Demoralization syndrome in burn patients: A cross-sectional study

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Genetic Risk For Depression and Quality of Life in Patients With Head and Neck Cancer

Importance

Although patients with head and neck cancer (HNC) have been shown to experience high distress, few longitudinal studies include a comprehensive evaluation of biopsychosocial factors affecting quality of life (QoL), including genetic risk for depression.

Objective

To identify factors at the time of cancer diagnosis associated with QoL scores at 3 months after treatment in patients newly diagnosed with a first occurrence of HNC.

Design, Setting, and Participants

This prospective longitudinal study of 1464 participants with a 3-month follow-up, including structured clinical interviews and self-administered measures was carried out at the Department of Otolaryngology Head and Neck Surgery at 2 tertiary care McGill University Affiliated Hospitals, McGill University Health Centre, and Jewish General Hospital. Eligible patients were adults newly diagnosed within 2 weeks with a primary first occurrence of HNC, had a Karnofsky Performance Scale score higher than 60, and an expected survival of more than 6 months. Two hundred and twenty-three patients (72%) consented to participate and completed the baseline questionnaire, and 71% completed the 3-month follow-up measures.

Exposures

An a priori conceptual model including sociodemographics, medical variables, psychosocial risk factors, and a polygenic risk score for depression (PRS-D) was tested.

Main outcomes and measures

The Functional Assessment of Cancer Therapy-Head and Neck measured QoL at baseline and at 3 months.

Results

Participants were mostly men (68.7%), with a mean (range) age of 62.9 (31-92) years, 36.6% having a university degree, 35.6% living alone, and 71.4% diagnosed with advanced HNC with mostly cancers being of the oropharynx (42.2%), oral cavity (17%), and larynx (16.3%). QoL at 3 months after HNC diagnosis was associated with higher PRS-D (B = -4.71; 95% CI, -9.18 to -0.23), and a diagnosis of major depressive disorder within 2 weeks of an HNC diagnosis (B = -32.24; 95% CI, -51.47 to 13.02), lifetime suicidal ideation (B = -22.39; 95% CI, -36.14 to -8.65), living with someone (B = 12.48; 95% CI, 3.43-21.52), having smoked cigarettes in the past 30 days pre-HNC diagnosis (B = -15.50; 95% CI, -26.07 to -4.93), chemotherapy type (B = -11.13; 95% CI, -21.23 to -1.02), and total radiotherapy dose (Gy) (B = -0.008; 95% CI, -0.01 to -0.002).

Conclusions and relevance

This study identified the predictive value of a genetic predisposition to depression on QoL and function immediately after oncologic treatments. These findings highlight the potential importance of genetic profiling pretreatment to identify those most susceptible to experience QoL and functional compromise. Depression is a clear area of public health concern and should be a central focus in the treatment of patients with HNC.

Psychometric properties for Persian version Demoralization Scale-24 (DS-24) in Iranian cancer patients

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.

Older adults coping with critical life events - results of the revised demoralization scale in a representative sample of older adulthood

Background

High suicide rates in older adults are a relevant public health concern. Social isolation or widowhood as well as physical decline play a crucial role for suicidality in older adulthood. Previous evidence suggested that demoralization is an important risk factor for suicide. Whether demoralization is a relevant phenomenon in older adulthood which possibly could account for high suicide rates remains unclear.

Methods

Demoralization Scale II (DS-II) scores assessed in a survey of the German general population were investigated with respect to older adults (aged ≥ 65 years). DS-II scores were compared between older (≥ 65 years) and younger (< 65 years) adulthood and between young-old (65-74y), middle-old (75-84y), and old-old (85+y) individuals. We tested the impact of sociodemographic factors on DS-II scores within older adults.

Results

The sample comprised N = 545 adults ≥ 65 years and N = 1922 adults < 65 years. DS-II scores increased in older compared to younger adults (F(1,2465) = 6.1; p = 0.013; d = 0.09) and further from young-old to old-old (Mdiff = 2.7; 95% CI 0.45, 5.46; p = 0.034). One-fourth of individuals ≥ 65 years and almost half of old-old individuals reported DS-II scores above the cut-off > 5. Living with a partner protected from demoralization in old-old individuals.

Discussion

This study provides first evidence for an increased rate of demoralization in very old adults, in particular women, which is partly related to partnership status. We suggest that demoralization is considered as a crucial entity in older adulthood which can be missed by standard psychological screenings.

Quality of life, mood disorders, and cognitive impairment in adults with β-thalassemia

Advances in understanding the disease process in β-thalassemia supported development of various treatment strategies that resulted in improved survival. Improved survival, however, allowed multiple morbidities to manifest and cemented the need for frequent, lifelong treatment. This has directly impacted patients' health-related quality of life and opened the door for various psychiatric and cognitive disorders to potentially develop. In this review, we summarize available evidence on quality of life, depression and anxiety, suicidality, and cognitive impairment in adult patients with β-thalassemia while sharing our personal insights from experience in treating patients with both transfusion-dependent and non-transfusion-dependent forms.

The Interrelationship of Benefit Finding, Demoralization, and Stigma among Patients with Parkinson's Disease and Their Caregivers

Parkinson's disease (PD) is a debilitating neurodegenerative disease with a relentlessly progressive course of illness. This study aimed to assess the dyadic dynamics of benefit finding (BF), demoralization, and stigma on the depression severity of PD patients and their caregivers. This study used a cross-sectional design with purposive sampling. In total, 120 PD patients and 120 caregivers were recruited from the neurological ward or neurological outpatient clinic of a medical center in Taiwan from October 2021 to September 2022. PD patients and their caregivers were enrolled and assessed using the Mini International Neuropsychiatric Interview, the Benefit Finding scale, Demoralization Scale, Stigma Subscale of the Explanatory Model Interview Catalogue, and Taiwanese Depression Questionnaire. Among the 120 patients and 120 caregivers that successfully completed the study, 41.7% (N = 50) and 60% (N = 72) were female, respectively. The most common psychiatric diagnoses of both the PD patients (17.5%) and their caregivers (13.3%) were depressive disorders. Using structural equation modeling, we found that the stigma, BF, and demoralization of PD patients might contribute to their depression severity. Demoralization and stigma of PD patients' caregivers might also contribute to the depression severity of PD patients. Caregivers' BF and demoralization were significantly linked with their depression severity. PD patients' BF degree and their caregivers' BF degree had significant interactive effects. Both patients' and their caregivers' stigma levels had significant interactive effects. Clinicians should be aware of and manage these contributing factors between PD patients and their caregivers in order to prevent them from exacerbating each other's depression.

