One in Three Patients With Cancer Meets the Criteria for Mental Disorders: What Does That Mean?

In a well-designed study, Mehnert et al¹ reported that 31.8% of patients with cancer met the strict diagnostic criteria for mental disorders. The highest prevalence was found in patients with breast cancer (42%) and patients with head and neck cancer (41%); the lowest prevalence was found in patients with stomach or esophageal cancers (21%) and prostate cancer (22%). From their observation, Mehnert et al¹(p3540) conclude, “Our findings provide evidence for the strong need for psycho-oncological interventions.” We believe that several issues must be considered before a conclusion about the need for psycho-oncological interventions can be drawn.

The first issue is whether mental disorders occur more frequently in patients with cancer than in the general population. A direct comparison between prevalence rates of mental disorders in patients with cancer and in the general population was made in a recent study in 24 countries.² The 12-month prevalence rate of anxiety and mood disorders was 18.4% among respondents with active cancer, 14.6% among survivors of cancer, and 13.3% among cancer-free respondents in all countries combined.² A similar pattern emerged in separate analyses of patients in high-income and low- to middle-income countries. Investigators from two recent studies reported an increased incidence of mental disorders after the diagnosis of breast cancer compared with rates in the general population.^3,4 On the basis of the data presented in these papers, we calculated the proportion of anxiety and mood disorders attributable to the diagnosis of cancer (Table 1). These calculations showed that approximately 20% to 25% of anxiety and mood disorders are attributable to the diagnosis of breast cancer. We concluded that the incidence and prevalence of mental disorders is indeed higher in patients with cancer than in the general population.

A second issue to consider is whether patients perceive their emotional concerns as a need for mental health treatment. In a US-based study,⁵ 8.3% of patients who survived cancer reported a mental health visit in the past 12 months. Another 2.5% had an unmet need for mental health services, which was defined as a report of psychological distress and no report of a mental health visit in the past 12 months. Thus, 10.8% of survivors of cancer had a need for mental health care. In individuals with cancer and other chronic disease, the percentages of patients who reported a mental health visit in the past 12 months and who had unmet needs for mental health services were 9.6% and 3.0%, respectively—a total of 12.6% of all patients (data were obtained in 2010).⁵ In a qualitative study of patients with hematologic malignancies who were undergoing autologous stem-cell transplantation,⁶ emotional concerns were perceived as problems only if they interfered with a desirable goal in life. If the issues did not interfere with such a goal, patients often accepted their emotional concerns.

It seems that meeting the criteria for a mental disorder does not necessarily imply the subjective need for treatment. Even when patients face a life-threatening disease and burdensome treatment, they seem to manage by themselves with help from their families and friends and with help from oncologists and nurses. These patients should not automatically be considered in need of formal mental health care, although they may benefit from other types of support, such as peer and self-management supports. Obviously, specific patients may have a true need for mental health care, and formal care should be available for them.

A third issue to consider is whether symptoms would improve if patients received mental health care. Systematic reviews showed some evidence to support psychosocial and pharmacologic treatments, although the number of high-quality trials was limited.^7,8 Recent high-quality trials of intensive treatment for depression demonstrated alleviation of depression symptoms in patients with cancer.^9,10Therefore, effective treatments for anxiety and depression in patients with cancer seem available, and additional studies to accurately determine their benefit are needed.

In conclusion, the incidence and prevalence of mental disorders are higher in patients with cancer than in the general population. Not all patients who meet the criteria for a mental disorder need formal mental health care. However, some patients may benefit from treatment, because, if properly treated, their symptoms are likely to improve. An accurate and feasible method to identify patients who may benefit from mental health care is urgently needed.