1
|
Mousavi N, Piryaei M, Nooripour R, Kissane D, Hooshyari Z, Effatpanah M, Ghanbari N. Psychometric properties for Persian version Demoralization Scale-24 (DS-24) in Iranian cancer patients. Brain Behav 2024; 14:e3589. [PMID: 39073680 DOI: 10.1002/brb3.3589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/04/2024] [Accepted: 05/14/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND This study focuses on the phenomenon of demoralization, a common experience among terminally ill patients, especially those diagnosed with cancer. The primary objective is to adapt and validate a practical assessment tool for demoralization, the Demoralization Scale-24 (DS-24), within the context of Iranian society. METHODS In this cross-sectional study, we employed the DS-24 as the principal instrument, which had been exactly translated and evaluated for its psychometric properties in 160 Persian cancer patients. The assessment included exploratory factor analysis, confirmatory factor analysis (CFA), as well as evaluations of convergent validity and internal consistency or reliability. RESULTS The CFA unveiled a five-factor model, consistent with the original structure of the DS-24. Moreover, statistically significant correlations were observed between the DS-24 and both the Beck Depression and MUNSH happiness scales. Cronbach's alpha indicated high internal consistency, with a value of .92 for the total score. CONCLUSION In Iran, like in other countries, the demoralization questionnaire demonstrates significant validity and reliability. This ensures the timely diagnosis of demoralization in cancer patients and the prompt initiation of therapeutic interventions.
Collapse
Affiliation(s)
- Nazanin Mousavi
- School of Psychology, Imam Khomeini University, Qazvin, Iran
| | - Mandana Piryaei
- Department of Psychology, Faculty of Literature and Humanities, University of Guilan, Rasht, Iran
| | - Roghieh Nooripour
- Department of Counseling, Qazvin Branch, Islamic Azad University, Qazvin, Iran
- Department of Counseling, Faculty of Education and Psychology, Alzahra University, Tehran, Iran
| | - David Kissane
- Cunningham Centre for Palliative Care Research, St Vincent's Sydney and Szalmuk Family Research Unit at Cabrini Health, University of Notre Dame Australia, Clayton, Australia
| | - Zahra Hooshyari
- Faculty of Psychology and Education, University of Tehran, Tehran, Iran
| | - Mohammad Effatpanah
- Professor of child & Adolescent Psychiatry, Pediatric Department, school of medicine, Imam Khomeini hospital, Tehran University of Medical Science, Tehran, Iran
| | - Nikzad Ghanbari
- Department of Clinical Psychology, Faculty of Psychology and Educational Sciences, Shahid Beheshti University, Tehran, Iran
| |
Collapse
|
2
|
Foroughi A, Khanjani S, Moghadam MS, Parvizifard A. The psychometric properties of the Persian version of the Demoralization Scale (DS-II) in women with breast cancer. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 29:14. [PMID: 38808221 PMCID: PMC11132418 DOI: 10.4103/jrms.jrms_94_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 05/30/2024]
Abstract
Background Demoralization is a syndrome of existential distress and despair in patients with cancer and other severe medical illnesses. The Demoralization Scale (DS-II) is self-administered and contains 16 items, and it has two factors: meaning and purpose and distress and coping ability. Materials and Methods Women with breast cancer (240) completed the scales DS-II, positive and negative affect, state hope, patient health, and quality of life. Confirmatory factor analysis (CFA) and divergent and convergent validity were used to measure the construct validity of DS-II. CFA was chosen to check the fit of the two-factor model. Divergent and convergent validity were investigated using Pearson's correlation test. The reliability of DS-II was evaluated by the internal consistency method. Cronbach's alpha was used to calculate the internal consistency of the DS-II. Results The Cronbach's alpha coefficient for the subscales of meaning and purpose, distress and coping ability, and the total score was obtained: 0.67, 0.72, and 0.81, respectively, indicated this scale's good reliability. Furthermore, the Pearson correlation coefficient results showed the appropriate convergent validity and good divergent validity of the DS-II. Conclusion The DS-II has sound psychometric properties and can be recommended as a reliable tool for assessing demoralization in women with breast cancer.
Collapse
Affiliation(s)
- Aliakbar Foroughi
- Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Sajad Khanjani
- Research Center for Cognitive and Behavioral Sciences in Police, Directorate of Health, Rescue and Treatment, Police Headquarter, Tehran, Iran
| | | | - Aliakbar Parvizifard
- Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
3
|
Soleymani Moghadam M, Parvizifard A, Foroughi A, Ahmadi SM, Farshchian N. An investigation of the effect of mindfulness-integrated cognitive behavior therapy on demoralization, body image, and sexual function in Iranian women with breast cancer: a randomized controlled trial. J Cancer Res Clin Oncol 2024; 150:128. [PMID: 38485807 PMCID: PMC10940429 DOI: 10.1007/s00432-024-05655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/18/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Breast cancer is an extremely unpleasant and unbearable experience that can have a profound impact on a person's life. Compared to other types of cancer, breast cancer has a more severe psychological impact on women. PURPOSE This study aimed to investigate the effect of mindfulness-integrated cognitive behavior therapy on demoralization, body image, and sexual function in Iranian women with breast cancer. METHOD A sample of 30 women with breast cancer were randomly divided into intervention and control groups. The research was conducted in the oncology division of Imam Reza Hospital in Kermanshah by the clinical trial method with a two-group pretest-posttest design and a 2 month follow-up. Participants in the intervention group received Mindfulness-integrated cognitive behavior therapy for eight sessions. The intervention was carried out individually in weekly 60 min sessions. While the control group received self-help treatment (through an educational book). A demographic questionnaire, Demoralization Scale (DS-II), Body Image Scale (BIS), and Female Sexual Function Index (FSFI) were used to collect data. For data analysis, means and standard deviations were calculated and repeated measures and the Bonferroni test was conducted using SPSS 26. RESULTS The results showed the effectiveness of mindfulness-integrated cognitive behavior therapy on demoralization, body image, and sexual function (p < 0.05). Concerning demoralization in the intervention group, the pre-test mean was 16.73 ± 3.33, and it reduced to 11.93 ± 1.49 in the post-test. The body image mean score showed a decreasing trend in the intervention group, from 12.47 ± 1.88 in the pre-test to 8.80 ± 3.21 in the post-test. The mean score for sexual function showed an increasing trend, increasing from 18.06 ± 2.29 in the pre-test to 23.07 ± 0.91 in the post-test. There was no significant difference in the mean score of the post-test compared to the pre-test and follow-up in the control group (p < 0.05). CONCLUSION MICBT can be used in conjunction with pharmaceuticals and medical treatments to improve the psychological symptoms of women with breast cancer, according to this study's results. Trial registration (IRCT20160103025817N6). 2022-04-06.
