Psycho-Oncology

Psycho-Oncology 19: 1294–1302 (2010)

Published online 11 February 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.1693

Assessment of psychological distress in cancer patients: a

pivotal role for clinical interview
A. Bonacchi1, A. Rossi1, L. Bellotti1, S. Franco1, A. Toccafondi1, G. Miccinesi2 and M. Rosselli1
1
Service of Psychosomatic Medicine, U.O. Internal Medicine and Hepatology, Department of Internal Medicine, University of Florence,
Florence, Italy
2
Epidemiology Unit, Institute for Cancer Research and Prevention-ISPO, Florence, Italy

* Correspondence to: Abstract

Service of Psychosomatic
Medicine, U.O. Internal
Medicine and Hepatology,
Department of Internal
Medicine, University of
Florence, Florence, Italy.
E-mail: andrea.bonacchi@unifi.it
Received: 19 March 2009
Revised: 30 November 2009
Accepted: 1 December 2009
Objective: The evaluation of psychological distress in cancer patients recently entered oncologic
clinical practice. The objective of this study was to evaluate the role of clinical interview within
psycho-oncologic assessment.
Methods: Questionnaires assessing distress (PDI), psychopathology (MHQ, HADS) and
needs (NEQ) and a subsequent clinical interview were proposed to 320 consecutive inpatients
from the Oncology Department of Careggi Hospital in Florence.
Results: The clinical interview made it possible to evaluate a significant percentage of patients
(30%) who did not fill in questionnaires and to detect the presence of distress in 39 (13.7%)
patients who would not have received a diagnosis in a protocol for the assessment of distress
based only on questionnaires. It also provided the possibility to ask for help or to receive clinical
support to a high percentage of patients (44.1%) who had not requested to speak to a
psychologist through the questionnaires (NEQ). Moreover, 25% of patients who received
prolonged clinical support had a low score in tests detecting distress, indicating that the
opportunity for therapeutic support can emerge during a clinical interview, also in the absence of
relevant symptoms detected by questionnaires.
Conclusions: The use of more than one questionnaire in the assessment of distress and
psychopathology is associated with reduced compliance and redundant information. On the
other hand, clinical interview has a pivotal role in clinical evaluation and access to
psychological support. We conclude that optimal efficacy of programs assessing distress in
cancer patients is reached when a single questionnaire evaluating distress is associated with a
clinical interview.
Copyright r 2010 John Wiley & Sons, Ltd.
Keywords: cancer; oncology; distress; clinical interview; questionnaire

Introduction Recently, growing attention has been focused on

The high prevalence of psychological distress in
cancer patients has been widely documented; about
40% of patients with cancer could be diagnosed with
psychological distress and psychopathology, while
about 15–20% show below threshold symptoms that
are, for number and intensity, insufficient to evidence
a psychiatric diagnosis but still retain strong
consequences for the patient’s health and social
relationships [1,2]. Psychological distress and psy-
chopathology in cancer patients, if not diagnosed
and therefore not treated, can have several con-
sequences: worsening of suffering, decrease in the
quality of life [3], longer hospital stay and reduced
compliance to treatments [4,5]. On the other hand,
different psychosocial treatments oriented to alleviate
distress levels in cancer patients have been employed
and their efficacy widely documented [6–10].
the diagnosis and treatment of psychological
distress, in its different aspects, in cancer patients
[11,12]. A bio-psychosocial model has been devel-
oped that, like a holistic model, considers the sick
person in his/her complexity and the disease in its
multiple levels of expression: biological, psycholo-
gical and social. Consensus-based guidelines devel-
oped by the Distress Management Panel of the
National Comprehensive Cancer Network recom-
mend regular screening of all patients with cancer
for psychological distress, as part of routine care
[13]. Therefore, in many oncology units, a clinical
approach by psychologists or psychiatrists, based
on episodic consultation for severe psychological
distress, has been substituted with a careful
evaluation of the psychological component of
suffering carried out on the single patient. In
several health departments specialising in the

Copyright r 2010 John Wiley & Sons, Ltd.

