Demoralization syndrome among cancer outpatients in Taiwan

Demoralization Syndrome in End-Of-Life Cancer Patients: A Qualitative Study

OBJECTIVES

In our previous study we analyzed the prevalence of demoralization in a sample of 235 end-of-life cancer patients using the Demoralization Scale (DS). The findings revealed that 50.2% of the participants reported experiencing a moderate level of demoralization. The main sub-dimensions observed from the original DS were Helplessness, Disheartenment, and Sense of Failure, which we have categorized as "Emotional Distress and Inability to Cope". The aim of this study was to qualitatively investigate the subjective experience of this factor among a group of terminal cancer patients.

METHOD

A sample of 30 patients was interviewed using seven open-ended questions, divided into 3 categories: helplessness, disheartenment and sense of failure. Content analysis was performed.

RESULTS

Faith and prayer, social support and preserving autonomy were the principal coping strategies used by the sample and have been classed as sources of hope. Sadness, anger, death anxiety, fear, and sickness were the most commonly expressed emotions. Faith, social support, autonomy, and fighting spirit were identified as the primary coping strategies.

CONCLUSIONS

This study allowed a better understanding of the patient's subjective experience of the demoralization sub-dimension. The deepening of the topic can increase personalized clinical interventions, according to the patient's needs.

Demoralization syndrome in burn patients: A cross-sectional study

AIMS

To investigate the status of demoralization syndrome and the factors affecting demoralization in burn patients.

METHODS

This study employed a cross-sectional research design and utilized a face-to-face questionnaire to gather data from adult burn patients with burn depths classified as second-degree or higher. The Demoralization Scale Mandarin Version, the Perceived Social Support Scale, the Herth Hope Index, and the Medical Coping Method Questionnaire were used to assess the level of demoralization, perceived social support, sense of hope, and coping strategies, respectively. General information, including socio-demographic data and disease characteristics, were collected. The patients' level of demoralization was categorized as the mean ± 1 standard deviation of the DS-MV scores. The data was analyzed using IBM SPSS 26.0 software to explore the relationship between the variables.

RESULTS

This study included 381 burn patients with a mean DS-MV score of 34.62 ± 18.319. Of these, 66 (17.3%) had mild demoralization, 241 (63.3%) had moderate demoralization, and 74 (19.4%) had severe demoralization. Cause of burn, total burn area, average monthly income of the individual, occupation, sense of hope, perceived social support, and medical coping strategies were the important factors associated with the severity of demoralization in burn patients.

CONCLUSIONS

Patients with burn injuries exhibit a notable prevalence and severity of demoralization indicating focused attention. By considering associated risk factors, healthcare professionals can devise and execute tailored intervention strategies aimed at mitigating the occurrence and intensity of demoralization in burn patients.

The Potential Mediating Effect of Symptom Burden on Demoralization Through Locus of Control and Coping Strategies in Chinese Patients With Cancer

BACKGROUND

Demoralization is a psychological syndrome that is highly prevalent in patients with cancer and detrimental to individuals' physical and mental health. To explore effective intervention, we first determined the relationships between locus of control, coping strategies, symptom burden, and demoralization.

OBJECTIVE

The aim of this study was to determine the relationship between symptom burden, locus of control, coping strategies, and demoralization in patients with cancer.

METHODS

In this descriptive-correlational study, 273 valid patients were selected with convenience sampling method from a hospital in China. Data were collected using the Chinese version of the M.D. Anderson Symptom Inventory, the Chinese version of the Multidimensional Health Locus of Control Scale, the Chinese version of the Medical Coping Modes Questionnaire, and the Mandarin version of the Demoralization Scale. Data were analyzed using descriptive and inferential statistics using SPSS and AMOS.

RESULTS

A total of 115 patients (42.12%) experienced clinical demoralization (Mandarin version of the Demoralization Scale > 30). Symptom burden (β = 0.295, P < .001), confrontation (β = -0.117, P = .028), and resignation (β = 0.456, P < .001) had direct effects on demoralization. Symptom burden also had an indirect effect on demoralization through the mediating role of resignation (β = 0.026, P = .002). Meanwhile, locus of control can affect demoralization entirely through the indirect mediating role of coping strategies (chance locus of control via resignation [β = 0.138, P < .01], powerful locus of control via confrontation [β = -0.017, P < .05]).

CONCLUSIONS

Symptom burden affects demoralization not only directly but also indirectly. Coping strategies play an important mediating role between symptom burden, locus of control, and demoralization in patients with cancer.

IMPLICATIONS FOR PRACTICE

It is urgent to screen demoralization and identify patients with high symptom burden, maladaptive locus of control, or coping strategies. For the patients targeted, a more comprehensive and systematic approach to symptom management and more appropriate guidance related to adaptive coping strategies are needed.

Existential distress and associated factors in advanced cancer patients: A cross-sectional study

BACKGROUND

Advanced cancer patients often experience existential distress (ED). However, the factors associated with ED remain unclear. This study investigated the current state of ED and identified the associated factors in Chinese patients with advanced cancer.

METHODS

A cross-sectional study was conducted among 352 advanced cancer patients from 3 tertiary hospitals in Fujian, China. Participants were invited to complete the Existential Distress Scale, Number Rating Scale, Self-Perceived Burden Scale, Quality of Life Concerns in the End-of-Life Questionnaire, and Hospital Anxiety and Depression Scale.

OBJECTIVES

This study aimed to investigate the level of existential distress among advanced cancer patients in China and identify the associated factors.

RESULTS

A total of 352 advanced cancer patients were recruited for this study. The average score for ED was 8.48 ± 7.12 among the advanced cancer patients. Multiple regression showed that the associated factors included depression (β = 0.32, p = 0.000), self-perceived burden (SPB) (β = 0.18, p = 0.001), the presence of a spouse (β = -0.10, p = 0.050), and reception of government subsidies (β = 0.17, p = 0.001). The factors accounted for 30.1% of the total variance in ED (F = 8.472, p < 0.001).

