The association of demoralization with mental disorders and suicidal ideation in patients with cancer

Demoralization in End-of-Life Cancer Patients' Family Caregivers: A Cross-Sectional Study

OBJECTIVES

The aims of this study were to evaluate the prevalence of demoralization in a sample of end-of-life cancer patients' family caregivers and investigate the association between demoralization and different factors, such as distress, hope, quality of life, and caregiver burden.

METHODS

The study used a cross-sectional design and 142 participants were sampled. Family caregivers were included if they were caring for a cancer patient in palliative care with a limited life expectancy.Socio-demographic data were gathered, and Italian versions of the following scales were administered: Demoralization Scale (DS), Herth Hope Index (HHI), Caregiver Reaction Assessment (CRA), Short Form-36 Health Survey (SF-36), and Distress Thermometer (DT).

RESULTS

The average total demoralization score was 29.04 (SD = 13.62). 19.50% of caregivers was the low scorers at DS (0-25th percentile), 27.50% was the middle scorers (25th-75th percentile), and 39.00% was the high scorers (75th-100 percentile). 19.50% of the caregivers showed mild demoralization, 27.50% moderate demoralization, and 39.00% showed severe demoralization. Strong Moderate correlations were found between the total DS score and the Temporality and Future HHI subscale (ρ = .520); the HHI total score (ρ = .528); the Social functioning (ρ = .536) and Mental health (ρ = .675) SF-36 subscales. The HHI total score and the Mental health SF-36 subscale emerged as the main predictors of demoralization.

CONCLUSIONS

The results show that not only end-of-life patients but also family caregivers may experience demoralization. This demoralization seems to be more associated to spiritual and psychological suffering rather than difficulties relating to caregivers' personal time, social roles, physical states, and financial resources.

Norm Values and Psychometric Properties of the 24-Item Demoralization Scale (DS-I) in a Representative Sample of the German General Population

Purpose: The Demoralization scale (DS-I) is a validated and frequently used instrument to assess existential distress in patients with cancer and other severe medical illness. The purpose of this study was to provide normative values derived from a representative German general population sample and to analyze the correlational structure of the DS-I.

Methods: A representative sample of the adult German general population completed the DS-I (24 Items), the Emotion Thermometers (ET) measuring distress, anxiety, depression, anger, need for help, and the Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-fatigue).

Results: The sample consists of N = 2,407 adults (mean age = 49.8; range = 18–94 years), 55.7% women). The percentages of participants above the DS-I cutoff (≥30) was 13.5%. The mean scores of the DS-I dimensions were as follows: (1) loss of meaning and purpose: M = 2.78 SD = 4.49; (2) disheartenment: M = 3.19 SD = 4.03; (3) dysphoria M = 4.51 SD = 3.20; (4) sense of failure: M = 6.24 SD = 3.40; and for the DS-I total score: M = 16.72 SD = 12.74. Women reported significantly higher levels of demoralization than men, with effect sizes between d = 0.09 (Loss of Meaning) and d = 0.21 (Dysphoria). Age was not associated with demoralization in our sample. DS-I reliability was excellent (α = 0.94) and DS-I subscales were interrelated (r between 0.31 and 0.87) and significantly correlated with ET, especially depression, anxiety, and need for help and fatigue (r between 0.14 and 0.69).

Conclusions: In order to use the DS-I as a screening tool in clinical practice and research the normative values are essential for comparing the symptom burden of groups of patients within the health care system to the general population. Age and sex differences between groups of patients can be accounted for using the presented normative scores of the DS-I.

Magnitude and Associated Factors of Suicidal Ideation Among Cancer Patients at Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia, 2019: Cross-sectional Study

Background

Suicide is a worldwide public health issue and considered as a psychiatric emergency. The majority of all completed suicides occur in low- and middle-income countries. A diagnosis of cancer has been associated with an increased risk of suicidal ideation and suicide is one of the leading causes of non-cancer-related mortality among cancer patients in recent years. Suicidal ideation is four times higher in cancer patients than in the general population. There is limited evidence on suicidal ideation on patients diagnosed with cancer in Ethiopia as well as in African countries.

Objective

To assess the magnitude and associated factors of suicide ideation among cancer patients at Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia, 2019.

Methods

An institution-based cross-sectional study was conducted from May 1 to 30, 2019. Systematic random sampling technique was used and a total of 410 of cancer patients participated in the study. Data were collected using the Suicide Manual of Composite International Diagnostic Interview (CIDI) questionnaire. Data were coded, entered into EpiData manager version 4.4 and analyzed using SPSS version 20. Descriptive, analytical statistical procedures, bivariable, multivariable logistic regression with odds ratio, 95% confidence interval were employed. The statistical significance was declared at P-value <0.05.

Results

The finding of the present study on magnitude of suicidal ideation among cancer patients were 28.5% with 95%CI: 24.1–33.2, respectively. In multivariable logistic regression analysis being female advanced stage, perceived stigma and anxiety was significantly associated with suicidal ideation.

Conclusion and Recommendation

The magnitude of suicidal ideation among cancer patients was higher than in the general population. It also reported that, advanced stage, perceived stigma, anxiety and being female were factors significantly associated with suicidal ideation. This study gives us clues that cancer patients are prone to suicide ideation. Therefore, cancer patients need special attention to reduce these problems.

Risk factors for suicide in individuals with cancer: an integrative literature review

OBJECTIVE

to develop an integrative literature review on risk factors for suicide in individuals with cancer.

METHOD

searching for articles was conducted in the Scientific Electronic Library Online, Medicinal Literature Analysis and Retrieval System Online, Latin American & Caribbean Literature in Health Sciences, Cumulative Index to Nursing and Allied Health Literature and SciVerse Scopus databases, using the descriptors "suicide" and "cancer".

RESULTS

eighteen articles were selected. Lung, bladder and colorectal cancers are the types of highest risk for suicide. Male, white and over 60 years of age are demographic factors with higher risk for suicide in individuals with cancer.

CONCLUSION

this review made it possible to verify that cancer may be a risk factor for suicide. This evidence can be useful for planning preventive actions in order to reduce the risk of suicide.

Existential distress in patients with advanced cancer and their caregivers: study protocol of a longitudinal cohort study

INTRODUCTION

At the end of life, patients with advanced cancer and their informal caregivers may confront multiple existential concerns. Despite the strong potential to alleviate existential distress through psychosocial interventions, existential distress and its impact on healthcare outcomes have not yet been studied systematically. We aim to investigate the frequency, longitudinal trajectory and predictive impact of existential distress on end-of-life outcomes. We further aim to determine patients' and caregivers' specific need for and utilisation of psychosocial support for existential distress.

METHODS

This longitudinal cohort study will consecutively recruit 500 patients with advanced cancer and 500 caregivers from oncological outpatient and inpatient clinics. Participants will complete self-report questionnaires (sociodemographic and disease-related characteristics, existential distress, end-of-life outcomes, resources and support needs) at five points of assessment (at baseline and after 3, 6, 9 and 12 months). At baseline and 6-month follow-up, we will conduct structured diagnostic interviews to assess mental disorders. Statistical analyses will include descriptive statistics to determine the prevalence of existential distress, mental disorders and end-of-life outcomes; multiple linear and logistic regression analyses to calculate the predictive impact of existential distress on end-of-life outcomes; and growth mixture models to analyse longitudinal trajectories of existential distress.

DISCUSSION

This study will provide comprehensive knowledge about patients' and caregivers' existential concerns. The longitudinal empirical data will allow for conclusions concerning the frequency and course of existential distress throughout 1 year. This important extension of existing cross-sectional research will contribute to further develop targeted psychosocial interventions. Profiles of existential distress may be applied by clinicians from multiple professions and help to address existential concerns effectively.

ETHICS AND DISSEMINATION

The study was approved by the institutional research ethics committee (reference number LPEK-0177). Results will be presented at scientific conferences and published in peer-reviewed journals. Other forms of dissemination will include sharing results on the psychometric properties of the structured demoralisation interview with international research groups and communication with healthcare professionals providing psychosocial treatment for patients and caregivers. Following scientific standards, our progress will be regularly updated on ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT04600206.

