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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs 2 Consequences of Unmet Psychosocial Needs CHAPTER SUMMARY Psychosocial problems can be created or exacerbated by cancer and its treatment, as well as predate the illness. The failure to address these problems results in needless patient and family suffering, obstructs quality health care, and can potentially affect the course of the disease. Social isolation and other social factors, stress, and untreated mental health problems contribute to emotional distress and the inability to fulfill valued social roles, and interfere with patients’ ability to adhere to their treatment regimens and act in ways that promote their overall health. Additionally, these problems can bring about changes in the functioning of the body’s endocrine, immune, and other organ systems, which in turn could have implications for the course of cancer and other conditions. Families and the larger community also can be affected when psychosocial problems are not addressed. Although it is clear that psychosocial problems influence health, evidence is still emerging on just how they do so. Moreover, some such problems (such as poverty) obviously cannot be resolved by the health care system. Nevertheless, evidence clearly supports the need for attention to psychosocial problems as an integral part of good-quality health care. Psychosocial health services can enable patients with cancer, their families, and health care providers to optimize biomedical health care, manage the psychological/behavioral and social aspects of the disease, and thereby promote better health. A significant body of research shows that the psychological and social stressors reviewed in Chapter 1—such as depression and other mental
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs health problems, limited financial and other material resources, and inadequate social support—are associated with increased morbidity and mortality and decreased functional status. These effects have been documented both for health generally (House et al., 1988; Kiecolt-Glaser et al., 2002) and for a variety of individual health conditions and illnesses, including heart disease (Hemingway and Marmot, 1999), HIV/AIDS (Leserman et al., 2002), pregnancy (Wills and Fegan, 2001; ACOG Committee on Health Care for Underserved Women, 2006), and cancer (Kroenke et al., 2006; Antoni and Lutgendorf, 2007). Psychosocial stressors are theorized to affect health adversely in a number of ways. First, emotional distress and mental illness can themselves be the source of suffering, diminished health, and poorer functioning through their symptoms and their adverse effects on role performance. Second, psychosocial problems can adversely affect patients’ abilities to cope with and manage their illness by limiting their ability to access and receive appropriate health care resources; adhere to prescribed treatment regimens; and engage in behaviors necessary to manage illness and promote health, such as maintaining a healthy diet, exercising, and monitoring symptoms and adverse responses to treatment (Yarcheski et al., 2004; Kroenke et al., 2006). In multiple focus groups and interviews, patients with chronic illnesses such as diabetes, arthritis, heart disease, chronic obstructive lung disease, depression, and asthma have identified lack of family support, financial problems, lack of health insurance, problems with mobility, depression and other negative emotions, and stress as obstacles to dealing with their illness and health (Wdowik et al., 1997; Riegel and Carlson, 2002; Bayliss et al., 2003; Jerant et al., 2005). Moreover, a growing body of evidence is illuminating how the stress resulting from psychosocial problems can induce adverse effects within the body’s cardiovascular, immune, and endocrine systems (Segerstrom and Miller, 2004; Yarcheski et al., 2004; Uchino, 2006; Miller et al., 2007). Although evidence of adverse health outcomes from these effects is strongest for cardiovascular disease, emerging evidence from animal models and some human data suggest pathways through which these effects can influence the course of other illnesses (Antoni and Lutgendorf, 2007). A wide range of psychosocial variables may affect the course of illness. For example, several studies have found that individual psychological traits such as optimism, mastery, and self-esteem (sometimes termed psychosocial resources) protect against stress (Segerstrom and Miller, 2004). This chapter details the health effects of three psychosocial factors—social support, financial and other material resources, and emotional and mental status—for which there is strong evidence on health effects, for which there are screening and assessment tools that can be used to detect problems, and for which psychosocial health services (described in Chapter 3) exist to address identified problems. Also presented is evidence of how problems in these areas
