Spiritual well-being and depression in patients with heart failure

Depression in heart failure: biobehavioral mechanisms

The etiology, predictive value, and biobehavioral aspects of depression in heart failure (HF) are described in this article. Clinically elevated levels of depressive symptoms are present in approximately 1 out of 5 patients with HF. Depression is associated with poor quality of life and a greater than 2-fold risk of clinical HF progression and mortality. The biobehavioral mechanisms accounting for these adverse outcomes include biological processes (elevated neurohormones, autonomic nervous system dysregulation, and inflammation) and adverse health behaviors (physical inactivity, medication nonadherence, poor dietary control, and smoking). Depression often remains undetected because of its partial overlap with HF-related symptoms and lack of systematic screening. Behavioral and pharmacologic antidepressive interventions commonly result in statistically significant but clinically modest improvements in depression and quality of life in HF, but not consistently better clinical HF or cardiovascular disease outcomes. Documentation of the biobehavioral pathways by which depression affects HF progression will be important to identify potential targets for novel integrative behavioral and pharmacologic interventions.

Religious and spiritual beliefs in stroke rehabilitation

Faith could dampen Post-Stroke Depression (PSD), which may negatively influence recovery. The present pilot study is an initial examination of the role of religion and spirituality on the functional recovery after a recent stroke. Data were analyzed from 112 consecutive stroke inpatients, who underwent a 2-month standard rehabilitation program. All participants received the Royal Free Interview (RFI), a semi-structured interview for religious and spiritual beliefs, and were assessed on their mood with the Hospital Anxiety and Depression Scale (HADS). Functional status was measured by means of the Functional Independence Measure (FIM). The relationship between religious beliefs, mood improvements, and functional recovery was explored by means of a multiple linear regression. No association between faith and recovery of functional independence could be verified, neither religiousness as a "coping strategy" was associated with functional recovery in this study. An explorative study of a larger size, which also takes into consideration the cultural background and religious beliefs of all patients, is warranted in the longterm.

O idoso e sua espiritualidade: impacto sobre diferentes aspectos do envelhecimento

INTRODUÇÃO: O interesse sobre a espiritualidade e a religiosidade sempre existiu no curso da história humana, a despeito de diferentes épocas ou culturas. Contudo, apenas recentemente a ciência tem demonstrado interesse em investigar o tema. Estudos e pesquisas demonstram que a faixa etária acima dos 65 anos é aquela com mais contato frente a sua espiritualidade e religiosidade. O objetivo do presente estudo é realizar uma revisão da literatura científica que norteia essa temática e investigar qual o impacto da espiritualidade em diferentes aspectos do envelhecimento. METODOLOGIA: Pesquisa nas bases de dados Pubmed/Medline, LILACS e Scielo, nos idiomas inglês e português, entre 1966 e 2009, utilizando as palavras-chave aged/idoso e spirituality/espiritualidade. RESULTADOS: Foram incluídos 48 artigos divididos nas seguintes temáticas: envelhecimento bem-sucedido, bem-estar, qualidade de vida, doenças crônico-degenerativas, doenças neuro-psiquiátricas, funcionalidade, mortalidade e impacto no fim da vida. CONCLUSÃO: Conclui-se que o envelhecimento possui uma relação íntima com a espiritualidade nos seus mais diferentes aspectos e percebe-se que há uma escassez de pesquisas sobre espiritualidade/religiosidade em idosos.

Religious struggle as a predictor of subsequent mental and physical well-being in advanced heart failure patients

Patients with congestive heart failure (CHF) often report high levels of religiousness, which may mitigate the stressfulness of their condition. However, religious struggle, reflecting negative attitudes toward God and a strained meaning system, may be detrimental to well-being. Little is known about religious struggle in those with CHF, particularly in relation to physical health and well-being over time. We examined associations of religious struggle and subsequent mental and physical well-being in 101 endstage CHF patients who completed questionnaires twice over 3 months. Religious struggle predicted higher number of nights subsequently hospitalized, higher depression, and marginally lower life satisfaction. When controlling for baseline levels of well-being, effectively assessing change in those outcomes, religious struggle remained a significant predictor of hospitalization and also emerged as a marginally significant predictor of lower physical functioning. Struggle was unrelated to health-related quality of life. Post-hoc analyses suggest that these effects were particularly strong for those endorsing greater religious identification. Religious struggle appears to have a potentially negative impact on well-being in advanced CHF; therefore, helping patients to address issues of struggle may meaningfully lessen the personal and societal costs of CHF.

