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Hello, I'm Norman Swan.
Welcome to this program on maintaining wellbeing,
depression and anxiety in men with prostate cancer, and their partners.
Prostate cancer is the most common cancer in Australian men
apart from non-melanotic skin cancer.
One in nine will develop the illness in their lifetime.
Men with prostate cancer report higher levels of depression
than the general community,
but the rate of depression and anxiety in their partners is even greater -
more than double the incidence of the Australian community.
Psychological distress and depression in men with prostate cancer,
and their partners, is often overlooked and underdiagnosed.
There's a fair bit of evidence that cancer-associated depression
has its own issues, and that's what we'll explore.
You'll find useful resources available
on the Rural Health Education Foundation's website:
You're can't go there yet because you've got to meet our panel.
Suzanne Chambers is director of research of the Cancer Council Queensland
and professor of psycho-oncology at Griffith University.
- Welcome, Suzanne. - Thank You, Norman.
Suzanne is a member of the Australian Cancer Network Working Party
for the development of Clinical Practice Guidelines
for the Management of Advanced Prostate Cancer.
As you'll hear, that's associated with significant psychological morbidity.
Caroline Johnson is a general practitioner
and lecturer at the University of Melbourne.
- Welcome, Caroline. - Thanks.
Caroline is about to complete her PhD
on monitoring depression in general practice.
Peter Strange is a nurse practitioner specialising 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 guys that won't come and see their doctors.
NORMAN: You're involved in the Men's Shed movement?
Yeah. Anywhere we can get to men for preventative-type health.
NORMAN: Getting close to too much information.
Colin Bartlett is a prostate cancer survivor,
and also suffered depression through his illness, as you'll hear.
He's facilitator for the Westmead Hospital Prostate Cancer Support Group
in Sydney, and is heavily involved in the Prostate Cancer Foundation.
- Welcome, Colin. - Good evening.
Welcome to you all.
Colin, tell me your story.
I was asked to have a PSA test by 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 to go to another stage.
At that time, it didn't really come home, but the next bit did.
NORMAN: You didn't realise you were on a truck hurtling towards the wall?
No, I didn't.
I then went to have a biopsy done.
It was after the biopsy that 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?
I think she was more devastated than I was.
The mind just goes into freefall - what am I going to do?
Do you remember the emotion attached 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 trap that 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 on to 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 urologist wasn't much help,
I did get a piece of paper
that indicated a prostate cancer support group at Westmead Hospital.
I found the guy who was the facilitator, who still is, by the way.
He gave me some information about choices.
I went to see him, and we talked about it.
We decided really there was no option but a radical prostatectomy
because the Gleason score was high - 7.
The PSA was 20.
It meant I 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's been growing and growing and growing.
Possibly, it really came home probably 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 know what 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 about how 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 which had brought us a bit closer together.
So we were in a fortunate position at that stage, but it unwound later on.
I'm afraid I was the one who 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 four hours' ride and coming home.
NORMAN: The male thing of riding off into the sunset?
Into the sunrise, actually, at that time of day when I'm around.
You sort of get yourself into your own little sphere,
into your own little bubble.
She wasn't able to 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 support from the support group itself.
It more or less put her out on a limb.
She really didn't do much in that course at all.
How did it get better?
I think it got better once we had got rid of the continence problem.
I suffered a post-operative hernia, and we had that fixed.
After that, things started to get back into a normal operation
but for one thing - I had continence troubles. I had incontinence.
It wasn't bad, but it was enough to cause us some concern.
And erectional function had also gone.
Did anybody recognise the depression?
That's the terrible thing about it.
I never talked to anyone, and I didn't see what was happening to me.
I didn't know what was happening to me.
How did the depression show itself in you?
The depression showed probably after 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 ashamed of some of the things I said to her,
like, I don't have to drive with you, do I?
I started to get very critical about 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 interest in things around you?
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 up not getting treated for it?
Quite a long time.
As a matter of fact, it's only after six years of going through this
that I finally was recognised as having a problem.
That was going to a Men's Shed function
and listening to somebody talk 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 person to see. He knows a lot about you.