A Systematic Review of Interventions for Demoralization in Patients with Chronic Diseases

BACKGROUND

Demoralization, a significant mental health concern in patients with chronic diseases, can have a large impact on physical symptom burden and quality of life. The present review aimed to evaluate the effectiveness of interventions for demoralization among patients with chronic diseases.

METHOD

PubMed, Scopus, Embase, and Web of Science were systematically searched. Research on providing interventions to patients with chronic diseases that included quantitative data on demoralization was then systematically reviewed.

RESULTS

Fourteen studies were included, most of which considered demoralization as a secondary outcome. Interventions included evidence-based meaning-centered psychotherapy, dignity therapy, psilocybin-assisted psychotherapy, and others. Ten studies used randomized controlled designs. Six of these investigated evidence-based meaning-centered therapy, and four investigated dignity therapy, showing the best empirical support for these intervention types. Most studies showed significant impacts on demoralization in patients with chronic diseases.

CONCLUSION

This systematic review provides insights into potential psychological interventions for reducing demoralization in patients with chronic diseases. Randomized controlled designs and adequately powered samples, with demoralization as the primary outcome, are needed to more clearly evaluate its effectiveness.

Demoralization in cancer survivors: an updated systematic review and meta-analysis for quantitative studies

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.

Supporting elderly patients in strengthening their personal and spiritual health resources

Care for the sick, including spiritual support is sometimes called holistic medicine. The term bio-psycho-social-spiritual model is sometimes used to describe this type of therapeutic approach patient-oriented medicine. This report indicates the importance of taking into account the spiritual aspect of life due to its beneficial impact on the coping resources activated and the patient's well-being. Existential and spiritual issues are on the verge of new clinical and research interest in medicine, especially in gerontology, oncology, and palliative care. Clinicians focus not only on symptom control but also on spiritual and existential issues such as spirituality, hope, and meaning. This paper reviews the topic of spirituality in the context of illness and end-of-life care trying to define spirituality within the context of health resources of the subject. Spirituality is perceived in two of its main components: faith/religious beliefs and spiritual well-being. Especially this second construct is reviewed and described as a health resource.

Investigating the levels of depression, anxiety, sexual disorders, and other influencing factors in breast cancer patients: Turkish radiation oncology integrative group study (12-05)

The fear of death associated with cancer and the side effects of its treatments can have a detrimental psychological impact on breast cancer patients. Early detection and support services play a crucial role in alleviating the expected symptoms of depression, anxiety, and sexual dysfunction. The objective of our study is to assess the levels of depression, anxiety, and sexual dysfunction in breast cancer patients, as well as identify the factors that influence these conditions. The study involved 329 voluntarily participating breast cancer patients who had undergone surgery and were in the follow-up stage. Data were collected from 8 different centers after obtaining ethical approval. The assessment utilized tools such as the Sociodemographic Information Form, Beck Depression and Anxiety Scale, and Arizona Sexual Experiences Scale. Data analysis was performed using SPSS 20. The study included 329 breast cancer patients in the follow-up stage post-surgery. Their average age was 52.7 years (range: 27-83). Results indicated that 33.1% experienced moderate to severe depression, 18.2% reported severe anxiety, and 82.7% scored above 11 on the sexual scale. Factors linked to higher scores were mastectomy, surgical dissatisfaction, insufficient information on sexual side effects, and comorbidities like smoking and diabetes. The study emphasizes the importance of closely monitoring anxiety, depression levels, and sexual side effects in breast cancer treatment. It underscores the need to focus not only on reducing mortality rates but also on supporting patients' psychological and sexual well-being, ultimately improving their overall quality of life.

A Prescription for Wellness in Early PD: Just What the Doctor Ordered

BACKGROUND

Being diagnosed with a neurodegenerative disease is a life-changing event and a critical time to help patients cope and move forward in a proactive way. Historically, the main focus of Parkinson's disease (PD) treatment has been on the motor features with limited attention given to non-motor and mental health sequelae, which have the most impact on quality of life. Although depression and anxiety have been described at the time of PD diagnosis, demoralization, intolerance of uncertainty, decreased self-efficacy, stigma and loneliness can also present and have negative effects on the trajectory of the disease. Hence, understanding the psychological impact of the diagnosis and how to provide better counselling at this critical time point may be the key to a better long-term trajectory and quality of life.

FOCUS

There has been a paradigm shift in the treatment of chronic illness moving beyond the medical model, which focuses on fighting illness with the physician being in charge of the treatment process and the patient being the passive recipient, toward a more holistic (i.e., physical, psychological, social, and spiritual health) biopsychosocial approach that emphasizes behavioral factors with the patient being an active collaborator in their treatment. Hence, we propose that fostering resilience, social support, and psychological flexibility offer promise toward attenuating negative reactions and improving overall well-being.

CONCLUSION

Through a proactive wellness approach incorporating lifestyle choices, people with PD (PwP) can not only achieve improved states of health, well-being, and quality of life, but actually thrive.

An Integrative Review of Measures of Spirituality in Experimental Studies of Psilocybin in Serious Illness Populations

Background: Psilocybin-assisted therapies (PAT) are reemerging as a treatment for complex distress often prompting mystical experiences, enhanced meaning, and spiritual wellbeing. We sought to investigate how measures of spirituality are employed in experimental studies of PAT conducted with seriously ill adults. Methods: We included experimental studies of psilocybin conducted with seriously ill adults, which employed measures that contained spirituality and mysticism concepts within their domains or subdomains. Included studies were peer-reviewed and published in English language (up to December 2021). Results: Seven articles met our inclusion criteria. A total of 12 unique instruments were identified. The most frequently used instruments were the Mystical Experience Questionnaire (MEQ30), the Functional Assessment of Chronic Illness Therapy-Spirituality (FACIT-Sp-12), and the Demoralization Scale (DS-I/II) (used in four studies each), followed by the Persisting Effects Questionnaire (PEQ) (used in three studies). Overall, studies did not consistently define and contextualize spirituality domains and subdomains studied. Conclusions: Despite well-recognized significance of spirituality in PAT, there was considerable heterogeneity in number and types of spirituality measures employed across studies. There also seemed a lack of attention to defining and operationalizing spirituality and its domains and subdomains. This is notable as spirituality and overlapping concepts (eg mystical experiences) contributes substantially to this body of research and patients' therapeutic outcomes. Towards developing more rigorous science of spirituality in PAT research, there is a critical need to evaluate and refine measures of spirituality to enhance their utility and replicability, limit participant burden, and better contextualize spirituality-related findings and outcomes.

