Knowledge Hub 5

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Knowledge Hub 05: Psychological and Emotional Distress

Learning Objectives

By the end of this Knowledge Hub, you will be able to:

  1. Describe the health impacts of psychological and emotional distress in patients living with cancer.
  2. Recognize risk factors for emotional distress in patients living with cancer.
  3. Apply a systematic approach to conduct screening and assessment of anxiety and depression following the BC Cancer practice guidelines.

Introduction

Cancer is an incredibly significant life event that can affect not only the physical health of the patient but also the psychological health. Emotional distress is extremely common within cancer patients and can peak at different times of one’s cancer journey. The loss of control, increase in anxiety, and risk factors for depression can all lead to emotional distress. We will cover the trajectory of emotional distress in patients’ cancer journeys, and how to screen and assess these symptoms (Howell et al., 2015).

1. Describe the health impacts of psychological and emotional distress in patients living with cancer.

1.1 What is emotional distress in patients?

Emotional distress can be defined as “a multifactorial unpleasant emotional experience of psychological (cognitive, behavioural, emotional), social or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment” (Howell et al., 2015). Emotional distress can range from normal feelings of sadness and fear to disabling distress such as depression, social isolation, and panic (Howell et al., 2015). The level of emotional distress in patients can vary across a continuum based on their cancer journey and the phase of cancer they are currently in (Howell et al., 2015). Distress levels have also been reported in post-treatment patients for fear of recurrence, body image concerns, and lasting- symptoms (Howell et al., 2015).

Refer to new patient forms at http://www.bccancer.bc.ca/our-services/patient-guide/new-patients-form (BC Cancer, 2024).

2. Recognize risk factors for emotional distress in patients living with cancer.

2.1 Why may patients not report emotional distress and may not be easily detected?

Patients may not report emotional distress for many different reasons, some examples include:

  1. Fear of stigma connected with mental illnesses and psychological concerns (Howell et al., 2015).
  2. Limited time with doctors in rushed environments (Howell et al., 2015).
  3. Patients may normalize their emotional feelings (Schofield et al., 2005).
  4. Patients may not feel comfortable enough to share their feelings with their healthcare provider (Schofield et al., 2005).
  5. May not be experiencing emotional difficulties during appointments in front of healthcare providers (Schofield et al., 2005).
  6. Patients worry about burdening doctors or feel the issue is not as ‘serious’ as their cancer (Schofield et al., 2005).
  7. Patients are anxious and worry about their families, and not wanting to be a burden to their families.

2.2 What is the psychological and emotional distress of patients living with cancer?

Moderate to High Distress includes hopelessness, suicidal thoughts, feeling outcast and alone, self-deprecating, unfocussed anxiety, depression, panic and extensional crisis (Howell et al., 2015).

2.3 What is the impact of psychological and emotional distress on patients living with cancer?

Psychological and emotional distress causes a tremendous impact on patients living with cancer which ultimately affects their health outcomes and patient experience (Abdelhadi, 2023). Distress has been directly linked to negative health outcomes, reduced quality of life, unhealthy behaviours, decreased adherence to medication/ treatment, and an overuse of healthcare services (Abdelhadi, 2023). Patients with distress can also exacerbate physical symptoms such as fatigue and nausea (Abdelhadi, 2023).

Video 1.

This video covers the psychosocial, behavioural, and emotional impacts of a cancer diagnosis, which can further help identify potential moments of distress in patients (AlMatMelenoma, 2021).

(AlMatMelenoma, 2021)

Distress across the Cancer Journey

2.4 How to assess patients’ anxiety, depression, and emotional distress?

3. Apply a systematic approach to conduct screening and assessment of anxiety and depression following the BC Cancer practice guidelines.

3.1 Anxiety and depression

Anxiety: Levels of anxiety peak very high at the beginning of the cancer care journey that involves diagnosis, imaging, diagnostic tests, fear of worrisome results, and worry of disease can invoke high levels of anxiety at this phase. Precipitating events such as new treatments, physical symptoms, fear of recurrence, fear of progression of cancer, and changes to life and role can also cause episodes of anxiety throughout the cancer journey (Davis, 2011; Fitch, 2008).