SIGNIFICANCE OF RESULTS

Among the advanced cancer patients queried, ED was found to be positively influenced by depression, SPB, and reception of government subsidies and negatively influenced by the presence of a spouse. Depression was the most important risk factor, and thus future ED interventions should target depression.

Prevalence, Associated Factors and Adverse Outcomes of Demoralization in Cancer Patients: A Decade of Systematic Review

Demoralization has been extensively studied in oncology and palliative care settings, and is characterized by a loss of meaning and purpose in life, a sense of powerlessness over life events, and a sense of helplessness. The objective of this systematic review is to synthesize the prevalence, associated factors, and adverse outcomes of demoralization in cancer patients by reviewing the literature of the last decade. Seven databases (PubMed, PsycINFO, Embase, Web of Science, Medline, CINAHL and Cochrane Library databases) were systematically searched from January 2012 to June 2022. Roughly speaking, the prevalence of demoralization in cancer patients ranges from 13.50% to 49.4%. A total of 45 factors are associated with demoralization, of which psychological factors have been studied more frequently in the last decade. There are nine outcomes related to demoralization, with the strongest evidence for the correlation between demoralization and suicidal ideation. The study emphasizes the complexity of factors associated with demoralization in cancer patients. There appears to be a intersection between the constructs of demoralization and depression, anxiety, and suicidal ideation, which may explain the correlation between them.

Psychometric properties and normative values of the revised demoralization scale (DS-II) in a representative sample of the German general population

BACKGROUND

Demoralization is a clinically relevant syndrome in chronic diseases. The demoralization scale (DS-II) was recently developed as an economic screening tool in clinical populations. Main aim of this study was to provide normative data of DS-II scores in the general population.

METHODS

We developed a new German version, the DS-II Münster, and tested internal consistency as well as the previously proposed two-factor structure with confirmatory factor analyses. The DS-II was applied in a household survey of the general population. Associations between DS-II scores and age, gender and other sociodemographic variables were explored.

RESULTS

The final sample consisted of N = 2471 participants (mean age = 49.8 years, range: 18-96; 50.1% men, 49.8% women). The DS-II Münster showed nearly excellent internal consistency. The model fit indices of the two-factor structure were not superior to those of the one-factor model. Mean scores of the DS-II were as follows. Total score: M = 3.76 (SD = 5.56), Meaning and Purpose subscale: M = 1.65 (SD = 2.77), Distress and Coping Ability subscale: M = 2.11 (SD = 3.02). DS-II scores were increased in women with an effect size of Cohen's d = 0.19. An age-related increase was specifically found for the Meaning and Purpose subscale (d = 0.21).

CONCLUSIONS

The study provides normative values of the DS-II with respect to age and gender in the general population to facilitate interpretation of DS-II scores in clinical samples. A DS-II total score > 5 is suggested as a cut-off value. The findings further our understanding of significant symptom burden that was previously suggested in young patients with cancer.

Risk Factors of Demoralization Among Lung Cancer Patients in Mainland China

Objectives: Due to the severity of cancer, patients may experience feelings of helplessness and despair, resulting in demoralization among lung cancer patients. In this study, we investigated the risk factors of demoralization in middle-aged and older Chinese lung cancer patients via their relationship with patients' demographic data and disease characteristics. Methods: This study is a cross-sectional descriptive study using a structured questionnaire including assessments of demographic data and disease, the Demoralization Scale Mandarin Version (DS-MV), the Social Support Rate Scale (SSRS), the Medical Coping Modes Questionnaire (MCMQ), as well as The European Organization for Research and Treatment of Cancer (EORTC QLQ-C30). Results: Overall, 289/300 (96.3%) patients with lung cancer completed questionnaires. The mean score of DS-MV was 49.27 (SD=15.19) (range, 21-81) and the mean score of SSRS was 33.37 (SD=5.43) (range,17-48). Multiple linear regression analysis identified high demoralization was significantly related to age (p<.001), medical payment (p=.003), times of chemotherapy (p=.026), family monthly income (p=.025), avoidance dimension (p<.001), surrender dimension (p<.001), social support (p=.001), symptom score (p<.001), overall health score (p=.009) and function score (p<.001). Conclusion: This study demonstrates the factors influencing demoralization among middle-aged and older lung cancer patients. Demoralization is a prevalent psychiatric problem in Chinese lung cancer patients. Therefore, we recommend strong social support to be protective against demoralization. We suggest that medical staff establish the concept of social support for patients with lung cancer, actively seek effective resources from family, friends, and other social support organizations to help patients establish a social support system that improves patient courage and confidence in their post-cancer life.

Contribution of coping style to the association between illness uncertainty and demoralisation in patients with breast cancer: a cross-sectional mediation analysis

OBJECTIVE

Demoralisation is a common psychological issue in patients with cancer and aggravates depression, reduces the quality of life and even causes suicidal ideation. There is a lack of knowledge about illness uncertainty, coping style and demoralisation in patients with breast cancer. The current study explored the relationship between illness uncertainty and demoralisation among those patients, as well as the potential mediating role of coping style.

DESIGN

A cross-sectional study.

SETTING

Participants were recruited from the Breast Tumor Center in a tertiary hospital in Shijiazhuang, Hebei province.

PARTICIPANTS

A total of 211 patients with breast cancer completed the survey.

OUTCOME MEASURES

A total of 211 patients with breast cancer completed the Mishel's Uncertainty in Illness Scale, Trait Coping Style Questionnaire and the Mandarin version of Demoralization Scale (DS-MV).