Collapse
Affiliation(s)
| | - Aliakbar Parvizifard
- Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Aliakbar Foroughi
- Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Seyed Mojtaba Ahmadi
- Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Negin Farshchian
- Department of Radiation Oncology, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
4
|
Thomas C, Kulikowksi JD, Breitbart W, Alici Y, Bruera E, Blackler L, Sulmasy DP. Existential suffering as an indication for palliative sedation: Identifying and addressing challenges. Palliat Support Care 2024:1-4. [PMID: 38419195 DOI: 10.1017/s1478951524000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Julia D Kulikowksi
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
| |
Collapse
|
5
|
Kissane DW. Education and assessment of psycho-existential symptoms to prevent suicidality in cancer care. Psychooncology 2024; 33:e5519. [PMID: 33463852 DOI: 10.1002/pon.5519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/10/2020] [Indexed: 11/06/2022]
Affiliation(s)
- David W Kissane
- University of Notre Dame Australia and Cunningham Centre for Palliative Care Research, St Vincent's Sydney, Sydney, Australia
- Cabrini Health Psycho-oncology and Palliative Care, Monash University, Melbourne, Australia
| |
Collapse
|
6
|
Lin CC, Her YN. Demoralization in cancer survivors: an updated systematic review and meta-analysis for quantitative studies. Psychogeriatrics 2024; 24:35-45. [PMID: 37877340 DOI: 10.1111/psyg.13037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 09/18/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Demoralization can cause impairments across all life aspects of cancer patients. Cancer patients are also vulnerable during their survivorship. The purpose of this review is to examine the risk of demoralization and associated risk factors among cancer survivors who have completed their primary anti-cancer treatment or time since diagnosis ≥5 years without recurrence. METHODS We searched databases of PubMed, Cochrane, Embase, PsycINFO and ClinicalTrial.gov to identify eligible studies which reported the demoralization level among cancer survivors. A random-effect meta-analysis model was used for calculating mean demoralization level. Heterogeneity was evaluated by I2 statistics. Funnel plots and Egger's regression tests were performed for checking publication bias. We used one-study-removed method for sensitivity analysis. Subgroup analysis was also done to examine the difference of demoralization level between cancer types. Meta-regression was performed to reveal risk factors of demoralization. RESULTS A meta-analysis of 12 articles involving 2902 cancer survivors was conducted. The mean demoralization score among cancer survivors was 25.98 (95% CI: 23.53-28.43). Higher demoralization level was seen in participants with older age, higher female ratio, higher married/living together status ratio and higher patient health questionnaire-9 score. The literature review revealed correlations between demoralization and suicide risk, anxiety and quality of life. No consistent correlation between demoralization and post-traumatic stress symptoms could be seen. CONCLUSIONS High demoralization level is noticed among cancer survivors. Risks for females, elder patients or breast cancer survivors are identified. More longitudinal or interventional studies for cancer survivors' demoralization are expected in the future.
Collapse
Affiliation(s)
- Cian-Cian Lin
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Ning Her
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| |
Collapse
|
7
|
Kang T, Liu F, Jiang Q, Han J, Guo R. Risk Factors of Demoralization Among Lung Cancer Patients in Mainland China. Am J Health Behav 2023; 47:588-594. [PMID: 37596747 DOI: 10.5993/ajhb.47.3.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
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.
Collapse
Affiliation(s)
- Tengteng Kang
- Nursing Department, Zhoukou Vocational and Technical College, Zhoukou, China
| | - Fangli Liu
- College of Nursing and Health, Henan University, Henan, China
| | - Qiuhuan Jiang
- Department of Nursing Quality Management, Henan Province Peoples Hospital, Henan, China
| | - Jingyi Han
- Nursing Department, Nanyang Central Hospital, Nanyang, China
| | - Rui Guo
- Medical School, Zhoukou Vocational and Technical College, Zhoukou, China
| |
Collapse
|
8
|
Pinucci I, Maraone A, Tarsitani L, Pasquini M. Insomnia among Cancer Patients in the Real World: Optimising Treatments and Tailored Therapies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3785. [PMID: 36900794 PMCID: PMC10001409 DOI: 10.3390/ijerph20053785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Insomnia is commonly reported by cancer patients. Its multifaceted pathophysiology makes this symptom a complex challenge for the clinician, who should bear in mind the manifold world of causes and consequences of sleep disturbances in these patients and the importance of accurate treatment that should consider the frequent co-prescription of multiple medications. With our work, we aim to provide a tool to better master the treatment of this symptom in cancer patients, considering the gap between clinical and pharmacodynamic knowledge about the efficacy of different molecules and evidence-based prescribing. METHODS A narrative review of the studies investigating the pharmacological treatment of insomnia in cancer patients was conducted. Three hundred and seventy-six randomised controlled trials (RCTs), systematic reviews and meta-analyses were identified through PubMed. Only publications that investigated the efficacy of the pharmacological treatment of insomnia symptoms in cancer patient were considered. RESULTS Among the 376 publications that were individuated, fifteen studies were eligible for inclusion in the review and were described. Pharmacological treatments were outlined, with a broad look at specific clinical situations. CONCLUSIONS The management of insomnia in cancer patients should be personalised, as is already the case for the treatment of pain, taking into account both the pathophysiology and the other medical treatments prescribed to these patients.
