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Psycho-Oncology Program: Providing Better Emotional Care
-Michelle B. Riba, M.D., M.S.
Clinical Associate Professor
Department of Psychiatry
Associate Chari for Education and Academic Affairs, Department of Psychiatry
Director, Psycho-Oncology Program
The Psycho-Oncology Program is a cooperative endeavor between
the University of Michigan Comprehensive Cancer Center and
the Department of Psychiatry. A main goal of the program is
to provide an infrastructure to deliver better emotional care
to patients and their families who are dealing with cancer.
Additionally, the program strives to improve health professional
education and training, and through research, investigate
the underpinnings of the relationship between mental health
and cancer.
The Psycho-Oncology Program is multidisciplinary in its approach
to patient care. Psycho-oncology services are provided by
a wide variety of professionals - psychiatrists, psychologists,
social workers, nurses, physicians, nurse practitioners, clergy
and education specialists. Typically patients are seen in
oncology clinics and referred for treatment with one of the
mental health professionals on the team. After an evaluation,
patients discuss options for care including individual psychotherapy,
medication, group therapy, marital or family therapy, cognitive-behavioral
therapy, etc. Coordination of care and good communication
between all clinicians and the patient and family are essential
for an optimal outcome.
Importance of Evaluating and Treating Emotional Distress
The relationship between mood and illness has become well
established. High levels of distress have been found to slow
recovery, increase morbidity and increase mortality through
faster disease course or even suicide (1, 2). Patients' children,
spouses and other family members also recognize the impact
of emotional distress (3).
Recently, the evaluation of emotional distress has been identified
as an important part of treating individuals with cancer (4).
In an early study, 47% of a random sample of individuals with
cancer met DSM-III criteria for a psychiatric disorder, with
68% of the diagnoses consisting of distress related to an
aspect of their illness and 32% constituting an adjustment
disorder (5). Other investigators have reported clinically
significant levels of emotional distress in various oncology
groups. In a follow-up study to the original Derogatis study,
Stefanek, Derogatis and Shaw (6) reported that approximately
33% of cancer patients (composed primarily of breast, lung
and colon cancer) had severe levels of depression and anxiety.
By far, the most common psychiatric problems in cancer patients
include adjustment disorders, depression and anxiety related
to cancer and its treatments, panic disorder and major depression
(5). It has been reported that approximately 30% of cancer
patients have emotional distress sufficiently high enough
that interventions from mental health professionals would
be beneficial (5). The National Comprehensive Cancer Network
(NCCN) has recently developed Distress guidelines to be used
to screen and evaluate for emotional distress in patients
(see Figures 1 and 2) (7).
The Psycho-Oncology Program:
RESEARCH PROJECTS
Measuring and Monitoring Distress
The current focus of research is an examination of the role
of distress in patients with cancer and the effects of distress
on quality of life, as well as outcome of disease. Peter Trask,
Ph.D., Lecturer in the Department of Psychiatry, has been
engaged in research that has primarily centered on individuals
with melanoma but is rapidly expanding to other cancer populations.
In patients with melanoma, we are trying to understand the
psychiatric aspects of interferon therapy. Interferon has
been associated with several psychiatric side effects, including
depression, anxiety, cognitive disturbances and psychosis.
The mechanism of these problems has neither been well explicated
nor have the prevalence and variables associated with these
clinical problems been well understood.
Our interferon study will measure emotional distress and quality
of life through the course of treatment. Using questionnaires
and serotonin and norepinephrine blood assays at various points
in time, we hope to better understand the prevalence of psychiatric
problems, as well as changes in levels of distress. We are
hopeful that there may be correlations between such emotional
distress and levels of interferon, serotonin and norepinephrine,
as well as other variables related to the melanoma itself.
Armed with this information, we could then devise earlier
interventions to accompany interferon administration that
would reduce the likelihood of developing significant emotional
problems.
In conjunction with colleagues in the departments of Internal
Medicine and Dermatology, we are also engaged in several additional
projects measuring distress in melanoma patients, as well
as those requiring bone marrow transplantation. Psychological
interventions will be tailored to the individual's level of
distress. The first phase of the project is to evaluate distress
upon initial presentation to hospital clinics. Allowing for
a period of time to pass, individuals would then be assessed
a second time and would be triaged to either a review of previously
provided educational material, group therapy, individual psychotherapy
and/or pharmacotherapy. The over-arching hypothesis guiding
these studies is that individuals who receive early interventions
based on levels of distress will experience reductions in
those emotional problems and have better medical outcomes
in terms of relapse, days in hospital and unplanned office
visits as compared to those who do not receive any specific
interventions. The goal for all of these studies is to determine
the optimal level of psychological intervention in order to
reduce the distress that individuals experience following
a diagnosis of cancer.