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).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk Factors of Demoralization Among Lung Cancer Patients in Mainland China

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

Psychometric Properties of the Greek Version of Demoralization Scale-II (DS-II) in Patients with Cancer

Introduction

The concept of demoralization is used to describe situations of existential distress and self-perceived inability to effectively deal with stressors. The Demoralization Scale-II (DS-II) is a short and modified version of the original DS that measures the level of demoralization in patients. The purpose of this study is to evaluate the psychometric properties of the Greek version of the Greek Demoralisation Scale-II (DS-II GR) in the population of patients with cancer.

Methods

The main tool used in this cross-sectional study is the DS-II GR translated and evaluated for its psychometric properties in a sample of 150 Greek patients with cancer. Exploratory factor analysis (EFA), confirmatory factor analysis (CFA), convergent validity, known groups' validity, cut-off points, internal consistency reliability and test-retest reliability were done.

Results

According to the CFA, a two-factor model emerged with a different conceptual content and grouping than the original. The correlation coefficients between DS-II GR and Hospital Anxiety and Depression Scale-Greek (HADS-GR) The internal consistency of DS-II GR for factor 1, factor 2, and total score were measured with Cronbach's alpha and calculated to be 0.906, 0.810, and 0.913.

Conclusion

The Greek version of the demoralization scale is reliable and valid for assessing demoralization in Greek patients with cancer.

Influence of spirituality on moral distress and resilience in critical care staff: A scoping review

OBJECTIVE

The Covid 19 pandemic has created a situation in which critical care staff experience moral distress. For reducing moral distress, resources such as spirituality can be used. The aim of this scoping review is to explore whether spirituality mitigates the moral distress of critical care staff and strengthens their resilience. The spiritual resources will be identified and the ability of the staff to use spiritual resources will be explored.

METHODOLOGY

A scoping review of studies reporting on the association between spirituality, moral distress, and resilience. Qualitative and quantitative studies from 2020 that examined critical care staff are included. This scoping review used the five-step framework proposed by Arksey and O'Malley and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework for scoping reviews. The literature searches were conducted in 12 databases.

RESULTS

13 studies met inclusion criteria. Critical care staff declaring themselves as spiritual have a higher risk of moral distress and are often not able to use spiritual resources on their own. For effective use of spiritual resources to reduce moral distress, staff need to be skilled in the practice of spirituality with the aim to find inner peace, focus on the positive, and regain a sense of purpose in the work.

CONCLUSION

Spirituality does not automatically help the critical care staff to cope with moral distress and strengthen resilience. Institutions need to create conditions in which the critical care staff are supported to use their spiritual resources.

IMPLICATION FOR CLINICAL PRACTICE

Institutions need to involve staff more in the design, implementation, and delivery of spiritual interventions to minimise moral distress. Further research is necessary to examine the impact of critical care staff's demographic characteristics on their spirituality, moral distress, and resilience.

Demoralization and spirituality in oncology: an integrative systematic review

OBJECTIVE

To synthesize the scientific findings on demoralization and spirituality in the oncology context.

METHODS

This is an integrative systematic review, in line with the PRISMA 2020 guidelines, as proposed by Whittemore and Knalf (2005). The MEDLINE via PubMed, Scopus, Web of Science, APA PsycNet, CINAHL, Cochrane Library, EMBASE, and LILACS databases were searched without limitations regarding language or year of publication. The studies were screened for inclusion according to the predefined eligibility criteria. Data extraction and evidence quality assessment were performed.

RESULTS

Out of the 1587 articles evaluated, 10 studies were included in this review. In general, it was found that demoralization tends to increase with the proximity of death and seems to be inversely related to spirituality, with spiritual well-being being a protective factor against demoralization, while the non-fulfillment of spiritual needs is related to increased demoralization in people with cancer. Furthermore, even among caregivers of people with advanced cancer, demoralization seems to be associated, among other factors, with spiritual suffering. These results should be analyzed with caution, considering that the studies included in this review are all observational studies, which prevents establishing cause and effect relationships.

CONCLUSIONS

Demoralization tends to increase with growing frailty and the proximity of death in people with cancer, and it seems to be inversely related to spirituality, both in these patients and in their caregivers.

Relationship between demoralization and quality of life in end-of-life cancer patients

OBJECTIVE

To examine the relationship between demoralization and health-related quality of life (HRQoL) in a sample of end-of-life cancer patients with a life expectancy of 4 months or less undergoing palliative care, controlling for sociodemographic, clinical, and psychological variables.

METHODS

Sociodemographic, clinical, and psychological data from 170 end-of-life cancer patients were collected using the following scales: Edmonton Symptom Assessment System for palliative care patients' symptoms; Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms; Functional Assessment of Cancer Therapy Scale - General Measure (FACT-G) for HRQoL; Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being for spirituality (FACIT-Sp); Demoralization Scale - Italian Version (DS-IT) for demoralization.

RESULTS

The DS-IT showed that 51.8% of cancer patients were severely demoralized. In addition, 36.5% of the sample had clinically significant depressive symptoms and QoL was severely impaired (FACT-G). The result of regression analysis showed that demoralization (especially "Disheartenment" and "Sense of failure") was the strongest contributor for HRQoL, followed by ESAS_Lack of Well-Being and depression (PHQ-9), with the final model explaining 66% of the variance of the FACT-G.

CONCLUSIONS

The results highlight a very high prevalence of severe demoralization in end-of life cancer patients. Moreover, demoralization was not only associated with patients' HRQoL, but it was also the most important contributing factor. This finding underscores the need to identify preventive or therapeutic psychological interventions that focus on preventing existential distress, and thus improve the QoL of dying patients in their last days of life.

Factors associated with anxiety and depression in cancer patients: Demographic factors and the role of demoralization and satisfaction with care

OBJECTIVE

Anxiety and depression are common in cancer patients and seem to affect quality of life, treatment compliance and even survival. Defining factors related to anxiety and depression and exploring the role of demoralization and satisfaction with care, could contribute to the improvement of patients' quality of life and quality of health services as well.

METHODS

A convenience sample of 150 cancer inpatients and outpatients from two oncology centers, with various types of solid tumors, participated in a prospective cross-sectional observational study. The psychometric tools used were the Greek versions of the Hospital Anxiety and Depression Scale, FAMCARE-Patient Scale and Oncology Palliative Care (FAMCARESCALE) and Demoralization Scale (DEMORALIZATION SCALE II, DS-II).