Importance of worthwhile life and social health as predictors of suicide ideation among cancer patients

OBJECTIVE

We identify the most associative factors among existential well-being, health-related quality of life, and health behaviors' sub-factors for cancer patients' suicidal ideation (SI) to develop practical intervention tools for general cancer patients in South Korea.

PARTICIPANTS

We surveyed 766 cancer patients from two hospitals in South Korea. The eligibility criteria were as follows: 18 years of age or older, diagnosed with cancer, aware of the stage, and capable of understanding the purpose of the study.

METHODS

We performed a multidimensional multivariate analysis to find the factors that are most associated with SI for cancer patients.

RESULTS

The results showed that life worthwhile (adjusted odds ratio (aOR), 3.946; 95% CI, 1.64-9.48), social functioning (aOR, 2.817; 95% CI, 1.19-6.65), and living with loved ones (aOR, 0.353; 95% CI, 0.15-0.84) were the most predictive factors for SI.

CONCLUSION

To prevent SI in cancer patients, it might be necessary to help them feel that their lives are worthwhile while helping them maintain a high degree of social health.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS OR POLICY

It is important to help cancer patients value their life and lead the high-quality social life to reduce their SI.

The role of attachment avoidance: A longitudinal mediation model predicting existential distress in patients with advanced cancer

OBJECTIVE

Although a protective effect of reliable interpersonal relationships on existential distress has been established, evidence remains inconclusive for attachment insecurity as an underlying factor of persistent psychological distress. We tested a longitudinal model hypothesizing attachment avoidance as a mediator of high demoralization and anxiety over time.

METHODS

We studied 206 patients with advanced cancer (mean age = 59.6, 61% female) participating in an intervention trial. Patients completed self-report measures for demoralization, anxiety, perceived relatedness, attachment insecurity, and death anxiety. Our mediated path model included perceived relatedness and death anxiety at baseline as predictors, attachment avoidance at baseline as mediator, and demoralization and anxiety at 6-month follow-up (N = 125) as outcomes.

RESULTS

Attachment avoidance partially mediated the relationship between death anxiety and demoralization (β = 0.07, 95% CI 0.02-0.12) and anxiety (β = 0.05, 95% CI 0.001-0.10). Findings for perceived relatedness were less conclusive. Its indirect effects through attachment avoidance were significant for both outcomes (demoralization: β = -0.07, 95% CI -0.13 to -0.02, anxiety: β = -0.05, 95% CI -0.11 to -0.003).

CONCLUSIONS

Due to its trait-like quality, attachment avoidance may play a less central role in explaining the course of existential distress over time than previous research indicated. Addressing change-sensitive relational concerns in psychosocial interventions may be more effective to alleviate existential distress.

Severe Suicidality in Athletes with Chronic Traumatic Encephalopathy: A Case Series and Overview on Putative Ethiopathogenetic Mechanisms

Chronic traumatic encephalopathy (CTE) results from repetitive brain injuries and is a common neurotraumatic sequela in contact sports. CTE is often accompanied by neuropsychiatric symptoms, which could escalate to suicidal ideation (SI) and suicidal behaviour (SB). Nevertheless, fairly limited emphasis about the association between suicidality and CTE exists in medical literature. Here, we report two cases of retired professional athletes in high contact sports (boxing and ice hockey) who have developed similar clinical trajectories characterized by progressive neuropsychiatric symptoms compatible with a CTE diagnosis and subsequent SB in its severe forms (medical serious suicide attempt (SA) and completed suicide). In addition to the description of outlining clinical, neuropsychological, neuroimaging, and differential diagnosis elements related to these cases, we also hypothesized some mechanisms that might augment the suicide risk in CTE. They include those related to neurobiological (neuroanatomic/neuroinflammatory) dysfunctions as well as those pertaining to psychiatry and psychosocial maladaptation to neurotraumas and retirement from professional competitive activity. Findings described here can provide clinical pictures to improve the identification of patients with CTE and also potential mechanistic insights to refine the knowledge of eventual severe SB development, which might enable its earlier prevention.

Are Demoralization and Insight Involved in Suicide Risk? An Observational Study on Psychiatric Inpatients

INTRODUCTION

Several features contribute to determining suicide risk. This study was designed with the aim of evaluating whether insight into illness and demoralization are involved in suicide risk (active suicidal ideation or behavior).

METHODS

For this purpose, in a sample of 100 adult psychiatric inpatients, we used the Columbia Suicide Severity Rating Scale to assess suicide risk, the Demoralization Scale for demoralization symptoms, and the Insight Scale to assess illness insight. We also investigated several demographic and clinical features, including gender, age, duration of untreated illness, previous suicide attempts, and nonsuicidal self-injurious behavior.

RESULTS

The results demonstrated that patients with higher scores on the insight-high dimension had 1.35 greater odds of having a higher suicide risk, and those with lifetime suicide attempts had 7.45 greater odds of having a higher suicide risk. Among the various clinical factors, the study indicated that only nonsuicidal self-harm behaviors in the last 3 months was a risk factor for suicide risk.

CONCLUSIONS

The results indicated that greater illness insight is involved in suicide risk regardless of demoralization.

Validation of Death and Dying Distress Scale-Chinese Version and Prevalence of Death Anxiety Among Patients With Advanced Cancer

Purpose: Death anxiety is commonly experienced by individuals with advanced cancer who have a limited life expectancy. The Death and Dying Distress Scale (DADDS) is a validated measure that was created to capture this experience; but no Chinese version is available to date. We conducted a cross-sectional study to explore the psychometric properties of a Chinese version DADDS (DADDS-C) and address prevalence of death anxiety among patients with advanced cancer. Methods: Patients with advanced cancer were recruited from Peking University Cancer Hospital. Measures administered included: DADDS-C, Patient Health Questionnaire (PHQ-9), General Anxiety Disorder-7(GAD-7), Quality of Life at End of Life in Cancer (QUAL-EC), Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-sp). McDonald's Omega, Cronbach's alpha, Exploratory Factor Analysis and Confirmatory Factor Analysis were used to test DADDS-C's reliability and validity. Logistic regression analysis was used to identify risk factors for death anxiety. Results: Of 300 patients approached, 256 (85%) provided informed consent and completed the questionnaires. Of these participants, 43 (16.8%) had moderate death anxiety based on scores of ≥45 on the DADDS-C. Three factors (feeling shortness of time, dying and death distress, being a burden to others) explained 71.643% of shared variation with factor loadings ranging from 0.629 to 0.822. Cronbach's alpha was 0.939; Omega total was 0.959. DADDS-C had acceptable convergent and discriminant validity. Logistic regression analysis indicated that two factors (better relationship with healthcare providers and preparation for end of life) protected patients from death anxiety. Conclusion: DADDS-C is a valid tool for measuring death anxiety in Chinese patients with advanced cancer. The presence of at least moderate death anxiety in a substantial minority of these patients calls for screening for this symptom and for more routine psychological interventions to alleviate and prevent such distress in this population.

Suicidality in Patients with Brain Tumors: A Brief Literature Review with Clinical Exemplar

Background: Suicidality and brain tumors are two life-threatening conditions and, somewhat unexpectedly, the associations between them have scarcely been reported. Objective: In this study, we aimed to provide a brief literature review of epidemiological studies on suicidal ideation (SI) and suicidal behavior (SB) in patients with brain tumors. To illustrate various aspects of brain tumors that potentially underlie the emergence of suicidality, the review is supplemented with a clinical exemplar of a long-term survivor of brain tumor (glioblastoma) who experienced persistent SI. Furthermore, we discuss putative both neurobiological (including anatomical and immunological) and psychosocial mechanisms that might be accountable for the development of SI and SB in patients with brain tumors. Conclusions: While the etiology of this phenomenon appears to be multifactorial and still remains a subject of much debate, it is of critical importance to identify patients for which a psychiatric evaluation could recognize, in a timely manner, a possible suicide risk and alleviate the deep related suffering, by appropriate psychopharmacological and supportive and psychotherapeutic interventions.

