Initiating Conversations on Mental Health in Oncology

Discussing mental and emotional well-being can be a daunting prospect for both patients and their health care providers. This is particularly true in the context of cancer care, where the focus is often intensely on physical health and medical treatments. However, a patient's psychological state is a critical determinant of their overall quality of life and their ability to successfully navigate their treatment journey.

Boris M. Kiselev, MD, discussed strategies to help clinicians break the ice and create a safe space for these essential conversations. He emphasized the value of structured screening and using open-ended questions and a gradual approach to uncover a patient's true state of mind, acknowledging that terms like "anxiety" or "depression" can carry a stigma. By shifting the conversation to the more general topic of stress, clinicians can build a bridge to a more in-depth understanding of a patient's needs, ultimately ensuring they receive the comprehensive care they deserve.

Kiselev is a consult liaison psychiatrist at Atrium Health Carolinas Medical Center, an assistant professor of the Psycho-Oncology Program in the Department of Supportive Oncology at Atrium Health Levine Cancer Institute, and an assistant professor in Internal Medicine.

Transcript:

These can be difficult conversations to have, both for patients and providers. That’s where screening is helpful. Because it can reveal the level of stressor symptoms that the patients may not be bringing up or may not be readily apparent. Usually, whenever we’re talking about these things, we start with open-ended questions, so we try to understand how the patient is doing. For instance, after reviewing their treatment so far, you can ask them, “I know it’s been a lot to deal with. How have you been managing with everything?” and see how they respond. [Many] times, giving patients a safe space to talk about their experience and paint a picture of how they’re doing will be helpful, and it also can be therapeutic for them, because it gives them a chance to talk about what they’ve been experiencing when they might be talking about things that might be difficult for them to discuss with their with their families or caregivers.

Terms like anxiety or depression can be loaded terms for some patients or have a stigma. It’s a lot easier to start talking about just stress in general. Asking about how the stress has been in general. How are they managing stress? As you’re talking about the stressors, you can clarify what the things are in their life that are causing their stress. Is it just the cancer treatment? Often it is other things as well, whether it be their finances or their relationships, or other things that have been affected by the cancer treatment, or even things that are separate from it.

Once we have a sense of what their stressors are, then we can start asking about specific symptoms. We want to start asking about anxiety and depression symptoms, and that’s things like mood changes, having any worrying, irritability, changes in sleep. In medical school, we’re taught the SIGECAPS as symptoms of depression, but we all know that during cancer treatment, things like sleep, energy, concentration, appetite, those are all going to be affected, especially people getting traditional chemotherapy or radiation. When we’re screening for depression or anxiety, you want to be asking about the psychological symptoms of depression, and that includes things like anhedonia, feelings of guilt, worthlessness, hopelessness, helplessness, irritability, loss of interest, and social withdrawal. Patients with cancer do have a 4 times elevated risk of suicide. Every patient where there’s a concern about depression, anxiety, or distress should be asked about suicidal ideation as well.