Assessment of psychological distress in cancer patients
diagnosis and treatment of cancer, programmes for
the assessment of psychological distress have been
set up. These programmes use two master instru-
ments to establish psychological distress: the
clinical interview and specific tests. Often the
evaluation is based exclusively on self-assessment
questionnaires.
The use of several different tests for the
evaluation of psychological distress in cancer
patients has been described. Among these some
of the most frequently used in Italy are as follows:
the Hospital Anxiety and Depression Scale
(HADS) [14], the Psychological Distress Inventory
(PDI) [15], the Brief Symptom Inventory [16] and
more recently the Distress Thermometer [17,18].
These are self-assessment questionnaires compiled
of a few items and, therefore, easy to fill in. These
tests, as are others evaluating distress, are useful to
screen a large number of cancer patients.
On the other hand, studies evaluating the role
and efficacy of clinical interview in the assessment
of psychological distress in cancer patients are
lacking.
Over the last few years at Careggi Hospital in
Florence, we have set up a psycho-oncological
clinical activity on the ward and in the Day
Hospital of the division of Medical Oncology; we
developed three levels of intervention. The first
level is psychodiagnostic and includes the follow-
ing: a preliminary meeting in which the psycholo-
gist introduces himself to the patient,
administration of a few questionnaires oriented to
point out distress and actual needs, a first brief
interview. The clinical interview, which lasts about
15–20 min, is focused on the awareness and the
experience of illness, on the presence of distress and
previous or actual psychopathology and on perso-
nal, family and social resources. Our first level of
intervention is carried out with all consenting
patients in the first two days after admission to
the oncology ward.
If during this first psychodiagnostic evaluation
the presence of psychological distress is observed
and the patient asks for support or accepts the
suggestion for support by the psychologist, a second
psychodiagnostic investigation takes place including
a second interview and/or psychiatric consultation
(or couple and family consultation) and a final team
evaluation. The third level consists of therapeutic
intervention (psychotherapy, counselling, suppor-
tive talk, psychopharmacological therapy).
During the past few years, we have carried out
the programme for the assessment of psychological
distress in the oncology department continuously,
trying to improve the method. For this improve-
ment process, studies evaluating the efficacy of the
programme have a key role. This study intends to
evaluate the compliance and clinical efficacy of a
programme for the assessment of psychological
distress in cancer patients focusing particularly on
Copyright r 2010 John Wiley & Sons, Ltd.
1295
the role of clinical interview; for this purpose, data
obtained during one year of psycho-oncologic
activity in the Oncology Division of Careggi
Hospital in Florence are analysed.
Methods
Program for the assessment of psychological
distress
This study was carried out over one year by
psychologists of the Psychosomatic Service-Unit of
Internal Medicine and Hepatology, Careggi Hos-
pital in Florence, in the Unit of Medical Oncol-
ogy—Department of Oncology (directed by Dr F.
Di Costanzo) of the same hospital.
The program for the assessment of psychological
distress evaluated in this study was the first step of
a wider psycho-oncologic intervention.
The psycho-oncologic intervention that took
place during the period of the study was divided
into three steps: (1) psychosocial assessment, (2)
psychodiagnostic deepening and therapeutic pro-
posal and (3) therapeutic intervention.
The psychosocial assessment included a preliminary
meeting in which the psychologist introduced himself
to the patient, a few questionnaires aimed at
evaluating distress, mood and actual needs were
given to the patient, and there was a first brief
interview. The first level of intervention was proposed
to all inpatients soon after admission to the ward.
Four short questionnaires were given simulta-
neously and graphically presented in the following
sequence to patients adhering to the program for
the assessment of psychological distress:
1. Needs Evaluation Questionnaire (NEQ)
[19,20]: A questionnaire compiled of 23 items
with yes/no answers used to evaluate patient’s
needs.
2. PDI [15]: A multiple choice test consisting of
13 items, giving a general score of psychologi-
cal distress.
3. HADS [14]: A multiple choice test compiled of
14 items. This test evaluates anxiety and
depression.
4. Middlesex Hospital Questionnaire (MHQ)
[21]: This is a test made up of 48 items,
assessing anxiety, depression, somatic symp-
toms, phobias, obsessions and hysteria.
Patients took about 20–30 min to fill in all the
questionnaires. The scoring of tests was calculated
and the clinical interview took place including a
brief discussion of test results.
The clinical interview, which lasted about
15–20 min, was non-structured and patients could
freely and spontaneously express thoughts and
emotions.
Psycho-Oncology 19: 1294–1302 (2010)
DOI: 10.1002/pon
1296
The interview focused on the following:
1. Awareness and the experience of illness and the
level of related distress;
2. The presence of previous or actual psycho-
pathology;
3. The presence of psychopharmacological
therapy;
4. Present relationships and family support;
5. Personal, family and social resources.
If the arguments related to these areas did not
emerge spontaneously, they were introduced
through specific questions.
The interviews were conducted by two clinical
