This week, Real World Health Care brings you an interview with Jon Levenson, M.D., Associate Professor of Psychiatry at Columbia University Medical Center, and member of the American Psychiatric Association’s Council on Consultation-Liaison Psychiatry. Dr. Levenson spoke about some of the challenges facing psychiatrists and integrated health teams when caring for patients with chronic medical problems such as cancer.
Real World Health Care: What is the mission of the American Psychiatric Association’s Council on Consultation-Liaison Psychiatry?
Jon Levenson: The Council focuses on the psychiatric care of people who are medically ill. It recognizes that the integration of biopsychosocial care is vital to the well-being of patients and their families, and that full membership in the house of medicine is essential to the well-being of psychiatry. We achieve our goals through initiatives related to research, clinical care, education and health policy, working closely with other physicians, residents and medical students.
Medical Health Linked to Behavioral Health
RWHC: Behavioral health issues can strike just about anyone, but are there certain types of chronic medical illnesses that are particularly associated with a higher incidence of patients being at risk for developing behavioral health problems?
JL: Often, that link between medical and behavioral health problems depends on whether the medically ill patient has pre-morbid behavioral health problems. For example, if someone has a pre-existing complication such as an alcohol or opioid use disorder, they tend to be at higher risk of non-adherence to their medical treatment. Or, a long-time tobacco user diagnosed with throat cancer may need treatment for his or her nicotine addiction.
From the other perspective, there are certain medical illnesses, such as heart disease and cancer, that carry a heavy burden and come with various complications, which can lead to a higher risk of depression. When patients are first diagnosed with cancer, it can be very common to have acute emotional symptoms such as numbing, anxiety, sleep disturbance and depressed mood for about 7-10 days. If these symptoms endure — and often, they do not — the concern is that the patient may develop acute psychiatric disorders including major depression, generalized anxiety disorder and a group of disorders called adjustment disorders.
We also can’t discount the behavioral health problems associated with survivorship. The patient’s cancer may be in remission, but they may continue to suffer from psychosocial complications, including marked distress around the anniversary of their diagnosis, surgery or end of treatment. For some, the end of treatment can be particularly challenging because they are not being as monitored as closely, which can produce anxiety around living with an uncertain medical future.
Other concerns that our profession focuses on include sexuality, intimacy and fertility issues among survivors and problems relating to re-entry back into normal life such as difficulties finding a job or obtaining medical insurance due to their pre-existing condition.
Challenges for Care Teams
RWHC: What are some of the biggest challenges facing integrated health care teams in terms of making sure cancer patients receive the proper behavioral health screening and treatment?
JL: There are a number of issues, from ensuring that patients adhere to their oncological treatments to regularly screening patients for behavioral health problems using standardized programs such as the distress screening thermometer developed by the late Dr. Jimmie Holland or the PHQ-9 Patient Health Questionnaire. These tools give cancer treatment teams an easy-to-use method for routinely evaluating the behavioral health of their patients, not just during active cancer treatment, but also during ongoing outpatient monitoring.
Our Council works closely with other organizations such as the Academy of Consultation-Liaison Psychiatry and the American Psychosocial Oncology Society to collaborate, share knowledge and develop programs that will help patients and their families navigate the behavioral health challenges associated with chronic and life-altering illnesses. For example, we’re currently working on a position statement related to palliative care. We’re intent on improving the knowledge base around end-of-life care and the role that psychiatrists play.
RWHC: Do psychiatrists have a hard time finding a “seat at the table” in integrated cancer care teams?
JL: Today, cancer care is whole-person care. Virtually every comprehensive cancer center has a psychosocial oncology program with staff that works closely with the medical oncology teams and palliative care teams treating patients.
Consultation liaison psychiatry is well immersed in the medical setting, and from that point of view, we all have a seat at the table. While there can be challenges, we work to overcome them through training in acute and outpatient care settings with medical students, residents and fellows so they learn how to effectively develop and maintain that seat at the table. We work especially closely with medical students studying psychiatry to help them understand what consultation liaison psychiatry is and get them interested in the field, which enhances recruitment and long-term support for the field.
Consultation liaison psychiatrists are well-regarded advocates for patients and can help our medical colleagues understand how to screen for distress as well as get patients the support and therapy they need. Often, issues can be openly addressed and discussed with short-term psychiatric support that ameliorates the bulk of patients’ fears, anxiety and behavioral distress.
Encouraging Patients to be Open
RWHC: What advice would you give to a cancer patient who may be undergoing behavioral health problems associated with his or her cancer diagnosis, but who may feel uncomfortable or unsure about reaching out to a psychiatrist for help?
JL: First, they should know that help exists. If someone is suffering from acute distress such as debilitating anxiety, panic attacks or strong feelings of despondency, they should seek immediate help in the form of psychiatric support and pharmacotherapy. If they are hesitant to reach out directly to a psychiatrist, they can start by reporting their distress to their physician, nurse or someone else on their care team.
There are also a wide variety of patient support organizations — at least one for just about every disease in the book — that can provide information and support. Many of these organizations have “buddy programs” through which a newly diagnosed patient is partnered with someone who has been there before. These groups can help tremendously with feelings of isolation or differentness, and many offer both in-person and online support, so no matter where you live, help is only a click away.
A Message from Our Sponsor
As the founding sponsor of Real World Health Care, the HealthWell Foundation is committed to helping patients get the medical treatments they need, regardless of their ability to pay. We’ve seen first-hand how financial distress can impact the health and lives of individuals and families. Cancer patients with behavioral health conditions are particularly hard hit; according to the American Society of Clinical Oncology (ASCO), patients with some forms of cancer incur $8,000 more per year in health care costs than cancer patients without behavioral health conditions.
In keeping with our mission, we are pleased to announce the introduction of a new Cancer-Related Behavioral Health Fund, specifically for treatment-related behavioral health issues in cancer. The Fund provides financial assistance to individuals with a diagnosis of cancer to help with cost-shares (deductibles, coinsurances and copayments) for covered services rendered by behavioral health providers (psychiatrists, psychologists, clinical counselors, and licensed social workers).