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1.  The association between malnutrition and psychological distress in patients with advanced head-and-neck cancer 
Current Oncology  2013;20(6):e554-e560.
Malnutrition and psychological distress are often seen in patients with head-and-neck cancer, but little is known about the interrelationships between those two symptoms. The present study examined the relationship between malnutrition and psychological distress in patients with advanced head-and-neck cancer.
Using the Patient-Generated Subjective Global Assessment, 99 patients with advanced-stage head-and-neck cancer were screened for nutrition status. The patients were also screened for psychosocial distress (using the Distress Thermometer) and for psychosocial issues (using the Problem Checklist). Any relationship between malnutrition and psychosocial distress was determined by regression and correlation analysis. We also used t-tests to compare distress levels for patients with and without specific nutrition-related symptoms.
The study group included 80 men and 19 women [mean age: 58.4 ± 10.9 years (range: 23–85 years)]. The correlation between poorer nutrition status and level of psychological distress was significant r = 0.37 (p < 0.001). Specifically, reduced food intake and symptoms were both positively associated with distress: r = 0.27 and r = 0.29 respectively, both significant at p < 0.01. After controlling for the effects of psychosocial problems and pain, nutrition status remained a significant predictor of distress, explaining 3.8% of the variance in the distress scores of the patients (p < 0.05).
Malnutrition and symptoms were strongly related to distress in patients with advanced head-and-neck cancer. Our results suggest the need for further research into the complex relationship between nutrition status and distress and into the management of both nutrition and distress in cancer care.
PMCID: PMC3851352  PMID: 24311956
Head-and-neck cancer; late effects; psychological distress; malnutrition; screening; symptoms
2.  Distress Screening in a Multidisciplinary Lung Cancer Clinic: Prevalence and Predictors of Clinically-Significant Distress 
Screening for distress in cancer patients is recommended by the National Comprehensive Cancer Network, and a Distress Thermometer has previously been developed and empirically-validated for this purpose. The present study sought to determine the rates and predictors of distress in a sample of patients being seen in a multidisciplinary lung cancer clinic. Consecutive patients (N = 333) were recruited from an outpatient multidisciplinary lung cancer clinic to complete the Distress Thermometer, an associated Problem Symptom List, and two questions about interest in receiving help for symptoms. Over half (61.6%) of patients reported distress at a clinically significant level, and 22.5% of patients indicated interest in receiving help with their distress and/or symptoms. Problems in the areas of family relationships, emotional functioning, lack of information about diagnosis/treatment, physical functioning, and cognitive functioning were associated with higher reports of distress. Specific symptoms of depression, anxiety, pain and fatigue were most predictive of distress. Younger age was also associated with higher levels of distress. Distress was not associated with other clinical variables, including stage of illness or medical treatment approach. Similar results were obtained when individuals who had not yet received a definitive diagnosis of lung cancer (n = 134) were excluded from analyses; however, family problems and anxiety were no longer predictive of distress. Screening for distress in a multidisciplinary lung cancer clinic is feasible and a significant number of patients can be expected to meet clinical criteria for distress. Results also highlight younger age and specific physical and psychosocial symptoms as predictive of clinically-significant distress. Identification of the presence and predictors of distress are the first steps toward appropriate referral and treatment of symptoms and problems that contribute to cancer patients’ distress.
PMCID: PMC1857305  PMID: 17084483
psychological distress; screening; lung cancer; Distress Thermometer; predictors
3.  The chronology of distress, anxiety, and depression in older prostate cancer patients 
The oncologist  2009;14(9):891-899.
Current research suggests that older cancer patients report less distress compared to younger cancer patients. However, this research has generally not teased apart the differences between general distress, anxiety, and depression.
We conducted a secondary analysis of merged datasets using cross-sectional data on 736 men with prostate cancer (Mean Age 68±10 years of age, range 50 to 93). Approximately half the participants were recruited from doctors’ offices throughout the United States and the other half from Memorial Sloan-Kettering Cancer Center (New York, NY). Participants were asked to complete the Distress Thermometer, the Hospital Anxiety and Depression Scale (HADS), the FACT-P Quality of Life questionnaire, and a demographic questionnaire.
Aging was related to reduced distress (r=−0.14), less anxiety (r=−0.22), and increased emotional quality of life (r= 0.16). In contrast, aging was associated with greater depressive symptoms in these cancer patients (r= 0.18). The mean depression scores of 5-year cohorts consistently trended upward. The significant association between age and depression remained after controlling for stage of disease, hormone therapy use, time since diagnosis, and social, physical and functional well-being.
Despite theoretical and empirical evidence that older cancer patients may cope more effectively than younger cancer patients, depressive symptoms remain an important concern for aging cancer patients and greater attention to this area is warranted. The increase in depression is in contrast to some findings in the general aging literature, raising the possibility that this trend is unique to older cancer patients.
PMCID: PMC2881474  PMID: 19738000
Psychological distress; Depression; Anxiety; Prostate Cancer; Aging
4.  The Feasibility of Inpatient Geriatric Assessment for Older Adults Receiving Induction Chemotherapy for Acute Myelogenous Leukemia 
To test the feasibility and utility of a bedside geriatric assessment (GA) to detect impairment in multiple geriatric domains in older adults initiating chemotherapy for acute myelogenous leukemia (AML).
Prospective observational cohort study.
Single academic institution.
Individuals aged 60 and older with newly diagnosed AML and planned chemotherapy.
Bedside GA was performed during inpatient exmination for AML. GA measures included the modified Mini-Mental State Examination; Center for Epidemiologic Studies Depression Scale; Distress Thermometer, Pepper Assessment Tool for Disability (includes self- reported activities of daily living (ADLs), instrumental ADLs, and mobility questions); Short Physical Performance Battery (includes timed 4-m walk, chair stands, standing balance); grip strength, and Hematopoietic Cell Transplantation Comorbidity Index.