RESULTS

Of the patients, 47.40% exhibited symptoms of demoralisation (DS-MV>30), and the mean of demoralisation score was (29.55±13.21). The results demonstrated that illness uncertainty and negative coping styles were positively related to demoralisation (p<0.001), while active coping styles were negatively related to demoralisation (p<0.001). Importantly, coping styles could partially mediate the relationship between illness uncertainty and demoralisation (p<0.01).

CONCLUSION

Our study illustrated that illness uncertainty was associated with demoralisation in patients with breast cancer, and coping style acted as a mediator in this relationship. The findings highlighted the critical role of reducing negative coping styles to the early prevention and efficient treatment of demoralisation among those patients.

Clinical utility of demoralization: A systematic review of the literature

Demoralization is a complex clinical phenomenon which has raised a growing interest in clinical and research realms. The present systematic review of the literature aimed at (1) updating on demoralization prevalence in different populations, (2) identifying the instruments more largely used to assess demoralization, and (3) verifying whether new tools of assessment have been proposed. PubMed and Web of Science were searched from inception to April 2022. Search terms were: demoralization/demoralized/demoralizing/demoralised/demoralising. PRISMA guidelines were followed. GRADE rating system was used. A total of 188 papers were included. Demoralization appeared to be a distinctive psychological state common in medical, psychiatric, and non-clinical settings, thus not limited to life-threatening diseases. Diagnostic Criteria for Psychosomatic Research (DCPR) and Demoralization Scale (DS) are the most commonly used tools to assess it. DCPR allow to diagnose demoralization as a manifestation of dealing with chronic stress. DS captures dimensionally a psychological distress related to end of life. Demoralization is associated with clinical features encompassing allostatic overload, quality of life, wellbeing/euthymia. Implications on health outcomes and treatment are discussed. Demoralization warrants careful consideration in clinical contexts through valid assessment procedures. DCPR are recommended to diagnose it, DS can be helpful to capture clinical details.

Prediagnosis Depression Rather Than Anxiety Symptoms Is Associated with Decreased Ovarian Cancer Survival: Findings from the Ovarian Cancer Follow-Up Study (OOPS)

Background: The relationship between prediagnosis depression, anxiety symptoms, and ovarian cancer (OC) survival is unknown. We aimed to explore these associations to provide further epidemiological evidence. Methods: We investigated the relationship between prediagnosis depression, anxiety symptoms, and OC survival in a prospective cohort study of newly diagnosed OC patients aged 18−79 years. Depression and anxiety symptoms were assessed using the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7 at diagnosis, respectively. Deaths were ascertained until 31 March 2021 via medical records and active follow-up. Multivariable-adjusted Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) with prediagnosis depression and anxiety symptoms and all-cause mortality of OC. Results: We found 56 (9.4%) and 235 (39.3%) OC patients with depression and anxiety symptoms, respectively. During a median follow-up of 37.2 months (interquartile range 24.7−50.2 months), 130 deaths were confirmed. Compared with non-depression symptoms, patients with prediagnosis depressive symptoms showed a significantly increased risk of OC mortality (HR = 2.10, 95% CI: 1.20−3.70). Of note, the association was still robust when focusing on the OC patients with severe depressive symptoms (HR = 2.10, 95% CI: 1.07−4.12). However, we observed no association between prediagnosis anxiety symptoms of different severity and OC mortality. Interestingly, OC patients with combined moderate depression and anxiety symptoms had a significantly increased risk of OC mortality (HR = 3.23, 95% CI: 1.14−9.11) compared to those with no symptoms of depression and anxiety. Notably, Wilms’s tumor 1 was significantly associated with depression and anxiety symptoms (p < 0.05). Conclusions: Prediagnosis depression increases the risk of OC mortality. Large multicenter studies are required to confirm this finding.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

Demoralization level fluctuated at various time frame of radiotherapy for patients with different cancers: a longitudinal observational study

Background

Demoralization is a psychological response that is frequently observed in patients with cancer or advanced diseases. It is affected by national characteristics, culture, disease characteristics and general conditions of the patient such as individual cultural features, nature of stress, personal expression preferences and social behavior. Compared with the results of previous studies on demoralization syndrome, patients with cancer in Taiwan exhibit a higher prevalence of demoralization. We aimed to investigate the prevalence of high demoralization and the changes in the level of demoralization in cancer patients during radiotherapy to explore the associated factors and the contributing factors to the high level of demoralization.

Methods

We used the Demoralization Scale-Mandarin Version to evaluate the demoralization level at six-time points in patients admitted for radiotherapy in a 3-month observational period. 101 patients allocated to three groups by cancer region completed the study. We applied the generalized estimating equation (GEE) to analyze the changes in the demoralization level among the three groups. The variables associated with the changes in the demoralization level were also investigated.

Results

In the analysis using univariate GEE, only patients in the chest and breast group exhibited significant changes at two different time points. The results obtained using multivariate GEE revealed that sociodemographic variables, stage of disease and use of surgery or chemotherapy had no impact on the changes in demoralization across three months.

Conclusion

The demoralization level certainly fluctuated in an extremely high range. The higher prevalence of demoralized patients may indicate that if medical staff neglect the importance of demoralization, demoralized patients with cancer may not receive appropriate care.

Demoralization in oral cancer inpatients and its association with spiritual needs, quality of life, and suicidal ideation: a cross-sectional study

Background

Demoralization is a common problem in oral cancer patients owing to the chronic and severe nature of their affliction. However, the association between demoralization and the patient’s spiritual needs, quality of life, and suicidal ideation remains unclear. This study aims to provide insights into possible links between demoralization among oral cancer patients and its effects on the patient’s spiritual needs, quality of life, and suicidal ideation.