Determinants of social activity and work status after coronary bypass surgery

Despite the occurrence of adverse events after coronary artery bypass, the degree of social integration can be increased following this operation. This study addresses the predictive power of risk factors as well as clinical status in determining long-term social functioning and rate of return to work following isolated bypass surgery. A prospective cohort study was conducted in 178 patients who underwent isolated bypass surgery between 2004 and 2007. Information on work status and social relationships was obtained 1-2 days before surgery and during a mean follow-up of 29.4 ± 1.1 months. The proportion of patients who engaged in social activities at 2, 3, and 4 years of follow-up was 0.3, 0.6, and just over 0.8, respectively, and the proportion who had returned to work at these time points was 0.2, 0.45, and 0.63, respectively. Social activity after surgery was less in patients with left ventricular dysfunction, cerebrovascular disease, and higher New York Heart Association functional class. The rate of return to work was lower for men and for patients with left ventricular dysfunction, diabetes, cerebrovascular disease, and those who were hospitalized for more than 14 days.

The Influence of a Spirituality-Based Intervention on Quality of Life, Depression, and Anxiety in Community-Dwelling Adults With Cardiovascular Disease

Purpose and Design: The specific aims of this pre-experimental pilot study were to determine the feasibility and preliminary efficacy of an individualized spirituality-based intervention on health-related outcomes (quality-of-life [QOL], depression, and anxiety) in community-dwelling patients with cardiovascular disease (CVD). Methods: Self-reported QOL, depression, and anxiety data were provided by cardiac patients recruited from three community-based organizations, ( N = 27) at baseline and one month later. The Spirituality Scale developed by the principal investigator assessed study participants’ level of spirituality and scoring on the subscales activated one or more of three spirituality-based interventions. Repeated measures analysis of variance was used to evaluate temporal changes. Findings: Patients who participated in the 1-month intervention demonstrated a significant modest increase in overall QOL. There was a trend toward lower depression scores but this was not significant. No significant changes were seen in anxiety scores. Content analysis of patients’ perceptions of feasibility supports the acceptability of the intervention. Conclusion: Results from this small pilot study provide preliminary evidence that the individualized spirituality-based intervention used in this study holds promise as an addition to traditional cardiac care and has the potential to improve QOL in community-dwelling adults with CVD.

Spiritual well-being in long-term survivors with chronic graft-versus-host disease after hematopoietic stem cell transplantation

Spiritual well-being (Sp-WB) is a resource that supports adaptation and resilience, strengthening quality of life (QOL) in patients with cancer or other chronic illnesses. However, the relationship between Sp-WB and QOL in patients with chronic graft-versus-host disease (cGVHD) remains unexamined. Fifty-two participants completed the Functional Assessment of Chronic Illness Therapy-Spiritual WellBeing (FACIT-Sp) questionnaire as part of a multidisciplinary study of cGVHD. Sp-WB was generally high. Those with the lowest Sp-WB had a significantly longer time since diagnosis of cGVHD (P = 0.05) than those with higher Sp-WB. There were no associations between Sp-WB and demographics, cGVHD severity, or intensity of immunosuppression. Participants with the lowest Sp-WB reported inferior physical (P = 0.0009), emotional (P = 0.003), social (P = 0.027), and functional well-being (P < 0.0001) as well as lower overall QOL (P < 0.0001) compared with those with higher Sp-WB. They also had inferior QOL relative to population norms. Differences between the group reporting the lowest Sp-WB and those groups who reported the highest Sp-WB scores consistently demonstrated a significant difference for all QOL subscales and for overall QOL. Controlling for physical, emotional, and social well-being, Sp-WB was a significant independent predictor of contentment with QOL. Our results suggest that Sp-WB is an important factor contributing to the QOL of patients with cGVHD. Research is needed to identify factors that diminish Sp-WB and to test interventions designed to strengthen this coping resource in patients experiencing the late effects of treatment.