RESULTS

Patients mean age was 62 years (20-85 years) and 89 patients (59.3%) were women. Among patients, 33% had breast, 24% gastrointestinal and 15% lung cancer. Eighty-two patients (54.7%) had metastatic disease. Women showed higher rates of anxiety (p = 0.054). Anxiety was inversely related to age (p = 0.043) and positively correlated with time since diagnosis (p = 0.076). Unmarried patients presented with higher rates of depression (p = 0.026). Multiple linear regression showed a statistically significant impact of Demoralization factor 'Meaning and Purpose' on anxiety (p < 0.001, R²  = 36.3%) and depression (p < 0.001, R²  = 49%). Moreover, higher educational level (p = 0.038, R²  = 3.1%) is related to higher levels of anxiety and higher scores of FAMCARESCALE factor-Information/interaction with the health care professionals, is related to lower levels of depression (p = 0.008, R²  = 2.7%).

CONCLUSIONS

The results highlight the significant impact of demoralization on anxiety and depression in cancer patients. Early recognition of demoralization and early referral to mental health professionals will hopefully alleviate the mental burden of cancer patients.

Demoralization and Suicidal Ideation in Chronic Pain Patients

The literature has clearly stressed that patients suffering from chronic pain are at high risk of suicidal behavior (SB). Hence the need to improve the characterization of this behavior risk profile in these patients. Some findings indicate a possible relationship between demoralization and pain, with functional disability found to be correlated with demoralization. The primary objective of this study was to investigate the relationship between demoralization and suicidal ideation (SI) in patients with chronic pain. The secondary objective was to verify whether demoralization can occur independently of depression in these patients. Inclusion criteria were patients with chronic pain, with SI or not, matched for age and gender, aged > 18 years. Seventy patients with SI and 70 patients without SI were included. Between-group difference was statistically significant (F=1.064; t= 7.21, p<0.001, d=1.22), confirming the presence of numerous and intense depressive symptoms in the patients of the SI group. Regarding the Demoralization Scale (DS), the difference between the two groups was statistically highly significant (F=1.49; t=9.44; p<0.001, d=1.6). There was also a strong positive correlation between DS and Beck Depression Inventory (BDI-II) (R=0.749; p<0.001 for the study group and R=0.704; p<0.001 for the control group). Furthermore, there was a strong positive correlation between the DS and the Scale for Suicide Ideation (SSI) in the SI patients group, meaning that high demoralization is associated with higher suicidal ideation as well. Our findings did not allow us to distinguish between the notions of depression and demoralization, since the two constructs show almost the same strong positive correlation with suicidal thoughts, the two also being strongly correlated with each other.

Critical Care Providers' Moral Distress: Frequency, Burden, and Potential Resources

BACKGROUND

Critical Care Providers (CCPs) experience situations that challenge their ethics and professional standards and may entail moral distress (MD).

AIM

To analyze MD perceived by CCPs in intensive care units (ICUs) or emergency departments (EDs) and further clarify whether CCPs who rely on spiritual resources differ in their perception of MD from those who do not utilize these resources.

METHODS

A cross-sectional anonymous survey was administered using a modified version of the German language version of the Moral Distress Scale (MDS) with 2 × 12 items to assess the frequency and the respective perceived burden of specific situations by applying a 5-point Likert scale. Explorative factor analysis was performed and the sub-constructs of the respective items regarding MD frequency and burden were identified. Job burden and professional satisfaction were measured using visual analogue scales (VAS) and a four-point Likert scale, respectively. The 15-item SpREUK questionnaire was applied to measure spiritual attitudes and behaviours and to differentiate between religious and spiritual persons. Data from 385 German-speaking CCPs were included (55% physicians, 45% nurses).

RESULTS

Conflict situations are similar for physicians and nurses although they are perceived as more burdensome by nurses. Among physicians, the MDS factor Looking away/Resignation scores highest for assistant physician residents, whereas distress caused by looking away is more often perceived by specialist physicians without a managerial position. Work satisfaction is inversely associated with MD and emotional exhaustion is positively associated with it. Participants' spirituality is marginally associated with MD. The best predictors of both MD frequency and burden are emotional exhaustion with further influences of work satisfaction, being a nurse, and being a non-believer on the frequency of MD perception. Being a nurse, participants' experience in ICU/ED, and being of the male gender are further predictors of MD burden.

CONCLUSIONS

MD is experienced differently by different groups of CCPs depending on their place in the hierarchy of responsibility. As MD perception is best predicted by emotional exhaustion, these situations should be avoided. Although some CCPs may rely on spiritual resources, all need individual and team support to cope with MD.

Wish to Die Among Residents of Swiss Long-Term Care Facilities: A Multisite Cross-Sectional Study

OBJECTIVES

The wish to die (WTD) in persons near the end of life is a clinically important, ethically and practically complex phenomenon as demonstrated by the intense debates on assisted dying legislation around the world. Despite global aging and increasing institutionalization in old age, WTD among residents of long-term care facilities (LTCF) is underexplored. We aimed to assess the prevalence of WTD and identify its predictors in older LTCF residents.

DESIGN

Multisite cross-sectional observational study.

SETTING AND PARTICIPANTS

31 LTCF in the 3 major linguistic regions of Switzerland, including residents 75 years or older, admitted to the LTCF 4 to 10 months before the study, without severe cognitive impairment.

METHODS

Between February 2013 and June 2017, trained research staff interviewed residents to assess WTD using 2 validated instruments and collected information on potential predictors, including depressive symptoms, anxiety, demoralization, feeling to be a burden, spiritual distress, symptom burden, multimorbidity, and drug use. Demographic data were obtained by chart review. Descriptive statistics as well as univariate and multivariate regression analyses were performed.

RESULTS

From 427 eligible residents, 101 were excluded, 46 refused, and 280 were included in the study (acceptance rate 85.9%). In general, residents readily and openly addressed the topic of WTD. The prevalence of WTD was 16.0% and 16.2% according to the 2 instruments, with all but 1 of the residents expressing a passive WTD. The strongest independent predictors for a WTD were depressive symptoms (OR 7.45 and 5.77 for the 2 WTD assessment instruments) and demoralization (OR 2.62 and 3.66).

CONCLUSIONS AND IMPLICATIONS

The WTD is a relevant concern affecting approximately 1 in 6 LTCF residents. Further research is needed to investigate which interventions could best address the potentially modifiable factors that were associated with the WTD in this specific setting and population.

The Demoralization Interview: Reliability and validity of a new brief diagnostic measure among medically ill patients

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.

Demoralization: Where it stands-and where we can take it: A bibliometric analysis

Objectives

The purpose is to analyze existing studies related to the field of demoralization through bibliometrics.

Methodology

Relevant literature on demoralization was searched from PubMed, Web of Science, the Cochrane Library, and CINAHL Complete. Bibliometric analysis was performed using GraphPad Prisma 8.2.1, VOSviewer 1.6.18 and R software. Research publication trends, author-country collaboration, research hotspots and future trends were explored by generating network relationship maps.