Of 54 participants (mean age 70.8 ± 6.4) eligible for this analysis, 92.6% completed the entire GA battery (mean time 44.0 ± 14 minutes). The following impairments were detected: cognitive impairment, 31.5%; depression, 38.9%; distress, 53.7%; impairment in ADLs, 48.2%; impaired physical performance, 53.7%; and comorbidity, 46.3%. Most were impaired in one (92.6%) or more (63%) functional domains. For the 38 participants rated as having good performance status according to standard oncologic assessment (Eastern Cooperative Oncology Performance Scale score ≤1), impairments in individual GA measures ranged from 23.7% to 50%. Significant variability in cognitive, emotional, and physical status was detected even after stratification according to tumor biology (cytogenetic risk group classification).
Inpatient GA was feasible and added new information to standard oncology assessment, which may be important for stratifying therapeutic risk in older adults with AML.
PMCID: PMC3782375  PMID: 22091497
geriatric assessment; acute myelogenous leukemia; cancer; functional status; elderly
5.  Symptom Distress and Quality of Life in Patients with Advanced Congestive Heart Failure 
Little is known about the burden of illness associated with advanced congestive heart failure (CHF). Understanding the needs of this population requires further information about symptoms and other factors related to quality of life. We studied a convenience sample of 103 community-dwelling patients with New York Heart Association Class III/IV CHF. The primary outcome, quality of life (QOL), was measured with the Multidimensional Index of Life Quality (MILQ). Potential correlates of QOL included overall symptom burden (Memorial Symptom Assessment Scale, MSAS), including global symptom distress (MSAS Global Distress Index, GDI); psychological state (Mental Health Inventory-5, MHI-5); functional status (Sickness Impact Profile, SIP); spirituality (Functional Assessment of Chronic Illness Therapy-Spirituality Scale, FACIT-Spirituality); and co-morbid conditions (Charlson Comorbidity Index). Patients had a mean age of 67.1 years (SD = 12.1); were mostly white (72.8%), male (71.8%), and married (51.5%); and had a mean ejection fraction of 22.3% (SD = 6.8). The most prevalent symptoms were lack of energy (66%), dry mouth (62%), shortness of breath (56%), and drowsiness (52%). Pain was reported by about one-third of patients. For each of these symptoms, high symptom-related distress was reported by 14.1−54.1%. Quality of life was moderately compromised (MILQ composite, median = 56, possible range 12−84). Impairment in quality of life was strongly associated with global symptom distress (MSAS GDI; r = 0.74, P < 0.001); burden of comorbid conditions (r = −0.32, P = 0.002), female sex (r = −0.22, P = 0.03), functional impairment, particularly psychological impairment (r = −0.55, P < 0.001), and poorer psychological well-being (r = 0.68, P < 0.001). In multivariate analyses, impairment in quality of life was significantly related to high symptom distress, poorer psychological well-being, and poor functional mobility (R2 = 0.67; P=0.002 for all). Distressful symptoms related to impaired quality of life included lack of energy (P=0.04), irritability (P=0.03) and drowsiness (P=0.02). Community-dwelling patients with advanced CHF experience numerous symptoms, significant symptom distress, and a compromised quality of life. Overall quality of life was strongly associated with symptom distress, psychological well-being and functional status. A focus on ameliorating prevalent physical symptoms and psychological distress, along with supportive measures that promote functional mobility, may lead to an improvement in the overall quality of life in this patient population.
PMCID: PMC2662445  PMID: 18215495
Congestive heart failure; quality of life; symptom distress
6.  Illness Uncertainty and Quality of Life of Patients with Small Renal Tumors Undergoing Watchful Waiting: A 2-year Prospective Study 
European urology  2013;63(6):10.1016/j.eururo.2013.01.034.
Few studies have examined factors associated with the quality of life (QOL) of patients with renal tumors. Illness uncertainty may influence QOL.
To prospectively examine the influence of uncertainty on general and cancer-specific QOL and distress in patients undergoing watchful waiting (WW) for a renal mass.
Design, setting, and participants
In 2006–2010, 264 patients were enrolled in a prospective WW registry. The decision for WW was based on patient, tumor, and renal function characteristics at the discretion of the urologist and medical oncologist in the context of the physician–patient interaction. Participants had suspected clinical stage T1–T2 disease, were aged ≥18 yr, and spoke and read English. The first 100 patients enrolled in the registry participated in this study.
Outcome measurements and statistical analysis
Patients completed questionnaires on demographics, illness uncertainty (Mishel Uncertainty in Illness Scale), general QOL (Medical Outcomes Study 36-item short-form survey), cancer-specific QOL (Cancer Rehabilitation Evaluation System–Short Form), and distress (Impact of Events Scale) at enrollment and at 6, 12, and 24 mo. Age, gender, ethnicity, tumor size, estimated glomerular filtration rate, comorbidities, and assessment time point were controlled for in the models.
Results and limitations
Among the sample, 27 patients had biopsies, and 17 patients had proven renal cell carcinoma. Growth rate was an average of 0.02 cm/yr (standard deviation: 0.03). Mean age was 72.5 yr, 55% of the patients were male, and 84% of the patients were Caucasian. Greater illness uncertainty was associated with poorer general QOL scores in the physical domain (p = 0.008); worse cancer-related QOL in physical (p = 0.001), psychosocial (p < 0.001), and medical (p = 0.034) domains; and higher distress (p < 0.001).
This study is among the first to prospectively examine the QOL of patients with renal tumors undergoing WW and the psychosocial factors that influence QOL. Illness uncertainty predicted general QOL, cancer-specific QOL, and distress. These factors could be targeted in psychosocial interventions to improve the QOL of patients on WW.
PMCID: PMC3866912  PMID: 23419322
Kidney cancer; Renal cell carcinoma; Quality of life; Prospective study; Illness uncertainty
7.  Screening for Distress in Routine Oncological Care—A Survey in 520 Melanoma Patients 
PLoS ONE  2013;8(7):e66800.