Methods

We examined 155 Taiwanese oral cancer inpatients in Taichung Veterans General Hospital, Taiwan, using the following three rating scales: (a) Demoralization Scale Mandarin Version (DS-MV), (b) Spiritual Interests Related to Illness Tool, and (c) The Taiwan Chinese versions of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. Suicidal ideation was established if at least one of the two suicide-related items on the DS-MV scale were checked. We divided the participants into high- and low-demoralization groups, per the cutoff score of 30. We then explored group associations with sociodemographic features, quality of life, and spiritual needs. Logistic regression and receiver operating characteristic (ROC) curves were used to determine demoralization and its association between these variables.

Results

Fifty-five (35.5%) patients were categorized as having high demoralization (DS-MV scale score > 30), with scores for DS-MV for all patients being 27.2 ± 16.8. The rates of suicidal ideation were 29.1% (16/55) in the high-demoralization group and 2% (2/100) in the low-demoralization group, with an odds ratio (95% confidence interval) of 20.10 (4.41–91.55). Logistic regression analysis revealed significant effects of spiritual needs and global health status on the DS-MV scores (p < 0.001). Multivariate analyses further confirmed that only overall quality of life scores < 62.5 and spiritual needs < 3.7 significantly predicted the occurrence of high demoralization.

Conclusion

High demoralization is associated with low satisfaction with spiritual needs, poor quality of life, and high risk of suicidal ideation. DS-MV may potentially be an effective tool for achieving holistic health care among oral cancer patients.

Psychometric Evaluation of the German Version of the Demoralization Scale-II and the Association Between Demoralization, Sociodemographic, Disease- and Treatment-Related Factors in Patients With Cancer

Objective: To test the psychometric properties, internal consistency, dimensional structure, and convergent validity of the German version of the Demoralization Scale-II (DS-II), and to examine the association between demoralization, sociodemographic, disease- and treatment-related variables in patients with cancer. Methods: We recruited adult patients with cancer at a Psychosocial Counseling Center and at oncological wards. Participants completed the 16-item DS-II, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-2 (GAD-2), Distress Thermometer (DT), and Body Image Scale (BIS). We analyzed internal consistency of the DS-II using Cronbach's Alpha (α). We tested the dimensional structure of the DS-II with Confirmatory Factor Analyses (CFA). Convergent validity was expressed through correlation coefficients with established measures of psychological distress. The associations between demoralization, sociodemographic, disease- and treatment-related variables were examined with ANOVAs. Results: Out of 942 eligible patients, 620 participated. The average DS-II total score was M = 5.78, SD = 6.34, the Meaning and Purpose subscale M = 2.20, SD = 3.20, and the Distress and Coping Ability subscale M = 3.58, SD = 3.45. Internal consistency ranged from high to excellent with α = 0.93 for the DS-II total scale, α = 0.90 for the Meaning and Purpose subscale, and α = 0.87 for the Distress and Coping Ability subscale. The one-factor and the two-factor model yielded similar model fits, with CFI and TLI ranging between 0.910 and 0.933, SRMR < 0.05. The DS-II correlated significantly with depression (PHQ-9: r = 0.69), anxiety (GAD-2: r = 0.72), mental distress (DT: r = 0.36), and body image disturbance (BIS: r = 0.58). High levels of demoralization were reported by patients aged between 18 and 49 years (M = 7.77, SD = 6.26), patients who were divorced/separated (M = 7.64, SD = 7.29), lung cancer patients (M = 9.29, SD = 8.20), and those receiving no radiotherapy (M = 7.46, SD = 6.60). Conclusion: The DS-II has very good psychometric properties and can be recommended as a reliable tool for assessing demoralization in patients with cancer. The results support the implementation of a screening for demoralization in specific risk groups due to significantly increased demoralization scores.

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.

The Effects of Logotherapy on Distress, Depression, and Demoralization in Breast Cancer and Gynecological Cancer Patients: A Preliminary Study

BACKGROUND

Globally, cancer is the second leading cause of death. Breast cancer and gynecological cancer can damage patients' body image and lead to psychological distress, depression, and demoralization syndrome. No studies have explored the effect of logotherapy in gynecological cancer patients' psychological distress, depression, and demoralization.

OBJECTIVE

To evaluate the effects of logotherapy on distress, depression, and demoralization in breast cancer and gynecological cancer patients.

METHODS

A quasi-experimental design was used in this study, involving 61 breast cancer and gynecological cancer patients: 31 in the experimental group and 30 in the control group. Participants in the experimental group received logotherapy 4 to 6 times during the 12 weeks of intervention. Outcomes were measured by the (1) Distress Thermometer, (2) Patient Health Questionnaire, and (3) Demoralization Scale Mandarin Version (DS-MV).

RESULTS

Distress Thermometer did not differ between groups, but significant differences in favor of the intervention group were noted in the Patient Health Questionnaire (U = 674.500, P = .002); the DS-MV subcategories of loss of meaning (U = 706.500, P = .000), dysphoria (U = 673.000, P = .002), disheartenment (U = 670.000, P = .003), helplessness (U = 621.000, P = .022), and sense of failure (U = 629.500, P = .016); and the total score of the DS-MV (U = 728.500, P = .000).

CONCLUSION

Logotherapy was effective in the reduction of breast cancer and gynecological cancer patients' depression and demoralization.

IMPLICATIONS FOR PRACTICE

Clinical professionals could add logotherapy to the treatment for breast cancer and gynecological cancer patients to reduce their depression and demoralization.

Demoralization and depression in Chinese cancer patients

OBJECTIVE

Demoralization and depression are common in cancer patients and closely related to suicide. But the association and difference between them are not clear. The aim of this study is to investigate demoralization and depression in Chinese cancer patients.

METHODS

This study is a cross-sectional study. Two hundred ninety-six cancer patients completed the questionnaire. First is using the DS-II to evaluate demoralization in advanced cancer patients and using the PHQ-9 to evaluate their depression. Then determine the association between demoralization and depression by Pearson rank correlation test. Finally, an ANOVA was conducted using DS-II as the categorical variable and PHQ-9 as the continuous variable and using PHQ-9 as the categorical variable and DS-II as the continuous variable.