Spiritual reconfigurations of self after a myocardial infarction: Influence of culture and place

This study explored illness narratives following a myocardial infarction (MI) in French Canadians. Qualitative interviews were completed using the McGill Illness Narrative Interview with 51 patients following a first MI. Content analysis of interviews suggested that the heart was perceived as a receptacle that contained an accumulation of life's ordeals, negative emotions and family traumas. This resulted in perceived heart strain, which was considered a direct cause of the MI. References to spirituality were central to the patients' narratives and were identified as instrumental in post-MI recovery. Results illustrate how place and culture interact to shape illness experience and recovery trajectories after a life-threatening health event.

Critical review of health-related quality of life studies of patients with aortic stenosis

BACKGROUND

While studies of health-related quality of life (HRQOL) are increasing among cardiovascular patients, very few have examined HRQOL in persons with aortic stenosis (AS).

PURPOSE

A critical review of studies (1997-2008) of HRQOL in persons with AS was conducted to summarize findings and identify clinical and research implications.

RESULTS

Twenty-eight studies were identified, all of which were quantitative and evaluated HRQOL after aortic valve replacement (AVR). No studies conducted by nurses or studies measuring HRQOL in persons who did not undergo AVR were found. The literature focused on age and type of valve as variables influencing HRQOL postoperatively. Although results varied, elderly patients often scored similar or better than comparison groups. Health-related quality of life was found to be affected by valve noise and anticoagulation rather than the specific valve type when comparing patients receiving biological versus mechanical valves.

CONCLUSIONS

Selection for surgery should not be based on age alone. Early consideration should be given to symptoms prior to surgery because of evidence that patients with fewer symptoms preoperatively have better HRQOL after AVR. Anticoagulation status should be evaluated as an independent variable of HRQOL in future studies.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Researchers need to augment generic HRQOL measures with disease-specific items that may pertain to life areas affected by AS, such as audible valve click, wound healing, and dyspnea. Future research should be inclusive of AS patients who do not undergo surgery. Nurses in a variety of roles can work independently or within a multidisciplinary team to provide interventions for the promotion of HRQOL for patients across all stages of the AS disease process.

Illness Cognitions as a Pathway Between Religiousness and Subjective Health in Chronic Cardiac Patients

The aim of this study was to examine the role of illness cognitions as a possible pathway between religiousness and subjective health in chronic illness. A sample of 135 chronic cardiac patients completed questionnaires about intrinsic religiousness, frequency of church service attendance, basic illness cognitions (i.e., helplessness, illness acceptance, perceived benefits), and physical and emotional well-being. According to the results, religiousness was significantly associated with subjective health. However, this relationship was indirect, with helplessness and illness acceptance serving as mediators between intrinsic religiousness and health. This finding is significant for understanding the complex relation of religiousness to chronic patients’ well-being.

A comparison of two spirituality instruments and their relationship with depression and quality of life in chronic heart failure

Spirituality is a multifaceted construct related to health outcomes that remains ill defined and difficult to measure. Spirituality in patients with advanced chronic illnesses, such as chronic heart failure, has received limited attention. We compared two widely used spirituality instruments, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) and the Ironson-Woods Spirituality/Religiousness Index (IW), to better understand what they measure in 60 outpatients with chronic heart failure. We examined how these instruments related to each other and to measures of depression and quality of life using correlations and principal component analyses. The FACIT-Sp measured aspects of spirituality related to feelings of peace and coping, whereas the IW measured beliefs, coping, and relational aspects of spirituality. Only the FACIT-Sp Meaning/Peace subscale consistently correlated with depression (r=-0.50, P<0.0001) and quality of life (r=0.41, P=0.001). Three items from the depression measure loaded onto the same factor as the FACIT-Sp Meaning/Peace subscale (r=0.43, -0.43, and 0.71), whereas the remaining 12 items formed a separate factor (Cronbach's alpha=0.82) when combined with the spirituality instruments in a principal component analysis. The results demonstrate several clinically useful constructs of spirituality in patients with heart failure and suggest that psychological and spiritual well-being, despite some overlap, remain distinct phenomena.

