[ORPHYS - Treatment Manual for a Short-Term Psychodynamic Psychotherapy in Patients with Serious Physical Illness]. / ORPHYS ­ Behandlungsmanual für eine psychodynamische Kurzzeitpsychotherapie bei schwerer körperlicher Erkrankung.

The diagnosis of a life-threatening illness may lead to a breakdown of psychological processing patterns and a reactualization of existential conflicts. The sudden loss of continuity, physical integrity and social roles can overwhelm patients' ability to cope psychologically. Psychosocial and medical care is likely compromised if patients suffer from affective disorders or symptoms of existential distress. Psychodynamic treatments may strengthen the experience of closeness and connectedness in order to cope with losses and enable farewell processes. ORPHYS describes a short-term psychodynamic psychotherapy (12-24 sessions) that aims to address the existential distress of seriously physically ill patients by taking into account relational conflicts at the end of life. The combination of supportive and expressive treatment techniques that focus on patients' subjective experience and illness situation may enable patients to integrate painful affective states and to explore their relationship and coping patterns. ORPHYS can thus facilitate a shared mourning process, in which the intense desire for connectedness at the end of life and the reality of dying can be reconciled.

Psychodynamic psychotherapy in serious physical illness: A systematic literature review of approaches and techniques for the treatment of existential distress and mental disorders.

Individuals with life-limiting physical illness experience lower mental health due to existential distress (e.g., demoralization, death anxiety) and mental disorders (e.g., depression, anxiety). Psychodynamic psychotherapy may be helpful in alleviating such distress by focusing patients' unconscious emotional and relational motivations. There is yet limited knowledge on the application of psychodynamic psychotherapies in this population. We systematically searched electronic databases and analyzed results using meta-ethnography. Of 15,112 identified records, we included 31 qualitative studies applying psychodynamic psychotherapies (n = 69, mean age: 49.3 [SD = 16.9)], 56% female). Psychodynamic treatment in this population can be beneficial when considering modification of the treatment setting to the illness reality, balancing needs for autonomy and separation in light of helplessness and death anxiety, and careful integration of supportive interventions and conflict-oriented interventions (e.g., exploring relational issues that interfere with mourning illness-related loss). We discuss future directions for the development and evaluation of treatments specific to serious physical illness.

Existential distress among family caregivers of patients with advanced cancer: A systematic review and meta-analysis.

OBJECTIVE: Caregiving for a loved one is challenging and requires significant resources. Existential distress in family caregivers may include hopelessness, demoralization, fear of death, pre-loss grief, or a sense of not being emotionally prepared. The aim of this systematic review is to synthesize the quantitative literature on existential distress among family caregivers of patients with advanced cancer, focusing on its prevalence, association with mental disorders, as well as with sociodemographic, disease, and treatment-related factors. METHODS: We systematically searched electronic databases for quantitative studies of the above-described existential distress concepts in family caregivers of patients with advanced cancer. Two independent reviewers extracted data and evaluated study quality. Data were analyzed using random-effects meta-analysis. RESULTS: We retrieved 17.587 records, of which 31 studies fulfilled inclusion criteria. 63% of the studies (n = 20) provided sufficient data for meta-analysis for 5558 patients. We found an overall pooled prevalence of 30.6% for existential distress, 95% CI [24.2-37.0]. For existential distress subconcepts, prevalence rates were 57.0%, 95% CI [37.8-76.2], for death anxiety, 13.9%, 95% CI [10.8-17.0], for demoralization, 24.0%, 95% CI [18.0-30.0], for pre-loss grief, 18.4%, 95% CI [4.0-32.7], for hopelessness, 35.2%, 95% CI [28.2-42.2], for loneliness, and 35.6%, 95% CI [13.0-58.3], for emotional unpreparedness. CONCLUSIONS: Approximately one third of the respondents were affected by high levels of existential distress. The review provides evidence for further development of support services that can reduce existential distress, focused on death anxiety, and improve the quality of life for family caregivers of patients with advanced cancer.

Effectiveness of a training program for healthcare professionals on parental cancer: Results of a randomized controlled pilot-study.