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs affect the way the body works and the course of certain diseases. Together, these effects reduce an individual’s ability to engage in valued roles, and also have negative impacts on both families and the community. PSYCHOSOCIAL STRESSORS AND THEIR EFFECTS ON PATIENTS Inadequate Social Support Humans are social animals, and inadequate social contact and support can have profound adverse consequences. It is not surprising, then, that social support plays a central role in helping cancer patients and their families manage the illness. Although there is currently no single definition of “social support” (King et al., 2006; Uchino, 2006), research reveals that it has multiple dimensions. The web of relationships that exist between a person and his or her family, friends, and other community ties and the structural and functional characteristics of that web are generally referred to as the person’s “social network” (Berkman et al., 2000). The number, breadth, and depth of these relationships together make up one’s degree of “social integration.” Beneficial1 social networks provide different types of support to individuals under stress, including emotional, informational, and instrumental support. Emotional support involves “the verbal and nonverbal communication of caring and concern,” including “listening, ‘being there,’ empathizing, reassuring, and comforting” (Helgeson and Cohen, 1996:135); informational support increases knowledge and provides guidance or advice; and instrumental support involves the provision of material or logistical assistance, such as transportation, money, or assistance with personal care or household chores (Cohen, 2004). Each type of support can improve health care outcomes. For example, emotional support may help people cope more effectively with the obstacles they encounter and with their own emotional response to the challenges of illness. Insofar as knowledge may be gained from others about treatment or other aspects of care, informational support can increase the effectiveness of health care utilization. And instrumental support may help individuals act on this knowledge. Morbidity and Mortality Effects Epidemiological studies across a variety of illnesses have found that when individuals have low levels of social support, they experience worse outcomes, including higher mortality rates (IOM, 2001). There is strong 1 Social networks can also have adverse effects, such as when they support illegal or other undesirable behaviors and attitudes.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs evidence that the perception of the availability of social support protects individuals under stress from psychological distress, anxiety, and depression (Wills and Fegan, 2001; Cohen, 2004), in part by buffering them from the effects of stress (House et al., 1988; IOM, 2001). Consistent with this evidence, greater social integration has been associated with reduced mortality in multiple prospective community-based studies (Wills and Fegan, 2001). Conversely, well-designed studies have shown social isolation to be a potent risk factor for mortality across all causes of death (including cancer), as well as death due to specific conditions such as heart disease and stroke (Berkman and Glass, 2000). Indeed, the relative risk of death associated with social isolation is comparable to that associated with high cholesterol, mild hypertension, and smoking (House et al., 1988; IOM, 2001). The mechanisms by which these effects occur are not fully known, but there is evidence that social relationships that are stressful, weak, or absent can lead to decreased ability to cope with illness, negative emotions such as depression or anxiety, and immune and endocrine system dysfunction (see the discussion below) (Uchino et al., 1996; Kielcolt-Glaser et al., 2002). Effects of social support on health outcomes have been found specifically among individuals with cancer (Patenaude and Kupst, 2005; Weihs et al., 2005). A recent study following 2,800 women with breast cancer for a median of 6 years, for example, found that women who were socially isolated before their diagnosis had a 66 percent higher risk of dying from all causes during the observation period compared with women who were socially integrated. They were also twice as likely to die from breast cancer during this period2 (Kroenke et al., 2006). Weakened Coping Abilities and Increased Mental Illness Psychological adjustment to an illness involves “adaptation to disease without continued elevations of psychological distress (e.g., anxiety, depression) and loss of role function (i.e., social, sexual, vocational)” (Helgeson and Cohen, 1996:136). Positive emotional support is linked to good psychological adjustment to chronic illnesses generally and cancer specifically, and to fewer symptoms of depression and anxiety (Helgeson and Cohen, 1996; Wills and Fegan, 2001; Maly et al., 2005). Conversely, unsupportive social interactions are associated with greater psychological distress (Norton et al., 2005), decreased social role functioning (Figueiredo et al., 2004), and higher rates of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms (PTSS) in children with cancer (Bruce, 2006). 2 The analysis of data adjusted for stage of cancer at diagnosis, age, and other variables that might also affect survival.