Facets of spirituality as predictors of adjustment to cancer: relative contributions of having faith and finding meaning

Spirituality is a multidimensional construct, and little is known about how its distinct dimensions jointly affect well-being. In longitudinal studies (Study 1, n = 418 breast cancer patients; Study 2, n = 165 cancer survivors), the authors examined 2 components of spiritual well-being (i.e., meaning/peace and faith) and their interaction, as well as change scores on those variables, as predictors of psychological adjustment. In Study 1, higher baseline meaning/peace, as well as an increase in meaning/peace over 6 months, predicted a decline in depressive symptoms and an increase in vitality across 12 months in breast cancer patients. Baseline faith predicted an increase in perceived cancer-related growth. Study 2 revealed that an increase in meaning/peace was related to improved mental health and lower cancer-related distress. An increase in faith was related to increased cancer-related growth. Both studies revealed significant interactions between meaning/peace and faith in predicting adjustment. Findings suggest that the ability to find meaning and peace in life is the more influential contributor to favorable adjustment during cancer survivorship, although faith appears to be uniquely related to perceived cancer-related growth.

The effects of religiosity, spirituality, and social support on quality of life: a comparison between Korean American and Korean breast and gynecologic cancer survivors

PURPOSE/OBJECTIVES

To examine the differences in religiosity, spirituality, and quality of life (QOL) between Korean American and Korean breast and gynecologic cancer survivors and investigate the effect of religiosity, spirituality, and social support on QOL.

DESIGN

Cross-sectional design.

SETTING

Participants were recruited from hospitals and community-based support groups in the areas of Southern California and Seoul, Korea.

SAMPLE

161 women diagnosed with breast and gynecologic cancer (110 Koreans and 51 Korean Americans).

METHODS

Participants completed a mailed questionnaire. To identify the QOL outcomes, religiosity, spirituality, and social support, four standardized measures were used.

MAIN RESEARCH VARIABLES

QOL outcomes, religiosity, spirituality, religious involvement, and social support.

FINDINGS

Religiosity and spirituality were related to some QOL outcomes in different patterns in Korean American and Korean breast and gynecologic cancer survivors. The effect on QOL, however, was not strong after controlling for covariates. Social support partially mediated the effect of spirituality on QOL but only among the Korean American cancer survivors.

CONCLUSIONS

The findings provide evidence that the effect of religiosity and spirituality on QOL varied between Korean American and Korean survivors. The mediating effect of social support between spirituality and QOL for Korean Americans also was demonstrated.

IMPLICATIONS FOR NURSING

The results present nursing practice and research implications that religiosity, spirituality, and social support need to be considered in developing services for enhancing QOL of immigrant cancer survivors.

EXPLORING SPIRITUAL WELL-BEING AMONG SURVIVORS OF COLORECTAL AND LUNG CANCER

This descriptive, exploratory study is part of a larger observational study of the quality of cancer care delivered to population-based cohorts of newly-diagnosed patients with lung and colorectal cancer. The current study explores the role of spiritual well-being in adjustment to life after the cancer diagnosis, utilizing the Functional Assessment of Chronic Illness Therapy - Spiritual Well-being - Expanded (FACIT-Sp-Ex) Scale. Survey data collected from 304 newly-diagnosed cancer survivors were analyzed to explore important aspects of spirituality, such as sense of meaning in one's life, harmony, peacefulness, and a sense of strength and comfort from one's faith. Spiritual well-being scores, particularly meaning/peace, were statistically significant for African Americans, women and colorectal cancer survivors. These findings amplify a need for oncology social workers and other practitioners to assess spiritual well-being in cancer survivors in an effort to strengthen psychosocial treatment plans. Implications for social work practice and research are discussed.

Coping as a mediator in the relationships of spiritual well-being to mental health in black women with type 2 diabetes

OBJECTIVE

Examine coping as a mediator in the relationships of spiritual well-being to mental health in Black women with type 2 diabetes (T2DM).

METHODS

Using a cross-sectional design, data were collected from a convenience sample of 45 Black women with T2DM. Measures of coping strategies, spiritual well-being (religious and existential well-being), and mental health, as measured by diabetes-specific distress (DSED), were collected. Bivariate findings informed mediational, trivariate model development.

RESULTS

Religious well-being was significantly related to cognitive reframing (CR) coping strategies (p = 0.026) but not DSED (p = 0.751). Existential well-being was significantly related to CR (beta = 0.575,p < 0.001), direct assistance (DA) coping (beta = 0.368, p = 0.006) and DSED (beta = -0.338, p = 0.023). Although CR (beta = -0.305, p = 0.021) and DA (beta = -0.262, p = 0.041) had significant bivariate associations with DSED, the relationships were not significant when existential well-being was controlled. However, the relationship of existential well-being to DSED was mediated by specific CR and DA strategies that were associated with DSED to varying degrees -"I came up with a couple different solutions to the problem" (beta = -0.301, p = 0.049); "I came out of the experience better than I went in" (beta = -0.308, p = 0.061); and "I talked to someone who could do something concrete about the problem" (beta = -0.272, p = 0.078).