Despite the increasing incidence of melanoma little is known about patients' emotional distress associated with this disease. Supplemented by the problem list (PL), the distress thermometer (DT) is a recommended screening instrument to measure psychosocial distress in cancer patients. Our objective was to explore the acceptance and the feasibility of the DT and PL as a concise screening tool in an ambulatory setting for routine care and to elucidate determinants of distress in melanoma patients with regard to sociodemographic and clinical variables.
Consecutive melanoma outpatients were asked to complete the DT with the PL prior to their scheduled consultation. Demographic and clinical data were obtained from the patients' charts. Clinical data included melanoma stage, time since diagnosis, previous treatment, current treatment, and other cancer disease.
Out of 734 patients recruited into the study, 520 patients (71%) completed both the DT and the PL. Forty-seven percent met the ≥5 cut-off score for distress. Younger and employed patients reported higher distress than older and retired patients. A cut-off score of ≥5 was closely associated with self-reported emotional sources of distress, with practical problems, especially at work, family problems (dealing with the partner), and physical problems like pain, appearance, getting around, and nausea. Apart from higher distress under current systemic treatment, no associations were found between distress and clinical data.
The DT together with the PL seems to be an economically reasonable screening tool to measure psychosocial distress in melanoma patients. In particular, younger melanoma patients who are currently employed are prone to experience distress at some point after diagnosis, but there appears to be almost no association between clinical data and the extent of distress. To characterize the impact of distress on disease outcome and quality of life in melanoma patients, further research is needed.
PMCID: PMC3702515  PMID: 23861748
8.  Acceptability of the Distress Thermometer and Problem List to community-based telephone cancer helpline operators, and to cancer patients and carers 
BMC Cancer  2011;11:46.
Cancer can be a distressing experience for cancer patients and carers, impacting on psychological, social, physical and spiritual functioning. However, health professionals often fail to detect distress in their patients due to time constraints and a lack of experience. Also, with the focus on the patient, carer needs are often overlooked. This study investigated the acceptability of brief distress screening with the Distress Thermometer (DT) and Problem List (PL) to operators of a community-based telephone helpline, as well as to cancer patients and carers calling the service.
Operators (n = 18) monitored usage of the DT and PL with callers (cancer patients/carers, >18 years, and English-speaking) from September-December 2006 (n = 666). The DT is a single item, 11-point scale to rate level of distress. The associated PL identifies the cause of distress.
The DT and PL were used on 90% of eligible callers, most providing valid responses. Benefits included having an objective, structured and consistent means for distress screening and triage to supportive care services. Reported challenges included apparent inappropriateness of the tools due to the nature of the call or level of caller distress, the DT numeric scale, and the level of operator training.
We observed positive outcomes to using the DT and PL, although operators reported some challenges. Overcoming these challenges may improve distress screening particularly by less experienced clinicians, and further development of the PL items and DT scale may assist with administration. The DT and PL allow clinicians to direct/prioritise interventions or referrals, although ongoing training and support is critical in distress screening.
PMCID: PMC3040161  PMID: 21281476
9.  The impact of clinical conditions and social factors on the psychological distress of cancer patients: an explorative study at a consultation and liaison service in a rural general hospital 
BMC Psychiatry  2013;13:226.
In recent decades, increasing attention has been paid to the subjective dimension of cancer, especially to psychosocial screening procedures, major psychiatric disorders but also psychological and psychosocial distress, and finally to met needs of oncologic patients. This study aims first to describe cancer patients in a rural hospital attended by a psycho-oncological consultation-liaison team, second to assess predictors for psychological distress in cancer patients, and finally to identify predictors for recommendation of further psychosocial support.
The sample (n = 290) comprises a full survey of patients at breast and bowel cancer services (n=209) and patients referred by other medical and surgical services because of psychosocial impairment (n = 81). All patients were assessed by means of the PO-Bado (Psycho-Oncological Basic Documentation) expert rating scale. Assessment of predictors for psychological distress was conducted by multivariate regression models and assessment for predictors for need for outpatient psychosocial support by a logistic regression analysis. All analyses were conducted using STATA 12.
Most members of the assessed sample (average age 65, 82% women) were not severely impaired from a functional and psychological point of view. A total of 14% had received psychiatric treatment before. Mood swings, anxiety, grief, and fatigue were the most important distress symptoms. Selectively referred patients vs. full survey patients of cancer centres, as well as bowel vs. breast cancer patients show a higher level of psychological and physical distress. Fatigue, assessed metastases, and functional limitations were the best predictors for psychological burden. Referral mode, gender, age, family problems, fatigue, and previous psychiatric treatment were associated with further need of psychosocial support.
Psycho-oncological consultation and liaison services may offer support to patients in an early stage of cancer, especially in cancer centres. Because of selectively referred patients show a higher burden, the use of basic screening instruments could be meaningful. Fatigue, metastases status, and functional limitations may better predict psychological distress than pain, duration of illness, psychosocial conditions or previous psychiatric treatment. More attention has to be paid to outpatient follow-up with older cancer patients, those with family problems, and those suffering from significant fatigue.
PMCID: PMC3815628  PMID: 24053562
PO-Bado; Psycho-oncology; Psychological distress; Physical distress; Psychosocial support; Needs of cancer patients
10.  Cognitive status and behavioral problems in older hospitalized patients 
(a) To determine the quantity and quality of behavioral problems in older hospitalized patients on acute care units; (b) to determine the burden of these behaviors on staff; and (c) to identify predictors of behavioral problems.
Upon admission, patients performed the Mini-Mental State Exam (MMSE), the Geriatric Depression Scale (GDS), and information was obtained on age, ethnicity, level of education, living arrangement, and psychiatric history. Two days post-admission, a clinical staff member caring for each patient, performed the Neuropsychiatric Inventory-Questionnaire (NPI-Q) to assess patients' behavioral problems and staff distress.
Participants and setting
Forty-two patients, over 60 years of age, admitted to medical and surgical units of the Veterans Affairs Hospitals in Palo Alto and San Francisco, participated.
