Chapter 1: The Clinical Psycho-oncology Assessment

INTRODUCTION

This chapter describes a practical, but comprehensive, approach to the clinical psycho-oncology assessment. Rather than representing a skill set that should be relegated only to mental health professionals, this approach has clinical utility for all oncology clinicians and can be incorporated into the comprehensive clinical assessment of any patient undergoing cancer treatment or evaluation. With practice, the initial psycho-oncology assessment can be seamlessly integrated into oncologic practice and does require the allocation of additional resources or referral to mental health professionals. Rather than experiencing the psycho-oncology assessment as an additional clinical burden, clinicians will discover that insights gained from this approach add valuable insights that enhance both the care of the patient and clinicians' satisfaction with their work.

THE IMPORTANCE OF THE PSYCHO-ONCOLOGY ASSESSMENT

The psycho-oncology assessment should be considered a vital part of the clinical assessment of any patient undergoing cancer evaluation or treatment. As will be described below, psychosocial spiritual factors are important determinants of physical morbidity and mortality. A failure to address these issues will inevitably impact the welfare of our patients and their families.

Emotional distress is common among cancer patients and their families. A recent evidence-based review reports prevalence rates of major depressive disorder of 10–25% and of anxiety disorders in oncology patients.¹ This prevalence is similar to that reported in other medical disorders such as diabetes and heart disease. However, the risk of depression varies greatly depending on the presence of risk factors (see Table 1-1) and the type and stage of cancer. It is however important to recognize that many patients who are experiencing significant emotional distress do not meet strict Diagnostic Statistical Criteria (DSM)—IVTR criteria for psychiatric disorders.² This has led to the development of the concept of distress as a distinct psychological state that may occur independently of any specific psychiatric diagnosis. Rather than representing a specific disorder, distress describes a symptom that can be the result of multiple biopsychosociospiritual factors. The development of instruments to assess general distress (eg, the Distress Thermometer,³ Psychosocial Screen for Cancer³) has resulted in more patients being screened for distress and the concept of distress becoming a "sixth vital sign" is gaining increasing acceptance as a valid indicator of psychosocial distress among cancer patients. Numerous psychometric tools are available to assist in the detection of emotional disorders (see Table 1-2). However, although these standardized psychometric instruments may have significant research utility, the clinical psycho-oncology assessment should remain the mainstay for identifying the nature and severity of psychosocial distress in medically ill patients. It is also interesting to note that only approximately one third of those scoring as significantly distressed would like to receive professional help in addressing their distress.^4,5 This further highlights the importance of identifying patients' distress in the context of an established therapeutic relationship and not as part of an impersonal screening program.