Prevalence of depression in a cohort of 400 patients with pancreatic neoplasm attending day hospital for major surgery: Role on depression of psychosocial functioning and clinical factors

OBJECTIVE

(1) To determine the prevalence and type of depressive symptoms at day-hospital clinical evaluation, before undergoing major surgery in patients diagnosed with pancreatic neoplasm. (2) To analyze the association between depression and sociodemographic, clinical, and psychosocial variables. (3) To understand how coping strategies, perceived social support, and self-efficacy might affect depressive symptoms in this cohort of patients.

METHODS

Secondary data analysis collected during the baseline phase of a randomized controlled trial performed at the Pancreas Institute of the University Hospital of Verona, Italy, between June 2017 and June 2018.

RESULTS

18.5% of pancreatic patients had a PHQ-9 score ≥10 (cut-off). Depressed patients were basically more often female (p = 0.07), younger (p = 0.06), and married/with a partner (p = 0.02). Depression was associated to high trait anxiety (p < 0.01), the use of anxiolytics (p < 0.01), sleep-inducing drugs (p < 0.01), and painkillers (p < 0.01). Among psychosocial variables, depressed patients showed lower perceived self-efficacy (p < 0.01) and family and friends' social support (p < 0.01) and used significantly more often dysfunctional coping strategies (p < 0.01), compared to nondepressed. A logistic multivariate model using psychosocial variables as explanatory and depression as dependent was calculated and post hoc analyses were conducted to describe the contribution of each psychosocial variable on depression.

CONCLUSIONS

Our study advocates the need for screening for distress and depression in cancer surgery units and recommends to strengthen patients' adaptive coping, social support, and sense of effectiveness in facing the challenges related to the medical condition and treatment process.

Psilocybin-assisted group therapy for demoralized older long-term AIDS survivor men: An open-label safety and feasibility pilot study

BACKGROUND

Psilocybin therapy has shown promise as a rapid-acting treatment for depression, anxiety, and demoralization in patients with serious medical illness (e.g., cancer) when paired with individual psychotherapy. This study assessed the safety and feasibility of psilocybin-assisted group therapy for demoralization in older long-term AIDS survivor (OLTAS) men, a population with a high degree of demoralization and traumatic loss.

METHODS

Self-identified gay men OLTAS with moderate-to-severe demoralization (Demoralization Scale-II ≥8) were recruited from the community of a major US city for a single-site open-label study of psilocybin-assisted group therapy comprising 8-10 group therapy visits and one psilocybin administration visit (0·3-0·36 mg/kg po). Primary outcomes were rate and severity of adverse events, and participant recruitment and retention. The primary clinical outcome was change in mean demoralization from baseline to end-of-treatment and to 3-month follow-up assessed with a two-way repeated measures ANOVA. Trial registration: Clinicaltrials.gov (NCT02950467).

FINDINGS

From 17 July 2017 to 16 January 2019, 18 participants (mean age 59·2 years (SD 4·4)) were enrolled, administered group therapy and psilocybin, and included in intent-to-treat analyses. We detected zero serious adverse reactions and two unexpected adverse reactions to psilocybin; seven participants experienced self-limited, severe expected adverse reactions. We detected a clinically meaningful change in demoralization from baseline to 3-month follow-up (mean difference -5·78 [SD 6·01], η_p ² = 0·47, 90% CI 0·21-0·60).

INTERPRETATION

We demonstrated the feasibility, relative safety, and potential efficacy of psilocybin-assisted group therapy for demoralization in OLTAS. Groups may be an effective and efficient means of delivering psychotherapy pre- and post-psilocybin to patients with complex medical and psychiatric needs.

FUNDING

Carey Turnbull, Heffter Research Institute, NIMH R25 MH060482, NIH UL1 TR001872, River Styx Foundation, Saisei Foundation, Sarlo Foundation, Stupski Foundation, Usona Institute, US Department of Veterans Affairs (Advanced Neurosciences Fellowship and IK2CX001495).

Exploring and assessing demoralization in patients with non-psychotic affective disorders

BACKGROUND

Demoralization, as assessed through the Diagnostic Criteria for Psychosomatic Research-Demoralization (DCPR/D) interview or the Demoralization Scale (DS), has been found to affect about 30% of patients with medical disorders, while few studies have been done in patients with psychiatric disorders.

METHODS

A convenience sample of 377 patients with ICD-10 diagnoses of mood, anxiety, stress-related disorders or other non-psychotic disorders was recruited from two Italian university psychiatry centers. The DCPR/D interview and the Italian version of the DS (DS-IT) were used to assess demoralization and the Patient Health Questionnaire-9 (PHQ-9) to assess depression.

RESULTS

Demoralization was diagnosable in more than 50% of the patients. Factor analysis of the DS-IT indicated four main factors, Meaninglessness/Helplessness, Disheartenment, Dysphoria and Sense of Failure, explaining 62% of the variance of the scale. Patients with bipolar or unipolar major depression and personality disorders had the highest prevalence of demoralization (DCPR/D) and the highest scores on all the DS-IT factors in comparison with patients with adjustment or anxiety disorders. About 50% of patients with moderate demoralization (DS-IT) were not clinically depressed (PHQ-9 <10), while almost all with severe demoralization were depressed.

LIMITATIONS

Prospective studies on larger samples with other psychiatric disorders, also taking into account subjective incompetence, are needed. Since the DCPR/D assesses demoralization as a categorical construct, a dimensional framework should be necessary.

CONCLUSIONS

The findings enrich the research on demoralization, showing for the first time the importance of this construct, as measured by the DCPR/D and the DS-IT, in patients with psychiatric disorders.

The Association Between App-Administered Depression Assessments and Suicidal Ideation in User Comments: Retrospective Observational Study

Background

Many people use apps to help understand and manage their depression symptoms. App-administered questionnaires for the symptoms of depression, such as the Patient Health Questionnaire-9, are easy to score and implement in an app, but may not be accompanied by essential resources and access needed to provide proper support and avoid potential harm.

Objective

Our primary goal was to evaluate the differences in risks and helpfulness associated with using an app to self-diagnose depression, comparing assessment-only apps with multifeatured apps. We also investigated whether, what, and how additional app features may mitigate potential risks.

Methods

In this retrospective observational study, we identified apps in the Google Play store that provided a depression assessment as a feature and had at least five user comments. We separated apps into two categories based on those having only a depression assessment versus those that offered additional supportive features. We conducted theoretical thematic analyses over the user reviews, with thematic coding indicating the helpfulness of the app, the presence of suicidal ideation, and how and why the apps were used. We compared the results across the two categories of apps and analyzed the differences using chi-square statistical tests.

Results

We evaluated 6 apps; 3 provided only a depression assessment (assessment only), and 3 provided features in addition to self-assessment (multifeatured). User comments for assessment-only apps indicated significantly more suicidal ideation or self-harm (n=31, 9.4%) compared to comments for multifeatured apps (n=48, 2.3%; X²₁=43.88, P<.001). Users of multifeatured apps were over three times more likely than assessment-only app users to comment in favor of the app’s helpfulness, likely due to features like mood tracking, journaling, and informational resources (n=56, 17% vs n=1223, 59% respectively; X²₁=200.36, P<.001). The number of users under the age of 18 years was significantly higher among assessment-only app users (n=40, 12%) than multifeatured app users (n=9, 0.04%; X²₁=189.09, P<.001).

Conclusions

Apps that diagnose depression by self-assessment without context or other supportive features are more likely to be used by those under 18 years of age and more likely to be associated with increased user distress and potential harm. Depression self-assessments in apps should be implemented with caution and accompanied by evidence-based capabilities that establish proper context, increase self-empowerment, and encourage users to seek clinical diagnostics and outside help.

Serial multiple mediation of demoralization and depression in the relationship between hopelessness and suicidal ideation

OBJECTIVE

Suicidal ideation is common in cancer patients and may be associated with hopelessness, demoralization, and depression. This study aims to investigate the serial multiple mediation of demoralization and depression in the relationship between hopelessness and suicidal ideation in cancer patients.