psychologists with similar training and periodic
team evaluation.
If the presence of psychological distress (emer-
ging through the questionnaires and/or from the
interview) during psychosocial assessment was
detected and the patient asked for support or
accepted the suggestion of support by the psychol-
ogist, psychodiagnostic deepening took place.
Therefore, the decision to provide therapeutic
intervention was not guided only by the psycho-
metric assessment of patient distress. This decision
was made by the psychologist, reflecting also the
contents of the interview with the patient; when
appropriate, therapeutic support was proposed to
the patient at the end of the interview.
The second step of psycho-oncologic interven-
tion that we called ‘psychodiagnostic deepening and
therapeutic proposal’ included a second interview, a
second group of psychodiagnostic tests (Mini
MAC and/or SF-36 and/or TCI-140), a psychiatric
consultation or couple and family consultation,
and a final team evaluation. This second step was
not based on rigid protocol but the focus of the
second interview, the choice of questionnaires and
the kind of consultation (psychiatric and/or family
consultation) were based on the clinical judgment
that emerged from the psychosocial assessment (the
first step). At the end of psychodiagnostic deepen-
ing and after the team evaluation, therapeutic
intervention was proposed to the patient.
The third step of psycho-oncologic intervention
consisted in ‘therapeutic intervention’.
Different therapeutic options were available:
1. A few sessions (one–three) of supportive
counselling before dismissal from hospital;
2. Family or couple consultation;
3. Psychiatric consultation with psychopharma-
cological therapy; psychiatric out-patient
follow-up after dismissal from the ward;
4. Prolonged therapeutic support based on
weekly sessions (lasting 50–60 min) with a
psychotherapist for a period of at least two
months (eight sessions). The total period of
Copyright r 2010 John Wiley & Sons, Ltd.
A. Bonacchi et al.
psychotherapeutic intervention varied from
patient to patient, with an average of 5 months
(20 sessions).
These options were not mutually exclusive and
could be integrated.
We considered ‘prolonged therapeutic support’ to
be those therapeutic interventions (psychotherapy
and/or psychiatric out-patient follow up) that
lasted at least two months after dismissal from
hospital.
The inclusion of patients in a specific protocol of
therapeutic support was not the result of a
decisional algorithm but emerged from team
evaluation based on several different criteria such
as clinical data from psychosocial assessment and
psychodiagnostic deepening, the existence of psy-
chosocial support that the patient was receiving or
could receive elsewhere, medical conditions, and
how far patients had to travel to reach the hospital.
The number of patients that took part in
different steps of the program for the assessment
of psychological distress and who received pro-
longed therapeutic support during the period of the
present study is summarised in Figure 1.
Subjects
During the period of the study, 320 patients were
hospitalised at least once in the Oncology ward.
Patients not adhering to the programme for the
assessment of psychological distress out of their
own choice were excluded from the study; also
patients with impaired cognitive level or severe
general conditions due to illness or therapy were
excluded.
Table 1 summarises some basic demographic
and clinical characteristics for the following: 320
patients who were hospitalised at least once in the
Unit of Medical Oncology at Careggi Hospital in
Florence throughout one year; 285 of these patients
who joined the proposed programme for the
assessment of psychological distress and 35 pa-
tients excluded from the study.
Table 2 shows the demographic and clinical
characteristics of 69 patients who filled in all four
questionnaires proposed, and also of 86 patients
who did not fill in any of the questionnaires
proposed.
Statistical analysis
In this study, usual univariate descriptive statistics
were performed. SPSS 9.0 statistical package was
used for the analysis.
Ethics
This study received the approval of the Local
Ethics Committee of Careggi Hospital in Florence.
Psycho-Oncology 19: 1294–1302 (2010)
DOI: 10.1002/pon
Assessment of psychological distress in cancer patients
Figure 1. Flowchart of the study describing the number of patients taking part in each step of the process of assessment of
psychological distress
Patients were asked to give written informed
consent and received an informative sheet on the
study.
Results
Involvement of hospitalised patients
Among the 320 patients who during one year were
hospitalised at least once in the Unit of Medical
Oncology at the Careggi Hospital in Florence, 285
joined the proposed programme for the assessment
of psychological distress, meeting the psychologist
for at least the clinical interview.
Copyright r 2010 John Wiley & Sons, Ltd.
1297
Among the 285 patients participating in the
programme, 199 completed at least one of the four
questionnaires proposed, 137 completed three
questionnaires including PDI and HADS; 69
patients completed all four questionnaires (NEQ,
PDI, HADS and MHQ). Forty-four patients
received a psychiatric consultation and 24 patients
received treatment extended over time (at least two
months) consisting of counselling, psychotherapy
or out-patient psychiatric follow-up with control
of drug therapy (Figure 2). As expected, the
percentage of patients filling in the tests gradually
reduced while considering an increasing number of
questionnaires. Among 285 patients undergoing
Psycho-Oncology 19: 1294–1302 (2010)
DOI: 10.1002/pon
1298 A. Bonacchi et al.

