Mindfulness is an attribute of consciousness long believed to promote well-being. This research provides a theoretical and empirical examination of the role of mindfulness in psychological well-being. The development and psychometric properties of the dispositional Mindful Attention Awareness Scale (MAAS) are described. Correlational, quasi-experimental, and laboratory studies then show that the MAAS measures a unique quality of consciousness that is related to a variety of well-being constructs, that differentiates mindfulness practitioners from others, and that is associated with enhanced selfawareness. An experience-sampling study shows that both dispositional and state mindfulness predict self-regulated behavior and positive emotional states. Finally, a clinical intervention study with cancer patients demonstrates that increases in mindfulness over time relate to declines in mood disturbance and stress. Many philosophical, spiritual, and psychological traditions emphasize the importance of the quality of consciousness for the maintenance and enhancement of well-being (Wilber, 2000). Despite this, it is easy to overlook the importance of consciousness in human well-being because almost everyone exercises its primary capacities, that is, attention and awareness. Indeed, the relation between qualities of consciousness and well-being has received little empirical attention. One attribute of consciousness that has been much-discussed in relation to well-being is mindfulness. The concept of mindfulness has roots in Buddhist and other contemplative traditions where conscious attention and awareness are actively cultivated. It is most commonly defined as the state of being attentive to and aware of what is taking place in the present. For example, Nyanaponika Thera (1972) called mindfulness “the clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception” (p. 5). Hanh (1976) similarly defined mindfulness as “keeping one’s consciousness alive to the present reality” (p. 11). Recent research has shown that the enhancement of mindfulness through training facilitates a variety of well-being outcomes (e.g., Kabat-Zinn, 1990). To date, however, there has been little work examining this attribute as a naturally occurring characteristic. Recognizing that most everyone has the capacity to attend and to be aware, we nonetheless assume (a) that individuals differ in their propensity or willingness to be aware and to sustain attention to what is occurring in the present and (b) that this mindful capacity varies within persons, because it can be sharpened or dulled by a variety of factors. The intent of the present research is to reliably identify these inter- and intrapersonal variations in mindfulness, establish their relations to other relevant psychological constructs, and demonstrate their importance to a variety of forms of psychological well-being.

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The Benefits of Being Present: Mindfulness and Its Role in Psychological Well-Being

www.mobilehealthmap.org 617‐442‐3200 New research shows that mobile health clinics improve health outcomes for hard to reach populations in cost‐effective and culturally competent ways . A Harvard Medical School study determined that for every dollar invested in a mobile health clinic, the US healthcare system saves $30 on average. Mobile health clinics, which offer a range of services from preventive screenings to asthma treatment, leverage their mobility to treat people in the convenience of their own communities. For example, a mobile health clinic in Baltimore, MD, has documented savings of $3,500 per child seen due to reduced asthma‐related hospitalizations. The estimated 2,000 mobile health clinics across the country are providing similarly cost‐effective access to healthcare for a wide range of populations. Many successful mobile health clinics cite their ability to foster trusting relationships. Qualitative research in such mobile health clinics has found that patients value the informal, familiar environment in a convenient location, with staff who “are easy to talk to,” and that the staff’s “marriage of professional and personal discourses” provides patients the space to disclose information themselves. A communications academic argued that mobile health clinics’ unique use of space is important in facilitating these relationships. Mobile health clinics park in the heart of the community in familiar spaces, like shopping centers or bus stations, which lend themselves to the local community atmosphere.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Death is the new sex, last great taboo in Western society and Western medicine, as Richard Smith discusses in his editorial (p 129). In the trinity of births, marriages, and deaths, only death does not have glossy magazines devoted to stylish consumption at the attendant ceremonies. On the web, of course, …

Death and dying

Purpose To update guidance for health care providers about fertility preservation for adults and children with cancer.

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Fertility Preservation for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Patient-centered communication in cancer care: Promoting healing and reducing suffering

The purpose of the study was to assess a large representative sample of cancer patients on distress levels, common psychosocial problems, and awareness and use of psychosocial support services. A total of 3095 patients were assessed over a 4-week period with the Brief Symptom Inventory-18 (BSI-18), a common problems checklist, and on awareness and use of psychosocial resources. Full data was available on 2776 patients. On average, patients were 60 years old, Caucasian (78.3%), and middle class. Approximately, half were attending for follow-up care. Types of cancer varied, with the largest groups being breast (23.5%), prostate (16.9%), colorectal (7.5%), and lung (5.8%) cancer patients. Overall, 37.8% of all patients met criteria for general distress in the clinical range. A higher proportion of men met case criteria for somatisation, and more women for depression. There were no gender differences in anxiety or overall distress severity. Minority patients were more likely to be distressed, as were those with lower income, cancers other than prostate, and those currently on active treatment. Lung, pancreatic, head and neck, Hodgkin's disease, and brain cancer patients were the most distressed. Almost half of all patients who met distress criteria had not sought professional psychosocial support nor did they intend to in the future. In conclusion, distress is very common in cancer patients across diagnoses and across the disease trajectory. Many patients who report high levels of distress are not taking advantage of available supportive resources. Barriers to such use, and factors predicting distress and use of psychosocial care, require further exploration.

