Психосоциальная реабилитация

Количество литературы, посвященной психосоциальным методам помощи онкологическим

больным, возросло. Авторы указывают на необходимость приспособления психотерапии к

специфическому контексту онкологии (Bloch и Kissane, 2000), а также создания новых подходов

для работы со специфическими проблемами, возникающими в связи с раком. Уже сделаны

важные шаги в разработке психосоциальных вмешательств, ориентированных на запущенные

стадии болезни. В рамках этих состояний существует необходимо помогать пациентам

сохранить чувство собственного достоинства и развивать духовные аспекты, связанные с

приближением смерти (Breitbart, 2002; Chochinov et al., 2005).

В нескольких исследованиях показано, что психологические вмешательства могут

способствовать значительному улучшению качества жизни пациентов, а также уменьшению

выраженности эмоциональных симптомов, включая депрессию и дезадаптивные стили

преодоления стресса (отчаяние, тревожная озабоченность) (Sheard и Maguire, 1999). Точная

постановка диагноза и направление на подходящее психологическое вмешательство

необходимы для повышения вероятности «полезного эффекта» и снижения процента

отказавшихся от лечения. Психотерапия (в индивидуальном или групповом формате)

продемонстрировала наибольшую эффективность у больных раком с выраженными

симптомами депрессии, в то время как психотерапевтическая работа с пациентами, имеющими

«нормальный» уровень психологического дистресса, почти не эффективна (Coyne et al., 2006;

Fawzy et al., 1995).

Ранее предполагалось, что психотерапевтические вмешательства могут влиять на увеличение

продолжительности жизни больных раком (Spiegel et al., 1989). Однако в более поздних

исследованиях это предположение не подтвердилось, и никакого влияния психотерапии на

улучшение прогноза у больных раком обнаружено не было (Goodwin et al., 2001; Kissane et al.

2007; Spiegel et al., 2007).

В качестве общей рекомендации, вариантом выбора лечения депрессии у больных раком

является комбинация психологического воздействия и психофармакотерапии, подобранная в

соответствии с потребностями каждого конкретного пациента. Некоторые авторы связывают

положительную динамику в лечении психических заболеваний, особенно депрессий, с

наличием у клиницистов инструментов скрининга, правильной диагностики, а также

психологического и психофармакологического аспектов помощи (Akechi et al., 2007; Sharpe et

al., 2004). О схожих результатах сообщается и в связи с применением недавно разработанных

NCCN руководств, предназначенных для проведения поддерживающей терапии при

расстройствах настроения (Holland и Bultz, 2007; NCCN, 2008).

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ВЫВОДЫ

Депрессия — важное коморбидное психическое расстройство, сопровождающее рак. Недавний

отчет Института медицины Национальной академии наук, «Всеобъемлющий уход за больным

раком: знакомство с психосоциальными аспектами здоровья», является важным ориентиром

для принятия мер в отношении депрессии и тревоги, которые часто развиваются у

онкологических больных (Комитет психосоциального обслуживания больных раком и их семей

в общественных учреждениях, 2007). В этом отчете приведена программа стандартных

мероприятий по психосоциальной поддержке больных раком. Важно, чтобы психиатры

работали вместе со своими коллегами и способствовали выработке наиболее эффективных

практических методик для скрининга и выявления депрессий и других психиатрических

проблем у пациентов, получающих лечение в онкологических учреждениях. Ко всему прочему,

необходимо проведение доказательных клинических исследований, направленных на

определение оптимальных методов лечения депрессии на всех стадиях заболевания и при всех

видах рака. По мере того, как разрабатываются новые технологии и более мощные

химиотерапевтические и не‐химиотерапевтические способы подвергаются клиническим

исследованиям, нам необходимо расширять свое понимание того, как это лечение влияет на

психиатрическое обслуживание пациентов и их семей.

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