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs Diminished Ability to Manage Illness The outcomes noted above are problematic in and of themselves, but they may also decrease individuals’ ability to take the actions necessary to adhere to treatment, change health behaviors, and otherwise manage their illness. Individuals with greater social support are more likely to engage in health-promoting behaviors and exhibit healthy physiological functioning (IOM, 2001). In a meta-analysis of studies of predictors of positive health practices, loneliness and degree of perceived social support were found to have the largest effects (in the expected direction) on the performance of healthy behaviors (Yarcheski et al., 2004). Insufficient Financial and Other Material Resources Multiple studies have shown that low income is a strong risk factor for disability, illness, and death. Inadequate income limits one’s ability to avoid stresses that can accompany everyday life and to purchase food, medications, transportation, and health care supplies necessary for health and health care (Kelly et al., 2006). To take just one example, lack of transportation to get to medical appointments, the pharmacy, the grocery store, health education classes, peer support meetings, and other out-of-home health resources can hinder health monitoring, illness management, and health promotion. As discussed in Chapter 1, in 2003 nearly one in five people in the United States with chronic conditions3 lived in families that had problems paying medical bills (Tu, 2004); 63 percent of these individuals also reported problems paying for housing, transportation, and food (May and Cunningham, 2004). Among the privately insured with problems paying medical bills, 10 percent went without needed medical care, 30 percent delayed care, and 43 percent failed to fill needed prescriptions because of cost concerns (Tu, 2004). Overall, 68 percent of families with problems paying medical bills had problems paying for other necessities, such as food and shelter (May and Cunningham, 2004). Such families may trade off medical care so they can fulfill basic needs. The 2006 National Survey of U.S. Households Affected by Cancer similarly found that 8 percent of families having a household member with cancer delayed or did not receive care because of the cost of care. Of those without health insurance, more than one in four delayed or decided not to get treatment because of its cost, and 41 percent were unable to pay for basic necessities (USA Today et al., 2006). A longitudinal study of a cohort 3 Asthma, arthritis, diabetes, chronic obstructive pulmonary disease, heart disease, hypertension, cancer, benign prostate enlargement, abnormal uterine bleeding, and depression.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs of 860 men being treated for prostate cancer found that even after controlling for state of disease at the start of treatment, type of treatment, and other possible influential variables, men without health insurance achieved lower physical functioning, had more role limitations, and experienced poorer emotional well-being over time than men with health insurance. The researchers concluded that “patients undergoing aggressive treatment, which can itself have deleterious effects on quality of life, are exposed to further hardships when they do not have comprehensive health insurance upon which to support their care” (Penson et al., 2001:357). The adverse effects of no or inadequate insurance contribute to poorer health prior to the receipt of health care; undermine the effectiveness of care by increasing the chances of delayed or no treatment and the inability to obtain needed prescription medications; and contribute to worse outcomes of medical treatment for people with cancer and other diseases (IOM, 2002; Tu, 2004; IOM and NRC, 2006). Emotional Distress and Mental Illness4 As discussed in Chapter 1, psychological distress is common among individuals with cancer. However, mental health problems and other types of psychological distress (which sometimes predate illness) (Hegel et al., 2006) are not unique to patients with cancer. People with chronic conditions such as diabetes, heart disease, HIV-related illnesses, and neurological disorders also are found to have high rates of depression, adjustment disorders, severe anxiety, PTSS or PTSD, and subclinical emotional distress (Katon, 2003). In a British sample of older adults living in the community, the development of serious physical illness in the respondent was frequently associated with the development of new-onset major depression (Murphy, 1982). A more recent longitudinal study in Canada found an increased risk of developing major depression to be associated with virtually any long-term medical condition (Patten, 2001). Most recently, an 8-year study followed a nationally representative sample of more than 8,000 U.S. adults aged 51–61 living in the community (and with no symptoms of depression at the start of the study) to examine the extent to which they developed symptoms of depression after a new diagnosis of several illnesses—cancer (excluding minor skin cancers), diabetes, hypertension, heart disease, arthritis, chronic lung disease (excluding asthma), or stroke. Those receiving 4 Portions of this section are from a paper commissioned by the committee entitled “Effects of Distressed Psychological States on Adherence and Health Behavior Change: Cognitive, Motivational, and Social Factors” by M. Robin DiMatteo, Kelly B. Haskard, and Summer L. Williams, all of the University of California, Riverside. This paper is available from the Institute of Medicine.