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

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4Portions 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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