For those with cancer, it is very likely the hurdles you face may not be just physical — but mental too. Oftentimes, between the side effects of your cancer treatment it can be hard to decipher which is which. According to Dr. Asher Aladjem, a physician psychiatrist at NYU Langone’s Perlmutter Cancer Center, addressing your symptoms one-by-one with a mental health professional, can go a long way in making treatment a more tolerable experience. In this interview with SurvivorNet, Dr. Aladjem walks through the mental health tools available for cancer patients from diagnoses, treatment, and even into survivorship.
The interview is lightly edited for clarity and brevity.
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SurvivorNet: When it comes to mental health and cancer, what does it mean to treat the symptoms and not the diagnosis?Dr. Aladjem: We always say even if you don’t meet all the criteria for a psychiatric diagnosis, it doesn’t mean that you’re not suffering. For example, insomnia or difficulty sleeping or the threshold for pain tolerance changes for people in different situations. I always say if you are in pain and you are irritable and you’re frightened, your tolerance for pain or for anything diminishes. So treating the emotional component of the pain is a very, very effective way of managing the pain as well as improving the patient’s experience from that particular symptom. The medication treats the symptoms and empowers the patients to be able to manage their diagnosis or their problems in a more effective way.
SurvivorNet: So if someone isn’t actually diagnosed with depression, they can still have the symptoms of depression and they’re still very legitimate symptoms and things that can be addressed.Dr. Aladjem: Yes. For example, fatigue is a big symptom, insomnia, and a lack of appetite. How do you separate that from side effects of chemotherapy or radiation? It’s all on a spectrum. They’re obviously a symptom, but they’re not necessarily bonafide psychiatric diagnoses. It helps also in terms of the stigma for the patients. Most patients will accept treatment for insomnia or to improve the pain tolerance or even stimulants to improve their cognition or the capacity to manage their lives better. But I think there’s still a lot of resistance to having a psychiatric diagnosis. They say, “I was just diagnosed with cancer, now you’re going to tell me that I’m also mentally ill? What else are you going to tell me?” So this is tied to being effective in the treatment of the symptoms and not focusing on the big concepts of psychiatric diagnosis.
SurvivorNet: Can you talk to me about patient advocacy and what that means in your role?
Dr. Aladjem: We do advocacy in terms of social services, in terms of what kind of support patients may need or advocacy in terms of coverage for medications that are expensive. We have a whole system of access to care to make sure that they can get their medications in the way that they can afford it. We are trying to advocate for patients to be able to get the services that they need with whatever support they may need – whether it’s medications or therapy or nursing staff.
SurvivorNet: Those are things I wouldn’t have necessarily associated with what psychiatrists do, but they probably alleviate anxiety in a whole different kind of way.
Dr. Aladjem: We have a distress thermometer that is being used in most patients. For example, the biggest items or distressing factors include access to care, affordability, transportation access. Very concrete services. So we don’t necessarily get involved in all of these things, but we advocate, for example, to get car services. Some people need to travel for hours to get to the cancer center for treatment and the psychiatric assessment or the psychiatric support of the need has always been very helpful.
SurvivorNet: Is anxiety OK?
Dr. Aladjem: Anxiety is a good defense mechanism and normalizing that and saying anxiety up to a point is a very effective tool. Your body senses danger and risk and it’s time to protect itself. So you don’t want not to feel any anxiety, particularly with a life-threatening illness. It’s actually a protective and normal kind of symptom. But sometimes the anxiety gets to the point that things stand in the way of the scan or whatever the test is, and people avoid it and run away from it. And treating the anxiety allows for completion of the workup or the treatment or whatever the situation may be in a much more effective way. And the outcome of that, is patients are not as traumatized by the experience. Once the anxiety is diminished, they may say, “Oh yeah, I was very anxious. But it wasn’t so bad.”
SurvivorNet: How do you help cancer patients deal with fear of scans and new workups?
Dr. Aladjem: I always tell patients that if they were not anxious before a scan or a test, I would be worried about them. I think that anxiety is predictable and expected. And I think that we don’t want to pathologize that anxiety and to say, “Oh, there’s something wrong with you because you’re anxious before a scan.” It is important to try to normalize it for people, the fact that there is going to be anxiety for any scan or any test that they’re going to experience for the rest of their lives. And besides normalizing it, dealing sometimes with medications before a test to reduce the anxiety.
SurvivorNet: So there is benefit to stop thinking about it and just doing it?
Dr. Aladjem: It’s easier said than done to stop thinking about it, particularly if it’s something that is happening. But we explain to the patient that there may be better ways of dealing with whatever the situation is, and we empower the patient to be able to go through whatever the workup or treatment is in a more effective way. It actually makes people very proud, “Oh, I did very well in that test.” “Oh, I did very well with that treatment.” People actually take pride in that. And working with increasing the satisfaction and pride in being able to complete a workup or treatment is very effective in the long run. I think that patients benefit from it a lot.
SurvivorNet: How do you help patients navigate the stigma around clinical trials?
Dr. Aladjem: Clinical trials are very stigmatized, and many people will say, “I don’t want to be a guinea pig.” There is a lot of mistrust in healthcare, I must say. My approach to dealing with people who are resistant to clinical trials is to help them understand that they may get the state of the art or the best treatment possibly available. That is a process. And unfortunately, there’s been a lot of abuse in healthcare in treatments. Some of the mistrust is understandable and it’s something that needs to be addressed. Overall, I must say that with the right support, people have been able to enroll in clinical trials more and more.
SurvivorNet: Should mental health services be required for everyone diagnosed with cancer?
Dr. Aladjem: I don’t think it should be mandated for everybody to have a referral for mental health, but it should definitely be universally offered to everybody as part of the spectrum of services. That will both diminish the stigma and facilitate access to a better quality of life during treatment and after treatment into survivorship.
SurvivorNet: If a doctor does not offer mental health services, but a patient is interested, can they ask for it?
Dr. Aladjem: Anybody can make a referral for mental health, including the patient themselves. Patients need to know, and I hate to use the word “entitled,” but they’re kind of entitled to get the whole spectrum of services. And the mental health service is a very important one. I’m biased about that, but a patient needs to know that it is available and their level of comfort with that is up to them to decide.