Additionally Dr. Brooke Brines, a Clinical Psychologist in
the Blood and Marrow Transplantation Program (BMT), is developing
a database to include demographic data and test scores of
recent BMT patients. This will be merged with medical outcome
data as it matures. Dr. Brines also is completing a validation
study comparing the Transplant Evaluation Rating Scale with
other brief assessment tools.
Clinical Resources
The Comprehensive Cancer Center Adult Social Work Team is
comprised of two inpatient masters-level social workers (M.S.W.s)
and five outpatient M.S.W.s, as well as two clinical support
associates. Services provided by the social work staff are
designed to help patients and their families cope with illness.
These services are part of our integrated care and include:
Community Resource Referrals
Patients and families are assisted with finding resources
in their own communities. These may include the American Cancer
Society, home health services, financial assistance or local
support groups.
Counseling
Social workers provide short-term and ongoing counseling to
support patients and families through the process of treatment.
Crisis Intervention
Our clinicians are available to respond if a patient or family
member in the Cancer Center is in severe emotional crisis
and needs urgent intervention.
Practical Assistance
Social workers and clinical support associates can inform
patients and their families about resources for practical
needs such as finding food, lodging or transportation services,
or contacting local community resources.
Peer Counseling
Social workers coordinate trained volunteers who offer support
and insight to patients and families. These volunteers are
either cancer survivors or their spouses.
Support/Education Groups
A wide range of support groups is provided for patients and
families. Some groups are short-term, while others are ongoing.
Topics include specific diagnoses and also the many aspects
of coping with cancer. Examples are the Breast Cancer Survivors
Support Group and the Young Adults with Cancer Support Group.
Wig Bank
The wig bank volunteer offers information on community resources
for a variety of needs. The wig bank offers gently used wigs,
free of charge.
Look Good, Feel Better
Our clinicians oversee this community American Cancer Society
program to help women better cope with cancer treatment and
its related side effects.
Educational Opportunities
One of the key missions of the Psycho-Oncology Program is
to enhance education and training for students, residents,
faculty, patients and families. There are multiple opportunities
and venues for providing such information.
The U-M Cancer Center's series of Cancer AnswerNights has
provided an opportunity to discuss the emotions of cancer
with patients and the community. Such topics as coping with
depression and anxiety; emotional issues for children with
cancer; and complementary medicine are some of the topics
chosen for discussion for this popular series.
Tony Ratliff, M.S.W., has helped develop an ongoing series
of monthly discussions for University of Michigan staff and
faculty on key psycho-oncology topics. Formal lectures and
presentations are delivered by our group at continuing medical
courses for nurse practitioners, physicians and other mental
health colleagues on ways to diagnose and treat emotional
distress in patients with cancer.
Core lectures on the emotions of cancer are provided to medical
students, residents, fellows and other trainees. The goals
are to help clinicians appreciate the importance of recognizing
and integrating the emotional care of patients early in the
treatment plan and to continue to monitor levels of distress
into survivorship.
Conclusion
Depression, anxiety and adjustment problems are so prevalent
in patients with cancer and in family members that heightened
awareness and treatment of these emotional issues will only
improve the quality of care that we can provide. We welcome
your suggestions and support of our endeavors.
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References
- Frasure-Smith N, Lesperance F, Juneau M. Differential
long-term impact of in-hospital symptoms of psychological
stress after non-Q-wave and Q-wave myocardial infarction.
Am Jrnl of Card. 69:1128-1134, 1992.
- Zabora J. Screening procedures for psychosocial distress.
In J.C. Holland (ed.): Psycho-oncology (pp.653-661), New
York: Oxford University Press, 1998.
- Kerns RD. Family assessment and intervention. In P.M.
Nicassio and T. W. Smith (eds.): Managing chronic illness:
a biopsychosocial perspective. Washington, D.C.: American
Psychological Association, 1996.
- Andersen BL. Psychological interventions for cancer patients
to enhance the quality of life. Jrnl of Cons and Clin Psych.
60:552-568, 1992.
- Derogatis LP, Morrow GR, Fetting J, Penman D, Piasetsky
S, Schmale AM, et al. The prevalence of psychiatric disorders
among cancer patients. JAMA. 249:751-757, 1983.
- Stefanek ME, Derogatis LP, Shaw A. Psychological distress
among oncology outpatients. Psychosom. 28:530-539, 1987.
- National Comprehensive Cancer Network Practice Guidelines
for the Management of Psychosocial Distress: DIS-64 and
DIS-6. Oncology. May Suppl: 116-117, 1999.
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