OBJECTIVE: Cancer patients parenting minor children face specific burden and supportive needs, which are often not adequately addressed by their healthcare professionals (HCPs), due to a lack of knowledge, self-efficacy and competencies. Therefore, we developed a 3-h intervention enhancing HCPs' competencies in caring for these patients. We pilot-evaluated the intervention's feasibility and efficacy, assuming intervention group participants reveal higher improvements over time compared to non-trained participants. METHODS: We conducted a 3-armed randomized controlled pilot-trial (RCT), comparing face-to-face training (F2F), e-Learning (EL), waitlist-control group with three measurements (baseline, post-training, 3-month follow-up). Primary outcome was the competency to approach child- and family-related themes; secondary outcomes were knowledge, self-efficacy in (specific) communication skills. Intervention effects were analyzed using linear mixed models. RESULTS: Participants (n = 152) were mostly female (89%) and psychologists (38%; physicians 26%; nurses 18%). F2F and EL participants reported high training satisfaction. Analyses did not reveal any significant differences on the primary outcome between groups, but indicate positive intervention effects over time regarding secondary outcomes including knowledge and self-efficacy in communication skills. CONCLUSIONS: This is the first pilot-study evaluating a training for HCPs in oncology on parental cancer using a 3-armed RCT. The 3-h training program is a feasible approach and findings indicate to increase HCPs' knowledge and self-efficacy in caring for cancer patients with minor children. Further research is needed to verify preliminary findings of this pilot study. The study was pre-registered within the German Clinical Trial Register (DRKS-00015794).

Prevalence of mental disorders in patients with cancer compared to matched controls - secondary analysis of two nationally representative surveys.

AIM: To compare prevalence rates of mental disorders in patients with cancer and general population controls. METHOD: In two stratified nationally representative surveys, the 12-month prevalence of mental disorders was assessed in 2141 patients with cancer and 4883 general population controls by the standardized Composite International Diagnostic Interview (CIDI). We determined odds ratios (ORs) to compare the odds for mental disorders (combined and subtypes) in cancer patients with age- and gender-matched controls. RESULTS: The 12-month prevalences rate for any mental disorder was significantly higher in patients with cancer compared to controls (OR 1.28, 95% CI 1.14-1.45). Prevalence rates were at least two times higher for unipolar mood disorders (major depression: OR 2.07, 95% CI 1.71-2.51; dysthymia: OR 2.93, 95% CI 2.13-4.02) and mental disorders due to a general medical condition (OR 3.31, 95% CI 2.32-4.71). There was no significant elevation for anxiety disorders overall (OR 0.95, 95% CI 0.81-1.11). Mildly elevated prevalence rates emerged for post-traumatic stress disorder (OR 1.57, 95% CI 1.11-2.23) and social phobia (OR 1.57, 95% CI 1.07-2.31), while specific phobia (OR 0.82, 95% CI 0.67-1.00) and agoraphobia (OR 0.49, 95% CI 0.33-0.73) were significantly less frequent in cancer. CONCLUSIONS: While elevated depression rates reinforce the need for its systematic diagnosis and treatment, lower prevalences were unexpected given previous evidence. Whether realistic illness-related fears and worries contribute to lower occurrence of anxiety disorders with excessive fears in cancer may be of interest to future research.

Psychometric properties of a patient-reported outcome set in acute stroke patients.

OBJECTIVES: Impairments after stroke may affect multiple domains of health-related quality of life (HRQoL). Patient-reported outcome measures (PROMs) have proven valuable in measuring patients' well-being. We examine the psychometric properties of a standard set of PROMs assessing global health, anxiety, and depression, and functioning in a German health care setting. METHOD: We included inpatients at the Department of Neurology at the University Medical Center Hamburg-Eppendorf, diagnosed with stroke. Following the stroke-specific standard set of the International Consortium for Health Outcome Measurement, we collected demographic and clinical information at baseline, and PROMs for global health (PROMIS-10), three items for self-reported functioning, anxiety, and depression (PHQ-4) at 90 days follow-up. We calculated confirmatory factor analyses to test factorial validity and correlation analyses to test construct validity. We further conducted item and reliability analyses. RESULTS: In a sample of 487 patients (mean age, SD: 71.1, 12.6; 47% female) with mild and moderate symptoms, model fit for the PROMIS-10 was acceptable for the two-factor and single-factor models. Factor loadings ranged from 0.52 to 0.94. The postulated single-factor model for functioning was saturated with zero degrees of freedom. Factor loadings ranged from 0.90 to 0.96. For the PHQ-4, the two-factor model showed excellent model fit. Factor loadings ranged from 0.78 to 0.87. Internal consistency was acceptable to good. Construct validity was generally confirmed. CONCLUSIONS: The PROMIS-10 is a valid and reliable instrument to measure HRQoL among German stroke patients. While the PHQ-4 was confirmed as a screening measure for mental disorders, further research is needed on items assessing self-reported functioning. Results are limited to patients showing minimal functional deficits.

