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Please note: This article is part of the Cancer Center's News Archive and is here for historical purposes. The information and links may no longer be up-to-date.

News Archive: Michigan Oncology Journal Fall 99

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

  1. 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.
  2. Zabora J. Screening procedures for psychosocial distress. In J.C. Holland (ed.): Psycho-oncology (pp.653-661), New York: Oxford University Press, 1998.
  3. 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.
  4. Andersen BL. Psychological interventions for cancer patients to enhance the quality of life. Jrnl of Cons and Clin Psych. 60:552-568, 1992.
  5. 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.
  6. Stefanek ME, Derogatis LP, Shaw A. Psychological distress among oncology outpatients. Psychosom. 28:530-539, 1987.
  7. 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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Please note: The articles listed in the Cancer Center's News Archive are here for historical purposes. The information and links may no longer be up-to-date.