Twenty-three of 42 (55%) patients exhibited behavioral problems. Anxiety, depression, irritability, and agitation/aggression were the most frequently observed behaviors. The severity of the behavioral problems was significantly correlated with staff distress. Lower performance on the MMSE at admission was significantly associated with higher NPI-Q ratings. Specifically, of those cases with scores less than or equal to 27 on the MMSE, 66% had behavioral problems during hospitalization, compared to only 31% of those with scores greater than 27.
Behavioral problems in older hospitalized patients appear to occur frequently, are a significant source of distress to staff, and can result in the need for psychiatric consultation. Assessment of the mental status of older adults at admission to hospital may be valuable in identifying individuals at increased risk for behavioral problems during hospitalization.
PMCID: PMC139956  PMID: 12537601
Acute Care; Older Patients; Agitation; Cognition
11.  Prevalence of psychological distress and associated factors in tuberculosis patients in public primary care clinics in South Africa 
BMC Psychiatry  2012;12:89.
Psychological distress has been rarely investigated among tuberculosis patients in low-resource settings despite the fact that mental ill health has far-reaching consequences for the health outcome of tuberculosis (TB) patients. In this study, we assessed the prevalence and predictors of psychological distress as a proxy for common mental disorders among tuberculosis (TB) patients in South Africa, where over 60 % of the TB patients are co-infected with HIV.
We interviewed 4900 tuberculosis public primary care patients within one month of initiation of anti-tuberculosis treatment for the presence of psychological distress using the Kessler-10 item scale (K-10), and identified predictors of distress using multiple logistic regressions. The Kessler scale contains items associated with anxiety and depression. Data on socio-demographic variables, health status, alcohol and tobacco use and adherence to anti-TB drugs and anti-retroviral therapy (ART) were collected using a structured questionnaire.
Using a cut off score of ≥28 and ≥16 on the K-10, 32.9 % and 81 % of tuberculosis patients had symptoms of distress, respectively. In multivariable analysis older age (OR = 1.52; 95 % CI = 1.24-1.85), lower formal education (OR = 0.77; 95 % CI = 0.65-0.91), poverty (OR = 1.90; 95 % CI = 1.57-2.31) and not married, separated, divorced or widowed (OR = 0.74; 95 % CI = 0.62-0.87) were associated with psychological distress (K-10 ≥28), and older age (OR = 1.30; 95 % CI = 1.00-1.69), lower formal education (OR = 0.55; 95 % CI = 0.42-0.71), poverty (OR = 2.02; 95 % CI = 1.50-2.70) and being HIV positive (OR = 1.44; 95 % CI = 1.19-1.74) were associated with psychological distress (K-10 ≥16). In the final model mental illness co-morbidity (hazardous or harmful alcohol use) and non-adherence to anti-TB medication and/or antiretroviral therapy were not associated with psychological distress.
The study found high rates of psychological distress among tuberculosis patients. Improved training of providers in screening for psychological distress, appropriate referral to relevant health practitioners and providing comprehensive treatment for patients with TB who are co-infected with HIV is essential to improve their health outcomes. It is also important that structural interventions are promoted in order to improve the financial status of this group of patients.
PMCID: PMC3410814  PMID: 22839597
12.  Diabetes Distress and its Association with Depression in Patients with Type 2 Diabetes in Iran 
Patients with diabetes experience some level of emotional distress varying from disease-specific distress to general symptoms of anxiety and depression. Since empirical data about symptom distress in relation to diabetes are sparse in Iran, this study was designed to assess the diabetes-specific distress in Iranian population.
Persian version of Diabetes Distress Scale (DDS) questionnaire was completed by volunteer outpatients on a consecutive basis between February 2009 and July 2010, in Endocrine Research Center (Firouzgar Hospital). Then, scheduled appointments were made with a psychiatrist in the same week following completion of the questionnaire. The psychiatrist was not aware about the results of this questionnaire and patients were interviewed based on DSM-IV criteria.
One hundred and eighty-five patients completed the questionnaire and were interviewed by a psychiatrist. Fifty-two percent of the patients were females. The mean age was 56.06 (SD=9.5) years and the mean of duration of diabetes was 9.7 (SD=7.3) years. Sixty-five (35%) had distress. Among the patients with distress, 55% were females and 64% had lower grade of education. Eighty patients were diagnosed as having Major Depressive Disorder. There was a relation between Emotional Burden subscale and age (P=0.004), employment status (P=0.03), and also diabetes duration (P=0.02). The physician-related distress subscale was also related to the type of medication (P=0.009) and marital status (P=0.01). It has been shown that the regimen-related distress subscale was also related to age (P=0.003) and duration of diabetes (P=0.005).
High prevalence rate of distress in the study highlights the significance of the need for identifying distress and also other mental health conditions in patients with diabetes in order to take collaborative care approaches.
PMCID: PMC3733189  PMID: 23930169
Type 2 diabetes; distress; depression; anxiety
13.  Depression, Anxiety and Quality of Life in Long-Term Survivors of Malignant Melanoma: A Register-Based Cohort Study 
PLoS ONE  2015;10(1):e0116440.
The purpose of the study was to determine anxiety and depression, quality of life, and their determinants in long-term survivors of malignant melanoma.
In a state cancer registry a cohort of survivors of malignant melanoma was contacted via the physician registered. Of 1302 contactable patients, 689 (52.2%) completed a questionnaire including the Patient Health Questionnaire with generalized anxiety (GAD-7) and depression (PHQ-9) and the EORTC Quality of Life Questionnaire (EORTC QLQ 30). Based on multiple regression analysis, predictors of quality of life and distress were identified. Comparison data were assessed in two waves of representative face-to-face household surveys of the adult German population.