Results

A total of 1,035 publications related to the field of demoralization were identified. The earliest relevant studies have been published since 1974, and the studies have grown faster since 2000. Psyche-oncology and Psychother Psychosom had the highest number of publications (n = 25). The United States, Italy and Australia have made outstanding contributions to the field and there was an active collaboration among leading scholars. Major research hotspots include the multiple ways of assessing demoralization, the specificity of various demographics and psychological disorders in different disease contexts, and the association and distinction of diverse clinical psychological abnormalities. The impact of COVID-19 on demoralization and subsequent interventions and psychological care may become a future research direction.

Conclusion

There has been a significant increase in research in the field of demoralization after 2000. The United States provided the most publications. There is overall active collaboration between authors, countries, and institutions. In future research, more attention will be paid to the effects of COVID-19 on demoralization and intervention care for this psychology.

Demoralization and Its Association with Quality of Life, Sleep Quality, Spiritual Interests, and Suicide Risk in Breast Cancer Inpatients: A Cross-Sectional Study

With decreasing mortality, the quality of life, spiritual needs, and mental health of breast cancer patients have become increasingly important. Demoralization is a poor prognostic factor for cancer patients. The extent of demoralization in breast cancer patients and its association with these factors remains unclear. This cross-sectional study was conducted at a Taiwanese medical center. We enrolled 121 participants (34 with high demoralization and 87 with low demoralization, as per the Mandarin Version of Demoralization Scale). High demoralization was associated with reduced quality of life, sleep quality, and spiritual interests. Multivariate analyses revealed that the scores of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire ≥ 62.5 (OR = 0.21, p = 0.002) and Spiritual Interests Related to Illness Tool Chinese Version ≥ 3.66 (OR = 0.11, p < 0.001) were associated with low demoralization. Demoralized patients with depression had a poorer quality of life and sleep quality. Although not statistically significant, depressed and demoralized participants were at a higher risk of suicide. Cancer patients with both depression and demoralization had the worst prognosis. Breast cancer patients exhibited demoralization when they had unmet bio-psycho-social-spiritual needs. An early assessment of demoralization may improve holistic healthcare for breast cancer patients.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

SIGNIFICANCE OF RESULTS

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

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Relationship between demoralization of the college student with their individual- and social-oriented self

Demoralization has become increasingly prevalent among college students who have lost motivation in life and feel hopeless about their future. Many college students who demonstrate symptoms of demoralization are neglected because they might fail to typical symptoms of depression. Taiwanese college students are simultaneously influenced by bicultural-self system, such as individual- and social-oriented views of self, which vary considerably in the view of self, achievement motivation, and the value of self-realization, and may even create contradictory expectations and behavioral standard. The purpose of this study was to investigate the extent of the relationship between attitude towards demoralization, individual- and social-oriented views of self. Three-hundred fifty-six college students completed the online questionnaire, which was designed to explore their demoralization status and cultural differences. Four groups were divided into bicultural self, individual-oriented self, social-oriented self, and unintegrated self. Bicultural group demonstrated significantly lower demoralization overall scores than other groups. Moreover, the five dimensions of demoralization in college students were mostly significantly and negatively correlated with individual- and social-oriented views of self, indicating that college students' bicultural views of self may contribute to or prevent demoralization.

Psychological interventions targeting patients with metastatic cancer and prolonged survival expectancies: advances and challenges

PURPOSE OF REVIEW

The purpose of this article is to review the formats and techniques of psychological interventions designed for patients with metastatic cancer and prolonged survival expectancies.

RECENT FINDINGS

Fifteen interventional studies were selected for this article. One group of psychological interventions focused primarily on patients' adaptation by increasing their knowledge, developing patients' stress management skills, promoting their open communication with healthcare providers, and helping them deal with existential concerns. Another group of interventions focused on patients with moderate and high levels of distress. These interventions provided specific techniques to manage anxiety, depression, fear of cancer progression, and existential distress. Interestingly, interventions targeting distressed patients are not necessarily longer or more intensive than interventions targeting adaptation. The interventions were examined in few randomized controlled trials, and incorporated a broad range of techniques, making comparison of their efficacy difficult. No intervention specifically targeted patients newly diagnosed with metastatic cancer.

SUMMARY

On the basis of this review, we proposed suggestions according to patients' levels of distress, which differ in intensity, format, techniques, and tools offered. These suggestions may be relevant for the future development and assessment of interventions targeting patients with newly diagnosed metastatic cancer and prolonged survival expectancies.

Demoralization in suicide: A systematic review

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.

A cross-sectional study on demoralization in prostate cancer patients: the role of masculine self-esteem, depression, and resilience

Purpose

The current cross-sectional study had three objectives: (1) to assess the prevalence of depression and demoralization in a sample of prostate cancer (PCa) patients; (2) to examine whether masculine self-esteem and depression were associated with demoralization; and (3) to evaluate the role of resilience as a factor buffering the effects of masculine self-esteem and depression on demoralization.

Methods

197 PCa patients aged 48 to 79 years (M = 67.19; SD = 6.83) answered questions about masculine self-esteem, depression, resilience, and demoralization. An ANOVA was conducted to examine whether the association between demoralization and depressive symptoms was linear. A chi-square test was calculated to determine differences between depression and demoralization. Finally, a hierarchical multiple linear regression analysis with interaction terms was conducted to examine the associations between masculine self-esteem, depression, resilience, and demoralization.

Results

Depression scores increased linearly with demoralization severity, but demoralization scores were higher than depression scores (21.3% vs. 15.2%). Lower scores on masculine self-esteem and higher scores on depressive symptoms were associated with greater demoralization. Resilience significantly moderated the association between masculine self-esteem and demoralization, but not between depression and demoralization.

Conclusion

Assessment of depression, masculine self-esteem, resilience, and demoralization in the clinical setting is critical for improving the mental health status of PCa patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

Frontal Lobe Functions, Demoralization, Depression and Craving as Prognostic Factors and Positive Outcomes of Patients with Heroin Use Disorder Receiving 6 Months of Methadone Maintenance Treatment

Methadone maintenance therapy (MMT) is a well-established and effective treatment for heroin use disorders. Whether frontal lobe function and demoralization serve as suitable prognostic and outcome assessment factors remains unknown. A quasi-experimental study was conducted with a single-group repeated-measures design at a medical center and mental hospital in Taiwan. We enrolled 70 participants (39 completed treatments and 31 dropped out). Frontal lobe function, demoralization, depression, and craving at three time points were analyzed. There were differences between patients who completed the treatment (n = 39) and those who did not (n = 31). Thirty-nine patients completed the treatment (average age, 45.5 years; 89.7% men; average duration of heroin use, 27.21 years; MMT, 38.18 mg/day). Post-MMT (6 months), frontal lobe function, demoralization, depression, and craving significantly improved. Dropouts had higher frontal lobe function, lower demoralization, higher craving, younger age, and earlier onset age than patients who completed the pretest treatment. Clinicians should be aware of the severity of demoralization. Clinicians may select suitable patients for MMT by assessing frontal lobe function, demoralization, craving, age, and onset age. A 6-month course of MMT improved demoralization, frontal lobe function, depression, and addiction. Six months of treatment was more effective than 3 months. Suitable patient identification and continuous treatment are important in MMT.

