Responding to the quality imperative to embed mental health care into ambulatory oncology

In 2008, the Institute of Medicine (IOM) released a report entitled Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. In this report, the IOM emphasized the need to address and embed psychosocial services in cancer care. The report called for 1) facilitating communication between the patient and provider, 2) identifying psychosocial health needs, 3) designing and implementing a plan that links the patient with appropriate services (eg, mental health counseling), and 4) updating and adjusting psychosocial care plans. This report brought attention to the fact that despite the growing number of people living with cancer, their psychosocial needs and practical concerns (eg, financial burden and transportation to follow-up appointments) were not being adequately addressed. Diagnostic, decision-making, and treatment-planning experiences can be stressful and overwhelming for cancer patients and their families. Treatment is often associated with chronic and debilitating side effects, and cancer care for many patients can be complex, fragmented, toxic, and expensive. Collectively, these challenges can cause psychological distress, a state that is characterized by “unpleasant emotional, psychological, social, or spiritual experiences that can interfere with the ability to cope with cancer treatment. ” Such distress states tend to be subjective in nature and occur on a continuum ranging from transient feelings of distress to persistent, severe, and unresolved symptoms that can lead to diagnosable mental health disorders. Before and after the IOM report, a body of literature documented the psychosocial needs of cancer patients due to the stressful experiences associated with a diagnosis and treatment. Approximately 1 in 3 cancer patients meets the criteria for a diagnosable mental health condition. For example, Mehnert et al found that on the basis of symptoms reported over a 4-week period via clinical interviews, approximately 32% of cancer patients met the criteria for Diagnostic and Statistical Manual of Mental Disorders (DSM)–defined or International Classification of Diseases (ICD)–defined mental health conditions. In a meta-analysis of 70 studies with more than 10,000 cancer patients in ambulatory settings, the rate of DSMor ICD-defined major depression was 16.3%, whereas the rate of DSM-defined minor depression was approximately 19.2%. The results also showed that the rates of adjustment disorder and anxiety were 10.3% and 19.4%, respectively, and that 38.2% of patients had a mood disorder. Although most studies documenting mental health disorders in cancer populations focus on prevalent and not incident conditions, several studies have shown that in comparison with individuals with no cancer, cancer patients report significantly greater rates of mental health disorders. The challenges of navigating a cancer diagnosis and treatment extend beyond emotional concerns. We and others have reported that fatigue, pain, anxiety, depression, and nausea are among the most common and debilitating symptoms reported in oncology settings. Depressive symptoms are a common component of psychosocial distress and can involve feelings of sadness, anhedonia, withdrawal, and guilt. Depressive mood disorders that reflect persistent, debilitating, and unresolved symptoms of depression have been associated with poorer survival in cancer patients. Despite the challenges of cancer and its sequelae and multiple calls for integrating psychosocial distress screening and services as standard of care, until recently, few standards have been in place to guide implementation in oncology settings. Because of the extraordinary demands placed on clinical workflows, which can affect physicians, nurses, social workers, palliative care teams, and administrators, even fewer practical, realistic approaches have surfaced. In this issue of Cancer, Wagner et al present the results of a practical, valid approach to screening for depression in outpatient oncology settings. In this study conducted by the Radiation Therapy Oncology Group, the authors evaluated whether a brief and valid 2-item depression screener effectively identified patients who needed further assessment for