October 20, 2014

Why Mental Health is the Missing Piece in Cancer Care

Addressing the unmet mental health needs of cancer patients provides a comprehensive approach to survival

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Approximately 25 percent to 30 percent of patients in the cancer setting will experience depression or anxiety—rates that greatly exceed those seen in the general population.

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According to the literature, these figures are likely underestimates, too. The impact of depression and anxiety can be critical, underscoring the importance of addressing mental health concerns as part of treatment.

In the early stages of cancer intervention, physicians and other practitioners tend to focus on treating the disease. As a result, individuals with mental health needs can slip under the radar. Evidence suggests oncologists can improve the odds of detecting depression, anxiety, and other psychiatric disorders if they incorporate key behaviors into their clinical practice. These include:

1. Engage in routine screening for psychosocial distress

Starting in 2015, a new mandate from the American College of Surgeons Commission on Cancer will go into effect requiring cancer centers to implement psychosocial screening to attain accreditation. Assessment should occur at the point of diagnosis, when patients are highly susceptible to distress. But given that some chemotherapies and agents — including immunosuppressive treatments and steroids — can induce depression, routine screening throughout treatment and into survival is also essential.

2. Be willing to have hard conversations

Screening measures, while a worthy start, are not a panacea. Clinicians need to take the initiative to talk to their patients about possible mental health symptoms rather than assuming they will raise the issue as needed.

“Studies have shown that patients are reluctant to bring up psychosocial distress for a variety of reasons,” says Isabel Schuermeyer, MD, Director of Psycho-oncology at the Taussig Cancer Center. “Stigma of mental illness can keep oncologists from asking about it but also can keep patients from talking about it.”

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The potential consequences of giving mental health the silent treatment are grave, Dr. Schuermeyer says. A recent study suggests that cancer patients with depression may be less likely to select definitive treatment than patients without depression. Further, there also may be the perception among well-meaning oncologists that depressed patients are simply unable to tolerate the treatment, physically and emotionally, although this is unsupported by data. Similarly, patients may perceive that admitting to feeling depressed or anxious will cause their physician to view them as weak.

3. To refer or not to refer…

Use of screening and engaging in honest dialogue both help open the door to appropriate mental health referral, but oncologists still need to remain vigilant for early clinical warning signs that may warrant specialized care.

“Cancer patients [with mental health needs] who don’t receive psychiatric or psychological treatment early don’t do as well with their cancer treatments,” Dr. Schuermeyer says. “They’re in the hospital longer, their pain is harder to control and they have a harder time adhering to chemotherapies.”

And because they may be more likely to miss chemotherapies or fail to follow their medication regimen, their mortality increases as well.

Although widespread referral of all patients to a psychiatrist or psychologist would be unnecessary, Dr. Schuermeyer does believe that every new cancer patient needing treatment should see a social worker.

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“Everyone who is diagnosed with cancer, no matter how resilient they are, is going to have some distress,” she explains, “For most people, that’s very short-lived, but talking to someone about how to take care of yourself and what resources are available is invaluable.”

4. Treat the person, not just the disease.

Embedding a psycho-oncology program directly into the cancer setting — as Cleveland Clinic’s program is positioned — helps convey the message that providers are concerned about the entirety of their patients’ health. Doing so helps patients be seen by a mental health expert at the point of care. It also aids in fostering collaborative relationships between the medical disciplines.

“Mental health care in the cancer patient is vitally important,” says Dr. Schuermeyer. “By working together and maintaining lines of communication, we can help ensure mental health is a routine part of cancer treatment.”

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