When I did go to Jim, he said, more or less, 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 onto medication, 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 man who has not had a prostatectomy.
which is quite surprising.
Asking then a beyondblue person what 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 story for you.
No. I'm very interested in your story,
particularly connecting with the act of discovery
for early diagnosis of depression was at Men In Sheds.
Well, it wasn't early - five, six years.
- True. - The first diagnosis.
It's interesting that community groups and support groups
and people you just have a chat to often 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 men with psychological issues,
particularly depression and anxiety, a lot.
Is it different when men have cancer,
and is it different when men have prostate cancer?
I think it is.
Perhaps the more extreme the morbidity or the condition...
Sometimes I think men bury it more so 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 they perceive 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 sense of 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 ahead right to - I'm going to have cancer,
erectile dysfunction, marriage problems and all those things.
As clinicians, we need to think about that and help where we can.
- It may not be unrealistic. PETER: I agree.
Caroline, a familiar story from your point of view
as a general practitioner interested in depression?
It is indeed.
One of the biggest tricks for GPs is getting this balance
between the physical and the psychological.
If someone comes in with 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 us screening for depression,
but patients often think we're saying, how are you coping with the cancer?
You're right, we have to be more specific with questions.
NORMAN: More systematic? - That's an interesting point.
There aren't many research trials that show
that by introducing systematic screening...
You might pick up more cases of depression
but whether you'll get better outcomes is controversial
unless you actually do something.
Hard to get better outcomes unless you find 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 mean anything will get done.
It's important to emphasise that if you ask the question,
you need some kind of plan of what to do next.
Suzanne, how could it have been different?
The first thing I would say is that the story we heard is very typical
of how men often present when they're distressed and have depression,
for example, after cancer - being withdrawn, angry,
a strain on the relationship.
It does get put down to being a cranky old man, which is quite untrue.
We know there's a range of risk factors predictive 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 symptomatology can be important as well.
But the one thing, if you measure at diagnosis the level of distress,
that's the biggest predictor of subsequent distress.
If someone had kept a close eye on your levels of distress from the beginning,
they probably would have picked up that they were high, and got in early.
In essence, you had a prolonged period of 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 that that went on for so long.
The other thing is, if you think about it,
there are three main components to think about with a cancer-specific distress.
There's the psychological aspect -
the distress the man exhibits whether he's depressed or anxious,
having intrusive thoughts.
Then there's the social context - what's his 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 symptoms of the cancer treatment.
Otherwise, the intervention doesn't look relevant to the man,
who's primarily identifying - I've got cancer - as his presenting problem.
One of the greatest problems that we face within the support group
is one of continence.
Incontinence is a big problem.
To a degree, a lot of people don't notice or recognise it.
We're focusing on it at the moment
to bring a little bit of awareness to the guys in the support group
to know that there is something there to help them.
A lot of them suffer greatly with continence problems.
- And it's pretty depressing. COLIN: Very much.
- Which is your point. - Exactly right.
You can't divorce those physical things from the psychological impact.
When they do unmet supportive care surveys of men with prostate cancer,
the big ones are unmet psychological needs
with regards to fear 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 equipment to ask the questions, Caroline?
For psychological things?
NORMAN: To explore this.
Everybody has a different style.
If you make it part of your routine practice to raise the issue...
We know that when you have a serious illness,
it can be psychologically distressing.
These are questions I'm going to ask, is it OK with you?
So people know you're not running through a checklist.
So give us the script that you...
It's often useful for GPs to hear the script that experts use.
What are some of the questions you might feel awkward about?
The screening tools that we use as psychologists
are a little different to what works in general practice.
I'll say what I would do, then I'll defer to Caroline.
We typically use the distress thermometer, a single item.
I'll say, I'm going to ask you a question that sounds a little strange
to check that I understand where you're at and I'm not missing anything.
On a scale from 0 to 10,
where 10 is really high distress and 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 less than 4, I think they're doing OK.
If it's over 4 or 5,
there's a good chance they've got anxiety or depression.
If it's over 7 or 8, I'm very concerned about them.