Collapse
|
9
|
Woźniewicz A, Cosci F. Clinical utility of demoralization: A systematic review of the literature. Clin Psychol Rev 2023; 99:102227. [PMID: 36462221 DOI: 10.1016/j.cpr.2022.102227] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/28/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Agnieszka Woźniewicz
- Department of Geriatrics, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Jurija Gagarina 11, 87-100 Toruń, Poland
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, via di San salvi n. 12, Florence, Italy; Department of Psychiatry and Neuropsychology, Maastricht University, PO Box 616 6200, MD, Maastricht, The Netherlands.
| |
Collapse
|
10
|
Bovero A, Zerbinati L, Grassi L, Mah K, Rodin G, Hales S, Malfitano C, TIberto E, Leombruni P, Miniotti M, Caruso R. The Italian validation of the Death and Dying Distress Scale. Palliat Support Care 2022; 21:1-9. [PMID: 36476559 DOI: 10.1017/s1478951522001638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Death anxiety (DA), a condition characterized by fear, angst, or panic related to the awareness of one's own death, is commonly observed in advanced cancer patients. The aim of this study was to examine the psychometric properties of the Italian version of the Death and Dying Distress Scale (DADDS-IT) in a sample of patients with advanced cancer. METHODS The sample included 200 Italian advanced cancer patients meeting eligibility criteria to access palliative care. Patients' levels of DA were assessed by using the DADDS-IT, while the levels of depression, anxiety, demoralization, spiritual well-being, and symptom burden were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Demoralization Scale, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale, and the Edmonton Symptom Assessment System, respectively; Karnofsky Performance Status was used to measure functional impairment. Confirmatory factor analyses (CFA) of previous structures and exploratory factor analyses (EFA) were conducted. RESULTS CFA revealed that none of the previous structures adequately fitted data from our sample. EFA revealed a 4-factor model comprising Finitude (α = 0.91), Regret (α = 0.86), Dying (α = 0.88), and Relational Burden (α = 0.73), accounting for the 77.1% of the variance. Dying subscore was higher in hospice patients than in those recruited in medical wards. SIGNIFICANCE OF RESULTS The present study provides further evidence that DA is a condition that deserves attention and that DADDS-IT shows good psychometric properties to support its use in research and clinical settings.
Collapse
Affiliation(s)
- Andrea Bovero
- Clinical Psychology Unit, Department of Neuroscience, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Luigi Zerbinati
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, Ferrara, Italy
- University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, University S. Anna Hospital and Health Trust, Ferrara, Italy
| | - Luigi Grassi
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, Ferrara, Italy
- University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, University S. Anna Hospital and Health Trust, Ferrara, Italy
| | - Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gary Rodin
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sarah Hales
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Carmine Malfitano
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Elisa TIberto
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, Ferrara, Italy
| | - Paolo Leombruni
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Marco Miniotti
- "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Rosangela Caruso
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, Ferrara, Italy
- University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, University S. Anna Hospital and Health Trust, Ferrara, Italy
| |
Collapse
|
11
|
Kissane DW, Appleton J, Lennon J, Michael N, Chye R, King T, William L, Poon P, Kanathigoda S, Needham K, Bobevski I. Psycho-Existential Symptom Assessment Scale (PeSAS) Screening in Palliative Care. J Pain Symptom Manage 2022; 64:429-437. [PMID: 35961431 DOI: 10.1016/j.jpainsymman.2022.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/21/2022] [Accepted: 08/02/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Psycho-existential symptoms are common yet often missed or neglected in palliative care. Screening can be an effective way to recognize and respond to this need. OBJECTIVES We aimed to implement routine use of the Psycho-existential Symptom Assessment Scale (PeSAS) as a screening tool in Australian palliative care services and discern the symptom prevalence identified. METHODS In a multi-site rolling design, we established implementation site committees and embarked on experiential workshops to train clinicians in the tool's efficient use. Patient symptom prevalence data were collected to compare uptake across sites. Descriptive statistics were applied. RESULTS Over one year, we trained 216 clinicians across six palliative care services in the use of the PeSAS as a screening tool and collected data from 1405 patients. Clinicians reported significant growth in their sense of efficacy in assessing psycho-existential wellness. Services using electronic records implemented most easily. Psycho-existential symptoms with clinically significant prevalence (scores ≥ 4/10) included anxiety 41.1%, discouragement 37.6%, hopelessness 35.8%, pointlessness 26.9%, depression 30.3%, and the wish to die 17%. The precision of measurement within 3% was found for severe ratings (score ≥ 8/10) including anxiety 10.6%, depression 10.2%, the wish to die 7.6%, and confusion 3.6%. CONCLUSION Clinicians can be trained to screen with the Psycho-existential Symptom Assessment Scale, which serves as a valuable measure to better recognize symptoms of psycho-existential distress among palliative care patients. Implementation barriers included the prior ethos of the service, confidence in talking about these themes, electronic data entry, and perceived time pressures.
