASA 4.11 0.048 UWQOL composite 4.38 0.042 UWQOL transitional 4.31 0.044 UWQOL overall NS

39. 12 10 8 HADS anxiety subscale Experimental 6 Control 4 2 0 Pre-intervention 1-wk post 3-mth post Within-subject effects - anxiety Mean anxiety score over time for the experimental and control groups

40. 8 7 6 5 Experimental HAD depression subscale 4 Control 3 2 1 0 Pre-intervention 1-wk post 3-mth post Within-subjects effect - depression Mean depression scores over time for the experimental and control groups

41. 16 14 12 10 Experimental 8 Control Social impairment score 6 4 2 0 Pre-intervention 1-wk post 3-mth post Within-subjects effect – social impairment Mean WASA score over time for the experimental and control group

42. Findings from descriptive survey • Generally very satisfied with the psychosocial intervention programme • Supported the statistical data provided on the efficacy of the intervention programme • Four themes identified • Cognitive restructuring • Simplicity and usefulness of the booklets • Combined treatment approach • Therapeutic relationship

43. Limitations • Lack of randomisation • Small sample size • Research Assistant who collected the post-treatment data was not blinded to which trail arm participants were in

44. Conclusion A problem-focused psychosocial intervention programme tailored to individuals’ needs following treatment for head and neck cancer has demonstrated efficacy in reducing psychological distress, improving social functioning and quality of life, which are sustained over time

45. Conclusion • Post-treatment problems can be managed within a biopsychosocial framework • Patients’ preferred mode of post-treatment psychosocial intervention delivery - individualised therapy with bibliotherapy as an adjunct