Psychosocial Screening for Bone Marrow Transplant Recipients.

Abstract

Bone marrow transplantation (BMT) is known to be both a physically and emotionally stressful procedure, due to the significant associated risk of developing life-threatening complications, and because of behavioural treatment related factors such as the post-transplant isolation period. BMT recipients have therefore been found to be at increased risk of experiencing a variety of psychosocial difficulties and factors that impact negatively on their quality of life. Identified factors include anxiety, depression, sexual difficulties, fatigue, interpersonal stressors and sleep disturbance. Psychosocial difficulties have been identified throughout the transplant process and into the recovery phase of treatment. Even disease-free BMT survivors report significantly disrupted cognitive, occupational and interpersonal functioning. Reported prevalence of psychosocial difficulties varies between 28% and 41% depending on the adopted diagnostic criteria and stage of transplant. Problems such as anxiety and depression are known often to go unrecognised in hospital settings. Unrecognised, or untreated psychosocial difficulties in the context of BMT are known to interfere with medical treatment and have been associated with reduced survival. It is therefore important that psychosocial difficulties in this patient group are identified at the earliest opportunity, and pro-actively addressed. In the BMT Unit at Glasgow Royal Infirmary, a nurse-led psychosocial screening programme has been established under the supervision of a clinical psychologist. All BMT recipients are now interviewed using a semi-structured interview prior to their transplant, to screen for psychological predictors of poor psychosocial outcome. Psychometric measures are also taken at this time. Measures comprise the Hospital Anxiety Depression Scale, The Brief Symptom Iventory-18, and the National Cancer Comprehensive Network ‘distress thermometer', which assesses domains associated with quality of life. Repeat assessment is performed at day +14 and +100 post-transplant, in order to monitor potential change in presentation. Data collected from the first twenty-six consecutive BMT recipients are presented. Clinically significant psychological morbidity was identified in 43% of this sample. Levels of anxiety and depression were generally high and stable, before, during and after the transplant process. Formal contact with a clinical psychologist was required by 53% of the sample. Data from the measure of distress revealed that emotional and physical problems were most commonly reported and most highly rated. Consistent themes that emerged through interview included overt anticipatory fear regarding the transplant process, systemic family issues, the importance of family support, and the prospect of financial difficulties post-transplant. Many patients held unrealistically positive views regarding post-transplant quality of life, or were relying on positive thoughts to help them through the process. In conclusion, the prevalence of psychological morbidity in this population of BMT recipients was found to be high and stable. A psychosocial screening programme has aided the identification and treatment of ‘at risk' cases. This highlights the need for continued awareness of psychosocial issues in this population, and the importance of ongoing formal, psychosocial support services for BMT recipients. Screening programmes are recommended for initial and ongoing assessment of psychosocial difficulties in this population.