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs a diagnosis of cancer were at the highest risk of developing symptoms of depression within 2 years (13 percent incidence), with more than triple the risk of all others combined (Polsky et al., 2005). (Those with a diagnosis of chronic lung disease, heart disease, and stroke also had higher-than-average rates of depressive symptoms.) Depressed or anxious individuals with a variety of comorbid general medical illnesses (including cancer) report lower social functioning, more disability, and greater overall functional impairment than patients without depression or anxiety (Katon, 2003). Distressed emotional states also often generate additional somatic problems, such as sleep difficulties, fatigue, and pain (Spitzer et al., 1995; APA, 2000), which can confound the diagnosis and treatment of physical symptoms. Among patients with a variety of chronic medical conditions other than cancer, those with depressive and anxiety disorders have significantly more medically unexplained symptoms than those without depression and anxiety, even when severity of illness is controlled for. Patients with depressive and anxiety disorders also have greater difficulty learning to live with chronic symptoms such as pain or fatigue; data suggest that depression and anxiety are associated with heightened awareness of such physical symptoms. Multiple studies of patients with major depression have also found higher-than-normal rates of unhealthy behaviors such as smoking, sedentary lifestyle, and overeating (Katon, 2003). Depression is associated as well with poor adherence to prescribed treatment regimens (DiMatteo et al., 2000). Impaired Adherence to Medical Regimens and Behavior Changes Designed to Improve Health While serious health events can trigger health-damaging behaviors—such as use of substances and consumption of unhealthful foods—as individuals cope with the distress associated with the illness, they can also motivate people to take up a number of health-promoting behaviors (McBride et al., 2003; Demark-Wahnefried et al., 2005). One study, for example, found that 6 months after surviving a heart attack, 17 percent of patients were engaged in four health-promoting behaviors (refraining from smoking, weight reduction, sufficient physical activity, and consumption of a low-fat diet), compared with just 3 percent of patients at baseline (Salamonson et al., 2007). Another study found that following HIV diagnosis, 43 percent of individuals reported increased physical activity and 59 percent improved diet (Collins et al., 2001). In general, research indicates that following a cancer diagnosis, many patients engage in behaviors such as stress management, quitting smoking, aerobic exercise, and major dietary change (Blanchard et al., 2003; Ornish et al., 2005; Andrykowski et al., 2006; Rabin and Pinto, 2006; Humpel et al., 2007). One study found
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs that following a cancer diagnosis, as many as half of those who smoked quit (Gritz et al., 2006). The concept of “teachable moments” has been used to explain how, after experiencing health events such as serious illness, people are motivated to take up health-promoting behaviors (McBride et al., 2003; Demark-Wahnefried et al., 2005). Over the course of many serious acute and chronic conditions, however, patients’ adherence to health professionals’ recommendations for improved health can be quite low. And despite motivation, changes in actual health behaviors do not always come about or persist. For example, dozens of studies have found more than 30 percent nonadherence to dialysis, dietary and fluid restrictions, and transplant management in patients with end-stage renal disease, diabetes, and lung disease. In patients with cardiovascular disease, nonadherence to lifestyle changes, cardiac rehabilitation, and medication regimens is almost 25 percent. In patients with HIV, nonadherence to highly active antiretroviral treatment regimens and behavior change is 11.7 percent (DiMatteo, 2004). Similar rates of nonadherence have been observed in cancer patients despite the importance to survival and better health care outcomes of adhering to a treatment regimen. More than 20 percent of cancer patients have been found to be nonadherent to a variety of treatments, including oral ambulatory chemotherapy, radiation treatment, and adjuvant therapy with tamoxifen (Partridge et al., 2003; DiMatteo, 2004). For adjuvant tamoxifen, for example, adherence can be as low as 50 percent after 4 years of treatment (Partridge et al., 2003). One study of the natural progression of exercise participation after a diagnosis of breast cancer found that women did not significantly increase their levels of exercise over time and were in fact exercising below recommended levels despite their expressed intentions otherwise (Pinto et al., 2002). As discussed below, depression and other adverse psychological states can thwart adherence to treatment regimens and behavior change in a number of ways, for example, by impairing cognition, weakening motivation, and decreasing coping abilities. Impaired Cognition To achieve healthy lifestyles and manage chronic illness effectively, patients must first understand what they need to do to care for themselves. The necessary information may come from many sources, including the media, family members, and health professionals, and may include, for example, reasons for needed chemotherapy, the exact ways in which medication should be administered, and the importance of sleep and a good diet. Distressed psychological states can seriously challenge the cognitive functioning and information processing required to understand treatments and organize health behaviors. Stress, anxiety, anger, and depression can