CONCLUSION

Findings indicate that diabetes care address spiritual well-being, both its religious and existential components, in Black women with T2DM.

Coping styles in heart failure patients with depressive symptoms

OBJECTIVE

Elevated depressive symptoms have been linked to poorer prognosis in heart failure (HF) patients. Our objective was to identify coping styles associated with depressive symptoms in HF patients.

METHODS

A total of 222 stable HF patients (32.75% female, 45.4% non-Hispanic black) completed multiple questionnaires. Beck Depression Inventory (BDI) assessed depressive symptoms, Life Orientation Test (LOT-R) assessed optimism, ENRICHD Social Support Inventory (ESSI) and Perceived Social Support Scale (PSSS) assessed social support, and COPE assessed coping styles. Linear regression analyses were employed to assess the association of coping styles with continuous BDI scores. Logistic regression analyses were performed using BDI scores dichotomized into BDI<10 vs. BDI> or =10, to identify coping styles accompanying clinically significant depressive symptoms.

RESULTS

In linear regression models, higher BDI scores were associated with lower scores on the acceptance (beta=-.14), humor (beta=-.15), planning (beta=-.15), and emotional support (beta=-.14) subscales of the COPE, and higher scores on the behavioral disengagement (beta=.41), denial (beta=.33), venting (beta=.25), and mental disengagement (beta=.22) subscales. Higher PSSS and ESSI scores were associated with lower BDI scores (beta=-.32 and -.25, respectively). Higher LOT-R scores were associated with higher BDI scores (beta=.39, P<.001). In logistical regression models, BDI> or =10 was associated with greater likelihood of behavioral disengagement (OR=1.3), denial (OR=1.2), mental disengagement (OR=1.3), venting (OR=1.2), and pessimism (OR=1.2), and lower perceived social support measured by PSSS (OR=.92) and ESSI (OR=.92).

CONCLUSION

Depressive symptoms in HF patients are associated with avoidant coping, lower perceived social support, and pessimism. Results raise the possibility that interventions designed to improve coping may reduce depressive symptoms.

Age and depression in patients with metastatic cancer: the protective effects of attachment security and spiritual wellbeing

Psychological distress in cancer patients is inversely related to age, although the reasons are unclear. The adult development literature suggests that ageing may be associated with the development of adaptive capacities, specifically greater attachment security (the sense that others will be available and supportive when needed) and spirituality (the capacity to view one's life as having meaning, purpose and value), that enable older people to cope better with disease. We examined whether age-related patterns in attachment security and spiritual wellbeing account for the protective effect of age against distress. Measures of depression, attachment security, spiritual wellbeing and disease burden were collected from 342 patients aged from 21 to 88 years with advanced, metastatic cancer. Attachment security and spiritual wellbeing were tested as mediators of the effect of age on depression, controlling for disease burden. It was found that age was associated inversely with depression and positively with spiritual wellbeing and attachment security. Depression was inversely related to attachment security and spiritual wellbeing, and the effect of age on depression was fully mediated by attachment security and spiritual wellbeing. The relative protection from psychological distress among older cancer patients may be the result of age-related developmental accomplishments and/or differences in the response to adverse life-events.

Five-factor model personality traits, spirituality/religiousness, and mental health among people living with HIV

We examined the association between five-factor personality domains and facets and spirituality/religiousness as well as their joint association with mental health in a diverse sample of people living with HIV (n=112, age range 18-66). Spirituality/religiousness showed stronger associations with Conscientiousness, Openness, and Agreeableness than with Neuroticism and Extraversion. Both personality traits and spirituality/religiousness were significantly linked to mental health, even after controlling for individual differences in demographic measures and disease status. Personality traits explained unique variance in mental health above spirituality and religiousness. Further, aspects of spirituality and religiousness were found to mediate some of the links between personality and mental health in this patient sample. These findings suggest that underlying personality traits contribute to the beneficial effects of spirituality/religiousness among vulnerable populations.

Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology

Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure-orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.

