Breaking the Silence: Unveiling Barriers to Mental Health Service Use in Breast Cancer Survivors with Clinically Significant Distress – A Mixed Methods Study

Abstract

Background: Breast cancer survivors (BCS) have an increased risk of psychological distress, including symptoms of depression, anxiety, and post-traumatic stress, compared to healthy controls. Fear of cancer recurrence (FCR) is an especially prevalent form of distress, with approximately 50% of BCS reporting clinically significant FCR. This mixed methods study explored relationships between psychological distress, mental health service (MHS) use, and barriers to MHS use among BCS. Methods: A mixed methods sequential explanatory design was utilized. Initially, baseline data from 384 early-stage, post-treatment BCS with clinically significant FCR at screening enrolled in a randomized controlled trial comparing 3 FCR interventions were analyzed. The prevalence of clinically significant FCR, anxiety, depression, and post-traumatic stress symptoms was measured. Associations between distress measures and MHS use were assessed. The quantitative findings prompted qualitative follow-up consisting of interviews with 24 distressed BCS to elucidate barriers hindering their use of MHS. Results: Clinically significant levels of at least one form of distress besides FCR were reported in 226 (58.85%) BCS. Of 298 (77.60%) BCS with at least one significant distress score including FCR, only 61 (20.47%) reported using any MHS within the 3 months before baseline. Clinically significant anxiety (p = 0.0027), depression (p = 0.0015), and post-traumatic stress symptoms (p = 0.0227) were significantly associated with MHS use. Conversely, FCR was significantly associated with fewer visits to certain MHS. Qualitative interviews revealed personal and systemic barriers contributing to underutilization of MHS in BCS, including avoidant coping, financial and logistical constraints, inaccessibility to providers with certain patient-preferred skillsets or backgrounds, such as speaking the survivor’s first language, and limited timely care options. In addition to pinpointing such barriers, valuable suggestions for improvement were elicited that may allow current and future providers to better meet the needs of BCS. Conclusions and Implications: Only a minority of clinically distressed BCS use MHS. Anxiety, depression, and post-traumatic stress symptoms may be better predictors of MHS use than FCR given the tendency for fearful survivors to cope with avoidance. Interventions emphasizing alternatives to avoidant coping may benefit BCS with FCR. Further research is needed to identify solutions to the multifaceted barriers impeding MHS use among BCS.