When Mental Health Challenges Appear During Cancer Treatment: Oncologists Shouldn’t Have to Manage It Alone

Most oncologists I have worked with are deeply invested in both the physical and emotional well-being of their patients. At the same time, when depression, anxiety, or insomnia emerge during treatment, prescribing psychiatric medications can feel like stepping outside one’s scope of expertise. Questions about medication interactions, diagnostic uncertainty, and the fear of opening something difficult to manage are common and completely understandable.

The collaborative care model makes it possible to address these challenges without adding burden to oncology clinicians. In this model, oncologists remain the primary prescribing clinicians, but they are not expected to manage psychiatric complexity alone. Instead, psychiatric expertise is embedded within the care team in a structured, supportive way.

How the Model Works

In the collaborative care model at Protocol, Behavioral Health Care Managers (BHCMs) serve as the central link between the patient, oncologist, and psychiatrist. They conduct focused behavioral health assessments, provide brief evidence-based support, and track symptoms over time using standardized measures. As the consulting psychiatrist, I meet regularly with BHCMs to review cases, clarify diagnostic questions, and develop thoughtful medication recommendations when appropriate.

When developing a medication recommendation, I evaluate each patient’s symptoms within the specific context of their oncological care, carefully accounting for chemotherapy regimens, renal and hepatic function, and the psychiatric side effects of high-dose steroids.

Ensuring the Right Level of Care

Our goal is not just to start a medication, but to ensure it is working effectively. This requires active titration to therapeutic levels, rather than settling for a partial response. Because the BHCM tracks symptoms regularly, we don't have to wait for a crisis to make a change. Any signal of a side effect or a plateau in progress triggers a collaborative review. This allows us to pivot, recommending an adjustment in dosages or switch in medications, to ensure that the benefits of treatment always outweigh the burdens, and that psychiatric stability remains a core pillar of the patient's cancer recovery.

Clinical Nuance: When Direct Psychiatry is Needed

While collaborative care is highly effective for many, we also recognize that some patients require a higher level of psychiatric intensity. If a patient presents with a significant diagnostic complexity, treatment-resistant symptoms, or severe psychiatric instability, the collaborative care model may not be the most appropriate fit. In these instances, we recommend and facilitate a transition to direct psychiatric prescribing. This ensures the patient receives dedicated medication management directly from a psychiatrist, providing the specialized oversight necessary for more acute or complex presentations.

A Partnership for Better Outcomes

For many oncology clinicians, collaborative care can initially feel unfamiliar, and I often hear concerns about workflow or added responsibility. In practice, the model is designed to reduce both. By creating a clear structure for identifying and treating mental health symptoms, whether through routine screening tools like the PHQ-9 and GAD-7 or clinical observation, collaborative care helps ensure that these concerns are addressed early, efficiently, and with appropriate support. 

When depression and anxiety are treated thoughtfully within the oncology setting, patients are better able to engage in treatment, communicate with their care teams, and navigate the uncertainty that accompanies serious illness.

Cancer care is already demanding. Collaborative care ensures that oncologists have psychiatric partnership available — so that caring for the emotional health of patients becomes something they are supported in doing, rather than something they must manage alone.

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