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs impair the ability to learn and maintain new behaviors (Spiegel, 1997) or to undertake complex tasks that require planning and behavioral execution (Wells and Burnam, 1991; Olfson et al., 1997). For example, research on kidney transplant recipients’ adherence to immunosuppressive medication has found that patients with poor adherence report higher levels of psychological distress relative to patients with good adherence (Achille et al., 2006). Patients undergoing dialysis treatment for end-stage renal disease have also been found to experience greater cognitive impairment and dysfunction due to depressive mood (Tyrrell et al., 2005). Disturbance of mood and motivation in HIV-positive individuals has been associated with decrements in several cognitive factors, such as neurocognitive performance, verbal memory, executive functioning, and motor speed (Castellon et al., 2006). Among patients with advanced cancer, depression and anxiety similarly have been found to contribute to cognitive impairments (Mystakidou et al., 2005). Even after controlling for the effects of pain and illness severity, anxiety and depression among patients with cancer have been independently associated with decreased cognitive functioning (Smith et al., 2003). Moreover, when patients are distraught about the course of their illness, they may be more likely to forget health professionals’ recommendations and less likely to ask questions about their care and participate in medical visits (Robinson and Roter, 1999; DiMatteo et al., 2000; Katon et al., 2004; Sherbourne et al., 2004). Lower levels of patient participation are associated with poorer health behaviors (Martin et al., 2001). Weakened Motivation Distressed psychological states can limit patients’ concern about the importance of their health behaviors and contribute to their belief that the benefits of adherence are not worth the trouble (Fink et al., 2004). Distressed psychological states can also lead to diminished self-perceptions and limitations in personal self-efficacy,5 which in turn negatively affect health behaviors and adherence. Pessimism about the future and about oneself can forestall the adoption of new health practices and interfere with health behaviors and adherence (Peterman and Cella, 1998; DiMatteo et al., 2000; Taylor et al., 2004). Limitations in personal self-efficacy that derive from both anxiety and depression can interfere with the behavioral commitment essential to the adoption and maintenance of new health practices. Distressed psychological states can also amplify somatic symptoms, causing 5 As discussed in Chapter 1, self-efficacy is defined as the belief that one is capable of carrying out a course of action to reach a desired goal (Bandura, 1997).
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs additional functional disability and further reducing patients’ motivation to change behavior. Less Effective Coping Self-efficacy and emotional resilience contribute to greater engagement in health-promoting behaviors, including adherence to treatment regimens. Conversely, these behaviors can be undermined by ineffective coping with psychological distress. Optimism and positive coping also have been explored as mechanisms through which ill individuals can become more emotionally resilient and better able to cope with and manage the course of their disease. Coping (which involves seeking of social support, positive reframing, information seeking, problem solving, and emotional expression) can bolster one’s adjustment to chronic illness (Holahan et al., 1997), and improving patients’ coping strategies can be effective in reducing symptoms of psychological distress that hinder health behaviors and the management of illness (Barton et al., 2003). For patients with cancer, optimism also predicts improved quality of life and functional status and the effective management of pain (Astin and Forys, 2004). Finding meaning in the illness experience is another coping mechanism that can improve a patient’s psychological adjustment (Folkman and Greer, 2000), contributing to a greater sense of control, improved psychological adjustment, and more positive focus (Fife, 1995). As many as 83 percent of patients with breast cancer come to realize at least one benefit following their diagnosis (Sears et al., 2003); such a realization involves positive reappraisal of their situation and results in better coping, mood, and health status. Research on patients with tuberculosis in South Africa found a significant relationship between assessment of meaning in life and adherence to treatment for the disease (Corless et al., 2006). Finding benefit also is linked to patients’ adherence to antiretroviral therapy for HIV (Stanton et al., 2001; Luszczynska et al., 2006). Conversely, coping mechanisms that are less adaptive can help in dealing with the immediate emotional distress associated with illness but create longer-term problems. Avoidant coping, which involves denial, emotional instability, avoidant thinking (avoiding thoughts about the reality of the illness), and immature defenses, is associated with less engagement in healthy behaviors (e.g., healthy diet, exercise, adherence to treatment), as well as the adoption of unhealthful behaviors (e.g., smoking, drinking alcohol to excess, abusing psychotropic medications) in an effort to cope with emotional distress (Stanton et al., 2007). Avoidant thinking about the illness is considered “harmful coping” because problems are not faced and solutions are not found, contributing to unhealthy behaviors and nonadherence (Carver et al., 1993).