RESULTS

There is a positive association between demoralization and depression. A special case that patients with high demoralization but low depression was discovered, which accounted for a large proportion.

CONCLUSION

Demoralization and depression are two different psychological states, which require medical staff to identify and take corresponding intervention measures in time. Patients with high demoralization but low depression require further attention.

The Mediation and Suppression Effect of Demoralization in Breast Cancer Patients After Primary Therapy: A Structural Equation Model

BACKGROUND

Because of the increasing 5-year survival rate of breast cancer, adjustment to breast cancer survivorship is pertinent to the patient's life after diagnosis. Despite the psychological changes occurring during the transitional period (first 5 years after diagnosis) and after primary therapy having a known, critical effect on survivorship status, the data related to this topic are very limited.

PURPOSE

This study was designed to examine the relationships among demoralization, stress, sleep disturbance, and psychological well-being in women with breast cancer after primary therapy.

METHODS

Two hundred eight women with breast cancer (mean age = 51.96 ± 8.27) participated in a cross-sectional study in central Taiwan. Recruitment was conducted using convenience snowball sampling at a local teaching hospital. All of the participants had completed primary therapy and were in the 5-year postdiagnosis period. The average duration of cancer was 28 months. The participants completed the Stress of Breast Cancer after Primary Therapy Scale, Demoralization Scale, Pittsburgh Sleep Quality Inventory, and Ryff's Psychological Well-Being Scale-Short Form. Data were analyzed using a structural equation model to find plausible path relationships among stress, demoralization, sleep disturbances, and psychological well-being.

RESULTS

Demoralization was shown to completely mediate the effect of stress on sleep disturbances. In addition, the predictive effect of sleep disturbances on psychological well-being was overwhelmingly explained by demoralization when competing with sleep disturbances. Furthermore, a positive path was found between stress and psychological well-being because of the suppression effect of demoralization.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Demoralization was found to be a mediator that suppressed the relationships among stress, sleep disturbances, and psychological well-being in the adaptation process of patients with breast cancer after primary therapy. This article adds to the limited research on women with breast cancer after primary therapy who are in their initial 5 years of diagnosis. In addition, this study used structural equation model to find the plausible path relationships among the psychological factors involved in the well-being of women with breast cancer. Supporting patients with cancer and effectively reducing their perceived demoralization will be key to transforming stress into personal growth and a facilitator of long-term recovery.

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.

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.

The differences and the relationship between demoralization and depression in Chinese cancer patients

BACKGROUND

Both demoralization and depression are common forms of psychological distress in cancer patients. This study aimed to investigate the severity of demoralization in Chinese cancer patients and to explore the factors influencing depression and demoralization and their effects on quality of life to better understand the differences and the relationship between demoralization and depression.

METHODS

Cross-sectional study design, in-patients sequentially recruited from a tertiary-level cancer hospital in Beijing between January 2016 and April 2016 completed Mandarin version of Demoralization Scale (DS-MV), Patient Health Questionnaire-9 (PHQ-9), Revised Life Orientation Test (CLOT-R), Beck Hopelessness Scale (BHS), and the 12-items Short Form Health Survey, version 2 (SF-12 V2) and provided socio-demographic and clinical information.

RESULTS

296/424 (70.0%) of patients completed questionnaires. The mean score of DS is 30.4 (SD = 13.0). There are 28% (83/296) patients who experienced a low level of depression but a high level of demoralization. Resignation medical coping method (b = 0.279, P < .001), hopelessness (b = 0.492, P < .001), positive life orientation (b = -0.170, P < .001), and education level (b = -0.132, P < .001) were found to be predictors of demoralization, while only resignation medical coping method (b = 0.373, P < .001) and hopelessness (b = 0.350, P < .001) were found to be predictors of depression. Depression is a mediator between demoralization and physical aspects of quality of life (γ = -0.1604, LLCI = -0.244, ULCI = -0.080).

CONCLUSION

Demoralization is a prevalent psychiatric problem in Chinese cancer patients, and a large proportion of patients had low depression but high demoralization. Therefore, screening for demoralization in Chinese oncology practice is essential. A positive life orientation was found to be protective against demoralization.

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.

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.

Quality of life, demoralization syndrome and health-related lifestyle in cardiac transplant recipients - a longitudinal study in Taiwan

BACKGROUND

Quality of life is an outcome indicator after health care treatment, and the factors that affect quality of life change over time after heart transplantation. As such, quality of life as related to heart transplantation warrants further investigation.

AIMS

The purposes of this study were to compare different post-transplant times of cardiac transplant recipients in terms of their quality of life, demoralization syndrome and health-related lifestyle and to identify the predictors of quality of life in Taiwan.

METHODS

This longitudinal study, which used convenience sampling, was conducted in one medical center. Participants were divided into three groups (1, 2 and 3) based on post-transplant time. Four questionnaires, that is, demographic, quality of life, including a physical and mental component summary (PCS and MCS), demoralization and health-related lifestyle, were used to collect data at baseline and at three, six and 12 months. Hierarchical regression was used to identify the predictors of quality of life.

RESULTS

There were 99 participants, who were divided into three groups: Group 1 ( n = 31), Group 2 ( n = 29) and Group 3 ( n = 39). The majority of participants were male, with a mean age of 53.68 years. In each group, fewer than half had good quality of life, and one-third had demoralization syndrome. Demoralization syndrome combined with post-transplant time, age, use of mechanical circulatory support during hospitalization and stress status accounted for 35.2% of PCS for all participants. Further, demoralization syndrome combined with age and religion accounted for 40.3% of MCS for all participants.

CONCLUSIONS

The results indicated that quality of life, demoralization syndrome and health-related lifestyle were correlated over time. Demoralization was an independent predictor of quality of life.