METHODS

A total of 244 cancer patients were investigated by using the following standardized self-reported questionnaires: self-rating idea of suicide scale, Beck hopelessness scale, demoralization scale-Mandarin version, and patient health questionnaire depression scale-9. The mediation hypothesis was tested with a serial multiple mediation model (PROCESS model 6). An exploratory graph analysis was performed to detect the correlations among the dimensions of the mental conditions measured by these instruments.

RESULTS

Bootstrap analyzes indicate that there were direct and indirect effects of hopelessness on suicidal ideation mediated solely by demoralization (B = 2.3074, SE = 0.1724, P < .001) or by demoralization together with depression (B = 0.1605, SE = 0.0303, 95% confidence interval [CI] = 0.1102 to 0.2303). The mediation of depression alone in the relationship between hopelessness and suicidal ideation was insignificant (B = 0.1541, SE = 0.0519, 95% CI = -0.0565 to 0.0715). The exploratory graph analysis suggests that the strongest edge of dimensions between demoralization and suicidal ideation was desperation-disheartenment (0.62).

CONCLUSIONS

The results of the study support the hypothesis that demoralization and depression mediate between hopelessness and suicidal ideation. The early identification of and interventions for hopelessness, demoralization, and depression may prevent cancer patients from developing suicidal ideation.

Meaning in life and quality of life: palliative care patients versus the general population

BACKGROUND AND OBJECTIVES

Meaning in life (MIL) represent a key topic in palliative care. The aims of this study were to explore (1) the differences in perceived MIL and in the meaning-relevant life areas between a representative sample of the Swiss population and palliative care patients, and (2) to what extent MIL can be considered as a significant predictor of quality of life (QOL).

METHODS

A cross-sectional study was conducted separately for the patients (face-to-face interviews) and the general population (telephone survey). MIL was measured with the Schedule for Meaning in Life Evaluation (SMILE) and QOL with a single-item visual analogue scale (0-10). Sociodemographic variables were controlled for in the analyses.

RESULTS

206 patients and 1015 participants from the Swiss population completed the protocol. Results indicated high MIL scores in both populations even if the difference was significant (patients 81.9 vs general population 87, p<0.001). Patients were more likely to cite 'family' (OR=1.78), 'social relations' (OR=1.9), 'spirituality and religion' (OR=3.93), 'social commitment' (OR=1.94) and 'growth' (OR=2.07), and less likely to cite 'finances' (OR=0.15) and 'health' (OR=0.21) as MIL-relevant areas. The SMILE scores and MIL areas explained 21.8% of the QOL variance for the patients and 15.1% for the representative sample.

CONCLUSIONS

Our data emphasise the importance of MIL as a contributor to QOL in both populations. It highlights the importance of the life areas contributing to MIL, especially social interactions for both populations, and spirituality and areas related to growth in palliative care patients.

The Use of Demoralization Scale in Italian Kidney Transplant Recipients

Demoralization is a commonly observed syndrome in medically ill patients. The risk of demoralization may increase in patients after a kidney transplant (KTRs) because of the stressful nature of renal transplantation, psychosocial challenges, and adjustment needs. No study is available on demoralization amongst KTRs. The purpose of our study was to evaluate the validity of the Italian version of the Demoralization Scale (DS-IT) and the prevalence of demoralization in KTRs. Also, we aimed at exploring the association of the DS-IT with International Classification of Diseases (ICD) psychiatric diagnoses, post-traumatic growth (PTG), psychological and physical symptoms, and daily-life problems. A total of 134 KTRs were administered the MINI International Neuropsychiatric Interview 6.0. and the Diagnostic Criteria for Psychosomatic Research-Demoralization (DCPR/D) Interview. The DS-IT, the Edmonton Symptom Assessment System (ESAS), the Canadian Problem Checklist (CPC), were used to measure demoralization, physical and psychological symptoms, and daily-life problems; also, positive psychological experience of kidney transplantation was assessed with the PTG Inventory. Routine biochemistry and sociodemographic data were collected. Exploratory factor analysis demonstrated a four-dimensional factor structure of the DS-IT, explaining 55% of the variance (loss of meaning and purpose, disheartenment, dysphoria, and sense of failure). DS-IT Cronbach alpha coefficients indicated good or acceptable level of internal consistency. The area under the Receiving Operating Characteristics (ROC) curve for DS-IT (against the DCPR/D interview as a gold standard) was 0.92. The DS-IT optimal cut-off points were ≥20 (sensitivity 0.87, specificity 0.82). By examining the level of demoralization, 14.2%, 46.3%, 24.6%, and 14.6% of our sample were classified as having no, low, moderate, and high demoralization, respectively, with differences according to the ICD psychiatric diagnoses (p < 0.001). DS-IT Total and subscales scores were positively correlated with scores of ESAS symptoms and CPC score. A correlation between DS-IT loss of meaning and purpose subscale and PTGI appreciation of life subscale (p < 0.05) was found. This study shows, for the first time, a satisfactory level of reliability of the DS-IT and a high prevalence of severe demoralization in KTRs.

Sequential use of the Demoralization Scale in palliative care: feasibility, strain, and personal benefits of participation for patients at the end of life

PURPOSE

To determine the efficacy of specifically targeted interventions in palliative care, sequential use of the Demoralization Scale (DS) could be a useful approach. This study's main objective was to evaluate the weekly use of the DS for palliative care inpatients. Secondary objectives were the analysis of the DS, self-perceived strain, and personal benefits of the assessment.

METHODS

Patients admitted to 3 palliative care units (PCUs) were tested for eligibility and asked to complete the DS weekly. Self-perceived strain was rated on a numeric scale (0-10). Open questions about strain and helpfulness of the survey were asked.

RESULTS

Over 10 months, 568 patients were admitted to the PCUs; 193 patients were eligible. A total of 120 patients participated once, of whom only 41 (34.1%) participated at least twice. The mean self-perceived strain caused by the assessment was 1.53 at T1 (N = 117, SD = 2.27, max = 8).

CONCLUSIONS

While the single use of the DS in PCUs seems justified in view of the possibility to detect severe demoralization with overall low to moderate strain and self-perceived helpfulness for patients, the feasibility of the sequential use of the DS has to be regarded critically. Our study undermines the complexity of assessing changes in self-reported psychological phenomena with end-of-life patients at a PCU. The most limiting factors for participating twice were that patients were either discharged from hospital or declined further participation.

Health-related quality of life in patients with advanced cancer who express a wish to hasten death: A comparative study

BACKGROUND

Some evidence suggests the wish to hasten death is related to poor health-related quality of life. Deficits in perceived dignity and self-efficacy are risk factors for wish to hasten death that also impact health-related quality of life.

AIM

To compare perceived health-related quality of life, dignity and self-efficacy in patients with advanced cancer who either do (case group) or do not (control group) express a wish to hasten death. Cases and controls were matched on sociodemographic and functional characteristics.

DESIGN

A comparative cross-sectional study.

PARTICIPANTS

A total of 153 adult patients with advanced cancer were assessed for wish to hasten death using the Desire for Death Rating Scale. Scores ⩾1 indicate some degree of wish to hasten death (case group, n = 51), and score = 0 implies no wish to hasten death (control group, n = 102). Assessments included health-related quality of life using the European Organization for Research and Treatment of Cancer Quality-of-Life Core 15-Item Palliative Questionnaire, perceived loss of dignity using the Patient Dignity Inventory and self-efficacy using the General Self-Efficacy Scale.

RESULTS

Patients with a wish to hasten death had worse emotional functioning (p < 0.001), greater perceived loss of dignity (p < 0.001) and lower self-efficacy (p = 0.001). There was no difference in most physical symptoms. Perceived overall health-related quality of life was significantly worse for those with a clinically relevant wish to hasten death (p = 0.023) and marginally worse for the case group than the control group (p = 0.052).

CONCLUSION

Patients with wish to hasten death showed lower perceived dignity, self-efficacy and emotional quality of life than patients without wish to hasten death without necessarily perceiving worse physical symptoms.