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs ALTERATIONS IN BODY FUNCTIONING DUE TO STRESS6 Psychological stress arises from the interaction between the individual and the environment. It is said to occur when environmental demands (stressors) exceed the individual’s capacity to deal with those demands (Lazarus and Folkman, 1984; Cohen et al., 1995). Stress is thought to exert its pathological effects on the body and increase the risk of disease in part by encouraging maladaptive behaviors as described above. People often cope with the negative emotions elicited by stress through behaviors that bring short-term relief but carry long-term risk. Under stress, people generally smoke more, drink more alcohol, eat foods with a higher fat and sugar content, and exercise less (Conway et al., 1981; Cohen and Williamson, 1988; Anderson et al., 1994). They also tend to have less and poorer-quality sleep (Akerstedt, 2006). In addition, stress is thought to influence the pathogenesis or course of physical disease more directly by causing negative affective states, such as anxiety and depression, which in turn exert direct effects on biological processes that stimulate and dysregulate certain physiological systems in the body. The immune, cardiovascular, and neuro-endocrine systems are well-known respondents to stress (IOM, 2001). Long-term stressful circumstances that reduce perceptions of control and increase feelings of helplessness, hopelessness, and anxiety damage health and can lead to premature death, in part because of the immune, cardiac, and other physiological responses they produce (WHO, 2003). Individuals are even more vulnerable to the adverse physiological effects of stress when they are exacerbated by other psychosocial factors (e.g., a weak social network) or the individual has inadequate psychosocial assets to buffer the effects of exposure to stress. Links Between Stress and Disease There is strong evidence that chronic stress influences the development and/or progression of certain illnesses, including major depression, heart disease, HIV-related illnesses, and (to a lesser extent) cancer. Depression Substantial research links stressful life events to both diagnosed depression and depressive symptoms (Monroe and Simons, 1991; Kessler, 1997; Mazure, 1998; Hammen, 2005). One study found that during the 3–6 6 Portions of this section are from a paper commissioned by the committee entitled “Stress and Disease,” authored by Sheldon Cohen and Denise Janicki-Deverts, both of Carnegie Mellon University. This paper is available from the Institute of Medicine.
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Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs 3 and 4. The rationale for and the significance of the committee’s definition of psychosocial health services are discussed in detail in Appendix B. Some might question whether effective psychosocial health services exist, exist in sufficient quantity, and are accessible to patients, and whether aiming to ensure the provision of psychosocial health services to all patients in need is a feasible goal for oncology providers. Moreover, some might question whether it is worthwhile to identify and attempt to address psychosocial problems through means not typically thought of as medical services, given that some psychosocial problems, such as poverty, are not resolvable. There are several reasons why the committee believes this to be a reasonable aim. In the next chapter, the committee documents the finding of another recent IOM report on cancer—that a “wealth” of cancer-related community support services exists, many of which are available at no cost to patients (IOM and NRC, 2006:229). The committee also notes that tools and techniques needed to identify and address psychosocial problems already exist and are in use by leading oncology providers. Although these tools and techniques have not yet been perfected, and there is not currently as ample a supply of psychosocial services as would be necessary to meet the needs of all patients, the committee describes in the next three chapters psychosocial services, tools, and interventions that do exist and are being used to help patients manage their cancer, its consequences, and their health. The committee urges all involved in the delivery of cancer care not to allow the perfect to be the enemy of the good. There are many actions that can be taken now to identify and deliver needed psychosocial health services, even as the health care system works to improve their quantity and effectiveness. The committee believes that the inability to solve all psychosocial problems permanently should not preclude attempts to remedy as many as possible—a stance akin to oncologists’ commitment to treating cancer even when the successful outcome of every treatment is not assured. REFERENCES Achille, M., A. Ouellette, S. Fournier, M. Vachon, and M. Hebert. 2006. Impact of stress, distress and feelings of indebtedness on adherence to immunosuppressants following kidney transplantation. Clinical Transplantation 20(3):301–306. ACOG Committee on Health Care for Underserved Women. 2006. Committee opinion: Psychosocial risk factors—perinatal screening and intervention. Obstetrics and Gynecology 108(2):469–477. Akerstedt, T. 2006. Psychosocial stress and impaired sleep. Scandinavian Journal of Work, Environment & Health 32(6, special issue):493–501. Andersen, B. L., W. B. Farrar, D. M. Golden-Kreutz, R. Glaser, C. F. Emery, T. R. Crespin, C. L. Shapiro, and W. E. Carson. 2004. Psychological, behavioral, and immune changes after a psychological intervention: A clinical trial. Journal of Clinical Oncology 22(17): 3570–3580.
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