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.

Protective Factors of Demoralization among Cancer Patients in Taiwan: An Age-matched and Gender-matched Study

PURPOSE

This study aimed to explore the protective factors of demoralization in cancer patients via investigation of cancer patients' demographic and disease characteristics.

METHODS

This was a cross-sectional descriptive study. We used a structured questionnaire, which contained items on demographic and disease characteristics, as well as the Demoralization Scale Mandarin Version (DS-MV), with a cutoff of 30 or more indicating high demoralization. Data were analyzed with age-matched and gender-matched conditional logistic regression analysis. For the study, 428 questionnaires were delivered and 411 were recovered. After being age-matched and gender-matched, 182 participants of high demoralization (DS-MV > 30) and low demoralization (DS-MV ≤ 30) were obtained respectively, for a total of 364 participants.

RESULTS

Cancer patients' demoralization was significantly related to family support (p = .019), education (p = .049), and monthly income (p = .001). Family support [odds ratio = 0.38; p = .028; 95% confidence interval (0.16, 0.91)] and monthly income [odds ratio = 0.49; p = .009; 95% confidence interval (0.29, 0.84)] were protective factors of demoralization in cancer patients.

CONCLUSION

Early and appropriate demoralization assessment of cancer patients' demographic and disease characteristics is very important in clinical settings. Healthcare providers might regularly monitor demoralization in cancer patients, and develop related nursing care guidelines or treatment for demoralization in cancer patients. The study results can be a reference for healthcare providers who work with cancer patients.

Demoralization in Cancer Patients and Related Factors in Taiwan

BACKGROUND

Demoralization frequently occurs in hospice, cancer, and critically ill patients. Severe demoralization can lead to suicidal ideation, making this issue of great import to healthcare providers.

OBJECTIVE

The aim of this study is to inform nursing professionals of the risk factors of demoralization in cancer patients via investigating its relationship with cancer patients' demographic data and disease characteristics.

METHODS

This is a cross-sectional descriptive study using a structured questionnaire including assessments of demographic data and disease characteristics, as well as the Demoralization Scale Mandarin version. Univariate logistic regression was used to explore the relations between demoralization and these other variables.

RESULTS

The mean (SD) Demoralization Scale Mandarin version score was 30.08 (13.68) (range, 0-73). Demoralization was significantly related to age (r = 0.1, P = .050), marital status (r = 0.11, P = .034), education (r = 0.17, P < .001), monthly income (r = 0.22, P < .001), disease status (r = 0.10, P = .050), and treatment type (r = 0.12, P = .014).

CONCLUSIONS

This study demonstrates the factors influencing demoralization among cancer patients. Future studies might expand to include patients with other chronic or critical illnesses or disadvantaged groups to better understand the prevalence of demoralization. This would help draw more attention from clinical healthcare providers, healthcare institutions, and other healthcare authorities to demoralization.

IMPLICATIONS OR PRACTICE

The results provide reference data for nursing professionals about the care of cancer patients.

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

BACKGROUND

Demoralization refers to a state in which there is a perceived inability to cope, that is associated with a sense of disheartenment and a loss of hope and meaning. This study investigated the co-occurrence versus independence of demoralization with mental disorders and suicidal ideation to evaluate its features as a concept of distress in the context of severe illness.

METHODS

In a cross-sectional sample of 430 mixed cancer patients, we assessed demoralization with the Demoralization Scale (DS); the 4-week prevalence of mood, anxiety, and adjustment disorders and suicidal ideation with the standardized Composite International Diagnostic Interview-Oncology (CIDI-O); and depressive symptoms with the Patient Health Questionnaire-9 (PHQ-9). We compared the relative risk (RR) for mental disorders associated with demoralization to that associated with self-reported depression.

RESULTS

Clinically relevant levels of demoralization were present in 21% of the patients. Demoralization co-occurred with a mood/anxiety disorder in 7%; 14% were demoralized in absence of any mood/anxiety disorder. Demoralization and adjustment disorders co-occurred in 2%. The RR for any mood/anxiety disorder was 4.0 in patients with demoralization (95% confidence interval [CI], 2.5-6.2) and 3.0 in those with depression (95% CI, 1.9-4.6). Demoralization, but not depression, was associated with a significantly increased risk for suicidal ideation after controlling for mental disorders (RR, 2.0; 95% CI, 1.1-3.5).

CONCLUSIONS

Clinically relevant demoralization frequently occurs independently of a mental disorder in patients with cancer and has a unique contribution to suicidal ideation. Demoralization is a useful concept to identify profiles of psychological distress symptoms amenable to interventions improving psychological well-being in this population. Cancer 2017;123:3394-401. © 2017 American Cancer Society.

Biopsychosocial correlates of hope in Asian patients with cancer: a systematic review

OBJECTIVE

To examine the factors associated with hope and hopelessness in patients with cancer in Asian countries, and the instruments used to measure hope and hopelessness.

METHORDS

A comprehensive systematic review was conducted with search terms, including cancer, hope, hopelessness and individual Asian country names, on CINAHL, Embase, PsycINFO, PubMed and Scopus databases. Only quantitative studies on adult cancer populations in Asia examining hope or hopelessness were included.

RESULTS

A total of 2062 unique articles were retrieved from the databases, and 32 studies were selected for inclusion in this review. Hope and hopelessness were most frequently measured with the Herth Hope Index and the Mental Adjustment to Cancer Scale, respectively. The biopsychosocial factors that were most consistently associated with hope and hopelessness included sociodemographic variables (education, employment and economic status); clinical factors (cancer stage, physical condition and symptoms); and psychosocial factors (emotional distress, social support and connections, quality of life, control or self-efficacy, as well as adjustment and resilience).