Determine the Symptom Intensities, Performance and Hopelessness Levels of Advanced Lung Cancer Patients for the Palliative Care Approach

This research was conducted descriptively to determine the symptom intensities, performance and hopelessness levels of advanced lung cancer patients for the palliative care approach. The research sample consisted of 130 patients with advanced lung cancer, who were selected from 600 lung cancer populations in thoracic surgery and intensive care, outpatient chemotherapy, oncology in a university hospital in Turkey. Ethics Committee permission and the patients' written consent was obtained. Study data were collected face to face between January 2020 and July 2020 using the Edmonton Symptom Assessment System, Karnofsky Performance and Beck Hopelessness Scale. The mean age of the patients was 62.68 ± 8.867, 72.3% were males, and 89.2% were not currently working. The most common symptom in the patients was found to be fatigue 5.46 ± 2.12, worsening in general health and well-being 5.69 ± 1.87, loss of appetite 5.40 ± 2.59, and total symptom score 47.17 ± 19.03. Feelings and expectations about the future 1.40 ± 1.66, loss of motivation 3.43 ± 2.41, hope 2.05 ± 1.75, and total score of hopelessness 7.41 ± 6.01. There was a positive correlation between the patients' hopelessness level and their symptom burden, and a negative correlation was found with Karnofsky performance (P < .05). A significant difference was found between the patients' age, months since diagnosis, gender, education and employment status, stage of the disease, presence of metastases and analgesic use, and hopelessness scores (P < .05). It was determined that the symptom burden of patients with advanced lung cancer increased and as their Karnofsky performance decreased, their hopelessness level further increased. Hopelessness scores are affected by the socio-demographic and disease variables of the patients.

Existential Distress in Cancer Patients: A Concept Analysis

BACKGROUND

Existential distress is a widely used concept used in describing cancer patients. However, this concept is vague and has failed to achieve a consensus. The lack of a recognized conceptual framework could hinder future research on existential distress.

OBJECTIVE

The aim of this study was to clarify and analyze the concept of existential distress in cancer patients.

METHODS

The Walker and Avant concept analysis approach was applied.

RESULTS

For cancer patients, the concept of existential distress included 5 core attributes: (a) lack of meaning; (b) loss of autonomy; (c) loss of dignity; (d) hopelessness; and (e) death anxiety. Existential distress is a key factor causing poor quality of life, a poor emotional state, demoralization, and even suicide. It is often underpinned by uncontrolled physical pain, serious psychological morbidity, and a perceived sense of being a burden on others.

CONCLUSION

The concept analysis provides a theoretical framework for healthcare providers to better understand existential distress in cancer patients, to improve patient well-being.

IMPLICATIONS FOR PRACTICE

On the basis of the antecedents of this concept, cancer patients experiencing uncontrolled physical pain, severe psychological morbidity, and a perceived sense of being a burden on others are at a high risk of existential distress. These factors should be eliminated in a timely manner to prevent cancer patients from being caught in a state of existential distress. The 5 defining attributes and empirical referents of this concept could be used to develop tools to screen for existential distress in cancer patients and distinguish it from similar concepts.

Voluntary assisted dying in gynaecological cancers: A discussion of the history, ethical principles and international perspectives

Voluntary assisted dying (VAD) is a provocative and ethically charged subject that will potentially be an increasing component of our clinical practice. This paper aims to give the history of VAD, ethical principles, controversies and international perspectives regarding the laws in each jurisdiction. It provides a discussion on the topic with respect to gynaecological oncology to enable clinicians to feel more comfortable with this difficult subject.

Psychedelics for the treatment of depression, anxiety, and existential distress in patients with a terminal illness: a systematic review

BACKGROUND

Terminally ill patients may experience existential distress, depression, or anxiety, limiting quality of life in the final stage. Existing psychotherapeutic or pharmacological interventions have (time) limited efficacy. Psychedelic treatment may be a safe and effective alternative treatment option.

AIM

Systematically review studies on psychedelic treatment with and without psychotherapy for existential distress, depression, and anxiety in terminally ill patients.

METHODS

Medline, PsycINFO, and Embase were searched for original-data studies on the treatment of depression, anxiety, and existential distress with classical or a-typical psychedelics in patients with a terminal illness, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 1850 records were screened, and 33 articles were included in this review: 14 studies on classical psychedelics (DPT, LSD, and psilocybin) and 19 studies on atypical psychedelics (MDMA and ketamine). Results of early pre-post studies are promising but have serious methodological flaws. Recent (controlled) trials with LSD, psilocybin, ketamine, and MDMA are of higher methodological quality and indicate positive effects on existential and spiritual well-being, quality of life, acceptance, and reduction of anxiety and depression with few adverse and no serious adverse effects.

CONCLUSIONS

Both classical and a-typical psychedelics are promising treatment options in patients with terminal illness. To draw final conclusions on effectiveness and safety of psychedelics, we need larger high-quality studies for classical psychedelics and MDMA. Ketamine studies should pay more attention to existential dimensions of well-being and the psychotherapeutic context of the treatment.

Autonomy and control in the wish to die in terminally ill patients: A systematic integrative review

BACKGROUND/OBJECTIVE

Personal autonomy and control are major concepts for people with life-limiting conditions. Patients who express a wish to die (WTD) are often thought of wanting it because of loss of autonomy or control. The research conducted so far has not focused on personal beliefs and perspectives; and little is known about patients' understanding of autonomy and control in this context. The aim of this review was to analyze what role autonomy and control may play in relation to the WTD expressed by people with life-limiting conditions.

METHODS

A systematic integrative review was conducted. The search strategy used MeSH terms in combination with free-text searching of the EBSCO Discovery Service (which provides access to multiple academic library literature databases, including PubMed and CINAHL), as well as the large PsycINFO, Scopus, and Web of Science library literature databases from their inception until February 2019. The search was updated to January 2021.