Table 1. Basic demographic and clinical characteristics of the 320 patients that during one year were hospitalised at least once in
the Unit of Medical Oncology at Careggi Hospital in Florence, of 285 of them that joined the proposed programme for the
assessment of psychological distress, of the 21 patients excluded from the study because of impaired cognitive level or severe general
conditions and of 14 patients not adhering to the proposed study out of their own choice

Characteristics Inpatients of the Oncology Inpatients of the Oncology Inpatients excluded from Patients not adhering to
Division hospitalized during Division included in the the study because of im- the proposed study out of
the period of the study study (n 5 285) paired cognitive level or their own choice (n 5 14)
(n 5 320) severe general conditions
(n 5 21)

N % N % N % N %

Gender
Male 159 49.7 141 49.3 12 57.1 6 42.9
Female 161 50.3 144 50.7
9 42.9 8 57.1
Age (mean) 64.6712.6 (range: 27–87) 63.2712.2 (range: 27–85) 74.579.7 (range: 54–87) 78.477.9 (range: 57–86)
Primary tumour site
Lung 46 14.4 39 13.7 5 23.8 2 14.3
Colon 38 11.9 36 12.6 1 4.8 1 7.1
Breast 30 9.4 29 10.3 — — 1 7.1
Stomach 20 6.3 15 5.2 4 19.0 1 7.1
Pancreas 15 4.7 14 4.9 1 4.8 — —
Lymphoma 7 2.2 7 2.5 — — — —
Other 164 51.1 145 50.8 10 47.6 9 64.4

Table 2. Demographic and clinical characteristics of 69 patients who filled in all 4 proposed questionnaires and of 86 patients who
did not fill in any of the proposed questionnaires

Characteristics Patients who filled in all 4 proposed Patients who filled in none of the proposed
questionnaires (n 5 69) questionnaires (n 5 86)

N % N %

Gender
Male 35 50.7 41 47.7
Female 34 49.3 45 52.3
Age (mean) 62713.6 64.7712.2
Primary tumour site
Lung 15 21.7 17 19.7
Colon-rectum 10 14.5 10 11.6
Breast 7 10.14 6 7.0
Stomach 6 8.7 8 9.3
Pancreas 5 7.24 6 7.0
Other 25 36.2 39 45.4

Figure 2. Acceptance of the psychological assessment by patients admitted to the Medical Oncology Unit. (A) Patients admitted to
the Oncology Unit. (B) Patients who accepted the proposed screening of distress. (C) Patients who completed at least 1
questionnaire. (D) Patients who completed NEQ, PDI, HADS. (E) Patients who completed NEQ, PDI, HADS, MHQ. (F) Patients who
received psychiatric consultation. (G) Patients who received prolonged therapeutic support (at least two months)