An average of 8.4 (5.7 to 12.2) years after diagnosis, distress was higher in women compared to men and in middle adulthood (vs. older patients). Symptoms were higher in women than in men, and there was a decline of functioning and increase of symptoms across the age range of both genders. Compared to the general population, there were slightly increased depression and anxiety (only women), but no impaired global quality of life. Yet, survivors evidenced functional decline and more physical symptoms. Distress and reduced quality of life were consistently predicted by lack of social support, fear of recurrence, pessimism and self-blame. Distress was increased by a family history of melanoma, and additional mental and somatic diseases.
Overall, long-term survivors have adjusted well achieving a global quality of life comparable to the general population. Yet, compromised functional dimensions, physical symptoms and distress indicate the need for integrating psychooncological screening into oncological follow-up, which might be guided by predictors such as family history or social support. Further prospective study is needed to determine the course of adaptation to the disease and corroborate the risk factors identified.
PMCID: PMC4304781  PMID: 25615573
14.  Receiving Palliative Treatment Moderates the Effect of Age and Gender on Demoralization in Patients with Cancer 
PLoS ONE  2013;8(3):e59417.
Existential distress is an important factor affecting psychological well-being in cancer patients. We studied occurrence and predictors of demoralization, a syndrome of existential distress, in particular the interaction of age, gender, and curative vs. palliative treatment phase.
A cross-sectional sample of N = 750 patients with different tumor sites was recruited from in- and outpatient treatment facilities. Patients completed the following self-report questionnaires: Demoralization Scale, Patient Health Questionnaire-9, Illness-Specific Social Support Scale Short Version-8, and physical problems list of the NCCN Distress Thermometer. Moderated multiple regression analyses were conducted.
We found high demoralization in 15% and moderate demoralization in 8% of the sample. Curative vs. palliative treatment phase moderated the impact of age and gender on demoralization (three-way interaction: b = 1.30, P = .02): the effect of age on demoralization was negative for women receiving palliative treatment (b = −.26, P = .02) and positive for men receiving palliative treatment (b = .25, P = .03). Effects of age and gender were not significant among patients receiving curative treatment. Female gender was associated with higher demoralization among younger patients receiving palliative treatment only. Analyses were controlled for significant effects of the number of physical problems (b = 6.10, P<.001) and social support (b = −3.17, P<.001).
Existential distress in terms of demoralization is a relevant problem within the spectrum of cancer-related distress. It is associated with a complex interaction of demographic and medical patient characteristics; existential challenges related to palliative treatment may exacerbate the impact of age- and gender-related vulnerability factors on demoralization. Psychosocial interventions should acknowledge this interaction in order to address the individual nature of existential distress in subgroups of cancer patients.
PMCID: PMC3598752  PMID: 23555030
15.  Incidence and Predictors of Acute Psychological Distress and Dissociation after Motor Vehicle Collision: a Cross-Sectional Study 
The authors examined the incidence and predictors of peritraumatic distress and dissociation after one of the most common forms of civilian trauma exposure: motor vehicle collision (MVC).
In this study, patients presenting to the emergency department after MVC who were without serious injury and discharged to home after evaluation (n = 935) completed an emergency department interview evaluating sociodemographic, collision-related, and psychological characteristics.
The incidence and predictors of distress (Peritraumatic Distress Inventory score ≥ 23) and dissociation (Michigan Critical Events Perception Scale score >3) were assessed. Distress was present in 355 of 935 patients (38%) and dissociation was present in 260 of 942 patients (28%). These outcomes showed only moderate correlation (r = 0.45), and had both shared and distinct predictors. Female gender, anxiety symptoms prior to MVC, and vehicle damage severity predicted both distress and dissociation. Higher socioeconomic status (higher education, higher income, full time employment) had a protective effect against distress but not dissociative symptoms. Better physical health and worse overall mental health were associated with increased risk of dissociation, but not distress. Distress but not dissociation was associated with lower patient confidence in recovery and a longer expected duration of recovery.
There are unique predictors of peritraumatic distress and dissociation. Further work is needed to better understand the neurobiology of peritraumatic distress and dissociation, and the influence of these peritraumatic outcomes on persistent psychological sequelae.
PMCID: PMC4182147  PMID: 24983475
Distress; Dissociation; Post-Traumatic Stress Disorder; Trauma; Motor Vehicle Collision
16.  Distress, anxiety and depression in patients with brain metastases before and after radiotherapy 
BMC Cancer  2014;14(1):731.
Many patients with cancer suffer from distress, anxiety and depression. However, studies on patients with brain metastases are lacking. In this exploratory study we prospectively assessed distress, anxiety and depression in patients with brain metastases from different solid primary tumour treated with radiotherapy to the brain.
Patients were recruited between May 2008 and December 2010. Distress, anxiety and depression were subjectively evaluated before radiotherapy, 6 weeks, 3 months and 6 months after radiotherapy using the validated National Comprehensive Cancer Network Distress Thermometer (DT) and the Hospital Anxiety and Depression Scale (HADS). The treatment group consisted of adult patients (n = 67) with brain metastases who were treated with whole-brain radiotherapy (n = 40) or hypofractionated stereotactic radiotherapy (n = 27). The control group comprised of patients (n = 32) diagnosed with breast cancer without cranial involvement who received adjuvant whole breast radiotherapy. Forty-six patients (24 in the treatment group) completed the study after six months.
Before radiotherapy, the treatment group experienced higher distress than the control group (p = 0.029). Using a cut-off ≥5, 70% of the treatment group were suffering from significant distress (66% of the control group). No significant time-by-group interaction on distress, anxiety and depression was observed. At all time points, a high proportion of patients reported psychological stress which featured more prominently than most of the somatic problems. Global distress correlated strongly with the Hospital Anxiety score before radiotherapy, but only moderately or weakly with both HADS scores after radiotherapy with the weakest association 6 months after radiotherapy.
In conclusion, the course of distress, anxiety and depression does not differ significantly between patients with brain metastases and breast cancer patients without cranial involvement. This finding suggests that both groups need similar psychological support during their treatment. Both screening instruments should be used as they cover different facets of distress.