Suicidal ideation in patients with cancer: A systematic review of prevalence, risk factors, intervention and assessment

OBJECTIVES

Suicidal ideation (SI) underlies risk of death by suicide. It is well established that patients with cancer are at increased risk of death by suicide. Therefore, understanding SI in patients with cancer is critically important. The goal of this systematic review was to investigate the prevalence, risk factors, intervention, and assessment of SI in patients with cancer.

METHODS

This systematic review was registered with the PROSPERO database (CRD42018115405) and was guided by the PRISMA statement. We searched Medline, PsycInfo, Embase, CINAHL, the Cochrane Database of Systematic Reviews, and Cochrane Central. Two reviewers independently screened abstracts and assessed for quality assurance using a revised Newcastle-Ottawa Scale.

RESULTS

We identified 439 studies to screen for eligibility. Eligible studies included adults with cancer diagnoses and listed SI as an outcome. Ultimately, 44 studies were included in the analyses. Prevalence of SI ranged greatly from 0.7% to 46.3%. Single items drawn from validated measures were the most frequent method of assessing SI (n = 20, 45.5%); additional methods included validated measures and psychological interviews. Commonly identified risk factors for SI included age, sex, and disease/treatment-related characteristics, as well as psychological constructs including depression, anxiety, hopelessness, existential distress, and social support.

SIGNIFICANCE OF RESULTS

Assessment of SI in patients with cancer is the concern of researchers worldwide. Prevalence of SI varied with study population and was likely influenced by the method of assessment. Psychological distress consistently predicted SI. Increasing awareness of demographic, clinical, and psychological associations is critical for risk assessment and intervention development.

Demoralization and Its Relationship with Depression and Hopelessness in Suicidal Patients Attending an Emergency Department

Emergency departments (EDs) play an increasingly crucial role in the management of patients with suicidal behavior (SB). Demoralization has been associated with SB in various populations and conditions, but little is known about the effect of this construct in SB patients who attend an ED. Therefore, a more inclusive SB assessment which considers the demoralization construct could be useful in clinical practice. The main aim of this study was to assess the presence and severity of demoralization in patients visiting EDs for SB. Secondly, the maintenance of the relationship between demoralization and SB after controlling for depression and the proportion of variance which accounted for hopelessness was investigated. A cross-sectional study of patients (N = 199) visiting an ED for SB was performed, which examined the role of demoralization, hopelessness, and depression on suicidal ideation (SI) and suicide attempts (SAs). Demoralization was strongly and positively correlated with SI. Demoralization was related to major depressive episodes, but it was confirmed to be a different and, probably, more sensitive construct for SB, validating its specificity in relation to depression. Hopelessness accounted for a small portion of the variance in SI, compared to demoralization. Formal support for the association of demoralization with SI was provided. Demoralization can improve SB assessment in EDs, particularly among patients whose suicide risk can be unnoticed. Furthermore, demoralization represents a clinically useful concept to increase comprehension of the suffering of the suicidal patient and a possible target for psychotherapeutic interventions.

Demoralization in essential tremor: prevalence, clinical correlates, and dissociation from tremor severity

OBJECTIVE

Essential tremor (ET) is associated with psychological difficulties, including anxiety and depression. Demoralization (feelings of helplessness, hopelessness, inability to cope), another manifestation of psychological distress, has yet to be investigated in ET. Our objectives are to (1) estimate the prevalence of demoralization in ET, (2) assess its clinical correlates, and (3) determine whether demoralization correlates with tremor severity.

METHODS

We administered the Kissane Demoralization Scale (KDS-II) and several psychosocial evaluations (ie, scales assessing subjective incompetence, resilience, and depression [eg, Geriatric Depression Scale]) to 60 ET subjects. Tremor was assessed with a disability score and total tremor score. KDS-II >8 indicated demoralization.

RESULTS

Among 60 ET subjects (mean age = 70.2 ± 6.8 years), the prevalence of demoralization was 13.3%, 95% confidence interval = 6.9-24.2%. Although there was overlap between demoralization and depression (10% of the sample meeting criteria for both), 54% of depressed subjects were not demoralized, and 25% of demoralized subjects were not depressed. Demoralization correlated with psychological factors, but demoralized subjects did not have significantly higher total tremor scores, tremor disability scores, or years with tremor.

CONCLUSIONS

Demoralization has a prevalence of 13.3% in ET, similar to that in other chronic or terminal illnesses (eg, cancer 13-18%, Parkinson's disease 18.1%, coronary heart disease 20%). Demoralization was not a function of increased tremor severity, suggesting that it is a separable construct, which could dictate how a patient copes with his/her disease. These data further our understanding of the psychological and psychosocial correlates of ET.

Assessing demoralization in medically ill patients: Factor structure of the Italian version of the demoralization scale and development of short versions with the item response theory framework

OBJECTIVE

Demoralization has been mostly investigated in oncology but is also relevant for patients with other physical illnesses. Our aims were to investigate the psychometric properties of the 24-item Italian version of the Demoralization Scale (DS-24) among medically ill inpatients, and to develop shorter versions for screening.

METHODS

Four-hundred and seventy-three participants were recruited from medical wards of the University Hospital of Ferrara. Patients were assessed using the Diagnostic Criteria for Psychosomatic Research-Demoralization module (DCPR/D), Demoralization Scale (DS-24), Patient Health Questionnaire-9 (PHQ-9), Brief-Symptom Inventory-18, Anxiety subscale (BSI-Anx) and EuroQol Group (EQ-5D). Confirmatory factor analyses of previous structures and exploratory factor analyses were conducted using an Item Response Theory approach, including a bifactor model.

RESULTS

According to DCPR/D criteria, the prevalence of demoralization was 40%. Confirmatory analyses revealed that none out of seven factor structures from oncology studies adequately fitted data from hospital inpatients. Exploratory Item Factor Analysis uncovered a four-factor model comprising Disheartenment, Dysphoria, Sense of Failure, Loss of Meaning and Purpose, or a bifactor model, comprising similar factors with the addition of a general factor accounting for 45% of the variance. Moreover, we developed 13 and 6-item versions of the DS, both retaining high correlation with DS-24 scores (r = 0.98 and r = 0.95, respectively) and concordance with DCPR/D criteria (AUC-ROC 0.82 and 0.81).

CONCLUSION

The DS factor structure differs between general hospital and cancer patients. Differences may depend on intrinsic disease features and cultural-geographic factors. The short versions of the DS-24 may aid clinicians in identifying demoralized patients in hospital settings.

Demoralization and chronic illness in rural Australia: A cross-sectional survey

OBJECTIVE

Demoralization is prevalent in patients with life-limiting chronic illnesses, many of whom reside in rural areas. These patients also have an increased risk of disease-related psychosocial burden due to the unique health barriers in this population. However, the factors affecting demoralization in this cohort are currently unknown. This study aimed to examine demoralization amongst the chronically ill in Lithgow, a town in rural New South Wales, Australia, and identify any correlated demographic, physical, and psychosocial factors in this population.

METHOD

A cross-sectional survey of 73 participants drawn from Lithgow Hospital, the adjoining retirement village and nursing home, assessing correlating demographic, physical, psychiatric, and psychosocial factors.

RESULTS

The total mean score of the DS-II was 7.8 (SD 26.4), and high demoralization scores were associated with the level of education (p = 0.01), comorbid condition (p = 0.04), severity of symptom burden (p = <0.001), depression (p = <0.001), and psychological distress (p = <0.001). Prevalence of serious demoralization in this population was 27.4% according to a cutoff of a DS-II score ≥11. Of those, 11 (15%) met the criteria for clinical depression, leaving 9 (12.3%) of the cohort demoralized but not depressed.

SIGNIFICANCE OF RESULTS

Prevalence of demoralization was high in this population. In line with the existing literature, demoralization was associated with the level of education, symptom burden, and psychological distress, demonstrating that demoralization is a relevant psychometric factor in rural populations. Further stratification of the unique biopsychosocial factors at play in this population would contribute to better understanding the burdens experienced by people with chronic illness in this population and the nature of demoralization.