Copyright r 2010 John Wiley & Sons, Ltd. Psycho-Oncology 19: 1294–1302 (2010)
DOI: 10.1002/pon
Assessment of psychological distress in cancer patients
evaluation, only 24.2% (69 patients out of 285)
completed all questionnaires, but if we observe the
small subgroup of 24 patients who received
prolonged treatment, 66.7% (16 out of 24) of them
completed at least three of these questionnaires and
54.1% (13 out of 24) completed all the proposed
tests. Therefore, patients receiving prolonged sup-
port have high compliance to filling in the tests.
Pivotal role of clinical interview in the assessment
of distress and in the selection of patients
undergoing therapeutic intervention
Among the 285 patients who joined the proposed
programme for the assessment of psychological
distress, 199 patients met the psychologist for the
clinical interview and filled in at least one
questionnaire; 84 of them (42.2%) met criteria for
psychological distress. Criteria for a distress diag-
nosis was the presence of at least one of two
possible grounds of distress: (1) over threshold
PDI and/or HADS score and (2) clinical judgment
based on the interview. A total of 79 patients
(39.7%) have shown over threshold PDI and/or
HADS. Five patients received a diagnosis of
distress based on clinical interview even if they
had shown below-threshold questionnaire scores;
four of them were not interested in psychodiagnos-
tic deepening or therapeutic support. The fact that
diagnosis made through above-threshold question-
naires could be unconfirmed by clinical interview
was not one of the aims of this study and therefore
this aspect was not evaluated.
Among the 285 patients, 86 patients met the
psychologist for the clinical interview but did not
fill in any proposed questionnaire. A total of 34 of
them (39.5%) experienced significant levels of
distress detected through clinical interview.
Altogether, 118 patients out of 285 (41.4%)
received a diagnosis of distress; the clinical inter-
view has made it possible to detect the presence of
distress in 39 (13.7%) patients who would not have
received a diagnosis in a protocol for the assess-
ment of distress based only on questionnaires.
Table 3. A total of 137 patients who entered the program for the assessment of psychological distress completed both PDI and
HADS questionnaires; 16 of them received prolonged therapeutic support (at least two months)
No of patients PDI HADS HADS de-
who concluded (average) anxiety pression who, from the first psycho-di-
the first psy- (average) (average) agnostic level (psychosocial as-
cho-diagnostic
level
PDIp25 43 19.98 4.80
26pPDIp29 28 26.3 7.16
30pPDIp35 39 31.84 9.11
PDI436 27 43.30 11.13
In this table the 137 patients have been divided into four groups according to the PDI score.
Copyright r 2010 John Wiley & Sons, Ltd.
1299
Among the 285 patients seen in the Unit of
Medical Oncology during the programme for the
assessment of psychological distress, 137 completed
both PDI and HADS. In Table 3, these 137
patients were divided into four groups based on
the score resulting from PDI. The number of
patients who received therapeutic support is
the highest in the presence of a higher distress but
also a considerable number of patients, who have
not shown significant distress through question-
naires, received therapeutic support. This suggests
that indication for therapeutic treatment could
emerge during clinical interviews even in the
absence of severe symptoms detected with ques-
tionnaires.
Interesting elements also emerge from the
analysis of responses to NEQ questionnaire with
regard to item number 19: ‘I need to speak with a
psychologist.’
Among the 155 patients who completed the
NEQ at the item 19, 25.8% (40 out of 155)
answered ‘yes’, 74.2% (115 out of 155) answered
‘no’. About 22.99% of males and 27.27% of
females answered ‘yes’. We evaluated if the request
to talk with a psychologist expressed through NEQ
was related to distress (Table 4). About 117
patients completed both NEQ and PDI. We
observed that the request to talk with a psychol-
ogist (NEQ, item 19) increases with growing levels
of the psychological distress (PDI).
Among the 24 patients who received prolonged
therapeutic support, 19 filled in the NEQ; among
them 57.9% (11 out of 19) had answered ‘yes’ to
item 19 and 42.1% had answered ‘no’. This fact
suggests that during screening of distress in cancer
patients the clinical interview allows the psycho-
oncologist to receive a request for help or to
propose a therapeutic intervention to a significant
number of patients (about 40%), who had not
made a specific request to meet the psychologist
through questionnaires.
All these data together indicate the crucial role
of the clinical interview in evaluating psychological
distress and in selecting cancer patients undergoing
therapeutic intervention.
No of patients (percentage) No of patients (percentage)
who, from the second psycho-
diagnostic level (psycho-diag-