Collapse
Affiliation(s)
- David W Kissane
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW; Cabrini Health (D.W.K., N.M., I.B.), Melbourne, Victoria; School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria; Monash Health (D.W.K., P.P.), Melbourne, Victoria.
| | - Jane Appleton
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Jonathon Lennon
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Natasha Michael
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; Cabrini Health (D.W.K., N.M., I.B.), Melbourne, Victoria; School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria
| | - Richard Chye
- St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Tania King
- Eastern Palliative Care (T.K.), Victoria
| | - Leeroy William
- School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria; Eastern Health (L.W.), Melbourne, Victoria
| | - Peter Poon
- School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria; Monash Health (D.W.K., P.P.), Melbourne, Victoria
| | | | - Katarina Needham
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; St. Vincent's Hospital (D.W.K., J.A., J.L., R.C., K.N.), Sydney, NSW
| | - Irene Bobevski
- School of Medicine (D.W.K, J.A., J.L., N.M., K.N., I.B.), University of Notre Dame Australia; Cabrini Health (D.W.K., N.M., I.B.), Melbourne, Victoria; School of Clinical Sciences (D.W.K., N.M., L.W., P.P., I.B.), Monash University, Victoria
| |
Collapse
|
12
|
The Demoralization Interview: Reliability and validity of a new brief diagnostic measure among medically ill patients. Gen Hosp Psychiatry 2022; 79:50-59. [PMID: 36274426 DOI: 10.1016/j.genhosppsych.2022.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Demoralization is a state of low morale and poor coping that is being increasingly recognized in stressful circumstances, such as illness. Meta-analyses show prevalence of 30% in the medically and 50% in the mentally ill. A brief structured diagnostic interview is needed to assess for and diagnose demoralization. METHODS The Demoralization Interview (DI) was designed from items of the Demoralization Scale-II (DS-II) and common items used in other clinical interviews. The resultant 26 items were administered to 264 patients with serious progressive medical illnesses, together with the DS-II, measures of depression, anxiety, and quality of life. Rasch analysis was used to co-calibrate the DI against the DS-II. Sensitivity, specificity, and area under the receiver operating characteristics curve (AUROC) were assessed. Concurrent validation was conducted against measures of anxiety, depression, and quality of life. RESULTS A 14-item Demoralization Interview (DI) with a diagnostic threshold of 6 symptoms generated sensitivity of 78.0%, specificity of 90.9%, and AUROC of 0.84 against the DS-II. Unidimensionality was indicated, with a Cronbach's alpha of 0.81. For respondents with 6 or more symptoms on the DI, 98% recognized a current stressor and 66% described significant distress or functional impairment. Demoralized respondents carried significantly lower quality of life, higher physical disability, and higher depressive and anxiety symptoms. CONCLUSIONS The DI has good reliability and validity, with a threshold of 6 symptoms supporting a diagnosis of demoralization. It could be used as a stand-alone diagnosis, or as a specifier for adjustment disorder or depression.
Collapse
|
13
|
Gan LL, Gong S, Kissane DW. Mental state of demoralisation across diverse clinical settings: A systematic review, meta-analysis and proposal for its use as a 'specifier' in mental illness. Aust N Z J Psychiatry 2022; 56:1104-1129. [PMID: 34879712 DOI: 10.1177/00048674211060746] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Lucy L Gan
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia.,Department of Psychiatry, Austin Health, Heidelberg, VIC, Australia
| | - Susanna Gong
- Department of Psychiatry, Monash Health, Clayton, VIC, Australia
| | - David W Kissane
- Department of Psychiatry, Monash Health, Clayton, VIC, Australia.,School of Medicine, University of Notre Dame Australia and Cunningham Centre for Palliative Medicine Research, St Vincent's Sydney, Sydney, NSW, Australia.,Cabrini Health, Monash University, Clayton, VIC, Australia
| |
Collapse
|
14
|
Costanza A, Vasileios C, Ambrosetti J, Shah S, Amerio A, Aguglia A, Serafini G, Piguet V, Luthy C, Cedraschi C, Bondolfi G, Berardelli I. Demoralization in suicide: A systematic review. J Psychosom Res 2022; 157:110788. [PMID: 35334350 DOI: 10.1016/j.jpsychores.2022.110788] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In psychiatric literature, few original studies exist on the topic of demoralization in suicide. In this review, we aim to identify original studies on suicidal ideation (SI)/suicidal behavior (SB) and demoralization in populations of community-dwellers and patients with somatic or psychiatric disorders. METHODS We employed a systematic approach that followed PRISMA guidelines, searching through four major electronic databases (PubMed/MEDLINE, Scopus, Science Direct, and PsychINFO) for relevant titles/abstracts published from January 1980-June 2021. We included original studies that explicitly mentioned the investigation of a potential association between SI/SB and demoralization. RESULTS A total of 18 studies met our inclusion criteria. Their synthesis revealed that demoralization can be associated with SI/SB in a wide range of populations (community dwellers, patients with somatic or psychiatric disorders) and lead to significantly higher suicide risk (odds ratios of >6 were encountered in community dwellers experiencing financial hardship or isolation). Moreover, demoralization alone (about half the patients who were demoralized did not meet the criteria for an affective disorder nor were they clinically depressed) or together with depression has been identified as a major risk factor for SI/SB. Regarding the crucial issue of progression from SI to SA, in the context of the "ideation-to-action" frame, some authors found that the interaction of demoralization and over-arousal could be a useful predictor for this progression, while others found that depression alone was sufficient to differentiate attempters from non-attempters or the interaction with shutdown (helplessness and low positive emotions). CONCLUSION These results emphasize the possibility to identify demoralization as an independent risk factor for suicide. In patients with psychiatric disorders, the association between demoralization and SI/SB may be transnosographic. Overall, from the clinical implications perspective, our findings highlight that: i. Assessment of demoralization may contribute to a more comprehensive suicide risk detection. This appears particularly relevant in Emergency Departments (EDs) where heterogeneous population typologies are usually admitted and a clinical diagnosis of depression is often difficult to be defined. ii. Additionally, since meaninglessness is considered one of the demoralization subcomponents, meaning-centered psychotherapeutic approaches prove to be indicated and they can be initiated already at the EDs upon first contact with the patient. Further studies are necessary to confirm these findings.