DISCUSSION

There is a need for more studies from South and Southeast Asia as most studies hailed from East Asia. This review highlighted the possibility of cultural differences influencing factors related to hope, suggesting that cross-cultural studies specifically would facilitate understanding behind these variations, although future reviews on hope should also include studies on hopelessness for a comprehensive understanding of the concept. Finally, more longitudinal research could be conducted to assess whether the factors associated with hope and hopelessness change over time and disease progression.

Refinement and revalidation of the demoralization scale: The DS-II-external validity

BACKGROUND

The recently refined Demoralization Scale-II (DS-II) is a 16-item, self-report measure of demoralization. Its 2 factors-Meaning and Purpose and Distress and Coping Ability-demonstrate sound internal validity, including item fit, unidimensionality, internal consistency, and test-retest reliability. The convergent and discriminant validity of the DS-II with various measures is reported here.

METHODS

Patients who had cancer or other progressive diseases and were receiving palliative care (n = 211) completed a battery of questionnaires, including the DS-II and measures of symptom burden, quality of life, depression, and attitudes toward the end of life. Spearman ρ correlations were determined to assess convergent validity. Mann-Whitney U tests with calculated effect sizes were used to examine discriminant validity and establish the minimal clinically important difference (MCID). Cross-tabulation frequencies with chi-square analyses were used to examine discriminant validity with major depression.

RESULTS

The DS-II demonstrated convergent validity with measures of psychological distress, quality of life, and attitudes toward the end of life. It also demonstrated discriminant validity, as the DS-II differentiated patients who had different functional performance levels and high/low symptoms, with a difference of 2 points between groups on the DS-II considered clinically meaningful. Furthermore, discriminant validity was demonstrated, as comorbidity with depression was not observed at moderate levels of demoralization.

CONCLUSIONS

The DS-II has sound psychometric properties and is an appropriate measure of demoralization. Given its structural simplicity and brevity, it is likely to be a useful tool in meaning-centered therapies. Cancer 2016;122:2260-7. © 2016 American Cancer Society.

The relationship between pain management and psychospiritual distress in patients with advanced cancer following admission to a palliative care unit

Background

Although many cross-sectional studies have demonstrated the association between cancer pain and psychospiritual distress, the time-dependent relationship has not been fully explored. For that reason, this study aims to investigate the time-dependent relationship between psychospiritual distress and cancer pain management in advanced cancer patients.

Methods

This is a prospective observational study. Two hundred thirty-seven advanced cancer patients were recruited from a palliative care unit in Taiwan. Demographic and clinical data were retrieved at admission. Pain and psychospiritual distress (i.e.: anxiety, depression, anger, level of family and social support, fear of death) were assessed upon admission and one week later, by using a “Symptom Reporting Form”. Patients were divided into two groups according to the pain status one week post-admission (improved versus not improved groups).

Results

One hundred sixty-three (68.8 %) patients were assigned to the improved group, and 74 (31.2 %) patients were assigned to the not improved group. There were no differences in the psychospiritual variables between groups upon admission. In overall patients, all psychospiritual variables improved one week post-admission, but the improvement of depression and family/social support in the not improved group was not significant. Consistent with this, for depression scores, there was a statistically significant pain group x time interaction effect detected, meaning that the pain group effect on depression scores was dependent on time.

Conclusions

We demonstrated a time-dependent relationship between depression and pain management in advanced cancer patients. Our results suggest that poor pain management may be associated with intractable depression. The inclusion of interventions that effectively improve psychospiritual distress may contribute to pain management strategies for advanced cancer patients.

A Systematic Review and Meta-Analysis of Demoralization and Depression in Patients With Cancer

BACKGROUND

Demoralization is a psychological response that is frequently observed in patients with cancer or advanced diseases. Depression and demoralization syndrome in patients with cancer are closely related to suicidal behavior.

OBJECTIVE

The purpose of this study was to explore the factors affecting demoralization of patients with cancer from a depression perspective, to assist with distinguishing patient emotions and provide appropriate intervention as early as possible, thereby enabling patients to receive proper care.

METHODS

A systematic review and meta-analysis was employed in this study. The databases included Cumulative Index for Nursing and Allied Health Literature, Cochrane, PubMed/ MEDLINE, PsycINFO, and Centre for European Policy Studies, and reference lists of articles. Experts in this field also were contacted. Based on inclusion criteria, 2 investigators selected the research and reviewed each study's quality according to the Newcastle-Ottawa Scale. Five correlational studies with 32 subjects were identified.

RESULTS

The countries of studies included Australia, Germany, Taiwan, and the United States. There was a statistically significant difference in depression between patients with cancer in the high-demoralization group and those of the low-demoralization group (odds ratio = 9.65, 95% CI: 6.99-13.33, Z = 15.002, p < 0.0001). Four studies regarded demoralization and depression as distinguishable.

CONCLUSIONS

The demoralization of patients with cancer was highly correlated with depression. Therefore, the suicide risk of demoralized patients without depression must also be assessed to prevent patients with high suicide risk from being neglected. If medical staff can perceive patient's demoralization issues earlier, they can more effectively prevent patients' depression from occurring, which benefits suicide prevention.

Posttraumatic growth and demoralization after cancer: The effects of patients' meaning-making

Objective:

It is common for patients to experience positive and negative psychological changes (e.g., posttraumatic growth or demoralization) after being diagnosed with cancer. Although demoralization and posttraumatic growth are both related to meaning-making, little attention has been paid to the associations among these concepts. The current study investigated the relationship between demoralization, posttraumatic growth, and meaning-making (focusing on sense-making and benefit-finding during the experience of illness) in cancer patients.

Method:

Some 200 cancer patients (with lung cancer, lymphoma, or leukemia) at the MacKay Memorial Hospital in New Taipei completed the Demoralization Scale–Mandarin Version (DS–MV), the Chinese Posttraumatic Growth Inventory (CPTGI), and a self-designed questionnaire for assessing sense-making and benefit-finding.

