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Chapter 90 Psychosocial Aspects of Hematologic Disorders 1467

and include individual patient, environmental, and disease-related referred routinely to formal home nursing care at discharge. An initial
factors. home visit can be invaluable in assisting patients and families with
the transition, in addition to identifying areas in which ongoing
assistance is needed. Given changes in the current health care system,
Individual Patient Factors informal family caregivers are increasingly expected to serve as the
major providers of care outside the hospital. Hence referral for home
Demographics, comorbid conditions including previous psychiatric care can be of significant support.
morbidity, and previous coping strategies have been consistently
documented as important predictors for psychosocial adjustment.
Female sex and younger age are important predictors for worse psy- Disease-Related Factors
chosocial adjustment and poorer quality of life for patients with
hematologic malignancies. 21,74–76 As the population ages, there are Disease-related factors including the type of disease, side effects of
more individuals diagnosed with cancer who already have comorbid treatment, and residual symptoms all greatly affect psychosocial
diseases, which complicates treatment decisions and recovery. 77,78 adjustment. Different treatment modalities introduce varying degrees
Many individual patient factors are interrelated; for example, higher of side effects, symptoms, and impact on quality of life. Without
anxiety scores and worse quality of life outcomes have been observed exception, the greatest difficulties in psychosocial adjustment were
in women more than in men. Poor quality of life after treatment has observed among patients who underwent allogeneic HSCT, followed
been associated with higher age of the recipient at the time of the by autologous HSCT recipients, and then patients who received
transplant, poorer self-image, decreased cognitive functioning, and conventional or maintenance chemotherapy. The latter groups
inability to return to work. 79,80 This makes it difficult to accurately experienced the least impairment in quality of life and psychologic
predict psychosocial adjustment solely based on these factors. distress. Patients who underwent transplant also had more psychiatric
One of the key predictors of psychosocial adjustment to cancer is morbidity if they experienced lower functional status and higher
the psychologic stability of the person before diagnosis. People with regimen-related toxicity. 27
a history of poor psychosocial adjustment before development of Time interval after treatment has been documented as an impor-
cancer are at highest risk for psychologic decompensation and should tant predictor for psychosocial adjustment. Particularly, time since
be monitored closely throughout all phases of treatment. 27,81 This is HSCT or completion of treatment was an important factor for facili-
particularly true of people with a history of a major psychiatric tating psychosocial adjustment and improving quality of life. In
syndrome, psychiatric hospitalization, or both. 27 general, during the first year after HSCT, patients perceived their
Because a person’s coping style is determined relatively early in life physical and overall well-being as being at its worst, during which
and tends to remain stable over time and across situations, it serves time they experienced more anxiety and total mood disturbance, and
as a useful predictor of adjustment to cancer. Several investigators reported the highest degree of illness intrusiveness in every aspect of
have identified specific personality characteristics, coping strategies, life. 32,57,91–95 With the passage of time, improvements in functional
and life experiences that enhance or inhibit positive adjustment to status, quality of life, levels of anxiety, depression, and satisfaction
cancer. 82,83 Empiric evidence demonstrates the beneficial impact of with life were frequently observed after transplant.
positive coping strategies and personality attributes on long-term
survival. 84–86 Coping strategies found to be most effective include:
having a “fighting spirit;” hopefulness and acceptance of the situa- DIFFERENTIATING PSYCHIATRIC COMPLICATIONS
tion; a belief that life has purpose and coherence; and having a feeling FROM EXPECTED PSYCHOLOGIC RESPONSE
of control over events. These strategies tend to result in active par-
ticipation in treatment and engagement in daily life. By contrast, Living with a chronic illness often requires continuing care and
poor adjustment has been associated with avoidant coping strategies; management by a team of specialists. Use of supportive care services
anxious preoccupation and high distraction; prior negative sexual has been related to improved quality of life; therefore it is in the
experiences; body image problems; and inhibition in discussing patient’s best interest to access services needed for psychologic distress
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personal and sexual problems. One study showed that patients who early in the continuum of care. Care usually is provided through
smoke are at higher risk for psychiatric morbidity, perhaps due to the follow-up visits to ambulatory or outpatient clinics and consulting
potential development of depression and/or anxiety with withdrawal rooms, rather than through hospitalization. However, several barriers
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symptoms. It is important to include smoking history in the that may impair the outpatient cancer survivor from accessing health
96
patient’s assessment of substance control use when preparing patients care services include economic and financial constraints. Differen-
for treatment options. tiating a psychiatric complication from expected psychologic responses
is imperative.
Although any individual experiencing the crisis of a cancer diag-
Environmental Factors nosis may become clinically depressed or experience a panic attack,
most patients do not experience a diagnosable psychiatric condition.
Environmental factors include partner and family support as well Currently the rates of adjustment disorder, depression, anxiety, and
as other forms of social support. The quality of spousal and family PTSD are 40%, 25%, 10%, and 5%, respectively. The ability of
relationships has a significant impact on the psychologic health health care providers to distinguish expected reactions from more
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and even mortality of the patient. Social support, network size, severe psychiatric complications is crucial.
satisfaction with social support, and reliance on formal and infor- Unfortunately, non–mental health providers often miss clinically
mal social ties have consistently been found to influence a person’s relevant and severe psychiatric syndromes. Being knowledgeable
psychosocial adjustment to cancer. 71,72 The ability and availability about common symptoms of adjustment disorder, depression, anxiety,
of significant others in dealing with a diagnosis and discussion of and PTSD are helpful. Table 90.2 provides a quick reference; also
treatment options can significantly affect the patient’s view of himself refer to the Diagnostic and Statistical Manual of Mental Disorders.
or herself. Patients diagnosed with all types of life-threatening chronic Another group of patients who are at high risk for developing
disorders experience a heightened need for interpersonal support. adjustment problems includes those with coexisting severe mental
Those who are able to maintain close connections with family and illness including schizophrenia, bipolar disorder, schizoaffective dis-
friends during the course of illness are more likely to cope effectively order, and obsessive-compulsive disorder. Integrated care of psychiatry
with the disease than are those who are not able to maintain such and oncology is the best option in treating these patients, first to
relationships. 69,86,90 stabilize the psychiatric illness and then to treat the cancer. 97,98 Good
Often the transition out of the hospital posttransplant can be a communication, empathy, listening skills, and providing emotional
fearful time for patients and families. Traditionally patients are not support are all skills that benefit these patients and specifically those