Collapse
Affiliation(s)
- Alessandra Costanza
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland.
| | - Chytas Vasileios
- Division of Clinical Pharmacology & Toxicology, Multidisciplinary Pain Centre (MPC), University Hospitals of Geneva (HUG), Switzerland
| | - Julia Ambrosetti
- Department of Psychiatry and Department of Emergency, Emergency Psychiatric Unit (UAUP), Geneva University Hospitals (HUG), 1211 Geneva, Switzerland
| | - Sanam Shah
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm U1018, Paris, France
| | - Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Valérie Piguet
- Division of Clinical Pharmacology & Toxicology, Multidisciplinary Pain Centre (MPC), University Hospitals of Geneva (HUG), Switzerland
| | - Christophe Luthy
- Division of General Medical Rehabilitation, Geneva University Hospitals (HUG), Switzerland; Department of Geriatrics and Rehabilitation, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
| | - Christine Cedraschi
- Division of Clinical Pharmacology & Toxicology, Multidisciplinary Pain Centre (MPC), University Hospitals of Geneva (HUG), Switzerland; Division of General Medical Rehabilitation, Geneva University Hospitals (HUG), Switzerland; Department of Geriatrics and Rehabilitation, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
| | - Guido Bondolfi
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland; Department of Psychiatry, Service of Liaison Psychiatry and Crisis Intervention (SPLIC), Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Isabella Berardelli
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
15
|
Sancassiani F, Gambino S, Lindert J, Sali L, Pinna I, Origa G, Cossu G, Scartozzi M, Preti A. The Reliability and Test-Retest Stability of the Treatment Perception Questionnaire (TPQ) in the Oncology Field: A Pilot Study. Clin Pract Epidemiol Ment Health 2021; 17:324-330. [PMID: 35444706 PMCID: PMC8985465 DOI: 10.2174/1745017902117010324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022]
Abstract
Background:
Patients' satisfaction is an indicator of technical, instrumental, environmental, and interpersonal aspects of care. It shows how much the health service “as a whole organization” meets the patients’ psychosocial expectations and if the health professionals combine their technical competence with relational skills. The Treatment Perception Questionnaire (TPQ) is a brief instrument developed in the United Kingdom for research with substance abuse disorder populations. The present study aimed at evaluating the reliability and test-retest stability of the TPQ Italian translation in a sample of patients with solid and blood cancers.
Methods:
The TPQ was administered to 263 people with solid and blood cancers. Test-retest reliability was evaluated in a subgroup of 116 participants who completed the TPQ again after 3 months.
Results:
The reliability of TPQ was good. Cronbach’s alpha: 0.83 (95%CI: 0.79-0.86), 0.66 (0.59-0.72), 0.71 (0.65-0.769), respectively, in the total test, and in subscales on “staff perception”, and “program perception”. Test-retest reliability was 0.82 (0.77-0.87). The mean difference between the first and the second assessment was 1.0 (SD = 7.1; 95% CI -0.35 to 2.33). By plotting the differences and the means of the two assessments, 5/116 cases (4.3%) were outside the upper and lower limits of agreement.
Conclusions:
This study points out good reliability and test-retest stability of the TPQ in the oncology field. The TPQ can be used to assess variation over time about satisfaction with care in patients with oncological diseases, favoring the identification of unmet patients’ needs about the quality of the service.
Collapse
|
16
|
Bobevski I, Kissane DW, Vehling S, Mehnert‐Theuerkauf A, Belvederi Murri M, Grassi L. Demoralisation and its link with depression, psychological adjustment and suicidality among cancer patients: A network psychometrics approach. Cancer Med 2021; 11:815-825. [PMID: 35122411 PMCID: PMC8817077 DOI: 10.1002/cam4.4406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/05/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background Demoralisation is a clinically significant problem among cancer patients with a prevalence of 13%–18%. It is defined by difficulty in adjusting to a stressor, wherein the person feels trapped in their predicament and experiences helplessness, hopelessness, loss of confidence and loss of meaning in life. Demoralisation has a strong link with the desire for hastened death and suicidal ideation among the medically ill. This study explored whether a group of symptoms could be identified, distinct from depression, but consistent with adjustment difficulties with demoralisation and linked to ideation of death and suicide. Methods Exploratory Graph Analysis, a network psychometrics technique, was conducted on a large German study of 1529 cancer patients. Demoralisation was measured with the Demoralisation Scale II and depressive symptoms with the PHQ‐9. Results A network of symptoms, with four stable communities, was identified: 1. Loss of hope and meaning; 2. Non‐specific emotionality; 3. Entrapment; 4. Depressive symptoms. The first three communities were clearly distinct from the PHQ‐9 depressive symptoms, except for suicidality and fear of failure. Community 1, Loss of hope and meaning, had the strongest association with thoughts of death and suicide. Hopelessness, loss of role in life, tiredness, pointlessness and feeling trapped were the most central symptoms in the network. Conclusions Communities 1 to 3 are consistent with poor coping without anhedonia and other classic depression symptoms, but linked to suicidal ideation. For people facing the existential threat of cancer, this may indicate poor psychological adjustment to the stressors of their illness.