Loss of resources and demoralization in the chronically ill

OBJECTIVE

The study examined whether the association between the severity of physical symptoms and demoralization is mediated by loss of resources in individuals with chronic conditions including conventional diagnoses, functional somatic syndromes, and medically unexplained symptoms.

METHOD

This cross-sectional study evaluated N = 194 patients (mean age = 46, 83.5% female) who reported at least 3 months of persistent physical symptoms using the following self-report instruments: PHQ-15 (modified), Loss of Resources Inventory, Psychosocial Questionnaire - Demoralization Subscale, and PHQ-8. The mediation hypothesis was tested by multiple regression analyses controlling for age, race, employment status, income, educational attainment, and depression.

RESULTS

Participants experienced M = 9.3 out of 16 possible health-related losses (SD = 4.4). Average to severe demoralization scores were indicated by 59.1% of individuals, of which only 17.1% experienced high demoralization. Loss of resources fully mediated the effect of symptom severity on demoralization, explaining 56% of the variance of demoralization and inhibiting the initially significant effect of symptom severity on demoralization to nonsignificant levels [from b = 0.67, 95% CI (0.26, 1.07) to b = 0.03, 95% CI (-0.27, 0.32)].

CONCLUSION

Early recognition of the loss of resources phenomena and interventions to reduce its progression through the introduction of resource gains may diminish, or even prevent, the installation of demoralization in individuals with chronic symptoms.

Interventions for Reducing Suicide Risk in Cancer Patients: A Literature Review

The suicide risk of people diagnosed with cancer is two times higher than the general population. The number of cases of diagnosed cancer is estimated to rise by 70% over the next two decades. Evidence-based prevention strategies are necessary to protect this vulnerable group of individuals. The purpose of this review was to find out the risk factors of suicide and which types of interventions can serve as prevention strategies. Psychosocial interventions, pharmacotherapy and physical activity can play a preventive role in reducing psychosocial and physical risk factors, such as mental disorders, poor social support, poor performance status and pain. Further research is needed to develop effective suicide prevention strategies for cancer patients.

Translation and psychometric properties for the Demoralization Scale in Chinese breast cancer patients

PURPOSE

To translate and validate the Chinese version of the Demoralization Scale among breast cancer patients.

METHOD

A cross-sectional, descriptive correlational design was employed. From September 2016 to May 2017, 203 breast cancer survivors completed the survey. Content, construct, concurrent and divergent validity and internal consistency of the Chinese version of the Demoralization Scale were evaluated.

RESULTS

The proposed factor structures of the Demoralization Scale in previous studies cannot be confirmed using confirmatory factor analysis in the present study. Moreover, four factors were extracted by exploratory factor analysis, which accounted for 58.66% of the variance. Each subscale yielded satisfactory internal consistency with coefficient alphas ranging from 0.720 to 0.894. Relationships/differences between demoralization, quality of life, despair and depression provide initial support for the concurrent/divergent validity. Given these results, the Chinese version of the Demoralization Scale appears to be both valid and reliable.

CONCLUSIONS

Our results preliminary supported that the Chinese version of the Demoralization Scale is a reliable and valid instrument for assessing demoralization among mainland Chinese breast cancer patients, and the factor structure of this measurement needs to be further addressed in future studies.

The desire to hasten death in advanced cancer patients at a Mexican palliative care service

Introduction. The desire to hasten death (DHD) might be present in patients with advanced cancer. Multiple distressing physical and psychosocial symptoms may be related to it. There is limited literature about the characteristics of these patients in México. Objective. To describe the prevalence and factors associated with DHD in advanced cancer patients evaluated by a palliative care psychiatrist. Method. We conducted a cross-sectional study, including all patients referred to psychiatric assessment at the Servicio de Cuidados Paliativos of the Instituto Nacional de Cancerología in Mexico City, from January to December 2016. DHD was defined as the presence of death ideas, suicidal ideation, and/or request for euthanasia or medically assisted suicide. Patients with delirium, dementia, psychosis, or uncontrolled physical symptoms were excluded. Results. Sixty-four patients were included in the study. Most of them were women (59%); the mean age was 49 years old (SD = 16). Of them, 64% met criteria for a major depressive disorder, 64% for generalized anxiety disorder and/or panic disorder, and 11% for substance use disorders. 44% expressed DHD. In a multivariate regression analysis predicting DHD, only one factor emerged: clinical depression (OR = 13.5, p = .002, 95% CI [02.562, 71.726]). Discussion and conclusion. The desire to hasten death is a frequent issue for the patients evaluated at the psychiatric palliative care clinic. Depression and other distressing psychiatric pathologies were associated with DHD. Interdisciplinary interventions are needed to treat DHD. More research is warranted in order to understand the factors associated with the expression of DHD.

Fear of Cancer Recurrence: A Model Examination of Physical Symptoms, Emotional Distress, and Health Behavior Change

PURPOSE

Fear of cancer recurrence is highly prevalent among adult survivors of cancer. The role of fear of recurrence in the emotional distress of survivors of cancer, as well as health behaviors that may directly affect their health, remains unclear. To advance oncology practice, this study sought to examine the extent to which fear of recurrence stemming from physical symptoms accounts for emotional distress in a large sample of adult survivors of cancer and to extend the model to explain postdiagnosis self-reported health behavior change.

METHODS

In 2016, 258 survivors of cancer at an academic hospital completed a survey of psychosocial needs. Items assessed physical symptoms (checklist), fear of cancer recurrence (Assessment of Survivor Concerns), emotional distress (anxiety and depressed mood), and health behaviors (current alcohol use, physical activity, diet, and sunscreen use, as well as changes after cancer diagnosis) informed by National Comprehensive Cancer Network survivorship guidelines. Indirect effects regression models accounting for relevant covariates (age and treatment history) used 5,000-iteration bootstrapping.

RESULTS

Higher fear of cancer recurrence was associated with greater number of physical symptoms (P < .001), greater emotional distress (P < .05), lower moderate or vigorous physical activity (P < .05), higher sunscreen use (P < .05), and postdiagnosis increases in alcohol use (P < .01) and reductions in physical activity (P < .01). Fear of cancer recurrence models accounted for almost half of the variance in distress of survivors of cancer (R² = 0.44, P < .001) and, to a lesser yet significant extent, changes in alcohol consumption (R² = 0.09, P < .001) and physical activity (R² = 0.06, P = .003).

CONCLUSION

Fear of cancer recurrence plays a central role in the emotional distress and key health behaviors of survivors of cancer. These findings support fear of cancer recurrence as a potential target for emotional health and health behavior change interventions.

Exploring demoralization in end-of-life cancer patients: Prevalence, latent dimensions, and associations with other psychosocial variables

Objective

Demoralization is an existential distress syndrome that consists of an incapacity of coping, helplessness, hopelessness, loss of meaning and purpose, and impaired self-esteem. It can affect cancer patients, and the Demoralization Scale is a valid instrument to assess it. The present study aimed to investigate the prevalence of demoralization in end-of-life cancer patients and its associations with the medical and psychosocial variables. In addition, the latent dimensions of demoralization emerging in this distinctive population were explored.

Method

The study is cross-sectional. The sample consisted of 235 end-of-life cancer patients with a Karnofsky performance status (KPS) lower than 50 and a life expectancy of a few weeks. For each patient, personal and medical data was gathered by a palliative physician and a set of validated rating scales, assessing demoralization, anxiety, depression, physical symptoms, pain, spiritual well-being, and dignity, was administered by a psychologist during the first consultation.

Result

Sixty-four participants (27.2%) had low demoralization, 50.2% (n = 118) had medium demoralization, and 22.6% (n = 53) had high demoralization. Factor analysis evidenced a five-factor solution that identified the following demoralization factors: Emotional Distress and Inability to Cope, Loss of Purpose and Meaning, Worthlessness, Sense of Failure, and Dysphoria. All the considered variables were associated with demoralization, except for pain, nausea, breathing problems, and sociodemographic and clinical variables.

