ORLANDO, Fla.—Some patients with newly diagnosed cancer will have already been coping with mental illness for many years. Others may have enjoyed good mental health only to experience the onset of emotional and cognitive issues at the same time as their cancer diagnosis. Navigators need to be aware of the signs and symptoms of cognitive and emotional distress and be able to determine which patients and family members need to be managed more closely, according to an oral presentation at the 2nd Annual Oncology Nurse Advisor Navigation Summit.1

Fear of disease recurrence, alteration of a life role identity, and perceived loss of support from the health care team, friends, and family can exacerbate mental health issues and increase long-term risks associated with more severe psychological disorders, explained Helen Meldrum, EdD, associate professor of psychology, Bentley University Program in Health Sciences and Industry, Waltham, Massachusetts.

Although a significant number of patients with cancer experience anxiety symptoms, few meet the diagnostic criteria for clinical anxiety disorders. However, one study found that almost 20% of patients with cancer did meet the criteria for panic disorder, generalized anxiety disorder, or a specific phobia, with some meeting the criteria for more than 1 disorder (eg, panic disorder with phobia).

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Distress in the patient with cancer is a challenge oncology care teams throughout the world have to be prepared to handle. Results of studies from the United States (up to 43% of people with cancer experience psychosocial distress), the United Kingdom (50% of patients experienced levels of anxiety and depression enough to adversely affect their quality of life), and Germany (on average, one-third of more than 2100 patients with cancer experienced a clinically meaningful level of mental distress) illustrate the psychological burden of cancer on patients and families.

“But what about those with preexisting mental illness?” Dr Meldrum pointed out. Uncontrolled psychiatric symptoms can affect a patient’s understanding of the diagnosis and treatment decisions, and clinicians working in oncology often do not have enough training and time to address these needs. “Mental health care is often fragmented from cancer care.”

Navigators can perform a basic examination of mental status by assessing for these 7 points: Appearance (neat and clean or dirty and unkempt); behavior (strange, threatening or violent); speech (rate, tone); thought content (delusions, suicide, bodily concerns); mood (sad, down, blue, high); perceptions (illusions, hallucinations); and cognitive capacity (orientation, attention span, memory).

Posttraumatic stress disorder (PTSD) This anxiety disorder can develop after experiencing a traumatic event or learning that a loved one has experienced trauma. Its essential feature is “severe and disabling anxiety and phobic reactions displayed by individuals in the wake of a traumatic experience.” Although cancer as a traumatic stressor is controversial, patients have reported PTSD-like symptoms resulting from traumatic experiences associated with medical treatments and the potential for a fatal prognosis for as many as 10 years after diagnosis. 

Severe anxiety An anxiety attack can manifest as palpitations, arrhythmia, chest constriction, difficulty breathing, choking, and hyperventilation. Other symptoms include dizziness, faintness, and hot and cold flashes. An intensely negative reaction indicate presence of a phobia and be a symptom of an anxiety attack. Panic attack can be triggered by a particular fear or a general dread. Loss of sanity is often a major fear of those experiencing an anxiety attack.

Depression vs distress Depression is a psychiatric disorder characterized by sadness, lack of energy, loss of pleasure in usual activity, and difficulty concentrating and making decisions. In addition, the patient may experience changes in appetite and sleep, hopelessness, and thoughts of suicide. Distress is described as unpleasant feelings or emotions ranging from normal and expected sadness and fears to severe levels that mimic true depression or an anxiety disorder. These feelings can interfere with a person’s ability to cope.

Severe mental illness Some patients come to cancer care with preexisting severe mental illness, Dr Meldrum noted, and the stigma associated with mental illness stays with them, even in health care settings. Severe mental illness with psychotic symptoms manifests as poor reality testing; a monotone voice and expressionless face, a bizarre appearance or behavior, and thought disturbances. These individuals can be paranoid or highly irritated and have the potential for violent behavior. They often appear to be preoccupied, cannot follow conversation, and have poor perception.

Caregivers should also be assessed for mental issues as they may experience depression; 35% to 50% of caregivers exhibit symptoms of clinical depression from anticipatory grief over losses and the eventual death of their loved one. Research has shown that children and spouses are also at significant risk for depression as a result of a cancer diagnosis in their loved one.

Complicated grief Intense grief can last beyond the expected period of mourning and can cause functional impairment. An estimated 10% to 20% of bereaved persons experience complicated grief. Its symptoms resemble both depression and PTSD and include feelings of isolation, bitterness, and hostility, along with deep sadness. The risk factors for a serious episode of grief reaction are related to the patient and family members’ emotional health before the loss. Even with an expected loss—after a poor prognosis, for example—grasping the reality can take time.

Severe situational stress This issue manifests in caregivers as expressions of guilt and anger; preoccupation with feelings of worthlessness; denial, shock, or disbelief; somatic symptoms; increased potential for substance abuse; and expressed fear that the pain will never lessen.

Providing verbal reassurance only is not always sufficient when addressing mental distress in patients. Clinicians need to be able to apply effective mental health first aid by responding to issues calmly and proactively, and promptly steering those in need toward the right resources. Navigators may need the same crisis-management tools used in emergency and critical care medicine.

No matter how you come to find that your patient or his or her caregiver is experiencing a mental issue such as distress, depression, complicated grief, or stress, clinicians still need to respond effectively, stressed Dr Meldrum. Supporting mental health needs is an essential component of a holistic care process and can affect long-term prognosis. Navigators should be prepared to take action when they notice a sharp change in a patient’s or caregiver’s appearance, behavior, or statements and refer for specialty care, when necessary.


1. Meldrum H. Communicating with patients experiencing mental distress. Oral presentation at: Oncology Nurse Advisor Navigation Summit; April 7-9, 2016; Orlando, FL.