Living with depressive symptoms: patients with heart failure

BACKGROUND

Patients with heart failure often experience depressive symptoms that affect health-related quality of life, morbidity, and mortality. Researchers have not described the experience of patients with heart failure living with depressive symptoms. Understanding this experience will help in developing interventions to decrease depressive symptoms.

OBJECTIVE

To describe the experience of patients with heart failure living with depressive symptoms.

METHODS

This study was conducted by using a qualitative descriptive design. The sample consisted of 10 outpatients (50% female, mean age 63 [SD, 13] years, 70% New York Heart Association class III or IV) with heart failure who were able to describe depressive symptoms. Data were collected via taped, individual, 30- to 60-minute interviews. ATLAS ti (version 5) was used for content analysis.

RESULTS

Participants described emotional and somatic symptoms of depression. Negative thinking was present in all participants and reinforced their depressed mood. The participants experienced multiple stressors that worsened depressive symptoms. The overarching strategy for managing depressive symptoms was "taking my mind off of it." Patients managed depressive symptoms by engaging in activities such as exercise and reading, and by using positive thinking, spirituality, and social support.

CONCLUSIONS

Patients with heart failure experience symptoms of depression that are similar to those experienced by the general population. Clinicians should assess patients with heart failure for stressors that worsen depressive symptoms. Strategies that researchers and clinicians can use to reduce depressive symptoms in patients with heart failure include engaging patients in activities, positive thinking, and spirituality. Helping patients find enhanced social support may also be important.

Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients

BACKGROUND

A lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer.

OBJECTIVE

We examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients.

DESIGN

This was a cross-sectional study.

PARTICIPANTS

Sixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer.

MEASUREMENTS

Symptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale).

MAIN RESULTS

Overall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction < or =30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer.

CONCLUSIONS

Patients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.

Consistent and breakthrough pain in diverse advanced cancer patients: a longitudinal examination

Although cancer pain, both consistent and breakthrough pain ([BTP]; pain flares interrupting well-controlled baseline pain), is common among cancer patients, its prevalence, characteristics, etiology, and impact on health-related quality of life (HRQOL) are poorly understood. This longitudinal study examined the experience and treatment of cancer-related pain over six months, including an evaluation of ethnic differences. Patients with Stage III or IV breast, prostate, colorectal, or lung cancer, or Stage II-IV multiple myeloma with BTP completed surveys on initial assessment and at three and six months. Each survey assessed consistent pain, BTP, depressed affect, active coping ability, and HRQOL. Among the respondents (n=96), 70% were white, 66% were female, and had a mean age of 56+/-10 years. Nonwhites reported significantly greater severity for consistent pain at its worst (P = 0.009), least (P < or = 0.001), on average (P = 0.004), and upon initial assessment (P = 0.04), and greater severity for BTP at its worst (P = 0.03), least (P = 0.02), and at initial assessment (P = 0.008). Women also had higher levels of some BTP measures. Ethnic disparities persisted when data estimation techniques were used. Examined longitudinally, consistent pain on average and several BTP measures reduced over time, although not greatly, indicating the persistence of pain in the cancer experience. These data provide evidence for the significant toll of cancer pain, while demonstrating further health care disparities in the cancer pain experience.

Reliance on God's help, depression and fatigue in female cancer patients

OBJECTIVE

Because an increasing number of studies indicate that a religious attitude is associated with lower depression, we intended to investigate the interrelationship between intrinsic religiosity and depressive behavioral symptoms in cancer patients with long-term courses.

METHOD

In 396 female cancer patients recruited in East-Germany, intrinsic religiosity was measured with the scale Reliance on God's Help (RGH) from the AKU questionnaire; anxiety and depression with the Hospital Anxiety and Depression Scale; fatigue with the cancer fatigue scale (CFS-D); physical and mental health with the SF-12; adaptive coping styles and ESCAPE from illness with the AKU; and life satisfaction with a modification of Huebner's Brief Multidimensional Students' Life Satisfaction Scale.

RESULTS

Moderate depression-associated fatigue was prevalent in cancer patients with long term-cancer courses, while depression and anxiety were of minor prevalence. RGH, which was valued by several patients, correlated with Reappraisal: Illness as Chance; with life satisfaction dimensions such as future perspectives, overall life, and financial situation; to a small extend with Escape from Illness; and negatively with mental health. No significant correlations were found with respect to depression, anxiety, or fatigue.