Significance of results

End-of-life cancer patients showed higher levels of demoralization than has been reported in other studies with advanced cancer. These data could suggest that demoralization could increase in proximity to death and with impaired clinical condition. In particular, the five demoralization dimensions that emerged could represent the typical concerns around which the syndrome evolves in end-of-life cancer patients. Finally, spiritual well-being could play a protective role with respect to demoralization.

Relationship of Suicidal Ideation With Demoralization, Depression, and Anxiety: A Study of Cancer Patients in Mainland China

Demoralization is a form of psychological distress that may cause suicidal ideation. Demoralization syndrome is common among cancer patients, but there has been little empirical study on the association of suicidal ideation with demoralization, depression, and anxiety in this population. This study aims to investigate the prevalence of high demoralization among cancer patients in mainland China and the contribution of high demoralization to suicidal ideation beyond the impact of self-report depression and anxiety. In this cross-sectional study, 303 patients with cancer were invited to complete questionnaires. In total, 14.5% participants reported suicidal ideation and 49.50% high demoralization. Logistic regression analysis identified high demoralization as an independent risk factor for suicidal ideation. Only depression (odds ratio [OR], 6.68) had a stronger influence on suicidal ideation than demoralization (OR, 5.85), and patients with both depression and high demoralization were most likely to experience suicidal ideation. These findings suggest that measures of demoralization can help identify cancer patients at high suicide risk and that such patients require further attention and measures targeting demoralization for suicide prevention.

Incorporating Demoralization into Social Work Practice

This article explores the relevance of demoralization to social work research and practice. Demoralization connects to the very core of being human. It is present in social work client groups and is an important but neglected concept in social work. Demoralization occurs when life becomes so overwhelming that daily functioning is affected and people lose all hope, agency, and the capacity to overcome their circumstances. Although a demoralized state is not recognized as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, it is often confused with psychiatric disorders and its presence can lead to clinical conditions and suicide. This article discusses demoralization and its place in social work practice, identification, and measurement, and appropriate psychosocial interventions are also explored. The article concludes that demoralization has particular relevance to contemporary social work and should be considered in social work practice and research.

The interplay among psychological distress, the immune system, and brain tumor patient outcomes

A malignant brain tumor diagnosis is often accompanied with intense feelings and can be associated with psychosocial conditions including depression, anxiety, and/or increased distress levels. Previous work has highlighted the impact of uncontrolled psychological distress among brain tumor patients. Given the negative impact of maladaptive psychosocial and biobehavioral factors on normal immune system functions, the question remains as to how psychological conditions potentially affect the brain tumor patient anti-tumor immune response. Since immunotherapy has yet to show efficacy at increasing malignant glioma patient survival in all randomized, phase III clinical trials to-date, this review provides new insights into the potential negative effects of chronic distress on brain tumor patient immune functions and outcomes.

Psychological Considerations in Hematopoietic Stem Cell Transplantation

BACKGROUND

In recent decades, advances in transplantation medicine, and improved posttransplant care have reduced morbidity and mortality from hematopoietic stem cell transplantations (HSCTs). However, patients undergoing HSCT report a high prevalence of psychological distress, which can negatively impact recovery, function, and health outcomes, including mortality and higher risk of graft vs. host disease. Appropriate assessment and management of these psychological symptoms lead to better engagement with treatment and a variety of superior health outcomes.

OBJECTIVE

We provide a narrative review of the psychological challenges that accompany HSCT and suggest management approaches to equip psychiatric consultants involved in the care of this patient population.

METHODS

We reviewed published work in PubMed, PsycInfo, and Scopus electronic databases on the common psychological challenges in HSCT, their vulnerability factors, as well as practical interventions for managing these challenges.

RESULTS

We outline the phases of the HSCT hospitalization and discuss common psychological challenges, such as depression, delirium, and post-traumatic stress reactions that accompany HSCT. We suggest an approach to psychiatric consults during the HSCT hospitalization and discuss practical interventions for managing psychological challenges in this population.

CONCLUSIONS

Though pharmacological and behavioral interventions have been successfully used to treat psychosocial challenges in HSCT, further research is needed to understand the optimal psychiatric assessment tools, treatment strategies, and the long-term psychiatric care needed to address psychiatric comorbidities in this growing patient population.

Attachment security and existential distress among patients with advanced cancer

BACKGROUND

Felt security in close relationships may affect individual adaptation responses to existential threat in severe illness. We examined the contribution of attachment security to demoralization, a state of existential distress involving perceived pointlessness and meaninglessness in advanced cancer.

METHOD

A mixed cross-sectional sample of 382 patients with advanced cancer (mean age 59, 60% female) was recruited from outpatient oncology clinics. Participants completed self-report measures of attachment security, demoralization, depression, and physical symptom burden. We used multiple linear regression to analyze the association between attachment security and demoralization, controlling for demographic factors and symptom burden and tested whether attachment security moderated the association of symptom burden with demoralization. Separate analyses compared the contribution of the dimensions of attachment anxiety and attachment avoidance.

RESULTS

The prevalence of clinically relevant demoralization was 35%. Demoralization was associated with lower attachment security (β = -0.54, 95%CI: -0.62 to 0.46). This effect was empirically stronger for attachment anxiety (β = 0.52, 95%CI: 0.44 to 0.60) compared to attachment avoidance (β = 0.36, 95%CI: 0.27 to 0.45). Attachment security also significantly moderated the association of physical symptom burden with demoralization, such that with less attachment security, there was a stronger association between symptom burden and demoralization.

CONCLUSION

Attachment security may protect from demoralization in advanced cancer. Its relative lack, particularly on the dimension of attachment anxiety, may limit adaptive capacities to deal with illness burden and to sustain morale and purpose in life. An understanding of individual differences in attachment needs can inform existential interventions for severely ill individuals.

Depressive Symptom Profiles and Survival in Older Patients with Cancer: Latent Class Analysis of the ELCAPA Cohort Study

BACKGROUND

The expression of depressive symptoms in older people with cancer is heterogeneous because of specific features of age or cancer comorbidity. We aimed to identify depressive symptom profiles in this population and describe the associated features including survival.

MATERIALS AND METHODS

Patients ≥70 years who were referred to geriatric oncology clinics were prospectively included in the ELCAPA study. In this subanalysis, depressive symptoms were used as indicators in a latent class analysis. Multinomial multivariable logistic regression and Cox models examined the association of each class with baseline characteristics and mortality.

RESULTS

For the 847 complete-case patients included (median age, 79 years; interquartile range, 76-84; women, 47.9%), we identified five depressive symptom classes: "no depression/somatic only" (38.8%), "no depression/pauci-symptomatic" (26.4%), "severe depression" (20%), "mild depression" (11.8%), and "demoralization" (3%). Compared with the no depression/pauci-symptomatic class, the no depression/somatic only and severe depression classes were characterized by more frequent comorbidities with poorer functional status and higher levels of inflammation. "Severe" and "mild" depression classes also featured poorer nutritional status, more medications, and more frequent falls. Severe depression was associated with poor social support, inpatient status, and increased risk of mortality at 1 year (adjusted hazard ratio, 1.62, 95% confidence interval, 1.06-2.48) and 3 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.06-2.10).

CONCLUSION

A data-driven approach based on depressive symptoms identified five different depressive symptom profiles, including demoralization, in older patients with cancer. Severe depression was independently and substantially associated with poor survival.

IMPLICATIONS FOR PRACTICE

Older patients with cancer present with distinct profiles of depressive symptomatology, including different severity levels of depression and the demoralization syndrome. Clinicians should use a systematic assessment of depressive symptoms to adequately highlight these distinct profiles. Geriatric and oncological features are differently associated with these profiles. For instance, severe depression was associated with more frequent comorbidities with poorer functional, poor nutritional status, polypharmacy, frequent falls, inpatient status and poor social support. Also, severe depression was independently and substantially associated with poor survival so that the identification and management of depression should be considered a high priority in this population.

Mind-body interventions for fear of cancer recurrence: A systematic review and meta-analysis

OBJECTIVE

Fear of cancer recurrence (FCR) is a common existential concern and source of distress among adults with a cancer history. Multiple randomized controlled trials (RCTs) have examined mind-body approaches to mitigating FCR. We summarized characteristics of these trials and calculated their pooled effects on decreasing FCR.

