Adding the Missing Psychiatric Dimension to Cancer Care

Patients coping with cancer often need help with the emotional and psychological part of treatment and recovery, but only about a quarter receive effective treatment. Collaborative care programs like the one developed by this month’s author, Michael Sharpe, M.D., F.A.C.L.P., are effective ways to integrate depression treatment with cancer care. —Jürgen Unützer, M.D., M.P.H.

It is not surprising that depression is a common complication of cancer and its treatment. Cancer is an alarming, life-changing, and sometimes life-threatening disease, with often severe effects on people’s sense of themselves, their roles, and their relationships.

Most people suffering from cancer have periods of distress. These typically occur at cancer diagnosis, discharge from care, and cancer recurrence. A significant minority of patients (about 1 in 10) develop a major depressive disorder. Comorbid major depression is a major complication of cancer, which not only has a devastating effect on the patient’s return to health and functioning, but it may also interfere with the ability to participate in the cancer treatment itself.

Mrs C. developed breast cancer in her 30s. She is a single parent of two small children with a clerical job. She has felt devastated by the diagnosis of cancer and the implications for herself and her children. Over the last month, she has felt increasingly low in mood, has lost interest in her appearance, and has missed appointments at the cancer center because she lacked motivation. Her friends tell her that it is important to “fight the cancer” and to remain positive. She thinks that her inability to continue doing this is a failure and consequently cannot tell them how she really feels. She has also not told her oncologist how she feels, as that would be “letting him down.”

However, the situation can be better. Most major cancer centers are now using a mandated screening program to proactively identify patients with emotional distress. A variety of tools is used to achieve this, some of which are relatively specific for depression, such as the PHQ-9, and some are not, such as the Distress Thermometer. Whatever screening questionnaire is used, it is important to use a high score as an opportunity to talk to patients to identify who has a depressive illness.

Despite this welcome innovation, we know that screening alone achieves little and that merely informing the primary care doctor offers only modest benefit. There are many reasons for this: the primary care physician may see depression as merely a “natural reaction to cancer,” the patient may not see himself or herself as needing treatment for depression and, if offered treatment, may not take it or the treatment offered may be inadequate. The lesson is that we need to follow screening for depression with treatment that is both effective and accepted by the patient.

A form of collaborative care can fulfill this need. Over the last 20 years, we have developed a depression treatment program that is integrated with cancer care. It is called Depression Care for People with Cancer (DCPC). Cancer nurses or social workers are specially trained to deliver DCPC under the supervision of a psychiatrist. The integrated nature of the program facilitates acceptance of treatment by the patient. It combines behavioral (activation and problem solving) interventions with active management of antidepressant medication, modifying the treatment according to the patient’s progress.

DCPC has been found to be highly effective in a number of randomized trials. It is also cost-effective, particularly in the context of the cost of cancer care. Indeed, a case can be made for its being an essential part of the cancer pathway that “completes the job’” of returning the cancer patient to health.

Integrated depression care programs have been successfully implemented in cancer services in Oxford in the United Kingdom and Seattle, Wash., and are being developed in other international settings. Such programs require that psychiatrists work as members of the oncology team. There are benefits not only for patients, but also for the whole cancer team and its understanding of mental illness. These integrated programs also offer great opportunities for psychiatrists to have a positive impact on a severely underserved group of patients with a serious and stigmatized medical condition and to fulfill their role as physicians taking care of the whole patient as part of an extended medical team. ■