Depression: Contrary to Anxiety, depression is seen more commonly at the beginning or end of cancer treatment (Davis, 2011). At the beginning of treatment, depressive symptoms can be caused by cancer-related stress. Examples of this include treatment, financial burden, informal relationships, inability to cope with diagnosis, medications, and adapting to stressors (Davis, 2011). The end of treatment symptoms of depression can be due to the unknown trajectory of the cancer, trying to begin survivorship and return to work, and worry of recurrence (Davis, 2011).

3.2 What are the risk factors related to stressors of cancer and individual factors?

Cancer-related risk factors that contribute to emotional distress include medication side effects, physical symptoms, treatment effects and poor prognosis (Howell et al., 2015). Individual factors that contribute to emotional distress include previous mental health history (anxiety, depression), coping strategies, genetics, change in functions/roles, lack of social support and financial strain (Howell et al., 2015).

3.3 When does emotional distress take place?

Emotional distress can be evident at many different times in a patient’s cancer care journey. Events such as diagnosis, treatment process, survivorship, palliative care, and stressful life events can all invoke distress in a patient’s life (Howell et al., 2015). The patient’s healthcare team needs to recognize that distress can come at several different points and that it should be made a priority to assess and show concern for a patient’s mental health and psychological symptoms at all stages (Howell et al., 2015).

3.4 What tools to use to screen for emotional distress?

  1. The Putting Patients First (PPF) screening tool questions the patient about how they feel since their last visit with the healthcare team and how they feel today. (CJAG, 2009). This tool covers physical symptoms on a numerical scale of 0-10, concerns and fears regarding emotional, social, practical, mobility, physical, nutrition, and informational issues, and briefly questions if medications have changed or other parts of the healthcare plan have changed in between visits (CJAG, 2009).

Putting Patients First PDF

  1. The COMPASS screening tool from Cancer Care Manitoba uses both the ESAS-r and CPC tools along with an advanced care planning section (with the option to not answer if uncomfortable) (Cancer Care Manitoba, 2021).

COMPASS Screening Tool

  1. The Edmonton Symptom Assessment System (ESAS-r) screening tool is a very common screening tool used in Canada (CJAG, 2009). It screens for nine different common symptoms related to cancer on a numerical scale from 0-10 (CJAG, 2009). This tool can be used for patients in the early or later stages of a cancer journey and can be tracked to evaluate for effectiveness in symptom management (CJAG, 2009). The tool screens for shortness of breath, pain, tiredness, nausea, anxiety, drowsiness, appetite, well-being and depression (CJAG, 2009).
  2. General anxiety disorder (GAD-7) is a screening tool that was developed to provide a scale for anxiety and scores common symptoms associated with anxiety (CAMH, 2023). GAD-7 (Spitzer et al., 2021).
  3. Patient Health Questionnaire can be used to monitor and evaluate interventions for depression in primary care (CAMH, 2023). PHQ-9

Refer to the patient guide at http://www.bccancer.bc.ca/our-services/patient-guide (BC Cancer, 2024).

Depression affects nearly 25% of cancer patients and can present in two classes of symptoms, emotional-cognitive (emotional symptoms) and neurovegetative (affected by disease process and treatment). Depression related to cancer can be screened by using the ESAS-r and the PHQ-9 tools to measure depression and differentiate between mild, moderate, and severe depression (CAMH, 2023). Anxiety screening completed by using the ESAS-r and GAD-7 tools to monitor the effectiveness of interventions and differentiate between mild, moderate, and severe anxiety in patients (CAMH, 2023).

Refer to patient and family counselling at http://www.bccancer.bc.ca/our-services/services/supportive-care/patient-family-counselling#:~:text=35%25%20to%2045%25%20of%20all,Fear%2C%20anxiety%20and%20depression (BC Cancer, 2024).

Refer to emotional support at http://www.bccancer.bc.ca/health-info/coping-with-cancer/emotional-support (BC Cancer, 2024).

3.5 What are the risks of self-harm to patients?

The suicide risk in cancer patients is nearly twice that of people in the general population (National Cancer Institute, 2023). The risk of suicide and suicidal ideation is determined by many different factors such as gender, social structures, co-morbidities, cancer-related pain, poor prognosis, feelings of hopelessness, and feeling of being a burden (National Cancer Institute, 2023). Possible strategies to lessen the risk of self-harm in cancer patients can be referring the patient to a mental health professional, closely observing and evaluating depressive symptoms and suicidal ideation thoughts and finding supports for the patient to use when having these thoughts (National Cancer Institute, 2023).