METHODS

Six electronic databases were systematically searched from inception to May 2017, using a strategy that included multiple terms for RCTs, cancer, mind-body medicine, and FCR. Data extraction and reporting followed Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pooled effect sizes on self-report measures of FCR were computed by using random-effects models.

RESULTS

Nineteen RCTs (pooled N = 2806) were included. Most studies (53%) were published since 2015 and targeted a single cancer type (84%; mostly breast). Intervention sessions (median = 6, mode = 4) tended to last 120 minutes and occur across 1.5 months. Delivery was predominantly in-person (63%) to either groups (42%) or individuals (42%). Most interventions incorporated multiple mind-body components (53%), commonly cognitive-behavioral skills (58%), or meditative practices (53%). Small-to-medium pooled effect sizes were observed postintervention (Hedges' g = -0.36, 95% CI = -0.49, -0.23, P < .001) and at follow-up assessments (median = 8 months, P < .001). Potential modifiers (control group design, group/individual delivery, use of cognitive-behavioral or mindfulness skills, number of mind-body components, cancer treatment status, and number of sessions) did not reach statistical significance.

CONCLUSIONS

Mind-body interventions are efficacious for reducing FCR, with small-to-medium effect sizes that persist after intervention delivery ends. Recommendations include testing effects among survivors of various cancers and exploring the optimal integration of mind-body practices for managing fundamental uncertainties and fears during cancer survivorship.

Demoralization and death anxiety in advanced cancer

OBJECTIVE

The circumstances of advanced cancer can cause considerable psychological distress, including death anxiety and demoralization. Although these states of existential distress have a negative impact on the quality of life of patients with advanced cancer, they are rarely evaluated as outcomes or targets of interventions in this population. In an effort to improve understanding of existential distress, a structural model of relationships among death anxiety, demoralization, symptom burden, and social relatedness was tested in patients with advanced cancer.

METHODS

A total of 307 patients with advanced cancer completed baseline measures including the Death and Dying Distress Scale, the Demoralization Scale, the modified Experiences in Close Relationships Scale, the Life Completion subscale of the Quality of Life Evaluation-Cancer scale, the Memorial Symptom Assessment Scale, and Karnofsky Performance Status. A structural equation model of protective and risk factors for demoralization and death anxiety was tested.

RESULTS

The final model had good fit (SRMR = 0.061; RMSEA = 0.077; CFI = 0.927; NNFI = 0.902) in which death anxiety was positively associated with demoralization (β = 0.71), and demoralization was positively associated with symptom burden (β = 0.31) and negatively associated with social relatedness (β = -0.74).

CONCLUSIONS

The findings of this study suggest that demoralization and death anxiety are closely linked in patients with advanced cancer. The contribution of both symptom burden and low social relatedness to demoralization suggests that an integrated intervention addressing both physical and psychosocial disease factors may be most effective at alleviating such states of existential distress.

Relationship of demoralization with anxiety, depression, and quality of life: A Southern European study of Italian and Portuguese cancer patients

BACKGROUND

Demoralization syndrome is a significant condition that has not been greatly studied in Southern European countries.

AIMS

To extend the knowledge of demoralization in Southern Europe by examining its prevalence according to different methods of assessment, its relationship with anxiety and depression, and its impact on quality of life (QoL) among cancer patients.

METHODS

A convenience sample of 195 cancer outpatients from two oncology centers (102 from Lisbon, Portugal, and 93 from Ferrara, Italy) participated in an observational, cross-sectional study using the Diagnostic Criteria of Psychosomatic Research-Demoralization interview (DCPR/D) and psychometric tools (Demoralization scale-DS; Patient Health Questionnaire-9/PHQ-9; Hospital Anxiety Depression Scale-HADS; and European Quality of Life-5-EQ-5D).

RESULTS

A 25.1% prevalence (CI 95%, 0.19-0.31) of clinically relevant demoralization was reported on the DCPR/D interview. A total demoralization score cutoff score ≥ 25 maximized sensitivity (81.6%), and specificity (72.6%) in identifying DCPR/D demoralized patients. The DCPR/D and DS were associated with poorer levels of QoL. About half of the patients who were demoralized were not clinically depressed (PHQ-9). Self-reported suicidal ideation (PHQ-9 item 9) was found in a minority of patients (8.2%), most of whom (77%) were cases of depression (PHQ-9), but one-quarter (23%) were not depressed, yet moderately/severely demoralized (DCPR/D and DS).

CONCLUSIONS

This Southern European study confirms the importance of demoralization in cancer patients as a different condition with respect to depression and its relationship with poor QoL and suicidal ideation.

Perceived doctor-patient relationship and its association with demoralization in patients with advanced cancer

BACKGROUND

Advanced diseases pose a great burden on patients and go hand in hand with existential concerns. Demoralization is considered as a syndrome of existential distress with a perceived inability to cope with loss of meaning in life and feelings of helplessness and hopelessness. Professional health care providers play an important role in providing support for patients and unfavorable conversational styles in their relationship can increase patient's distress. In this study, we examine the association between the patient's perceived relationship to health care providers and demoralization.

METHODS

We used baseline data of a randomized control trial intervention study for advanced cancer patients (UICC-Stage ≥ III; PHQ ≥ 9 and/or Distress-Thermometer ≥5). We used a subscale of the QUAL-EC-P for assessing doctor-patient relationship, Beck Depression Inventory-II for depressive symptoms, a modified version of the MSAS as physiological symptom checklist, and the Demoralization Scale to assess demoralization. A hierarchical regression analysis was calculated.

RESULTS

In our sample of 187 patients with stage III or IV cancer (62% women), demoralization was present in 53.4% (16% moderate demoralization; 37.4% high demoralization) of the patients. Relationship to health care provider was an independent predictor (β = -.33, t(186) = -6.70, P < .001) of demoralization.

CONCLUSIONS

Our findings underline the importance of the physician-patient relationship in the context of coping with existential challenges in advanced cancer patients. Trainings on how to communicate and build a sustainable relationship with patients and their specific needs may increase the buffering effect of social support by the physicians on patient's existential distress.

Prevalence and Risk Factors of Suicidal Ideation among Patients with Head and Neck Cancer: Longitudinal Study

OBJECTIVES

(1) Determine 1-year period prevalence of suicidal ideation, suicide attempt, and completed suicide among patients newly diagnosed with a first occurrence of head and neck cancer (HNC). (2) Characterize stability and trajectory of suicidal ideation over the year following cancer diagnosis. (3) Identify patients at risk of suicidal ideation.

STUDY DESIGN

Prospective longitudinal study with 1-year follow-up.

SETTING

Three university-affiliated outpatient departments of otolaryngology-head and neck surgery.

SUBJECTS AND METHODS

The study comprised a representative sample of 223 consecutive patients who were newly diagnosed (<2 weeks) with a first occurrence of primary HNC, were ≥18 years old and able to consent, and had a Karnofsky Performance Scale score ≥60. Patients completed the Beck Scale for Suicidal Ideation and Structured Clinical Interview for DSM-IV-TR Axis I Disorders.

RESULTS

Sixteen percent (15.7%) of patients with HNC were suicidal <1 year from diagnosis, with point prevalences of 8.1% <2 weeks, 14.8% at 3 months, 9.4% at 6 months, and 10.4% at 12 months; 0.4% committed suicide within 3 months, and 0.9% attempted suicide. An a priori comprehensive conceptual model revealed 2 predictors of 1-year period prevalence of suicidal ideation in HNC: psychiatric history ( P = .017, β = 2.1, 95% CI = 0.4-3.8) and coping with the diagnosis by using substances (alcohol/drugs; P = .008, β = 0.61, 95% CI = 0.16-1.06). All other predictors, including medical predictors, were nonsignificant. A clinical suicide risk assessment revealed low risk among 71.4% and medium to high risk among 28.6%.

CONCLUSION

Suicide prevention strategies are clearly needed as part of routine clinical care in head and neck oncology, as well as their integration into clinical practice guidelines for HNC.