sessment), entered the second nostic deepening), entered the
(psycho-diagnostic deepening) clinical support program
3.86 9 (21%) 4 (44%)
6.19 5 (18%) 2 (40%)
7.30 9 (23%) 3 (33%)
11.67 7 (26%) 7 (100%)
Psycho-Oncology 19: 1294–1302 (2010)
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1300
Table 4. The request to talk with a psychologist expressed
through NEQ increases with distress evaluated by PDI
(N 5 117)
N. I need to speak with a psychologist
Yes No
PDIp25 5 35
26pPDIp29 6 19
30pPDIp35 10 23
PDI435 9 10
Discussion
Guidelines for distress management published by
the American National Comprehensive Cancer
Network suggested that ‘distress should be recog-
nised, monitored, documented, and treated
promptly at all stages of disease’ [13]. This study
aimed at giving a contribution to improve evalua-
tion strategies to detect psychological distress in
hospitalised cancer patients focusing on the role of
clinical interview.
First, this study describes some aspects of
patients’ participation in the programme for the
assessment of psychological distress. It is possible
to observe that most of the inpatients (89%)
admitted to the Medical Oncology Department of
Careggi Hospital in Florence adhered to the
programme. This high percentage is probably due
to the fact that the psychological assessment was
proposed soon after admission to the ward as an
integral part of procedures for the patient’s ‘global
diagnostic evaluation’.
Every patient adhering to the programme met a
psychologist for a short clinical interview and 69%
(199 patients out of 285) filled in at least one test.
About one-third of patients refused or were not
able to fill in the questionnaires. The fact that these
patients had a clinical interview with the psycho-
logist made evaluation possible. Hence, the clinical
interview was the only instrument of evaluation for
about 30% of patients.
We proposed four short questionnaires: 69.8% of
patients filled in one questionnaire, 48.7% filled in
three questionnaires and only 24.0% (69 patients out
of 285) filled in all four questionnaires (Figure 2).
These data confirm that it is useless to employ more
than one or two tests for the evaluation procedure
because most of the patients are not able or
interested in filling in a larger number of question-
naires. Furthermore, our data suggest that patients
who received prolonged therapeutic support repre-
sent a subset of persons with high compliance to fill
in questionnaires. Therefore, a higher number of
questionnaires eventually could be used during a
second diagnostic step with selected patients inter-
ested in a programme of therapeutic support.
During the period of our study, 118 patients out
of 285 (41.4%) received a diagnosis of distress; the
Copyright r 2010 John Wiley & Sons, Ltd.
A. Bonacchi et al.
clinical interview made it possible to detect the
presence of distress in 39 (13.7%) patients who
would not have received a diagnosis in a protocol
for the assessment of distress based only on
questionnaires.
% of Yes Most of this opportunity to improve the detec-
tion of distress through the clinical interview results
12.5
24.0
from the potential of the interview to make
30.3 evaluable patients who refused or were not able
47.4 to fill in the questionnaires. Several of these
patients underwent psychodiagnostic deepening
and some of them received psychological support.
The percentage of patients who entered psycho-
diagnostic deepening after psychosocial assessment
and then received psychological support was higher
for patients who had completed at least one
questionnaire than for those who had completed
none (Figure 1). This is understandable because,
even if the prevalence of distress in both groups
was similar, patients who had not completed the
questionnaires were either not interested in receiv-
ing psychological support or their health condi-
tions related to disease or therapies made it difficult
to access psychological support, especially after
dismissal from hospital.
In few cases (5 patients out of 39), the clinical
interview had made it possible the diagnosis of
distress in patients who had shown under threshold
questionnaires scores; most (4 out of 5) of these
patients even if suffering from distress were not
interested in psychodiagnostic deepening or psy-
chological support.
This study pointed out the pivotal role of the
clinical interview not only in the diagnosis of
psychological distress but also in the selection of
patients who received treatment.
During the one-year period of the programme
for the assessment of psychological distress, 155
patients completed the NEQ. This is a question-
naire that investigates several main needs of cancer
inpatients. Item 19 in NEQ questionnaire is as
follows: I need to speak with a psychologist. About
25.8% of patients answered yes to this item. The
need to speak to the psychologist increased with
increasing levels of psychological distress measured
by PDI (Table 4). Almost half of patients (47.4%)
