Differentiation between demoralization, grief, and anhedonic depression

A tale of two constructs: combined assessment of demoralization and subjective incompetence

Demoralization comprises multiple dimensions. Among them, Subjective Incompetence (SI) is the perception of being incapable of appropriate action in demanding circumstances. SI may be an early sign of demoralization preceding hopelessness, thus we aimed at integrating items related to Subjective Incompetence into the clinical assessment of demoralization. We assessed 414 subjects from the general population with the Demoralization Scale, 24 items (DS24) and the Subjective Incompetence Scale, 12 items (SIS12). We used multiple approaches to detect the optimal number of factors and their item structure, then conducted Bayesian Item Response Theory analyses to study item psychometric properties. Item Response Theory models were used to extrapolate latent severity ratings of clinical dimensions. We modelled the DS24 with five factors (Disheartenment, Sense of Failure, Helplessness, Irritability, Loss of Purpose) and the SIS12 with three (Subjective Incompetence, Inability to plan, Inability to Deal). The more complex IRT model had the best predictive value and helped to identify the items with better discrimination properties across the different dimensions. Twenty items were retained and used to develop the combined Demoralization and Subjective Incompetence Scale (DSIS20), which maintained high correlation with raw and latent trait scores of the longer versions. We combined selected items of the DS24 and the SIS12 to develop the DSIS20, a shorter assessment instrument that includes Subjective Incompetence as well as other clinical dimensions of demoralization. Further study may clarify if DSIS20 may be helpful for the early detection of demoralization.

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.

Distinguishing and treating demoralization syndrome in cancer: A review

IMPORTANCE

Demoralization, characterized by a persistent inability to cope, as well as helplessness, hopelessness, and despair, is highly prevalent in oncology, with between 36% to 52% of patients exhibiting demoralization syndrome. Given established evidence linking demoralization in patients with cancer to physical symptom burden, quality of life, sleep disturbance, and suicidality, assessment and treatment of demoralization syndrome is critical for optimizing clinical and psychosocial outcomes.

OBSERVATIONS

The term "demoralization" is highly relevant to the care of patients with cancer facing life-limiting illnesses. Indeed, demoralization can be conceptualized as a feeling state characterized by the perception of being unable to cope with some pressing problems and/or of lack of adequate support from others. Despite a considerable overlap in symptoms, demoralization and depression should be regarded as distinct and independent clinical syndromes. Patients who are demoralized but not clinically depressed often describe a sense of subjective incompetence and do not report anhedonia (i.e., loss of interest and inability to enjoy things). Although the definition of demoralization is now included as a distinct syndrome in the International Classification of Diseases (ICD)-11, it has been neglected by the current U.S. official nosology in psychiatry, such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). As such, demoralization syndrome may be under- or misdiagnosed and treated ineffectively in the oncology setting, potentially prolonging suffering and influencing cancer outcomes.

CONCLUSIONS AND RELEVANCE

Optimization of methods to diagnose and assess demoralization syndrome is critical to underpin rigorous studies evaluating the efficacy of psychotherapeutic and pharmacological interventions for patients with cancer experiencing demoralization. Our review supports the use of specific diagnostic criteria for demoralization in cancer patients, introduces methodological considerations relevant to treatment studies, and presents a novel measurement approach to the assessment of demoralization severity with the Clinical Interview for Demoralization (CIDE).

Mental state of demoralisation across diverse clinical settings: A systematic review, meta-analysis and proposal for its use as a 'specifier' in mental illness

OBJECTIVE

Demoralisation is a state of poor coping characterised by low morale, hopelessness, subjective incompetence, and loss of meaning and purpose in life. While studied extensively in oncology and palliative care, there has been recent exploration in broader medical and mental health settings. The aim was to investigate the prevalence of demoralisation and associated sociodemographic and psychological factors across these clinical settings.

METHOD

Six electronic databases were used to locate articles from January 2014 to March 2020. A pre-publication update of non-oncology populations was completed in September 2021. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled prevalence of demoralisation was determined through % prevalence and mean demoralisation score; this was synthesised through meta-analysis of single means to determine pooled mean prevalence of Demoralisation Scale scores using the 'R' statistical software.

