Blending behavioral health with medical care for cancer patients

Receiving a cancer diagnosis is a life-altering moment. For many people, the physical considerations are front and center. “What will happen to my body? Will I be in pain? How long will I live?” But the behavioral, psychological, and emotional concerns of cancer patients are also important to consider from the beginning.

The timeline for cancer care alone presents unique mental and emotional burdens. When someone breaks a leg or suffers from a stroke or heart attack, interventions are immediate. Rehabilitation and recovery may take time, but the acute event is swiftly addressed — a clean pivot point in someone’s trajectory, which can then bend back toward healing. People have come to expect a rapid diagnosis from the healthcare system, followed by timely surgical or pharmaceutical fixes, leading to resolution of the initial problem.

Cancer care is different. It’s often a marathon, not a sprint. The journey from the initial moment of feeling a lump or noticing unusual weight loss to the completion of a course of treatment can take months, sometimes years. It often involves visits with multiple specialists, many diagnostic procedures, and rounds of complicated care interspersed with breaks to accommodate significant side effects. From doctor visits to labs to radiology, managing cancer becomes a consuming job for those it touches, often at a time when they are feeling at their worst.

Even survivors report mental health challenges. They may wonder when the other shoe is going to drop. A cloud might be cast over their future plans. By 2040, a National Library of Medicine article  estimates that approximately 26 million people will be living with cancer in the U.S. alone.

People with cancer experience higher rates of depression  compared to the general population. Anxiety, anger, or grief can have a profound impact on functioning, sometimes even leading to a desire for hastened death. Untreated distress is associated with increased mortality, poorer outcomes, and less treatment adherence. Addressing these issues is not peripheral to the aims of oncology; it is part and parcel of holistic treatment.

 

The link between psychiatry and oncology

Following my training as a psychiatrist, I completed fellowship training in consultation-liaison psychiatry, a subspecialty that focuses on the diagnosis and treatment of psychiatric symptoms and disorders in the context of complex medical illnesses such as cancer. In this capacity, I have experienced firsthand both the profound need for such intervention in cancer patients, as well as the transformative impact of integrating behavioral health with oncology care.

Whether it’s preexisting mental health problems or symptoms that develop with the illness or its treatments, the complex needs of cancer patients are best addressed with close collaboration between oncologists and psychiatrists. Psychiatrists with experience in this field often help distinguish between various underlying causes of mental health symptoms and offer more precise treatment plans. For instance, understanding the difference between illness-related cognitive impairment, treatment-related brain fog, and depressive disorders is very challenging, but often leads to more targeted treatments and the avoidance of unnecessary medications. Experience and expertise with nontraditional prescribing for depression and anxiety (such as using fast-acting psychostimulants instead of antidepressant medications for fatigue) can provide quicker relief for people with limited life expectancies.

Psychiatrists can also help oncology providers understand the interaction between psychiatric medications and cancer treatments. For example, women with estrogen-sensitive breast cancers are commonly prescribed a drug called Tamoxifen. Some commonly prescribed antidepressants prevent the metabolism of Tamoxifen and render it less effective. Knowledge of such intricate details can significantly impact the effectiveness of treatment plans.
 

Advances in behavioral healthcare for cancer patients

Approaches to addressing the behavioral health needs of cancer patients have evolved over time, with increasing recognition of the impact of psychological distress on overall cancer treatment trajectory. One notable advancement is the widespread implementation of tools like the Distress Thermometer, a simple, patient self-report instrument that helps clinicians screen for psychological distress in cancer patients. In addition to measuring severity, the tool provides a checklist of potential distress sources, including physical problems, emotional concerns, social impacts (interpersonal relationships), and everyday issues like child care and transportation. Identifying sources of distress during treatment allows clinicians to target their interventions to what patients really need. Rather than reflexively referring to a therapist or reaching for an antidepressant, care providers find they can sometimes help patients more with antinausea medications, chaplaincy referrals, or transportation vouchers. 

Dignity-conserving therapy is another welcome addition to the behavioral health toolkit. This approach is about more than alleviating symptoms; it’s about helping patients maintain their identity and sense of self-worth throughout their cancer journeys. It underscores the importance of understanding and supporting the patient’s life beyond their illness. It helps people realize that their life stands for something and means something to others. A teacher, for instance, may not be able to stand in front of a high-school classroom for an entire day, but could transition to teaching a weekly online class at a community college or work part time as a docent at a local museum. Helping people maintain a sense of pride, dignity, and purpose is the aim of this approach, as all these things undergird a deeper sense of hope and resilience.

The future of oncology care lies in the expansion of collaborative care models that will make these kinds of behavioral health tools and treatments widely available to all cancer patients. Ideally, behavioral health should be an integral part of oncology care, minimizing the need for patients to navigate yet another specialty care setting. Having a consultation-psychiatrist as part of the treatment team ensures that patients receive accurate diagnoses and treatments aimed at the many ways cancer can impact mental health. 

 

The role of psycho-oncology in holistic cancer care

One of the patients I remember most from my time working on the front lines of medical psychiatry was an attorney in his mid-fifties with aggressive leukemia. Initially perceived as depressed, further evaluation revealed cognitive impairment due to his treatment. He was snapping at nurses, grouchy, and irritable. His oncologist thought he needed an antidepressant, but a more detailed examination made it clear that he required a more nuanced approach, including the use of a low-dose antipsychotic to address confusion and agitation.

Within a few days, he was more cognitively clear. But as his admission wore on, he developed distress and despair. When he stopped eating, I prescribed methylphenidate, which can stimulate appetite in hospitalized adults. After his release, I continued to see him on an outpatient basis, working with him in psychotherapy on the changes and transitions in his various life roles. We were able to stop all the psychiatric medications that were prescribed when he was hospitalized.

The patient’s psychiatric symptoms during his hospital-based cancer treatment were primarily related to his cancer treatments and a cooccurring infection. Once he was in remission, however, he remained pessimistic about his future, so our focus shifted to his demoralization, which we addressed with psychotherapy. We discussed his sense of purpose and meaning, areas of gratitude, and what he wanted out of his relationships. With this kind of integrated approach, behavioral health can offer the right support at the right time and make a real difference in a patient’s trajectory.

Optimal cancer care takes a village. Addressing patients’ multifaceted needs requires not only a broad array of specialists with diverse skills and approaches, but also close collaboration among them. By integrating behavioral health into oncology, we can offer care that is not only comprehensive but also profoundly humanistic, ensuring that each patient is seen, heard, and supported through every step of the cancer journey.