PMCID: PMC4192799  PMID: 25266325
Brain metastases; Distress thermometer; HADS; Whole-brain radiotherapy; hypofractionated stereotactic radiotherapy
17.  Discrepancy in patient-rated and oncologist-rated performance status on depression and anxiety in cancer: a prospective study protocol 
BMJ Open  2012;2(5):e001799.
Psychological distress is common in patients with cancer. We need a rapid means of screening for and identifying depression and anxiety in patients with cancer. The present study evaluates the potential of the Eastern Cooperative Oncology Group (ECOG) performance status (PS) scoring as a brief screening tool to assess psychological distress in routine cancer care. The ECOG PS is widely used by oncologists and the WHO, as a standardised measure to assess general well-being in patients with cancer and quality of life in cancer trials. We examine the discrepancy between patient-rated and oncologist-rated PS scores on the ECOG in a comparative assessment against the Hospital Anxiety and Depression Scale (HADS).
Methods and design
This is a prospective evaluation of approximately 500 ambulatory adult cancer patients from a large academic medical centre. Participants will be asked to assess their own ECOG PS on a scale of 0–4, which will be compared to ECOG PS as rated by their oncologists. Higher ECOG PS scores indicate poorer daily functioning. Both patient-rated and oncologist-rated ECOG PS and their absolute differences will be tested for predictive and concurrent validity against the HADS. A HADS cut-off ≥15 will be used. Ethics approval for this study has been secured from the institutional ethics board. Outcomes are re-evaluated at 4-week to 6-week and 1-year follow-up.
This study holds practical significance for rapid screening of psychological distress in the cancer clinic with the use of the ECOG PS scoring. Given the high prevalence of anxiety and depression in patients with cancer, screening is important to increase its recognition, which will, in turn, help to direct referrals and deliver appropriate intervention. This study also generates greater insight into the association between psychosomatic complaints and psychological distress.
Trial registration number
MEC 896.52.
PMCID: PMC3488734  PMID: 23035016
Mental Health; Oncology
18.  Problem-solving style and adaptation in breast cancer survivors: a prospective analysis 
Emotional care of the breast cancer patient is not well understood; this lack of understanding results in both a high cost to the patient, as well as the health care system. This study examined the role of problem-solving style as a predictor of emotional distress, adjustment to breast cancer, and physical function immediately post-surgery and 12 months later.
The sample consisted of 121 women diagnosed with breast cancer and undergoing surgery as a primary treatment. The survivors completed a measure of problem-solving style and three outcome measures immediately post-surgery, as well as at 1 year later. There was a 95.6% retention rate at 1 year.
Multiple hierarchical regressions revealed, after controlling for patient demographics and stage of cancer, that problem-solving style (particularly personal control) was associated with emotional distress, adjustment to chronic illness, and physical function immediately following surgical intervention. In addition, a more positive problem-solving style was associated with less emotional distress, but not a better adaptation to a chronic illness or physical functioning 12 months later; the Personal Control again was the best single predictor of the emotional distress, adding 10% of the variance in predicting this outcome.
The utility of post-surgery assessment may help identify those in need for problem-solving training to improve these outcomes at 1 year. Future studies need to determine the impact of interventions tailored to levels of problem-solving styles in cancer survivors over time.
Implications for Cancer Survivors
Understanding the role of problem solving style in breast cancer survivors deserves attention as it is associated with emotional distress immediately and one year after medical intervention. Problem-solving style should be evaluated early, and interventions established for those most at risk for emotional distress.
PMCID: PMC2948574  PMID: 19396549
Breast cancer survivors; Problem-solving style; Psychological distress; Adaptation to illness; Function; Prospective
19.  Measuring Psychosocial Distress and Parenting Concerns among Adults with Cancer: The Parenting Concerns Questionnaire 
Cancer  2012;118(22):5671-5678.
We conducted a two phase, mixed methods study to develop a Parenting Concerns Questionnaire (PCQ) for adults with cancer. Limited information about this area of psychosocial distress highlights the need for a measurement tool that can identify adult oncology patients with heightened parenting concerns who could benefit from additional intervention.
Telephone focus groups were conducted with 16 oncology patients who had children 18 years old and younger. Group interview transcripts were analyzed to generate qualitative themes and candidate items for the PCQ. A 38-item version of the questionnaire was completed by 173 oncology outpatients with children 18 years old and under. Participants also completed the Distress Thermometer, HADS, and FACT-G. Exploratory factor analyses revealed the emergence of 3 subscales of 5 items each, yielding a 15 item questionnaire. Associations between total PCQ scores, standardized measures of distress, depression, anxiety, quality of life, and demographic and illness characteristics were examined.
The 15 item PCQ demonstrates good internal consistency (Cronbach’s α = .83). PCQ scores were significantly associated (p<.01) with standardized measures of psychosocial distress (Distress Thermometer, HADS, and FACT-G) in the expected directions. Higher PCQ scores were associated with female gender, single parenthood, metastatic or recurrent cancer, subjective understanding of incurable disease, co-morbid chronic health condition, and current mental health treatment.
The Parenting Concerns Questionnaire proved a reliable and valid measure of parenting distress among cancer patients meriting further study.
PMCID: PMC3422599  PMID: 22517236
psychosocial aspects; quality of life; psychometrics; parenting
20.  Psychological distress and quality of life after orthopedic trauma: an observational study 
Canadian Journal of Surgery  2008;51(1):15-22.
Little is known about the clinical consequences of psychological morbidity associated with orthopedic trauma. The objective of our study was to investigate the extent of psychological symptoms that patients experience following orthopedic trauma and whether these are associated with quality of life.
All patients attending 10 orthopedic fracture clinics at 3 university-affiliated hospitals between January and October 2003 were screened for study eligibility. Eligible patients were aged 16 years or older, were English-speaking, were being followed actively for a fracture(s), were cognitively able to complete the questionnaires and provided informed consent. All consenting patients completed a baseline assessment form, the Symptom Checklist-90-Revised and a health-related quality of life questionnaire (the Medical Outcomes Study 36-item Short Form [SF-36]). We conducted regression analyses to determine predictors of quality of life among study patients.