High levels of untreated distress and fatigue in cancer patients

Psychosocial care of patients has traditionally been seen as separate from routine medical care and has been criticized as being “soft” and lacking evidence. This traditional perspective continues in many settings, despite the fact that patients and families, when asked, state that emotional care is highly valued. The question of how to integrate psychosocial care into routine cancer care has also been an issue, partly because of the stigma associated with cancer. In 1997, the National Comprehensive Cancer Network (NCCN) established a multidisciplinary panel to examine this problem. 1 Because patient and physician attitudes toward pain can pose similar barriers to care as with distress, the panel used as a model the rating system for assessing pain that resulted in successful improvement of pain management in the United States. The rating system’s success seemed partly based on routinely using a single question to assess a patient’s pain: “How is your pain on a scale of 0 to 10?” The system uses a score of 5 or higher as the indication to reassess pain medications or refer the patient for more expert management. This system is widely used, and patient self-report of subjective symptoms is now accepted as appropriate and reliable. Pain has become the fifth vital sign, after pulse, respiration, blood pressure, and temperature, ensuring that it is evaluated as part of routine care. Drawing on this experience, the NCCN panel recommended a simple question to ask patients about psychosocial concerns. They found that distress was the best umbrella word to represent the range of emotional concerns patients with cancer experience and that it did not carry the stigma of other words sometimes used for emotional symptoms. Several studies have now validated the approach of asking, “How is your distress on a scale of 0 to 10?” and using a score of 4 or above as the trigger for further questions and possible referral to a psychosocial service. 2,3 In 2004, the Canadian Federal Government’s public health agency, Health Canada‐Canadian Strategy for Cancer Control, approved “Emotional Distress as the 6th Vital Sign.” 4 We propose that this system should also be considered in the United States to ensure that psychosocial distress is routinely assessed as part of cancer care and managed according to the NCCN distress management guidelines. This commentary outlines the potential benefits that can accrue for patients, families, and the health care system. Over 2 years beginning in 1997, the NCCN’s multidisciplinary panel de

The NCCN Guideline for Distress Management: A Case for Making Distress the Sixth Vital Sign

Cancer distress screening. Needs, models, and methods.

Historically, those who work to treat and cure illness have converged on five key indicators: temperature, respiration, heart rate, blood pressure and more recently, pain (National Pharmaceutical Council, 2001) to gauge whether a patient’s physiological systems are functioning sufficiently well to support survival and provide a platform for achieving wellness. In cancer care an area that is often, due the complexity and ubiquity of the disease, a leader in progressive approaches to managing disease}there is a growing recognition of the role a well-functioning mind and spirit play in the path to health. In parallel, there is recognition that interventions to support this vitality need to be empirically supported. Therein lies the need for the sixth vital sign to highlight the importance of distress as a marker of well-being and its reduction as a target outcome measure. For the most part, cancer care is still biomedically focused, despite numerous well-designed studies demonstrating high prevalence of emotional distress in cancer patients. As well, rigorous intervention studies have clearly demonstrated the benefits of psychosocial care to patients, families, health-care systems, and society. Given the advances in psychosocial screening and care, we propose that psychosocial oncology be considered a standard component of care of the cancer patient. Further, given the advances in our understanding of the psychosocial elements of the disease, we suggest that it is timely to consider cancer a biopsychosocial illness. In Canada, the Canadian Strategy for Cancer Control (CSCC) (Rebalance Focus-Action Group, 2005) elected to recognize emotional distress as a core indicator of a patient’s health and well-being. Along with the other vital signs, it designated emotional distress as the sixth vital sign. Here was the argument used to accomplish this goal: Cancer is well known to be a difficult disease, affecting cancer patients and their families both emotionally and physically. Despite biomedical progress, cancer is still often considered synonymous with death, pain, and suffering (Powe and Finnie, 2003). Research has demonstrated that across the trajectory of the illness}from the time of diagnosis to treatment, termination of treatment, survivorship, or recurrence and palliation}the incidence of emotional distress in North America ranges from 35 to 45% (Zabora et al., 2001; Carlson et al., 2004; Carlson and Bultz, 2003). Up to 58% of patients in palliative care experience significant levels of emotional distress (Potash and Breitbart, 2002), and in a Jordanian sample of cancer inpatients the prevalence of distress was 70% (Khatib et al., 2004). Similar overall rates to those in North America were recently reported in several European countries (Gil et al., 2003; Dolbeault et al., 2003; Mehnert et al., 2004), the Middle East (Isikhan et al., 2001; Sadeh-Tassa et al., 2004; Montazeri et al., 2004), South America (Santos, 2004), and Asia (Fielding et al., 2004; Shimizu et al., 2004). Large studies at Johns Hopkins Kimmel Cancer Center in Baltimore (Zabora et al., 2001) and the Tom Baker Cancer Centre in Alberta, Canada (Carlson et al., 2004) found high levels of fatigue (in 49% of all patients), pain (26%), anxiety (24%), and depression (24%) along with significant financial hardship and material challenges in a representative cross-section of patients screened for emotional distress.

Emotional distress: the sixth vital sign--future directions in cancer care.

Purpose Distress has been recognized as the sixth vital sign in cancer care and several guidelines recommend routine screening. Despite this, screening for distress is rarely conducted and infrequently evaluated. Methods A program of routine online screening for distress was implemented for new patients with breast and lung cancer. Patients were randomly assigned to one of three conditions: (1) minimal screening: the distress thermometer (DT) only plus usual care; (2) full screening: DT, problem checklist, Psychological Screen for Cancer part C measuring anxiety and depression, a personalized report summarizing concerns and the report on the medical file; or (3) triage: full screening plus optional personalized phone triage with referral to resources. Patients in all conditions received an information packet and were reassessed 3 months later with the full screening battery. Results Five hundred eighty-five patients with breast cancer and 549 patients with lung cancer were assessed at baseline (89% of all...

Barry D. Bultz

Papers

High levels of untreated distress and fatigue in cancer patients

The NCCN Guideline for Distress Management: A Case for Making Distress the Sixth Vital Sign

Cancer distress screening. Needs, models, and methods.

Emotional distress: the sixth vital sign--future directions in cancer care.

Screening for Distress in Lung and Breast Cancer Outpatients: A Randomized Controlled Trial