CONCLUSIONS

In contrast to cancer patients in final stages, cancer patients with long-term courses had just a moderate reliance on external divine powers. The addressed depressive behavioral symptoms were connected with internal adaptive coping styles such as Conscious Living/Positive Attitudes rather than intrinsic religiosity in response to disease.

The importance of hopelessness among university students seeking psychiatric counseling

Hopelessness is a clinically important state relative to morbidity and suicide risk among university students. We examined its role in relation to presenting concerns, diagnosis, psychopharmacologic treatment and spiritual orientation among students seeking treatment at a university counseling center. The most commonly identified concern was anxiety, followed by stress and depression. Eighty-two percent were given a DSM IV diagnosis. Hopelessness was higher among students dually diagnosed with anxiety and depressive disorders and those who were started on psychiatric medication. Spirituality was inversely correlated with hopelessness and constitutes a personal characteristic warranting further investigation. The concerns bringing students to counseling, the rates of DSM IV diagnosis and the use of psychiatric medication suggest a preponderance of psychopathology over developmental or situational concerns that may be more prominent than has been noted in the counseling literature. In this regard, hopelessness appears to be an important feature even beyond its relationship to suicidality and merits attention and evaluation in student counseling.

Concerns about measuring "spirituality" in research

Spirituality is increasingly being examined as a construct related to mental and physical health. The definition of spirituality, however, has been changing. Traditionally, spirituality was used to describe the deeply religious person, but it has now expanded to include the superficially religious person, the religious seeker, the seeker of well-being and happiness, and the completely secular person. Instruments used to measure spirituality reflect this trend. These measures are heavily contaminated with questions assessing positive character traits or mental health: optimism, forgiveness, gratitude, meaning and purpose in life, peacefulness, harmony, and general well-being. Spirituality, measured by indicators of good mental health, is found to be correlated with good mental health. This research has been reported in some of the world's top medical journals. Such associations are meaningless and tautological. Either spirituality should be defined and measured in traditional terms as a unique, uncontaminated construct, or it should be eliminated from use in academic research.

Pacific Islanders' perspectives on heart failure management

OBJECTIVE

To identify the health beliefs, attitudes, practices, and social and family relations important in heart failure treatment among Pacific Islanders.

METHODS

Four focus groups were convened with 36 Native Hawaiians and Samoans with heart failure and their family caregivers. Thematic data analysis was used to categorize data into four domains: health beliefs and attitudes, preferred health practices, social support systems, and barriers to heart failure care.

RESULTS

Common coping styles and emotional experiences of heart failure in this population included avoidance or denial of illness, hopelessness and despair, and reliance on spiritual/religious beliefs as a means of support. Among study participants, more Samoans preferred to be treated by physicians whereas more Native Hawaiians preferred traditional Hawaiian methods of healing. Two types of social support (informational and tangible-instrumental) were identified as important in heart failure care. Barriers to heart failure care included poor knowledge of heart failure, lack of trust in physicians' care, poor physician-patient relations, finances, dietary changes, and competing demands on time.

CONCLUSION

The recruitment, retention, and adherence of Pacific Islanders to heart failure interventions is affected by an array of psychosocial and socio-cultural factors.

PRACTICE IMPLICATIONS

Interventions might be improved by offering participants accurate and detailed information about heart failure and its treatment, engaging the extended family in providing necessary supports, and providing tools to facilitate physician-patient relationships, among others, within the context of a larger socio-cultural system.

Defining the role of palliative care in older adults with heart failure

While palliative care is often thought of as only being applicable to dying patients, its focus on symptom alleviation, patient function, and quality of life has much to offer older adults with chronic heart failure. Heart failure worsens patients' health status through patients' symptom burden, functional limitations, and reduced health-related quality of life. Moreover, older adults with heart failure have multiple other comorbidities and polypharmacy that further contribute to poor health status. Comorbid depression is a particularly important issue. In this patient population, prognosis is limited and often uncertain. Spouses and caregivers of patients report significant distress and depression. Through symptom management, depression and psychosocial care, assistance with defining goals of care and planning for the future, and caregiver support, palliative care has the potential to improve patient health status and reduce costs and hospitalizations. This care is complementary to contemporary heart failure care and can be provided concurrently at any point during the illness based on patient and caregiver needs.