Of the patients, 250 were eligible, and 215 agreed to participate; 59% were men; the patients' mean age was 44.5 (standard deviation [SD] 18.8) years. Over one-half (54%) of the patients had lower extremity fractures. Patient Physical Component summary scores were associated with older age (β = –0.28, p < 0.001), ongoing litigation (β = –0.18, p = 0.02), fracture location (β = –0.18, p = 0.01) and Positive Symptom Distress Index (i.e., the intensity of psychological symptoms; β = –0.08, p = 0.003). This model predicted 21% of the variance in patients' Physical Component summary scores. Somatization was an important psychological symptom negatively associated with Physical Component summary scores. Reduced Mental Component summary scores were associated with ongoing litigation (β = –0.18, p = 0.03) and Global Severity Index of psychological symptoms (β = –0.50, p < 0.001). This model explained 31% of the variability in patients' Mental Component summary scores.
In a prospective study of 215 patients, 1 in 5 met the threshold for psychological distress. Only ongoing litigation and psychological symptoms were significantly associated with both SF-36 Physical Component and Mental Component summary scores. Future research is necessary to determine whether orthopedic trauma patients would benefit from early screening and intervention to address comorbid psychopathology.
PMCID: PMC2386305  PMID: 18248701
21.  A Cross-Sectional Study of the Psychosexual Impact of Cancer-Related Infertility in Women: Third-Party Reproductive Assistance 
This study empirically assessed emotional and sexual functioning, reproductive concerns, and quality of life (QOL) of cancer-related infertile women in comparison to those without a cancer history and explored awareness of third-party reproduction options in cancer survivors.
One hundred twenty-two cancer survivors (Gynecologic and Bone Marrow/Stem Cell Transplant) with cancer-related infertility and 50 non-cancer infertile women completed a self-report survey assessing: reproductive concerns(RCS), mood(CES-D), distress(IES), sexual function(FSFI), menopause(SCL), QOL(SF-12), relationships(ADAS), and exploratory (reproductive options) items.
Cancer survivors exhibited greater sexual dysfunction and lower physical QOL than non-cancer infertile women (P<0.001). No significant group differences were identified for mood (CES-D), mental health QOL (SF-12), reproductive concerns (RCS), and relationship satisfaction (ADAS). All groups scored in the FSFI range of sexual dysfunction, and with RCS scores above published means. Multivariate comparisons showed comparable depression and distress levels for all groups, but cancer survivors had poorer physical QOL [F(5,146)=4.22, P<0.01]. A significant effect was also found for knowledge of third-party reproductive options on depression and distress levels [F(3,97)=4.62, P<0.01]. Adjusted means demonstrated higher depression and distress scores for women with perceived unmet informational needs.
Overall, loss of fertility was an emotionally challenging experience for women regardless of its cause. Cancer survivors were found to have lower scores of physical QOL and sexual function than non-cancer infertile women. Unmet informational needs about reproductive options appeared to be associated with negative mood and increased distress in cancer survivors.
Implications for Cancer Survivors
Targeted interventions to increase knowledge about reproductive options could be of great assistance to women pursuing parenthood in cancer survivorship. Additionally, intervention studies to improve sexual functioning and QOL in women with cancer-related infertility should be a priority of future research.
PMCID: PMC3701949  PMID: 20373042
cancer; infertility; survivorship; quality of life; third-party parenting
22.  An Examination of Distress, Sleep, and Fatigue in Metastatic Breast Cancer Patients 
Psycho-oncology  2010;21(1):100-107.
Few studies have used rapid screening instruments to document the prevalence of distress among metastatic breast cancer patients. This study used the one-item Distress Thermometer (DT) to assess distress in this population. Anxiety and depressive symptoms, sleep problems, fatigue, and mental health service use were assessed for patients who met the cutoff on the DT for probable distress (score ≥ 4).
A total of 173 metastatic breast cancer patients rated their distress on the DT. Respondents who met study eligibility criteria (n = 90), including a score > 4 on the DT, completed a telephone survey one week later that assessed anxiety, depressive symptoms, sleep problems, and fatigue. Associations of study outcomes with demographic and medical characteristics were computed.
Sixty percent of the 173 patients met the cutoff for probable distress on the DT. Meeting this cutoff was not associated with age, ethnicity, time since diagnosis, or medical treatments. The majority (61%) of respondents who were classified as distressed on the DT reported clinically significant anxiety or depressive symptoms one week later. On average, these patients also showed significant fatigue and sleep disturbance, with 70% reporting decrements in sleep quality. Only 29% of patients with significant anxiety or depressive symptoms accessed mental health services.
Results point to a high prevalence of distress, sleep problems, and fatigue across demographic and medical subgroups of metastatic breast cancer patients. A rapid one-item screening tool may be used to identify patients with a potential need for psychosocial assessment and intervention.
PMCID: PMC3756885  PMID: 21105175
metastatic breast cancer; oncology; sleep; fatigue; psychological distress; mental health services
23.  Prevalence of mental disorders, psychosocial distress and need for psychosocial support in cancer patients – study protocol of an epidemiological multi-center study 
BMC Psychiatry  2012;12:70.
Empirical studies investigating the prevalence of mental disorders and psychological distress in cancer patients have gained increasing importance during recent years, particularly with the objective to develop and implement psychosocial interventions within the cancer care system. Primary purpose of this epidemiological cross-sectional multi-center study is to detect the 4-week-, 12-month-, and lifetime prevalence rates of comorbid mental disorders and to further assess psychological distress and psychosocial support needs in cancer patients across all major tumor entities within the in- and outpatient oncological health care and rehabilitation settings in Germany.
