Managing Anxiety and Depression in Cancer Patients

Today we are discussing how clinicians can help cancer patients manage their stress with Dr. William Pirl, an associate professor of psychiatry at the Harvard Medical School, and the vice chair for psychosocial oncology and palliative care, at the Dana-Farber Cancer Institute in Boston. Dr. Pirl’s research focuses on how cancer patients’ moods can influence their wellbeing and survival.

Cancer Network: What are the types of mental health issues that you frequently encounter in cancer patients?

Dr. Pirl: I would say that the most frequent mental health issues we encounter are not actually psychiatric disorders. Cancer is something that can cause a lot of anxiety in people. We often see people within the first month or so after their diagnosis, as they are still trying to cope with the news and figure out what their treatments are going to be and how they are going to get through treatment. After that, the most common things that we see are anxiety as well as depression.

Cancer Network: You and your colleagues came out with recommendations a few years ago on ways to implement distress screening programs in cancer cancers. What are some of the key recommendations and have you seen an increase in this type of screening at cancer centers across the country following the release of these recommendations?

Dr. Pirl: In 2015, the American College of Surgeons’ Commission on Cancer created a new standard of care that all cancer centers needed to fulfill in order to be accredited. Screening for psychosocial distress was one of the commission’s recommendations that cancer centers had to do. They left the recommendation very vague so centers could interpret it in their own ways and so a group of professionals who help people manage psychosocial distress who are psychiatrists, psychologists, social workers, and nurses came together to give some guidance around how best to put the recommendations into practice.

I think that many institutions across the country are still struggling with how to do this in their clinics, but it is something that more and more clinics are doing. We recommended that people are screened not just for depression and anxiety, but in a broader way to capture things that may not necessarily be psychiatric disorders, but may be stress and could be interfering with people’s abilities to participate in their cancer treatment or do the things they need to do in their life in order to get through cancer treatment.

We also recommended that the cancer screening is done at more than one time point because often stress is related to what is happening in terms of the person’s cancer treatment. There are times that we know are particularly vulnerable for people like the first month after diagnosis, around the completion of a treatment or change in a treatment. Screening at that time may not give you an accurate picture of how that person is doing overall. So, we recommended doing screening at more than one time.

We also recommended if people are having distress that providers assess if people have any suicidal thoughts. Unfortunately, people who have cancer have a higher risk of committing suicide so if we are assessing distress, we want to make sure that we are able to identify those people who are having those kinds of thoughts so that we can intervene and help reduce the risk of that.

Cancer Network: There are studies showing that cancer patient distress can have negative effects on treatment outcomes. Are there any key results from these studies that you could highlight?

Dr. Pirl: I think that there have been enough studies that we can say it is well-established that depression can impact people’s survival, maybe not just in cancer, but in general. Although, there are many studies in cancer patients showing this link.

Even though we have that evidence, we are not exactly sure how depression might be impacting people’s survival. It may be that people who are depressed may not be able to participate in treatment in the way that they need to get the full benefit. Perhaps it is that those who are depressed are not doing all of the healthy routines that they need to do to stay healthy during cancer treatment such as exercise and eating well.

There are some people who believe that depression impacts the immune system and makes it not as effective so that it may be harder for people’s bodies to fight the cancer. There are many different theories as to how depression may negatively effect cancer patients’ outcomes even though we know that there is some relationship between depression and survival.

Cancer Network: For those physicians and nurses who want to help guide their patients to the right care but may not be well trained in pinpointing signs of stress, what are your recommendations for resources for clinicians and nurses to better guide their patients to receive the appropriate support?

Dr. Pirl: I would hope that wherever someone is getting cancer treatment, there is an oncology social worker and I think that oncology social work is a great place to start. Oncology social workers are skilled and trained in being able to assess distress and are able to triage patients to the right kind of treatment. Whether that be working with the oncology social worker in counseling, or a referral to a psychologist or psychiatrist.

It can sometimes be hard to find a mental health professional in the community. Sometimes we work with patients’ primary care providers who often know of mental health professionals in the through their own practice.

There are some national groups that offer some supportive services without charge to patients such as Cancer Support Community which has physical centers in many cities around the US. Gilda’s Club is included in this and is a place where patients can get psychosocial support. They also offer some telephone counseling as well for those patients who don’t live in areas where there is a physical center. There may be additional resources that aren’t affiliated with a hospital and may be available nationally.

Cancer Network: Thank you so much for joining us today Dr. Pirl.

Dr. Pirl: Thank you, it was my pleasure.