A Matter of Mind: When Patients With Cancer Have Psychiatric Comorbidities

With diagnoses such as schizophrenia, bipolar disorder, or major depression, about one in every 25 Americans suffers from a serious mental illness that directly affects major life activities. The prevalence of mental illness in the United States can have a downstream effect on cancer care and patient outcomes, and with these statistics, oncology nurses may encounter patients with cancer who have pre-existing psychiatric disorders. Healthcare providers in fields outside of psychology need to be prepared to address the unique needs and individualized care required to support this patient population during and beyond cancer treatment.

Challenges in Psychiatric Oncology

ONS member and oncology nurse practitioner Nancy Jo Bush, DNP, RN, MA, AOCN^®, FAAN, director of the doctor of nursing practice program in the School of Nursing at the University of California, Los Angeles, explains that patients require individualized support when being treated concurrently for cancer and a mental illness.

“Although it certainly depends on the mental illness, patients and providers should recognize specific obstacles,” Bush says. “Cognitive functioning could be affected based on a patient’s diagnosis, and his or her response and outlook on treatment plans and caregiving may present a challenge. Patients may experience issues associated with treatment adherence and follow-up care. With severe mental illness, patients may not have the support systems in place to help them navigate the often-challenging facets of cancer care, such as making it to appointments, seeking initial and follow-up care, managing symptoms, and more, which affects them tremendously throughout all stages of the cancer continuum.” 

Amy Corveleyn, MSW, LICSW, clinical social worker at Massachusetts General Hospital in Boston and member of the Association of Oncology Social Workers, knows the impact of a mental illness on the outcomes for patients with cancer. 

“Patients with a serious mental illness, such as schizophrenia or bipolar disorder, are 15%–30% more likely to die from cancer. This is true in many of the major cancer diagnoses, including breast and head and neck cancers,” Corveleyn says. “These patients face difficulty when navigating the cancer care system, which includes challenges with making appointments, confusion about medications, and trouble coordinating transportation. Beyond navigation challenges, they also face stigma because of their mental health diagnoses, which leads to patients with mental illness not seeking cancer treatments or having disruptions in their care plans. The combination of these issues means that patients are not receiving the standard of cancer care, and this shortens their life expectancy.” 

For patients with mental illness and cancer, healthcare professionals need to recognize the complexity of both diagnoses. Not all mental illness is the same and developing a working knowledge of disease types and required treatments can be helpful when supporting this patient population. Recognizing the relationship between treatment for mental illness and cancer treatments requires astute assessment: for example, psychiatric medications may interact with chemotherapy or other cancer treatments, dictating the need for oncology nurses to reach across disciplinary lines to coordinate with the larger healthcare team. 

Collaboration Ensures High-Quality Care

“Interprofessional collaboration is absolutely crucial to addressing the needs of this population,” Bush says. “Alongside a patient’s psychiatric physician and oncologist, a multidisciplinary approach should definitely involve social workers. They’re a tremendous resource to help patients connect with the support available to them. Other members of the team can include pharmacists, chaplains, navigators, and advanced practice nurses. The oncology nurse is in a vital position to help coordinate and organize who should be involved and how the team can routinely follow up with the patient.” 

Corveleyn echoes the benefit that oncology social work colleagues can bring to practitioners unfamiliar with supporting patients with mental illness. 

“Oncology social workers are licensed mental health professionals with master’s-level training. From a clinical perspective, we can offer supportive therapy to patients and caregivers while also making use of motivational interviewing and solution-based therapy. This allows for patients to be goal oriented throughout their treatment,” Corveleyn says. “When I think about logistics, oncology social workers collaborate with navigators, nurses, and resource specialists to reduce barriers to care for patients and their caregivers.”

She encourages her oncology nursing colleagues to lean on the experience and expertise of their social work colleagues when facing challenging situations, especially when they relate to a patient’s mental illness.

“I’m fortunate to work side by side with excellent nursing colleagues from our outpatient infusion unit, radiation oncology, and inpatient medical floors,” Corveleyn says. “Nurses are trained to collaborate with many disciplines, so it makes for a good match in the oncology setting. Nurses can offer support to their patients through strong communication with social work staff regarding patient status and medical needs. We can work together to problem solve and find opportunities to debrief with the rest of the medical team."

Dispelling Stigmas and Stereotypes

Mental illness may carry an undue and undeserved stigma for patients. By addressing stereotypes, oncology professionals can put to rest any fears, concerns, or uncertainties about patients with psychiatric disorders.

“Some research has shown that patients with mental illness typically receive care at a later stage of cancer than that of the general public. This can stem from a number of reasons: perhaps other treatments impact their decision making or they may not fully understand the disease process and symptoms of cancer,” Bush says. “Unfortunately, this contributes to stigmas for patients with mental illness, suggesting that they aren’t capable of carrying out treatment. That’s simply not the case. In the same way people suffer from a disease that plagues the body, patients with mental illness suffer from a disease that impacts cognitive functioning. Through a team-based approach and holistic care, we can help these patients succeed.”  

Corveleyn recognizes that mental illnesses aren’t as rare as the general public may think, and that can lead to a lack of understanding for the scope of how this affects patients. 

“I want to address the idea that mental illness is uncommon. Mental illness is not unusual. There are 13 million people in the United States with schizophrenia, bipolar disorder, and major depression, and 5–6 million more people who haven’t received any treatment for their mental illness,” Corveleyn says. “Next to cardiac disease, cancer is one of the leading causes of death for patients with mental illness. It’s a human rights issue that this population is not receiving timely, stage-appropriate cancer treatment. People deserve to be treated for their cancer—period—regardless of mental illness.”
 

Using Resources, Family Members to Support Patients

Working with family members and other caregivers who know a patient can help oncology nurses deepen their understanding of what the patient is experiencing. As expert relationship builders, nurses are in a prime position to engage with family members to help guide their patients’ cancer care.

“Family members of patients with mental illness can be a resource for oncology professionals. They can act as a touchstone to understanding the patient’s medical history,” Bush says. “From help with decision making, emotional support, treatment adherence, monitoring for cognitive changes, and more, a patient’s family member is a valuable advocate during the treatment journey.”  

Corveleyn says that sometimes patients with mental illness may not have a family support system, and that means healthcare professionals must connect with their community-based caregivers.

“Many patients with mental illness may not have family or friends who can be supportive. They may rely on community-based mental health caregivers as their foundation for support,” Corveleyn says. “Some caregivers may only be able to do things like fill prescriptions or give rides to treatment. Other caregivers may be more comfortable sitting with someone at home or listening to their fears. It’s important for all caregivers—family or community—to know they can find support through the patient’s cancer team.”

Patients with mental illness and cancer rely on their care team to provide a holistic approach to cancer treatment, Bush explains.

“This patient population is more vulnerable than others and requires extra support for their treatment throughout the entire continuum of care,” she says. “Oncology nurses already practice with a holistic philosophy, and this population really brings the importance of that style of care to light. Psychosocial responses to cancer such as depression and anxiety may be exacerbated if the patient has a prior history of mental illness demanding individualized care to promote coping and adaptation.”

Corveleyn encourages nurses to connect with their colleagues when facing a challenging patient situation. “If you’re concerned that a patient’s mental illness isn’t being addressed, reach out to the oncology social worker, psychiatry, or even the oncology team to share your concerns,” she says. “If we work together with these patients, we can help them complete treatment successfully.”