D Kissane, D Clarke, A Street. Journal of Palliative Care 17:1/2001; 12-21

Prepared by: : Dr Ingrid de Kock

Received during: Case Rounds, Regional Palliative Care Program

Abstract:

Hopelessness, loss of meaning and existential distress are proposed as the core features of the diagnostic category of demoralization syndrome. This syndrome can be differentiated from depression and is recognizable in palliative care settings. It is associated with chronic medical illness, disability, bodily disfigurement, fear of loss of dignity, social isolation, and - where there is a subjective sense of incompetence - feelings of greater dependency on others or the perception of being a burden. Because of the sense of impotence or helplessness, those with the syndrome predictably progress to a desire to die or to commit suicide. A treatment approach is described which has the potential to alleviate the distress caused by this syndrome. Overall, demoralization syndrome has satisfactory face, descriptive, predictive, construct, and divergent validity, suggesting its utility as a diagnostic category in palliative care.

Comments:

Strengths/uniqueness: This suggested syndrome does address a grey area between normal grief reaction and depression. Recognizing and naming this condition of hopelessness, helplessness and existential distress might help to focus on possible interventions.

Weaknesses: The authors do not state whether the treatments mentioned are effective in treating the proposed syndrome. It is not clear how the proposed treatment options differ from well-established basic Palliative Care principles. There are concerns that such a label might conversely lead to further under-recognition of depression.

Relevance to Palliative Care: At this stage it is a suggestion only and it will be interesting to see where further research will lead the authors.

Psychiatric disorders and associated and predictive factors on patients with unresectable nonsmall cell lung carcinoma: a longitudinal study

Akechi T, Okamura H, Nishiwaki Y, Usbitomi Y. Cancer 2001; 92:2609-22.

Prepared by: : Yoko Tarumi, M.D

Received during: Journal Rounds on the Regional Palliative Care Program

Abstract:

Background

Few longitudinal studies have investigated psychiatric disorders in patients with unresectable nonsmall cell lung carcinoma (NSCLC). This study addressed three questions: 1) Which psychiatric disorders are prevalent among patients with unresectable NSCLC? 2) What is the clinical course of psychological distress? 3) Which factors are associated with this distress, and do any antecedent variables predict subsequent psychological distress?

Methods

A series of 129 consecutive patients with newly diagnosed, unresectable NSCLC participated. Psychiatric assessments were conducted by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised between the time of diagnosis and initial treatment for NSCLC (baseline) and 6 months after diagnosis (follow-up). Potential associated and predictive variables, including sociodemographic, biomedical, and psychosocial factors, were explored.

Results

The most common psychiatric disorder at baseline was nicotine dependence (67%), followed by adjustment disorders (14%), alcohol dependence (13%), and major depression (5%). At follow-up, adjustment disorders were diagnosed in 16% of patients, and major depression was diagnosed in 3% of patients. Thirty-five percent of patients who experienced depressive disorders (adjustment disorders and/or major depression) at baseline continued to experience the same disorders at follow-up. Multivariate analysis revealed that relatively younger age and pain were associated significantly with psychological distress at baseline. Only self-reported anxiety and depression at baseline could predict subsequent psychological distress.

Conclusions

Substance dependence and depressive disorders are common psychiatric disorders in patients with unresectable NSCLC. Although this form of malignant disease often is progressive, depressive disorders do not seem to increase during its clinical course. Pain management is essential for alleviating patients' depressive disorders, and self-rating depression and anxiety seems to be an indicator of subsequent depressive disorders.

Comments:

Strengths/uniqueness:This is one of a few longitudinal studies with a relatively large number (129 consecutive patients) investigating psychiatric disorders in patients with newly diagnosed with advanced NSCLC. Psychiatric assessments were conducted by a trained psychiatrist along with validated self-report questionnaires, patients' use of confidants, and biochemical factors. The authors suggest careful interpretation of the result of prevalence of psychological distress in light of the limitations of selection bias of a homogeneous group, as well as validation of the translated questionnaire, cultural issues, prevalence of organic mental disorders, and Hawthorne effects. There are many suggestions for further clarification of correlated factors for psychiatric distress as well as management of these issues.

Weaknesses: The authors fail to describe the potential problems with using DSM IIIR as diagnostic tool (which includes neurovegetative or somatic signs and symptoms such as fatigue, loss of energy and appetite, or weight loss) for major depression in this population. Hopelessness, or feeling of unworthiness may represent depression.

Relevance to Palliative Care:This report is valuable to help us add more information to the Edmonton Staging System in the area of psychological distress as poor prognostic factor for pain control or vice versa. The result helps us to understand the characteristics of adjustment disorder in our setting.