That helps guide how much I will go in-depth with that person
about their psychological condition.
What I always do is let a person set their agenda first with me
by saying, tell me what's been happening to you,
why you've come to me and 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 way of raising distress.
NORMAN: And it's a psychic thing. - Right.
If we're talking specifically about depression,
I still think questions are good -
in the last two weeks or month, have you been feeling down most of the the time?
Have you lost interest in pleasure?
Researchers in New Zealand did a trial where they added the question -
would you like help with that? No, yes or yes but not today.
They found that extra question was 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 bell that you should focus on them.
Could something have been done at the diagnostic stage?
For example, one of the better predictors
of whether or not you'll regain erectile function
is how much erectile function you had before, regardless of your age.
Could things have been done with Colin earlier?
Is there any evidence of preventability?
There is evidence of preventability.
What's important is that at the outset people understand
this is going to be psychologically tough.
It validates them. If you start feeling distressed, 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 man and his partner.
The best thing to do is get them working as a team
and pre-empt relationship issues,
which are not uncommon after a diagnosis of prostate cancer.
Research in South Australia showed
that much as men don't like expressing their distress,
women don't like expressing it either
'cause they feel they have to be the rock in this time of turbulence.
Women are often the emotional sponge in a relationship.
They take responsibility for 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 have different communication patterns
about dealing with difficulties.
If you can help them negotiate a way to help them do that,
that helps each person feel validated.
It's important that people know tough times are ahead,
and that they give a hint of,
if you start feeling this way and 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.
We may need to ask more than once.
We may be asking someone like Colin how he's going, how he's feeling,
and at that stage of the process -
and this is stretched out over five or six years - he may be doing well,
so we need to keep asking him how he's travelling
and asking those important questions.
There will be periods when he goes up and down.
How important do you think setting expectations is at the beginning
so people know the journey they're on?
We need to be very honest.
We need to keep it very simple because men that are having stresses
won't be able to 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 think could have been done for you
at that diagnostic stage, before anyone had laid a hand or knife on you,
that would have made a difference?
One of the things that would make a difference
is having what we call a road map laid down
of what's going to be, what the expectations are,
what's going to happen.
NORMAN: Physically and psychologically? - Yes.
The psychological one would have been very important
because I didn't realise that 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 still devastating, the psychological bit.
In country towns, it is going to be the GP who will carry the burden.
There are more opportunities now for GPs to get support,
but it is harder in the rural setting
because there are less health professionals.
It's great that there are nurse practitioners now.
Some practices have mental-health nurses that can help,
particularly people with more serious psychiatric illness.
There's also telephone support for GPs through GP Psych Support.
But, ultimately, the GP is often seeing both partners in a relationship,
so they often get the warning signs earlier.
Knowing how to act on that is the challenge.
Suzanne, as the journey progresses?
Things like hormone treatment can be pretty rough psychologically.
That's right. It's important to recognise it is a journey.
Stress is typically very high at diagnosis,
usually quite rapidly diminishes, then can spike when critical events happen,
for example, a cancer occurrence,
where distress can be higher than at initial diagnosis.
If a man is diagnosed with recurrent cancer,
he's at some point going to be put onto hormone treatment.
Hormone treatments have serious side effects
such as mood disturbance, cognitive changes, changes in muscle mass,
central adiposity, osteoporosis.
NORMAN: Libido disappearing. - Libido goes, erectile dysfunction.
There's good work being done in Western Australia using high-intensity exercise
to help with that.
There are things that can be done that 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 aware that things change over time for men.
Every time you see them is an opportunity to check
how things are with the prostate cancer.
Let's go to our case study and 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.
First of all, any time you do a test for cancer,
you should try and discuss with the person before you do the test
what the possible outcomes would be,
because you don't want to read someone and say, the test is abnormal,
and them getting very distressed and panicking
before they hear what it really means.
I try and tell people beforehand the possible outcomes
without going into detail.
Then when the test comes back and there is concern this could be cancer,
taking into account his risk factors, past history.
He's also had experience of cancer through his brother and his wife.
That might alter his perception of what that might mean.