RESULTS

After the screening process, 85 full texts were included for the final analysis. Twenty-seven studies, recording the experiences of 1,824 participants, were identified. The studies were conducted in Australia (n = 5), Canada (n = 5), USA (n = 5), The Netherlands (n = 3), Spain (n = 2), Sweden (n = 2), Switzerland (n = 2), Finland (n = 1), Germany (n = 1), and the UK (n = 1). Three themes were identified: (1) the presence of autonomy for the WTD, (2) the different ways in which autonomy is conceptualized, and (3) the socio-cultural context of research participants.

SIGNIFICANCE OF RESULTS

Despite the importance given to the concept of autonomy in the WTD discourse, only a few empirical studies have focused on personal interests. Comprehending the context is crucial because personal understandings of autonomy are shaped by socio-cultural-ethical backgrounds and these impact personal WTD attitudes.

"Hard to Say, Hard to Understand, Hard to Live": Possible Associations between Neurologic Language Impairments and Suicide Risk

In clinical practice, patients with language impairments often exhibit suicidal ideation (SI) and suicidal behavior (SB, covering the entire range from suicide attempts, SA, to completed suicides). However, only few studies exist regarding this subject. We conducted a mini-review on the possible associations between neurologic language impairment (on the motor, comprehension, and semantic sides) and SI/SB. Based on the literature review, we hypothesized that language impairments exacerbate psychiatric comorbidities, which, in turn, aggravate language impairments. Patients trapped in this vicious cycle can develop SI/SB. The so-called “affective prosody” provides some relevant insights concerning the interaction between the different language levels and the world of emotions. This hypothesis is illustrated in a clinical presentation, consisting of the case of a 74-year old woman who was admitted to a psychiatric emergency department (ED) after a failed SA. Having suffered an ischemic stroke two years earlier, she suffered from incomplete Broca’s aphasia and dysprosody. She also presented with generalized anxiety and depressive symptoms. We observed that her language impairments were both aggravated by the exacerbations of her anxiety and depressive symptoms. In this patient, who had deficits on the motor side, these exacerbations were triggered by her inability to express herself, her emotional status, and suffering. SI was fluctuant, and—one year after the SA—she completed suicide. Further studies are needed to ascertain possible reciprocal and interacting associations between language impairments, psychiatric comorbidities, and SI/SB. They could enable clinicians to better understand their patient’s specific suffering, as brought on by language impairment, and contribute to the refining of suicide risk detection in this sub-group of affected patients.

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

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

Acceptance and Commitment Therapy for Demoralization Syndrome and Cancer-related Trauma: A Randomized Clinical Trial Study

Background: Many women with breast cancer in the process of diagnosing, treating, and surviving show psychological distress such as hopelessness and cancer-related stress. On the other hand, Acceptance and Commitment Therapy (ACT) as a psychological intervention provides a good model for coping with the disease. Objectives: This study aimed at investigating the effectiveness of ACT on demoralization syndrome and cancer-related trauma in patients with breast cancer and survivors. Methods: The present study was a clinical trial with pre-test and post-test. It was performed on 52 patients with breast cancer and survivors referred to the Golestan Cancer Patients Association in Gorgan in 2020. Initially, participants were selected by convenient sampling and randomly divided into two treatment groups (patients group and survivors group) and two control groups (patients group and survivors group). Then, the treatment groups underwent ACT for 8 consecutive weekly sessions, but the control groups did not receive any intervention. The data were obtained, using the Demoralization Scale (DS) and Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) and analyzed by multivariate analysis of covariance (MANCOVA). Results: The results of the study showed a significant difference in demoralization syndrome components and PCL-5 between the treatment groups of patients and survivors with control groups of patients and survivors (P < 0.05). Also, there was no significant difference between the treatment groups of patients and survivors in the components of demoralization and PCL-5 (P > 0.05) except for the feeling of failure component (P = 0.048). Conclusions: According to the results, using ACT as a complementary treatment along with medical treatment to prevent and reduce demoralization syndrome and cancer-related trauma is recommended in patients with breast cancer and survivors.

Demoralization, depression and anxiety in postpartum women of culturally and linguistic diverse backgrounds in Australia

INTRODUCTION

The present study aims to investigate whether mothers from Culturally and Linguistically Diverse (CALD) backgrounds present with higher levels of demoralization in comparison with their non-minority counterparts, and to explore potential correlations between demoralization and anxiety as well as depression in the same sample of mothers.

METHODS

Women admitted to a public tertiary care teaching hospital were invited to participate in the study within 24–48 hours following delivery. The study compared women who did not regard English as their main spoken language to native English-speaking women. Women were asked to complete the demographic Kissane Demoralization Scale (KDS) and Being a Mother Scale (BaM-13) questionnaires. Participants were contacted by phone, 6 to 8 weeks after they had completed the KDS and the BaM-13 questionnaires, to complete an Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Scale (STAI) questionnaires.

RESULTS

Mothers of CALD background presented with significantly higher scores on the KDS (p<0.001), STAI (p<0.001) and EPDS (p<0.001) scales in comparison with their non-CALD counterparts. Furthermore, when mothers were reassessed after 6 to 8 weeks, higher KDS scores in the postnatal period predicted significantly higher anxiety and depression scores, according to STAI (p<0.001) and the EPDS (p<0.001), respectively.

CONCLUSIONS

The results of this study reveal that, mothers of CALD background manifest higher levels of demoralization as well as anxiety and depression in the postpartum period when compared with their non-CALD counterparts.

Exploring the Level of Post Traumatic Growth in Kidney Transplant Recipients via Network Analysis

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.

Efficacy of Meaning-Centered Psychotherapy in adult patients with advanced cancer: A systematic review and meta-analysis

Objective: We conducted a PRISMA-compliant systematic review of clinical trials, and a meta-analysis of randomised clinical trials (RCTs) of manualised Meaning-Centered Psychotherapy (MCP) interventions for adult advanced cancer patients. We searched seven databases for trials published in English and Spanish, until March 27, 2021. Results: Seven trials were included in the systematic review, and four in the meta-analysis. The systematic review favoured the effectiveness of MCP for the improvement of spiritual well-being, quality of life (QoL), sense of meaning and psychological distress, although inconsistencies between the trials were found. In pre-post meta-analytic estimates, MCP had a superior therapeutic effect than control conditions for spiritual well-being (d=0.52, p<0.001), QoL (d=0.60, p<0.001), anxiety symptoms (d=-0.47, p<0.001), depressive symptoms (d=-0.50, p<0.001) and desire for hastened death (d=-0.28, p<0.001). No differences were observed in between-group comparisons. MCP was not associated with an increased risk of abandonment at post-treatment (OR=0.86, p=0.57). Conclusion: Manualised MCP interventions are a promising treatment for the improvement of spiritual well-being and quality of life and the reduction of psychological distress in adult patients with advanced cancer. The evidence base is still in an emerging state and should be expanded by higher methodological quality studies.