RESULTS

Demoralisation has been examined in 52 studies (n = 11,670) and found to be prevalent in 24-35% of oncology and non-oncology, including mental health, populations. The mean score on the Demoralisation Scale was 24.3 (95% confidence interval, CI = [21.3, 27.3]). There was evidence of divergent validity in addition to significant comorbidity between depression, demoralisation and suicidal ideation. Burdensome physical symptoms, and psychological and demographic factors are strongly correlated with demoralisation.

CONCLUSION

There remains a need to recognise demoralisation in various clinical and cultural settings and to strongly consider its inclusion as a 'specifier' within formal nosological systems for adjustment and depressive disorders. This is important to initiate targeted interventions and prevent significant morbidity.

The relationship between demoralization and depressive symptoms among patients from the general hospital: network and exploratory graph analysis

INTRODUCTION

Depression and demoralization are highly prevalent among individuals with physical illnesses but their relationship is still unclear.

OBJECTIVE

To examine the relationship between clinical features of depression and demoralization with the network approach to psychopathology.

METHODS

Participants were recruited from the medical wards of a University Hospital in Italy. The Demoralization Scale (DS) was used to assess demoralization, while the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms. The structure of the depression-demoralization symptom network was examined and complemented by the analysis of topological overlap and Exploratory Graph Analysis (EGA) to identify the most relevant groupings (communities) of symptoms and their connections. The stability of network models was estimated with bootstrap procedures and results were compared with factor analysis.

RESULTS

Life feeling pointless, low mood/discouragement, hopelessness and feeling trapped were among the most central features of the network. EGA identified four communities: (1) Neurovegetative Depression, (2) Loss of purpose, (3) Frustrated Isolation and (4) Low mood and morale. Loss of purpose and low mood/morale were largely connected with other communities through anhedonia, hopelessness and items related to isolation and lack of emotional control. Results from EGA displayed good stability and were comparable to those from factor analysis.

LIMITATIONS

Cross-sectional design; sample heterogeneity CONCLUSIONS: Among general hospital inpatients, features of depression and demoralization are independent, with the exception of low mood and self-reproach. The identification of symptom groupings around entrapment and helplessness may provide a basis for a dimensional characterization of depressed/demoralized patients, with possible implications for treatment.

Impact of Depression and Demoralization on Blood Pressure Control in African Americans with Hypertension: Findings from the TRIUMPH Trial

BACKGROUND

African Americans develop hypertension earlier and have worse cardiovascular outcomes than Caucasians. Accumulating evidence suggests that psychological distress may play a role in the observed racial differences in hypertension. Several studies have investigated the relationship between depression and hypertension while little is still known about the role of demoralization.

METHODS

Using data from the Trial Using Motivational Interviewing, Positive Affect, and Self-affirmation in African Americans with Hypertension (TRIUMPH), logistic regression models were used to estimate differences in blood pressure control at 12 months among participants with demoralization, depression, and both conditions.

RESULTS

Our logistic models showed that reported psychosocial symptoms significantly differed in predicting success in blood pressure control at 12 months. Contrast analyses showed that, after adjusting for sociodemographic, clinical, and psychosocial variables, demoralized patients were less likely to achieve blood pressure control than participants without affective conditions (p = 0.020). Similar results emerged for patients with depression (p = 0.042) and both conditions (p = 0.022).

CONCLUSIONS

Depression can be extremely debilitating and has serious health consequence. Our findings confirm this result and show that, even though depression and demoralization share common features, they are two distinct clinical phenomena with similar negative impact on blood pressure control in African Americans.

Demoralisation syndrome does not explain the psychological profile of community-based asylum-seekers

BACKGROUND

Demoralisation syndrome (DS) has been advanced as a construct that features hopelessness, meaninglessness, and existential distress. Demoralisation and DS have predominantly been considered secondary only to illness; hence there is scant research on demoralisation or DS in populations affected by extreme environmental stress.