Results:

Demoralization was negatively correlated with posttraumatic growth, sense-making, benefit-finding, and time-since-diagnosis. Multiple regression analysis showed that meaning-making had different effects on demoralization and posttraumatic growth. The interactions of sense-making with either benefit-finding or time-since-diagnosis significantly predicted demoralization. Individuals with relatively higher sense-making and benefit-finding or shorter time-since-diagnosis experienced less demoralization.

Significance of Results:

The suffering of cancer may turn on the psychological process of demoralization, posttraumatic growth, and meaning-making in patients. Cancer patients who evidenced higher posttraumatic growth experienced less demoralization. Trying to identify positive changes in the experience of cancer may be a powerful way to increase posttraumatic growth. As time goes by, patients experienced less demoralization. Facilitating sense-making can have similar effects. Cancer patients with less benefit-finding experience higher demoralization, but sense-making buffers this effect.

Demoralization: a systematic review on its clinical characterization

BACKGROUND

Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope.

METHODS

We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word 'demoralization' in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected.

RESULTS

Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes.

CONCLUSIONS

Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.

A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research

CONTEXT

Demoralization can be understood as a condition that results from existential conflict. It presents with symptoms of hopelessness and helplessness caused by a loss of purpose and meaning in life. It is a significant mental health concern given there can be an associated desire for hastened death.

OBJECTIVES

The aim of this systematic review was to synthesize the recent empirical evidence on demoralization in patients with progressive disease or cancer, including prevalence rates; the relationships between demoralization and sociodemographic, disease- and treatment-related, and psychological factors; and the psychometric properties of demoralization measures.

METHODS

A comprehensive literature search using key words and subject headings was performed following PRISMA guidelines with nine electronic bibliographic databases, resulting in 25 studies (33 articles) with a total of 4545 participants reviewed. Full articles underwent methodological quality assessment, and correlational information was synthesized according to the strength of evidence.

RESULTS

The findings suggest that demoralization is prevalent in patients with progressive disease or cancer and clinically significant in 13%-18%. A range of factors were consistently associated with demoralization: poorly controlled physical symptoms, inadequately treated depression and anxiety, reduced social functioning, unemployment, and single status. The Demoralization Scale has demonstrated good psychometric properties across five studies.

CONCLUSION

Overall, this systematic review was limited by the extent of variability in the characteristics of studies. Patients who are single, isolated or jobless, have poorly controlled physical symptoms, or have inadequately treated anxiety and depressive disorders are at increased risk for demoralization. Clinical recognition of demoralization can trigger more focused interventions.

A correlational study of suicidal ideation with psychological distress, depression, and demoralization in patients with cancer

PURPOSE

This study aims to study the effects of depression and demoralization on suicidal ideation and to determine the feasibility of the Distress Thermometer as a screening tool for patients with cancer who experience depression and demoralization, and thus to establish a model screening process for suicide prevention.

METHODS

Purposive sampling was used to invite inpatients and outpatients with lung cancer, leukemia, and lymphoma. Two hundred participants completed the questionnaire, which included the Distress Thermometer (DT), Patient Health Questionnaire-9 (PHQ-9), Demoralization Scale-Mandarin Version (DS-MV), and Beck Scale for Suicide Ideation. All data obtained were analyzed using SPSS 18.0 and SAS 9.3.

RESULTS

Tobit regression analysis showed that demoralization influenced suicidal ideation more than depression did (t = 2.84, p < 0.01). When PHQ-9 ≥ 10 and DS-MV ≥42 were used as criteria for the DT, receiver operating characteristic analysis revealed that the AUC values were 0.77-0.79, with optimal cutoff points for both of DT ≥5; sensitivity 76.9 and 80.6 %, respectively; and specificity of 73.9 and 72.2 %, respectively.

CONCLUSIONS

Demoralization had more influence on suicidal ideation than depression did. Therefore, attention should be paid to highly demoralized patients with cancer or high demoralization comorbid with depression for the purposes of suicide evaluation and prevention. The DT scale (with a cutoff of ≥5 points) has discriminative ability as a screening tool for demoralization or depression and can also be used in clinical settings for the preliminary screening of patients with cancer and high suicide risk.

Receiving palliative treatment moderates the effect of age and gender on demoralization in patients with cancer

Background

Existential distress is an important factor affecting psychological well-being in cancer patients. We studied occurrence and predictors of demoralization, a syndrome of existential distress, in particular the interaction of age, gender, and curative vs. palliative treatment phase.

Methods

A cross-sectional sample of N = 750 patients with different tumor sites was recruited from in- and outpatient treatment facilities. Patients completed the following self-report questionnaires: Demoralization Scale, Patient Health Questionnaire-9, Illness-Specific Social Support Scale Short Version-8, and physical problems list of the NCCN Distress Thermometer. Moderated multiple regression analyses were conducted.

Results

We found high demoralization in 15% and moderate demoralization in 8% of the sample. Curative vs. palliative treatment phase moderated the impact of age and gender on demoralization (three-way interaction: b = 1.30, P = .02): the effect of age on demoralization was negative for women receiving palliative treatment (b = −.26, P = .02) and positive for men receiving palliative treatment (b = .25, P = .03). Effects of age and gender were not significant among patients receiving curative treatment. Female gender was associated with higher demoralization among younger patients receiving palliative treatment only. Analyses were controlled for significant effects of the number of physical problems (b = 6.10, P<.001) and social support (b = −3.17, P<.001).

Conclusions

Existential distress in terms of demoralization is a relevant problem within the spectrum of cancer-related distress. It is associated with a complex interaction of demographic and medical patient characteristics; existential challenges related to palliative treatment may exacerbate the impact of age- and gender-related vulnerability factors on demoralization. Psychosocial interventions should acknowledge this interaction in order to address the individual nature of existential distress in subgroups of cancer patients.