Collapse
Affiliation(s)
- Irene Bobevski
- Department of Psychiatry School of Clinical Sciences at Monash Health Faculty of Medicine, Nursing and Health Sciences Monash University Clayton VIC Australia
- Palliative Medicine University of Notre Dame Darlinghurst NSW Australia
| | - David W. Kissane
- Department of Psychiatry School of Clinical Sciences at Monash Health Faculty of Medicine, Nursing and Health Sciences Monash University Clayton VIC Australia
- Palliative Medicine University of Notre Dame Darlinghurst NSW Australia
| | - Sigrun Vehling
- Department of Medical Psychology University Medical Center Hamburg‐Eppendorf Hamburg Germany
| | - Anja Mehnert‐Theuerkauf
- Department of Medical Psychology and Medical Sociology University Medical Center Leipzig Leipzig Germany
| | - Martino Belvederi Murri
- Institute of Psychiatry Department of Biomedical and Specialty Surgical Sciences University of Ferrara Ferrara Italy
- University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior S. Anna University Hospital and Health Authorities Ferrara Italy
| | - Luigi Grassi
- Institute of Psychiatry Department of Biomedical and Specialty Surgical Sciences University of Ferrara Ferrara Italy
- University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior S. Anna University Hospital and Health Authorities Ferrara Italy
| |
Collapse
|
17
|
Koranyi S, Hinz A, Hufeld JM, Hartung TJ, Quintero Garzón L, Fendel U, Letsch A, Rose M, Esser P, Mehnert-Theuerkauf A. 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. Front Psychol 2021; 12:789793. [PMID: 34899543 PMCID: PMC8652041 DOI: 10.3389/fpsyg.2021.789793] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Susan Koranyi
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
| | - Andreas Hinz
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
| | - Julia M. Hufeld
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
| | - Tim J. Hartung
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonhard Quintero Garzón
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
| | - Uta Fendel
- Department of Psychosomatic Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anne Letsch
- Department of Hematology and Oncology, Campus Benjamin Franklin, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Medicine II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Matthias Rose
- Department of Psychosomatic Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Quantitative Health Sciences, Medical School, University of Massachusetts, Amherst, MA, United States
| | - Peter Esser
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
| | - Anja Mehnert-Theuerkauf
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
| |
Collapse
|
18
|
Battaglia Y, Zerbinati L, Belvederi Murri M, Provenzano M, Esposito P, Andreucci M, Storari A, Grassi L. Exploring the Level of Post Traumatic Growth in Kidney Transplant Recipients via Network Analysis. J Clin Med 2021; 10:jcm10204747. [PMID: 34682870 PMCID: PMC8540707 DOI: 10.3390/jcm10204747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023] Open
Abstract
Although kidney transplant can lead to psychiatric disorders, psychosocial syndromes and demoralization, a positive post-traumatic growth (PTG) can occur in kidney transplant recipients (KTRs). However, the PTG-Inventory (PTGI), a reliable tool to measure PTG is scarcely used to explore the effect of this stressful event in KTRs. Thus, the purpose of our study was to assess the level of PTG and its correlation with demoralization, physical and emotional symptoms or problems via network analysis in KTRs. Additionally, we aimed at exploring the association of PTG with psychiatric diagnoses, Diagnostic Criteria for Psychosomatic Research (DCPR) conditions, and medical variables. A total of 134 KTRs were tested using MINI International Neuropsychiatric Interview 6.0 (MINI 6.0), DCPR interview, PTGI, Edmonton Symptom Assessment System (ESAS), Canadian Problem Checklist (CPC) and Demoralization scale (DS-IT). PTGI was used to investigate the positive psychological experience of patients after KT. It consists of 21 items divided in five factors. Routine biochemistry, immunosuppressive agents, socio-demographic and clinical data were collected. A symptom network analysis was conducted among PTGI, ESAS and DS-IT. Mean score of PTGI total of sample was 52.81 ± 19.81 with higher scores in women (58.53 ± 21.57) than in men (50.04 ± 18.39) (p < 0.05). PTGI-Relating to Others (16.50 ± 7.99) sub-score was markedly higher than other PTGI factor sub-scores. KTRs with DCPR-alexithymia or International Classification of Diseases, tenth revision (ICD-10) anxiety disorders diagnosis had lower PTGI total score and higher PTGI-Personal Strength sub-score, respectively (p < 0.05). The network analysis identified two communities: PTGI and ESAS with DS-IT. DS-IT Disheartenment, DS-IT Hopelessness and PTGI Relating to Others were the most central items in the network. After 1000 bootstrap procedures, the Exploratory graph analysis revealed the presence of a median of two communities in the network in 97.5% of the bootstrap iterations. A more extensive use of PTGI should be encouraged to identify and enhance the positive psychological changes after KT.
Collapse
Affiliation(s)
- Yuri Battaglia
- Nephrology and Dialysis Unit, St. Anna University Hospital, 44124 Ferrara, Italy;
- Correspondence:
| | - Luigi Zerbinati
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (M.B.M.); (L.G.)
| | - Martino Belvederi Murri
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (M.B.M.); (L.G.)
| | - Michele Provenzano
- Nephrology and Dialysis Unit, Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (M.P.); (M.A.)
| | - Pasquale Esposito
- Department of Internal Medicine, Division of Nephrology, Dialysis and Transplantation, University of Genoa and IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Michele Andreucci
- Nephrology and Dialysis Unit, Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (M.P.); (M.A.)
| | - Alda Storari
- Nephrology and Dialysis Unit, St. Anna University Hospital, 44124 Ferrara, Italy;
| | - Luigi Grassi
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (M.B.M.); (L.G.)
| |
Collapse
|
19
|
Kim SY, Kissane DW, Richardson G, Senior J, Morgan J, Gregory P, Birks S, Ooi C, Lipton L, Antill Y, Vereker M, Michael N, Bobevski I. The role of depression and other psychological factors in work ability among breast cancer survivors in Australia. Psychooncology 2021; 31:167-175. [PMID: 34460129 DOI: 10.1002/pon.5802] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/30/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Identifying modifiable factors affecting work ability among cancer survivors is important. The primary aim of the present study was to examine the effects of depression and related psychological factors on work ability among breast cancer survivors in Australia. METHODS In this cross-sectional electronic and postal survey, Australian breast cancer survivors were investigated. Work status and conditions before and after cancer treatment were analysed. Work ability was measured using the Work Limitation Questionnaire©-Short Form (WLQ-SF) with its four domains (time management, physical tasks, mental-interpersonal tasks, and output tasks). Three psychological factors were investigated: depression, fear of cancer recurrence, and demoralisation. Sociodemographic and clinical data were also collected. Multivariate regression analysis was used to identify the associations of psychological factors with WLQ-SF. RESULTS Among eligible survivors, 310 (50%) responded to the survey and were analysed. Nearly one third reported their work conditions had changed after cancer treatment. The depressed group reported limited work ability in 35%-44% of the four domains of WLQ-SF, while the non-depressed group reported limited work ability in only 8%-13%. At-work productivity loss was approximately fourfold higher in the depressed group than in the non-depressed group. In multivariate analysis, at-work productivity loss was associated with depression, demoralisation, and past history of anxiety. CONCLUSIONS After breast cancer treatment, work conditions changed toward lower wages and working hours. Depression, demoralisation, and past history of anxiety were associated with lower work ability. Further evaluations of work rehabilitation in breast cancer survivors are warranted.