He has existing knowledge, but it may be helpful or unhelpful.
You might want to know what 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 with that sort of history.
Start asking questions about his brother and how he feels
and how much that's affected him.
That's going to drive him into that condition, perhaps, of depression.
Suzanne, is there anything you can do at this point to steel-belt him,
apart from improving his psychological reserves?
The things I've already mentioned are appropriate for this person.
I guess, close surveillance.
Like Peter said, find out what picture he has in his head
about what prostate cancer diagnosis means.
It may be he's more focused on what happened to his wife -
she died a difficult death, and that might happen to me.
Or it could be focused on what happened to his brother.
You don't know until you ask those questions.
If he's got lay beliefs about cancer that 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 anticipate they would need support
and perhaps some relationship counselling.
This is going to be a tough experience. It happens to you as a couple.
Talk about things you can do to support each other through it.
The fact that he's got the history of depression,
it rings bells that he'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 screening and found he was depressed?
I would ask what worked for him last time.
If he had antidepressants and they were very effective
and he had similar symptoms this time,
I'd have no hesitation that he try it again.
Suzanne, the evidence is
that antidepressants don't make a lot of difference
at the mild to moderate end of the scale
and that cognitive behavioural therapy will improve their resilience.
The only thing that improves your resilience
in terms of reducing recurrence is psychotherapy.
I don't know that I would agree with that.
A combined approach is appropriate and 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 people develop adaptive coping strategies
if their predominant coping strategies have been unhelpful
is part of it as well.
Maybe that's part of building their resilience.
Coming back to Colin's point of information being important,
what evidence is there that information has an antidepressive effect?
I don't know of evidence that information alone
has an antidepressive effect.
It's just a basic thing that you need information you understand
so you can make difficult decisions and live with the consequences.
It's just basic good care.
The difficulty for people diagnosed with prostate cancer is,
no-one with cancer expects a choice.
I don't know how many times I've had men say to me,
what's this business of, I've got a choice, and one is, I don't do anything?
Don comes back to the GP because he's had 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 wait for a couple of years
and see what happens to your PSA levels.
It's only 7 at the moment.
You're not going to die if we wait for a year or so.
He goes home, he's miserable, angry,
and he's dragged in by his partner to 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 experience from previous patients
or stories we've heard.
We have to empower the patient to make a decision
using information they're given.
One thing tested in general practice is 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 as choosing which therapy.
You work with the patient to generate as many problems
associated with that as possible.
There's still cognitive restructuring involved?
No, no. It's a very structured approach.
You can download structured problem-solving worksheets
off the internet if you're so inclined.
It's not a difficult technique to learn.
It's just guiding the patient through that decision-making process,
generating as many solutions as possible,
then listing them and looking at the 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 go at problem-solving therapy,
you might not choose a distressed man with prostate cancer
as your first subject.
Try it on yourself or on a more simple case,
then if it works, try it with someone like this man.
If there's more than one clinician involved,
we need to get our stories together.
That can cause more confusion for the patient
if we're giving different stories.
We need to do that on behalf of the patient,
otherwise it becomes confusing.
A nurse in Northern Queensland asks,
'Are there any antidepressant medications
contraindicated with prostate cancer?'
I'd start with the antidepressants I'm used to using.
I'd use ones that don't interfere with urinary function.
I don't know if there's a strong evidence base for that.
I'd start with SSRIs rather than tricyclics,
'cause tricyclics have urine symptoms.
Obvious SSRIs, the message I get from the experts is,
they're pretty much all in the same bunch.
Some have slightly different advantages.
They do have *** side effects.
That's true, but that's going to be a problem with all of the antidepressants.
You have to make a decision of how severe the symptoms are.
Again, if someone has had these treatments and they've worked,
that's a reliable indicator that they'll work again,
or are at least worth trying.
The same nurse in Queensland asks, 'Should all men on hormone treatment
be automatically prescribed antidepressant medication?'
I wouldn't do that. I can't see any reason why you would.
If they weren't having those specific side effects, I don't think you would.
You'd do it based on the severity of their symptoms and their preference.