Summary

Emotional Distress can be seen among cancer patients at several stages in their cancer journey. Symptoms of distress can often go unseen or not reported for long periods and need to be screened and assessed frequently to provide the patient with the utmost support. Anxiety and depression are commonly seen in cancer patients and follow the specific trajectory that can help healthcare providers understand a patient’s experience psychologically. Healthcare providers must understand risk factors and barriers that contribute to a patient’s development of emotional distress. Many screening tools can be utilized to screen patients for distress and can assist with implementing appropriate interventions (Howell et al., 2015; Davis, 2011; Fitch, 2008).

References

  1. Abdelhadi O. (2023). The impact of psychological distress on quality of care and access to mental health services in cancer survivors. Frontiers in health services , 3 , 1111677. https://doi.org/10.3389/frhs.2023.1111677
  2. Cancer Care Alberta. (2021). Putting Patients First (PPF). Retrieved from https://www.albertahealthservices.ca/assets/info/cca/if-cca-putting-patients-first-virtual.pdf
  3. Cancer Care Manitoba. (2021). Comprehensive Problem And Symptom Screening (COMPASS).Retrieved from https://www.cancercare.mb.ca/export/sites/default/Patient-Family/.galleries/files/your-first-visit-files/COMPASS.pdf
  4. Cancer Journey Action Group [CJAG]. (2009). Guide to Implementing Screening for Distress, the 6th Vital Sign: Moving Towards Person-Centered Care.
  5. Centre for Addiction and Mental Health. (2023). Depression: Screening & Assessment). https://www.camh.ca/en/professionals/treating-conditions-and-disorders/depression/depression—screening-and-assessment
  6. Howell, D. K., H., Esplen, M. J., Hack, T., Hamel, M., Howes, J., Jones, J., Li, M., Manii, D., McLeod, D., Mayer, C., Sellick, S., Riahizadeh, S., Norrozi, H., & Ali, M. (2015). Pan-Canadian Practice Guideline: Screening, assessment and management of psychosocial distress, depression and anxiety in adults with cancer.
  7. National Cancer Institute. (2023). Anxiety and Distress – Health Profession Version. https://www.cancer.gov/about-cancer/coping/feelings/anxiety-distress-hp-pdq
  8. National Cancer Institute. (2023). Depression- Health Profession Version. https://www.cancer.gov/about-cancer/coping/feelings/depression-hp-pdq
  9. Ryan, H., Schofield, P., Cockburn, J., Butow, P., Tattersall, M., Turner, J., Girgis, A., Bandaranayake, D., & Bowman, D. (2005). How to recognize and manage psychological distress in cancer patients. European Journal of Cancer Care , 14 (1), 7–15. https://doi-org.ezproxy.tru.ca/10.1111/j.1365-2354.2005.00482.x
  10. Spitzer, R. L., Kroenke, K. et al. (2021). General Anxiety Disorder (GAD-7) Assessment Form.

Resources

  1. BC Cancer. (2024, April). new patients forms. Provincial Health Services Authority, BC Cancer, British Columbia.

http://www.bccancer.bc.ca/our-services/patient-guide/new-patients-form

  1. BC Cancer. (2024, April). patient guide. Provincial Health Services Authority, BC Cancer, British Columbia. http://www.bccancer.bc.ca/our-services/patient-guide
  2. BC Cancer. (2024, April). patient and family counselling. Provincial Health Services Authority, BC Cancer, British Columbia.

http://www.bccancer.bc.ca/our-services/services/supportive-care/patient-family-counselling#:~:text=35%25%20to%2045%25%20of%20all,Fear%2C%20anxiety%20and%20depression

  1. BC Cancer. (2024, April). emotional support. Provincial Health Services Authority, BC Cancer, British Columbia.

http://www.bccancer.bc.ca/health-info/coping-with-cancer/emotional-support

Videos

AlMatMelenoma. (2021). The Psychological, Emotional, & Behavioral Impact of a Cancer Diagnosis. [Video]. Youtube. https://youtu.be/rXOvjDHZjgE?si=7da26GwIVHg9rEcT

Images

Timothy Vollmer. (2009). [breakups]. Flickr. https://flic.kr/p/6beEif

Ryan Melaugh. (2014). [Depression]. Flickr. https://flic.kr/p/nhRkoY