Collapse
Affiliation(s)
- Seon-Young Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, South Korea.,Mental Health Clinic, Chonnam National University Hwasun Hospital, Hwasun, South Korea
| | - David W Kissane
- Cabrini Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,School of Medicine, University of Notre Dame Australia and Cunningham Centre, Sydney, New South Wales, Australia
| | - Gary Richardson
- Cabrini Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | | | | | | | - Sarah Birks
- Cabrini Health, Melbourne, Victoria, Australia
| | - Corinne Ooi
- Cabrini Health, Melbourne, Victoria, Australia
| | - Lara Lipton
- Cabrini Health, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Yoland Antill
- Cabrini Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | | | - Natasha Michael
- Cabrini Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,School of Medicine, University of Notre Dame Australia and Cunningham Centre, Sydney, New South Wales, Australia
| | - Irene Bobevski
- Cabrini Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
20
|
Caruso R, Nanni MG, Rodin G, Hales S, Malfitano C, De Padova S, Bertelli T, Murri MB, Bovero A, Miniotti M, Leombruni P, Zerbinati L, Sabato S, Grassi L. Effectiveness of a brief manualized intervention, Managing Cancer and Living Meaningfully (CALM), adapted to the Italian cancer care setting: Study protocol for a single-blinded randomized controlled trial. Contemp Clin Trials Commun 2020; 20:100661. [PMID: 33089003 PMCID: PMC7566943 DOI: 10.1016/j.conctc.2020.100661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/29/2020] [Accepted: 10/03/2020] [Indexed: 12/19/2022] Open
Abstract
Patients with advanced cancer suffer from psychosocial distress that may impair quality of life and that may be ameliorated by psychotherapeutic treatment. We describe here the methodology of a randomized controlled trial (RCT) to assess the effectiveness of a novel, brief, semi-structured psychotherapeutic intervention to reduce distress and increase well-being in patients with advanced or metastatic cancer. The intervention, called Managing Cancer and Living Meaningfully (CALM), was originally developed in Canada and we are now testing its Italian adaptation (CALM-IT). The study is a single-blinded phase III RCT with assessment at baseline, 3 and 6 months with two conditions: CALM-IT versus a nonspecific supportive intervention (SPI). Eligibility criteria include: ≥ 18 years of age; fluency in the Italian language; no cognitive deficit, and diagnosis of advanced or metastatic cancer with an expected survival of 12–18 months. CALM-IT includes up to 12 sessions, delivered over 6 months and covers 4 domains: i) Symptom Management and Communication with Health Care Providers; ii) Changes in Self and Relations with Close Others; iii) Sense of Meaning and Purpose; and iv) the Future and Mortality. The primary outcome is difference in severity of depressive symptoms between treatment arm and the primary endpoint is 6 months. The secondary endpoint is 3 months and secondary outcomes are: generalized anxiety, distress about dying and death, demoralization, spiritual well-being, attachment security, posttraumatic growth, communication with partners, quality of life, and satisfaction with clinical care. If shown to be effective, CALM-IT can be implemented nationally to relieve distress and to promote psychological well-being in patients with advanced cancer.
Collapse
Affiliation(s)
- Rosangela Caruso
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy.,University Hospital Psychiatry Unit, Program on Psycho-Oncology and Psychiatry in Palliative Care, Integrated Department of Mental Health and Addictive Disorders, Health Trust and University S. Anna Hospital, Ferrara, Italy
| | - Maria Giulia Nanni
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy.,University Hospital Psychiatry Unit, Program on Psycho-Oncology and Psychiatry in Palliative Care, Integrated Department of Mental Health and Addictive Disorders, Health Trust and University S. Anna Hospital, Ferrara, Italy
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Center, University Health Network, 16th Floor, 610 University Avenue, Toronto, ON M5G 2M9, Canada.,Department of Psychiatry, University of Toronto, 8th Floor, 250 College Street, Toronto, ON M5T 1R8, Canada
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Center, University Health Network, 16th Floor, 610 University Avenue, Toronto, ON M5G 2M9, Canada.,Department of Psychiatry, University of Toronto, 8th Floor, 250 College Street, Toronto, ON M5T 1R8, Canada
| | - Carmine Malfitano
- Department of Supportive Care, Princess Margaret Cancer Center, University Health Network, 16th Floor, 610 University Avenue, Toronto, ON M5G 2M9, Canada.,Department of Psychiatry, University of Toronto, 8th Floor, 250 College Street, Toronto, ON M5T 1R8, Canada
| | - Silvia De Padova
- Psycho-Oncology Unit, Istituto Scientifico Romagnolo per Lo Studio e La Cura Dei Tumori (IRST), IRCCS, Meldola, Italy
| | - Tatiana Bertelli
- Psycho-Oncology Unit, Istituto Scientifico Romagnolo per Lo Studio e La Cura Dei Tumori (IRST), IRCCS, Meldola, Italy
| | - Martino Belvederi Murri
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy.,University Hospital Psychiatry Unit, Program on Psycho-Oncology and Psychiatry in Palliative Care, Integrated Department of Mental Health and Addictive Disorders, Health Trust and University S. Anna Hospital, Ferrara, Italy
| | - Andrea Bovero
- Clinical Psychology Unit, Department of Neuroscience, University of Turin, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
| | - Marco Miniotti
- Clinical Psychology Unit, Department of Neuroscience, University of Turin, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
| | - Paolo Leombruni
- Clinical Psychology Unit, Department of Neuroscience, University of Turin, "Città Della Salute e Della Scienza" Hospital, Turin, Italy
| | - Luigi Zerbinati
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Silvana Sabato
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Luigi Grassi
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy.,University Hospital Psychiatry Unit, Program on Psycho-Oncology and Psychiatry in Palliative Care, Integrated Department of Mental Health and Addictive Disorders, Health Trust and University S. Anna Hospital, Ferrara, Italy
| | | |
Collapse
|
21
|
Grassi L, Pasquini M, Kissane D, Zerbinati L, Caruso R, Sabato S, Nanni MG, Ounalli H, Maraone A, Roselli V, Murri MB, Biancosino B, Biondi M. Exploring and assessing demoralization in patients with non-psychotic affective disorders. J Affect Disord 2020; 274:568-575. [PMID: 32663989 DOI: 10.1016/j.jad.2020.05.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 04/03/2020] [Accepted: 05/10/2020] [Indexed: 01/09/2023]
Abstract
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.