It's been awhile since we had a question from Western Australia.
Also a nurse. 'Is there any information on suicide rates
in patients diagnosed with prostate cancer?'
There was a paper published recently, I've got a feeling it was European data,
which showed an increase in the relative risk of suicide
in men with advanced prostate cancer.
I've certainly had experience
of men with advanced prostate cancer committing suicide.
It's something you 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 depression needs 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 mild to moderate depression,
I always ask whether there's self-harm.
Given that you're seeing men in men's situations,
how do you involve the partner?
NORMAN: They've got to be involved.
Sometimes men come in because of the partner in the first place.
So the partner may be involved from the word go.
NORMAN: You just don't necessarily see 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 ask how he perceives the relationship is.
If the discussion wants to go on from there,
I offer whether it would be of benefit seeing them both together.
That's a really positive move, particularly if he agrees to that.
Caroline, do we know to what extent treating the man
helps the woman's depression?
I don't think I could answer.
I mainly see women who are worried about their partners.
I find talking to them can help them deal with their partner's depression.
I can give them generic strategies.
The risk factors Suzanne spoke about for 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 better in a relationship or a family situation
makes things better for everybody,
but whether you can automatically assume that treating the man
will make the woman better, it depends on the severity of his depression
and how it's impacting on their problems.
If the thing that's worrying her is that he's going to die
or be impotent forever, treating his depression might not help her.
You have to have a conversation with the individuals.
If you only see one partner and the man sees another doctor,
it's easier if the doctor is in the same practice.
I've had that conversation of -
would it be OK if told his doctor you 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 will pass on as a testimony to other people,
is that if the man is 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 bike in the sunrise,
she was in the garden, pottering around.
I was burying myself in prostate 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 paid on the problem
that would come of this business of depression. It wasn't in our case.
It's only when it was too late that it was noticed in me
because of my crankiness, then suddenly she came down too.
I say it was too late. It should have been 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 carers have more distress than do patients,
but there's enough that suggests that in many cases they do.
In our experience in running trials at Cancer Council Queensland
into psychological interventions for people with cancer,
we find carers are relatively difficult, comparatively, to recruit into trials
because they think they don't really count.
I'm busy looking after my partner who's unwell,
and I don't have cancer, so I don't deserve that support.
They neglect themselves while trying to support the person who has cancer.
When you're looking after someone with cancer,
you have to be as concerned about their partner
as you do about that person who has cancer.
Don and his partner Glenda come back to see you, Caroline, a year later.
He's had a radical. He's got erectile dysfunction. He's had it for a year.
He's got a bit of incontinence.
He's been dragged back by Glenda, rather than 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 story that Colin tells.
What are you going to do here?
Obviously my relapse-prevention strategy
from the first part of this case didn't work so well.
NORMAN: You don't need to beat yourself up.
I'll say to him, I told you if the symptoms came back, to talk to me.
It's great that you're here now.
Clearly, that sounds like he has the symptoms of depression,
but I would complete a more thorough assessment.
NORMAN: You'd go into full mode.
Ask all the questions.
There's a list of symptoms you have to have
to qualify for a DSM diagnosis of depression, but in general practice,
we tend to think more dimensionally than categorically.
If people have got distress at a sufficient level,
we start talking about more proactive treatment.
In his case, I'd come back to what's worked before.
If he has symptoms of depression,
treatments that have helped him in the past should help again,
even though circumstances have changed.
These treatments work for the symptoms even if you've got another diagnosis.
But you have to be aware that medications have side effects,
which you'd revisit if he's had them in the past.
Suzanne, this notion of stepped care. You talk about the pyramid.
Certainly. We have developed in Queensland a tiered model of care
that's been widely used across the country.
The essence of this is to acknowledge the fact that,
while we're talking tonight particularly about extreme depression or anxiety,
most people will do well over time without deeper psychological care.
At the bottom of the pyramid is where most people are.
What they need is effective communication from their clinicians,
access to support groups and cancer helplines -
Cancer Council Australia runs those sorts of things -
to know there's a Peter around if there 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 booklet we've contributed to,
a general wellness book,
a sexuality after prostate cancer treatment booklet
that's on the Andrology Australia website.