AIMS

The current study aimed to determine the prevalence of demoralisation, its predictors, and the relevance of DS in a community-based forced-migrant population.

METHOD

A convenience sample of 131 adult asylum-seekers (n=98) and refugees (n=33) without recognised mental disorders in Melbourne, Australia, were assessed cross-sectionally on posttraumatic stress, anxiety, depression, post-migration stress, and demoralisation. Socio-demographic data were analysed with relevant clinical data. Predictive aims were investigated using bivariate statistical tests and exploratory aims were investigated using correlational and linear regression analyses.

RESULTS

Seventy nine percent of the sample met criteria for demoralisation (asylum-seekers=83%; refugees=66%), with asylum-seekers being 2.55 (95% C.I.=1.03-6.32, Z=2.03, p=.04) times more likely to be demoralised than refugees. No relationship between demoralisation and time in the refugee determination process emerged. The regression model explained 47.5% of variance in demoralisation scores for the total sample F(9,111)=13.07, p<.0001, with MDD and anxiety score making unique significant contributions.

CONCLUSIONS

Demoralisation was widespread through the asylum-seeker and refugee population and its prevalence was attributable to a range of social and psychiatric factors. However, DS had little explanatory power for psychiatric morbidity, which was more suggestive of a pan-distress symptom complex.

A Review of the Construct of Demoralization

Demoralization has been the subject of discussion in relation to end-of-life care. It is characterized by hopelessness and helplessness due to a loss of purpose and meaning. The purpose of this review was to consolidate the conceptual understanding of demoralization and argue for its existence as a psychiatric syndrome. The history of the construct is explored, including the nature of existential distress and related psychological conditions that precipitate demoralization. Recent definitions of demoralization are described and differentiated from similar constructs. Future directions are highlighted, specifically in relation to the assessment, diagnosis, and treatment of demoralization in palliative care. Overall, demoralization is a clinically useful construct for those facing existential threat, guiding the clinician toward efforts to restore morale, meaning, and purpose.

Demoralization in health professional practice: development, amelioration, and implications for continuing education

Demoralization is a feeling state of dejection, hopelessness, and a sense of personal "incompetence" that may be tied to a loss of or threat to one's own goals or values. It has an existential dimension when beliefs and values about oneself are disconfirmed. Numerous sources describe high rates of dissatisfaction and burnout in physicians and other health professionals. This article reviews historical and empirical findings that describe the professional and personal value orientations of physicians and other health professionals. It reviews empirical and theoretical findings to consider the implications of conflict between these values and negatively perceived ethical and values orientations of health care organizations and commercial health care entities. Conflicts between personal and professional values of health professionals and larger health care related organizations and commercial entities with which they are associated may contribute to the development of demoralization and burnout. Physicians and other health professionals frequently experience values related conflicts with larger social, organizational or bureaucratic systems. These conflicts place health professionals at risk for demoralization and burnout. "Remoralization," or renewal of morale, depends on the reestablishment of the potential for fulfillment of one's values in the work environment. This depends on organizational, group, and personal efforts. Continuing education and continuing professional development programs should have a programmatic focus on the importance of a values orientation in health care and support program development aimed at recognizing, addressing, and reducing demoralization and its potential for negative health care consequences for health professionals and patients.

Addressing demoralization in clinical staff: a true test of leadership

Demoralization is a state that occurs when an individual's personal or professional goals, principles, or values are threatened. Psychiatrists working in mental healthcare organizations may experience demoralization for numerous reasons, including diminished funding for valued programs, personnel reductions, and administrative burdens hindering patient care. Demoralization places psychiatrists and other mental health professionals at increased risk for burnout, and its associated problems related to physical and mental difficulties, poor patient care, and staff losses and turnover. Demoralization, therefore, presents an important challenge to medical and clinical leaders who must address this issue to maintain the organizational commitment to optimal patient-centered care. This can be done using sound and accepted leadership principles coupled with a values orientation. The paper provides an illustration.