Collapse
Affiliation(s)
- Luigi Grassi
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Fossato di Mortara 64a, 44100 Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behaviors, Health Authorities and University S. Anna Hospital, Ferrara, Italy.
| | - Massimo Pasquini
- Department of Human Neurosciences, SAPIENZA University of Rome, Rome Italy.
| | - David Kissane
- Department of Palliative Medicine, University of Notre Dame Australia and Cunningham Centre, St Vincent's Hospital, Sydney, NSW, Australia; Szalmuk Family Research Unit at Cabrini Health, Victoria, Australia.
| | - Luigi Zerbinati
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Fossato di Mortara 64a, 44100 Ferrara, Italy.
| | - Rosangela Caruso
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Fossato di Mortara 64a, 44100 Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behaviors, Health Authorities and University S. Anna Hospital, Ferrara, Italy.
| | - Silvana Sabato
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Fossato di Mortara 64a, 44100 Ferrara, Italy.
| | - Maria Giulia Nanni
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Fossato di Mortara 64a, 44100 Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behaviors, Health Authorities and University S. Anna Hospital, Ferrara, Italy.
| | - Heifa Ounalli
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Fossato di Mortara 64a, 44100 Ferrara, Italy.
| | - Annalisa Maraone
- Department of Human Neurosciences, SAPIENZA University of Rome, Rome Italy.
| | - Valentina Roselli
- Department of Human Neurosciences, SAPIENZA University of Rome, Rome Italy.
| | - Martino Belvederi Murri
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Fossato di Mortara 64a, 44100 Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behaviors, Health Authorities and University S. Anna Hospital, Ferrara, Italy.
| | - Bruno Biancosino
- University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behaviors, Health Authorities and University S. Anna Hospital, Ferrara, Italy.
| | - Massimo Biondi
- Department of Human Neurosciences, SAPIENZA University of Rome, Rome Italy.
| |
Collapse
|
22
|
Battaglia Y, Zerbinati L, Piazza G, Martino E, Massarenti S, Provenzano M, Esposito P, Andreucci M, Storari A, Grassi L. The Use of Demoralization Scale in Italian Kidney Transplant Recipients. J Clin Med 2020; 9:E2119. [PMID: 32635625 PMCID: PMC7408932 DOI: 10.3390/jcm9072119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023] Open
Abstract
Demoralization is a commonly observed syndrome in medically ill patients. The risk of demoralization may increase in patients after a kidney transplant (KTRs) because of the stressful nature of renal transplantation, psychosocial challenges, and adjustment needs. No study is available on demoralization amongst KTRs. The purpose of our study was to evaluate the validity of the Italian version of the Demoralization Scale (DS-IT) and the prevalence of demoralization in KTRs. Also, we aimed at exploring the association of the DS-IT with International Classification of Diseases (ICD) psychiatric diagnoses, post-traumatic growth (PTG), psychological and physical symptoms, and daily-life problems. A total of 134 KTRs were administered the MINI International Neuropsychiatric Interview 6.0. and the Diagnostic Criteria for Psychosomatic Research-Demoralization (DCPR/D) Interview. The DS-IT, the Edmonton Symptom Assessment System (ESAS), the Canadian Problem Checklist (CPC), were used to measure demoralization, physical and psychological symptoms, and daily-life problems; also, positive psychological experience of kidney transplantation was assessed with the PTG Inventory. Routine biochemistry and sociodemographic data were collected. Exploratory factor analysis demonstrated a four-dimensional factor structure of the DS-IT, explaining 55% of the variance (loss of meaning and purpose, disheartenment, dysphoria, and sense of failure). DS-IT Cronbach alpha coefficients indicated good or acceptable level of internal consistency. The area under the Receiving Operating Characteristics (ROC) curve for DS-IT (against the DCPR/D interview as a gold standard) was 0.92. The DS-IT optimal cut-off points were ≥20 (sensitivity 0.87, specificity 0.82). By examining the level of demoralization, 14.2%, 46.3%, 24.6%, and 14.6% of our sample were classified as having no, low, moderate, and high demoralization, respectively, with differences according to the ICD psychiatric diagnoses (p < 0.001). DS-IT Total and subscales scores were positively correlated with scores of ESAS symptoms and CPC score. A correlation between DS-IT loss of meaning and purpose subscale and PTGI appreciation of life subscale (p < 0.05) was found. This study shows, for the first time, a satisfactory level of reliability of the DS-IT and a high prevalence of severe demoralization in KTRs.
Collapse
Affiliation(s)
- Yuri Battaglia
- Nephrology and Dialysis Unit, St. Anna University Hospital, 44124 Ferrara, Italy;
| | - Luigi Zerbinati
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Giulia Piazza
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Elena Martino
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Sara Massarenti
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Michele Provenzano
- Nephrology and Dialysis Unit, Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (M.P.); (M.A.)
| | - Pasquale Esposito
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Michele Andreucci
- Nephrology and Dialysis Unit, Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (M.P.); (M.A.)
| | - Alda Storari
- Nephrology and Dialysis Unit, St. Anna University Hospital, 44124 Ferrara, Italy;
| | - Luigi Grassi
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| |
Collapse
|