There are lots of resources.
beyondblue have a stack of them and cancer councils have them.
There's an excellent array of resources, Cancer Helpline is a national service.
If you've got someone who's got mild to moderate distress,
they're further up the pyramid. They're a smaller number.
They need care with a deeper but narrower focus.
They might need a psychoeducational program.
NORMAN: What do you mean by psychoeducational?
Teaching people in-depth about what 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 want to do relationship or family therapy.
At the top of the pyramid are your vulnerable people
who might be suicidal or demonstrating high levels of distress.
They might need a psychiatrist, a mental-health care team.
You don't muck around with people in trouble.
You get them straight to serious care.
If you're in a country town and referral sources are limited,
what's your view of the self-help areas?
St Vincent's Hospital in Sydney now has internet-based therapy,
where they will offer a therapist online.
You're not just doing internet CBT,
a psychologist will actually talk to you.
There's MoodGYM at the Australian National University.
Swinburne has something.
They seem to have good randomised control-trial evidence that they work.
Would you refer somebody with cancer to one?
I think so, if it was a reputable one and I knew about it.
It's an emerging area, and important for Australia
because we have a decentralised population.
Remote-access therapies are important for us
to get population-based translation of psychological care,
not just for cancer but in every area.
There is randomised-control evidence for these therapies being able to deliver
through the internet and 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 necessarily have access to the internet.
That's an issue, but it also depends upon the level of distress.
We're doing a trial on this now.
We're offering two types of remote-access, telephone-based therapy.
Our hypotheses are that people who are over 4 on the distress thermometer
but not up around 8 will probably do well
with minimal telephone intervention,
where the more distressed people will need the higher level.
That study hasn't been done in cancer before.
Is there evidence that response to therapy is different
when cancer underlies the depression?
I'm familiar with cancer psycho-oncology literature,
where there's good evidence to support a range of cognitive-based therapies,
One of the best studies was on problem-solving therapy,
where they targeted people who already had anxiety and depression.
It's also about health economics.
You've got a limited number of resources.
Let's get our in-depth resources and throw those at people in trouble.
A lot of the others will do fine with 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 disempowered than we are
because they have no access to 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 of who have had recurrence
of their prostate cancer and it's metastasised. Too late.
If somebody had been in contact with them regularly, probably their own GP,
maybe that would not have happened.
They don't have time to go for a PSA test.
Let's have a look at our next case study,
a film study on a prostate cancer support group
created some years ago by David and Pam Sandoe.
It's based at the 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 diagnosed with 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 lucky as Pam and I.
They're the people we're trying to look after.
Some guys are in tunnel vision for a long time after getting their diagnosis.
They don't want to speak about what can happen in their treatment options.
It's usually the wife that has this huge learning curve,
and knows more about the disease than the partner does.
We need to know if there's a situation where that woman needs extra assistance.
She's probably got anxiety and depression herself,
rather than just the male with his recent diagnosis.
It's easy to talk to people that have been similarly diagnosed.
Through the support group,
we can match people up with whatever they're going through.
I can think of one couple who came to us in some despair
because they weren't communicating with one another.
He didn't talk about it at work,
and when he came home he didn't talk about it.
Somehow, they came to our support group and we gave them some facts.
We gave them connections to medical professionals that could help them.
Now they're a great couple that help telephone-counsel people
going through a similar situation.
beyondblue information about anxiety and 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 work through things in a realistic way.
Mostly, they're the health managers of 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 got all the different *** parts to them.
Men think as long as their *** is functioning correctly
and they're having great sex,
that's all there is to the anatomy of it.
They need to speak to their partner
and talk to other men, if they're brave enough,
to find out how they can best move forward.
My erectile function and urinary function
are returning pretty well, I'd say to 90% to 100%.
It's good to be able to express yourself in 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 along as 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 people about prostate cancer.
The advice I'd give medical professionals
giving information to their patients about mental health
is that they've got to be mindful of the anxiety and state of depression
that people get in when they don't, for instance,
have full *** rehabilitation.