Attitudes Toward Euthanasia: A Longitudinal Analysis of the Role of Economic, Cultural, and Health-Related Factors

CONTEXT

It is crucial that physicians understand differing attitudes toward euthanasia and which factors to consider when discussing end-of-life decisions with patients and families from diverse backgrounds.

OBJECTIVES

To investigate how attitudes toward euthanasia differ among countries, how they change, and how economic, religious, and health-related factors affect these attitudes.

METHODS

We analyzed attitudes toward euthanasia and economic, religious, and health-related indicators using longitudinal (1981-2018) World Values Survey (WVS) data. They included 62 countries with at least a 15-year, three-wave, time series (total n = 389,243 participants). Each national survey interviewed representative samples of adults (mean = 1405).

RESULTS

In the latest wave, The Netherlands had the most favorable views of euthanasia (10-point scale with 1 = least justifiable: mean = 7.47) and Jordan the least (mean = 1.50). Residents of 23 of 24 high-income countries came to view euthanasia as more justifiable, while residents of 12 of 38 middle- and low-income countries came to view it as less justifiable over time. The higher GDP per-capita at the time of survey, the more euthanasia was accepted (r = 0.703; P< 0.0001); the more important respondents viewed religion as being, the less euthanasia was accepted (r = -0.834; P< 0.0001); the higher life expectancy and the lower infant mortality were, the more euthanasia was accepted (r = 0.669; P< 0.0001/r = -0.716; P< 0.0001).

CONCLUSION

Euthanasia-related attitudes differ widely depending on the cultural context; changes over time varied in both directions; euthanasia-related attitudes were associated with economic, religious and health-related factors. With globalization increasing cultural diversity, these findings can inform physicians' communication about end-of-life decisions with patients and families from diverse backgrounds.

Refractory psycho-existential distress and continuous deep sedation until death in palliative care: The French perspective

OBJECTIVE

Since February 2016, French Claeys-Leonetti law has recognized patients' right to confront incurable diseases with short-term prognosis and refractory physical or psychological or existential symptoms by requesting continuous deep sedation until death (CDSUD). Determining when psychological or existential distress is refractory and unbearable remains complex and controversial.This review provides a comprehensive thought on CDSUD for advanced incurable patients with refractory psychological and/or existential distress in palliative care settings. It offers guidance on psychiatric or psychological diagnosis for explaining patients' requests for CDSUD.

METHOD

A narrative literature review (2000-2019) was conducted on the MedLine search about the use of palliative sedation in cases of refractory psychological and/or existential distress.

RESULTS

(1) Definitions of "refractory symptom," "refractory psychological distress," and "refractory existential distress" are inconsistent; (2) alternative diagnoses might obscure or be obscured by psycho-existential distress; and (3) criteria on meanings, reasons for requests, decision-making processes, and functions are evolving in practice.

SIGNIFICANCE OF RESULTS

Before implementing CDSUD, palliative healthcare professionals should seek input from psycho-oncologists in palliative care. Mental health professionals should analyze and assess the reasons for psychological and/or existential distress, consider the intentionality processes of requests, and explore alternative diagnoses, such as depressive or adjustment disorders, demoralization syndrome, desire to hasten death, and desire for euthanasia. Therapeutic responses (e.g., pharmacological and psychotherapeutic) should be implemented before deciding that psycho-existential distress is refractory.

[Association of Illness Perceptions with Demoralization and Psychological Distress in Cancer: a Longitudinal Study]

Hintergrund Diese Längsschnittstudie untersucht den Einfluss der Ausprägung subjektiver Krankheitstheorien auf den zeitlichen Verlauf von Demoralisierung, Depression und Angst bei Patienten mit einer Krebserkrankung.

Methode Wir untersuchten n=307 Patienten mit gemischten Tumordiagnosen und Erkrankungsstadien zu drei Messzeitpunkten: während der ambulanten bzw. stationären Behandlung, nach 6 Monaten (n=213, 69%) sowie nach 12 Monaten (n=153, 50%). Subjektive Krankheitstheorien wurden anhand der Subskalen Konsequenzen, Kontrolle, Behandlungskontrolle und Kohärenz des Illness Perception Questionnaire (IPQ-R) erfasst. Psychische Belastung wurde anhand der Demoralisierungsskala (DS) sowie der Module Depression und Angst des Gesundheitsfragebogens für Patienten (PHQ-9 und GAD-7) erfasst. Längsschnittliche Analysen erfolgten anhand von Varianzanalysen mit Messwiederholung (MANOVA).

Ergebnisse Zu Studienbeginn nahmen 20% der Teilnehmer die Erkrankung als mit einschneidenden Konsequenzen verbunden wahr (12-Monats-Follow-up: 16%); 25% nahmen sie als persönlich kontrollierbar (12-Monats-Follow-up: 17%), 42% als durch die medizinische Behandlung kontrollierbar (12-Monats-Follow-up: 26%) und 24% als kohärent/verstehbar wahr (12-Monats-Follow-up: 30%). Zu Studienbeginn war die Wahrnehmung einschneidender Konsequenzen mit einer signifikant höheren psychischen Belastung verbunden, von Kontrollierbarkeit und Kohärenz mit einer signifikant geringeren psychischen Belastung. Die Größe dieses Zusammenhangs war jeweils am höchsten für Demoralisierung (Konsequenzen: r=0,45, p<0,001, Kontrolle: r=− 0,25, p<0,001, Behandlungskontrolle: r=− 0,31, p<0,001, Kohärenz: r=− 0,27, p<0,001). Keine der Subskalen hatte einen signifikanten Einfluss auf die zeitliche Veränderung der psychischen Belastung über den Verlauf von 12 Monaten (d≤0,29, p≥0,09).

Diskussion Die subjektive Wahrnehmung einschneidender Konsequenzen, geringer Kontrollierbarkeit sowie Verstehbarkeit der Erkrankung kann eine wichtige Quelle für aktuell erlebte hohe Belastungen bei Krebspatienten sein. Sie geht jedoch nicht zwangsläufig mit einem weiteren Anstieg oder Abfall der psychischen Belastung einher. Ein möglicher Grund könnte in den begrenzten Möglichkeiten des eingesetzten IPQ-R liegen, adaptiv-angemessene von maladaptiv-verzerrten Krankheitswahrnehmungen zu differenzieren.