In this multicenter, epidemiological cross-sectional study, cancer patients across all major tumor entities will be enrolled from acute care hospitals, outpatient cancer care facilities, and rehabilitation centers in five major study centers in Germany: Freiburg, Hamburg, Heidelberg, Leipzig and Würzburg. A proportional stratified random sample based on the nationwide incidence of all cancer diagnoses in Germany is used. Patients are consecutively recruited in all centers. On the basis of a depression screener (PHQ-9) 50% of the participants that score below the cutoff point of 9 and all patients scoring above are assessed using the Composite International Diagnostic Interview for Oncology (CIDI-O). In addition, all patients complete validated questionnaires measuring emotional distress, information and psychosocial support needs as well as quality of life.
Epidemiological data on the prevalence of mental disorders and distress provide detailed and valid information for the estimation of the demands for the type and extent of psychosocial support interventions. The data will provide information about specific demographic, functional, cancer- and treatment-related risk factors for mental comorbidity and psychosocial distress, specific supportive care needs and use of psychosocial support offers.
PMCID: PMC3434016  PMID: 22747671
24.  Pain, distress, and anticipated recovery for older versus younger emergency department patients after motor vehicle collision 
BMC Emergency Medicine  2014;14(1):25.
Motor vehicle collisions (MVCs) are the second most common injury mechanism resulting in emergency department (ED) visits by older adults. MVCs result in substantial pain and psychological distress among younger individuals, but little is known about the occurrence of these symptoms in older individuals. We describe the frequency of and characteristics associated with pain, distress, and anticipated time for physical and emotional recovery for older adults presenting to the ED after MVC in comparison to younger adults.
In-person interviews were conducted for adults presenting to one of eight EDs after MVC without an obvious fracture or injury requiring admission as part of two prospective studies. Pain severity was assessed using a 0–10 verbal scale. Distress was assessed using the Peritraumatic Distress Inventory (range 0–52). Patients were asked to estimate their expected time for physical and emotional recovery; these responses were dichotomized to <30 or ≥30 days. ED pain and distress and associations between patient and collision characteristics and ED pain and distress were examined for patients age 65 years and older and patients age 18 to 64.
Older (n = 96) and younger (n = 943) adults had the same mean pain scores (5.5, SD 2.5 vs. 5.5, SD 2.4). Distress scores were lower in older than in younger adults (15.5, SD 9 vs. 19.2, SD 10). A higher percentage of older adults than younger adults had an anticipated time to physical recovery ≥30 days (41%, 95% confidence interval [CI] 28%-55% vs. 11%, 95% CI 9%-13%). Similarly, older adults were more likely to have an anticipated time for emotional recovery ≥30 days (45%, 95% CI 35%-55% vs. 17%, 95% CI 15%-20%). Older adults were less likely than younger adults to have moderate or severe neck pain (score ≥4) (25%, 95% CI 23% to 41% vs. 54%, 95% CI 48% to 60%) or back pain (31%, 95% CI 23% to 46% vs. 56%, 95% CI 51 to 62%) but more likely to have moderate or severe chest pain (42%, 95% CI 32% to 50% vs. 20%, 95% CI 16 to 23%). Pre-MVC depressive symptoms and pain catastrophizing were positively associated with pain and distress in both older and younger adults.
In our cohort, older adults who presented to the ED after MVC experienced similar pain severity as younger patients and less distress but were more likely to estimate their times for physical and emotional recovery to be 30 days or more. Increased emergency provider awareness of acute pain and distress symptoms among older patients experiencing MVC may improve outcomes for these patients.
PMCID: PMC4307167  PMID: 25547869
Geriatrics; Pain; Emergency medicine; Traffic accidents
25.  Validation of the spiritual distress assessment tool in older hospitalized patients 
BMC Geriatrics  2012;12:13.
The Spiritual Distress Assessment Tool (SDAT) is a 5-item instrument developed to assess unmet spiritual needs in hospitalized elderly patients and to determine the presence of spiritual distress. The objective of this study was to investigate the SDAT psychometric properties.
This cross-sectional study was performed in a Geriatric Rehabilitation Unit. Patients (N = 203), aged 65 years and over with Mini Mental State Exam score ≥ 20, were consecutively enrolled over a 6-month period. Data on health, functional, cognitive, affective and spiritual status were collected upon admission. Interviews using the SDAT (score from 0 to 15, higher scores indicating higher distress) were conducted by a trained chaplain. Factor analysis, measures of internal consistency (inter-item and item-to-total correlations, Cronbach α), and reliability (intra-rater and inter-rater) were performed. Criterion-related validity was assessed using the Functional Assessment of Chronic Illness Therapy-Spiritual well-being (FACIT-Sp) and the question "Are you at peace?" as criterion-standard. Concurrent and predictive validity were assessed using the Geriatric Depression Scale (GDS), occurrence of a family meeting, hospital length of stay (LOS) and destination at discharge.
SDAT scores ranged from 1 to 11 (mean 5.6 ± 2.4). Overall, 65.0% (132/203) of the patients reported some spiritual distress on SDAT total score and 22.2% (45/203) reported at least one severe unmet spiritual need. A two-factor solution explained 60% of the variance. Inter-item correlations ranged from 0.11 to 0.41 (eight out of ten with P < 0.05). Item-to-total correlations ranged from 0.57 to 0.66 (all P < 0.001). Cronbach α was acceptable (0.60). Intra-rater and inter-rater reliabilities were high (Intraclass Correlation Coefficients ranging from 0.87 to 0.96). SDAT correlated significantly with the FACIT-Sp, "Are you at peace?", GDS (Rho -0.45, -0.33, and 0.43, respectively, all P < .001), and LOS (Rho 0.15, P = .03). Compared with patients showing no severely unmet spiritual need, patients with at least one severe unmet spiritual need had higher odds of occurrence of a family meeting (adjOR 4.7, 95%CI 1.4-16.3, P = .02) and were more often discharged to a nursing home (13.3% vs 3.8%; P = .027).
SDAT has acceptable psychometrics properties and appears to be a valid and reliable instrument to assess spiritual distress in elderly hospitalized patients.
PMCID: PMC3368768  PMID: 22455520

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