They've got to think beyond the diagnosis
and the treatment of the disease
in its crudest form, and think more about
getting the person back to normal of life,
or as normal as possible.
Now more and more, people are being aware
of anxiety and depression and how it affects the family.
David and Pam Sandoe at the San in Sydney.
It's not for everybody though, is it, Colin?
- What, support groups? NORMAN: Yes.
A lot of people prefer to have one-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 dragged with his heels skidding ground.
Just about. It's humorous, but yes.
NORMAN: How long does it take on average for the light to go on?
What, in getting something done?
Realising that, I don't need to resist coming. This is not for wimps.
It's something that's good for me.
Some people, it's usually a year
before they really get involved with 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 guys who are keen on themselves
come before any procedure is done.
That's where they get their road map from.
Peter, what are the benefits and limits of support groups?
The benefits are enormous.
I've talked to a few support groups.
The first thing I did is see how many partners there were.
There were 20 men and 20 women at one in Bendigo.
It was a terrific social event as well as education.
But I agree, not every guy will want to turn up to that.
Which is not a problem, just a different way of dealing with that man.
That's a bloke, I suppose.
Men are like that.
They can be withdrawn.
Particularly if they're depressed, they don't want to go out and be in public.
We have to have our door open to give consults and give them time to talk.
Sometimes, I think they may benefit
from talking to the guy on the bar stool next to them.
It may not give great medical information,
but they need somewhere to chat.
That can grow through the clinician if we give them more time.
Then maybe they will join the support group, even if it takes a year.
NORMAN: How do you find a support group in your area, Colin?
It's reasonably active.
We've got something like 70 couples registered,
and we get a floating attendance.
That's in Sydney. But if you're in Kalgoorlie or the Northern Territory,
is there a network of support groups?
The network of support groups is done
from the Prostate Cancer Foundation of Australia.
They have published a list of where support groups are.
Any evidence, Suzanne, that they work, beyond the anecdotal?
We've done research ourselves.
There are a lot of descriptive studies that are cross-sectional,
looking at people who go to support groups, how are they doing
and what are the aspects of support groups they appreciate.
They've been very positive studies.
The important thing is that there are a range of services available.
Different things suit different people.
NORMAN: A menu.
Which might be the Cancer Helpline, the cancer counselling service,
the support group or one of the volunteers from the group
who's available to talk on the phone anonymously,
your GP, your men's-health practitioner.
People need to know that some things might not suit, but don't give up.
If it doesn't seem like it'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 sticks and run these nights,
towns that have 200 or 300 people, and you'll get 100 turn up.
At those, even though it may not be specifically on prostate cancer,
we will get guys that come and sneak in the back.
We'll talk about things like mental health and *** health,
and those guys will absorb that information.
That's incredible. So much for blokes not wanting to come forward.
Give them the right environment, they will.
Particularly if you put on a barbecue and a drink, they'll turn up,
and you can talk frankly to them.
Thank you all very much. What are your take-away messages? Colin?
Take-away message for people watching
is to look at getting a proper road map of where you're going
with some of these things we've mentioned tonight included in that,
of course, the big one being depression.
For clinicians to ask the questions to the patients,
then to give them time and to listen to them.
I agree with that.
To believe that you can make a difference
by helping people with psychological problems as well as physical ones.
NORMAN: The evidence base is there. Suzanne?
Cancer is a major life stress for both the person with cancer and the carer.
Good psychosocial and psychological care is central to good care.
Thank you all very much, and thank you.
I hope you've enjoy the program on maintaining wellbeing,
depression and anxiety in men with prostate cancer.
Our thanks to beyondblue, the national depression initiative,
and the Prostate Cancer Foundation of Australia
for making the program possible.
Our thanks to you for taking time to attend and contribute.
If you're interested in obtaining more information,
there are a number of resources available
on the Rural Health Education Foundation website:
To register for CPD points, complete and send in your evaluation forms.
I'm Norman Swan. I'll see you next time.
Captions by Captioning & Subtitling International
Funded by the Australian Government Department of Families, Housing,
Community Services and Indigenous Affairs