with high distress (PDI436) asked to speak with
the psychologist. The degree of psychological
distress is confirmed as one of the crucial elements
for asking for help.
About 47.4% of patients with high distress
(PDI436) asked to speak with a psychologist but
52.6% did not request any help. This finding is
coherent with previous studies, in which it was
found that about 50% of those patients suffering
elevated distress did not express the wish for
supportive counselling [22]. This aspect is particu-
larly significant if we consider that even high-level
distress often goes unnoticed to medical doctors or
nursing staff [23]. We can find in clinical interviews
Psycho-Oncology 19: 1294–1302 (2010)
DOI: 10.1002/pon
Assessment of psychological distress in cancer patients
some suggestions on why several patients with high
distress did not ask for psychological support.
Coping style is the first element that seems to play
an important role; for example, people with a coping
style of avoidance or minimisation tend less to seek
psychological help. Another important factor ap-
pears to be the support of family and friends. People
with greater social support tend to make fewer
requests for psychological support. Finally, some
patients are convinced that they would not benefit
from psychological support. Beyond this qualitative
information derived from clinical interviews, the lack
of a quantitative assessment of perceived social
support and coping style of patients remains a
limitation of the present study.
Another important element appears if we focus on
patients who received prolonged therapeutic support
(at least two months): 57.9% of patients answered
yes to the NEQ item: ‘I need to speak with a
psychologist’ but 42.1% (8 out of 19) answered ‘no’.
This element is worthy of notice because it suggests
that in the assessment for psychological distress in
cancer patients the clinical interview allows the
psycho-oncologist to receive a request for help or to
propose therapeutic support to a significant number
of patients (about 40%) who, when filling in the
questionnaires, did not spontaneously and specifi-
cally ask to meet the psychologist.
An intriguing element is the observation
(Table 3) that 25% of patients who received
prolonged clinical support had a low score (o25)
in the PDI questionnaire. This observation is
coherent with emerging data suggesting that the
wish for psychosocial support often does not
correlate with distress [22]. In our clinical experi-
ence, a request for help could often emerge during
the clinical interview even in the absence of distress
pointed out by questionnaires. Furthermore, a
proposal for clinical support could be suggested
by the psychologist in the presence of specific
problems or symptoms that do not cause general
psychological distress. Previous studies [24,25] have
pointed out an active coping style of patients as a
predictor of acceptance of an offer for psychologi-
cal counselling. Patients who want to deal actively
with cancer could perceive psychological support
as a useful resource to cope with the disease and,
therefore, could accept an offer of supportive
counselling or ask for psychological support also
in the absence of high perceived distress.
In our opinion, the central role of clinical
interview for diagnosing psychological distress
and selecting patients for treatment do not
invalidate an appropriate use of questionnaires.
Tests give important information and offer sugges-
tions for deep investigation during the following
clinical interview. On the other hand, a warm and
empathic relation established during the clinical
interview could improve compliance to filling in
questionnaires.
Copyright r 2010 John Wiley & Sons, Ltd.
1301
In conclusion, we suggest that optimal efficacy of
programs assessing distress in cancer patients is
reached when a single questionnaire evaluating
distress is associated with a clinical interview.
Such interview could take place either with a
psychologist or with an oncologist. In the latter
case, it would constitute a more accurate and
extended medical history. A questionnaire evaluat-
ing patients’ needs (e.g. the NEQ) could also be
employed, considering the importance of including
this in the care-taking process.
We think that wherever possible, in psycho-
oncologic clinical practice, multistep models of
intervention should include a clinical interview
focused on the assessment of distress, among other
procedures. In this way, the exclusion from psycho-
oncologic intervention of a high number of cancer
patients suffering from great distress, who either
refused or were not able to fill in questionnaires,
could be avoided. The opportunity of psychological
support for patients asking for it in the absence of
marked perceived distress could also be evaluated.
Acknowledgements
The authors thank Mrs Susan Seeley for her linguistic
assistance.
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