Existential distress in patients with advanced cancer and their caregivers: study protocol of a longitudinal cohort study.

INTRODUCTION: At the end of life, patients with advanced cancer and their informal caregivers may confront multiple existential concerns. Despite the strong potential to alleviate existential distress through psychosocial interventions, existential distress and its impact on healthcare outcomes have not yet been studied systematically. We aim to investigate the frequency, longitudinal trajectory and predictive impact of existential distress on end-of-life outcomes. We further aim to determine patients' and caregivers' specific need for and utilisation of psychosocial support for existential distress. METHODS: This longitudinal cohort study will consecutively recruit 500 patients with advanced cancer and 500 caregivers from oncological outpatient and inpatient clinics. Participants will complete self-report questionnaires (sociodemographic and disease-related characteristics, existential distress, end-of-life outcomes, resources and support needs) at five points of assessment (at baseline and after 3, 6, 9 and 12 months). At baseline and 6-month follow-up, we will conduct structured diagnostic interviews to assess mental disorders. Statistical analyses will include descriptive statistics to determine the prevalence of existential distress, mental disorders and end-of-life outcomes; multiple linear and logistic regression analyses to calculate the predictive impact of existential distress on end-of-life outcomes; and growth mixture models to analyse longitudinal trajectories of existential distress. DISCUSSION: This study will provide comprehensive knowledge about patients' and caregivers' existential concerns. The longitudinal empirical data will allow for conclusions concerning the frequency and course of existential distress throughout 1 year. This important extension of existing cross-sectional research will contribute to further develop targeted psychosocial interventions. Profiles of existential distress may be applied by clinicians from multiple professions and help to address existential concerns effectively. ETHICS AND DISSEMINATION: The study was approved by the institutional research ethics committee (reference number LPEK-0177). Results will be presented at scientific conferences and published in peer-reviewed journals. Other forms of dissemination will include sharing results on the psychometric properties of the structured demoralisation interview with international research groups and communication with healthcare professionals providing psychosocial treatment for patients and caregivers. Following scientific standards, our progress will be regularly updated on ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: NCT04600206.

The role of attachment avoidance: A longitudinal mediation model predicting existential distress in patients with advanced cancer.

OBJECTIVE: Although a protective effect of reliable interpersonal relationships on existential distress has been established, evidence remains inconclusive for attachment insecurity as an underlying factor of persistent psychological distress. We tested a longitudinal model hypothesizing attachment avoidance as a mediator of high demoralization and anxiety over time. METHODS: We studied 206 patients with advanced cancer (mean age = 59.6, 61% female) participating in an intervention trial. Patients completed self-report measures for demoralization, anxiety, perceived relatedness, attachment insecurity, and death anxiety. Our mediated path model included perceived relatedness and death anxiety at baseline as predictors, attachment avoidance at baseline as mediator, and demoralization and anxiety at 6-month follow-up (N = 125) as outcomes. RESULTS: Attachment avoidance partially mediated the relationship between death anxiety and demoralization (ß = 0.07, 95% CI 0.02-0.12) and anxiety (ß = 0.05, 95% CI 0.001-0.10). Findings for perceived relatedness were less conclusive. Its indirect effects through attachment avoidance were significant for both outcomes (demoralization: ß = -0.07, 95% CI -0.13 to -0.02, anxiety: ß = -0.05, 95% CI -0.11 to -0.003). CONCLUSIONS: Due to its trait-like quality, attachment avoidance may play a less central role in explaining the course of existential distress over time than previous research indicated. Addressing change-sensitive relational concerns in psychosocial interventions may be more effective to alleviate existential distress.

Testing the Treatment Integrity of the Managing Cancer and Living Meaningfully Psychotherapeutic Intervention for Patients With Advanced Cancer.

INTRODUCTION: The Managing Cancer and Living Meaningfully (CALM) therapy for patients with advanced cancer was tested against a supportive psycho-oncological counseling intervention (SPI) in a randomized controlled trial (RCT). We investigated whether CALM was delivered as intended (therapists' adherence); whether CALM therapists with less experience in psycho-oncological care show higher adherence scores; and whether potential overlapping treatment elements between CALM and SPI can be identified (treatment differentiation). METHODS: Two trained and blinded raters assessed on 19 items four subscales of the Treatment Integrity Scale covering treatment domains of CALM (SC: Symptom Management and Communication with Health Care Providers; CSR: Changes in Self and Relationship with Others; SMP: Spiritual Well-being and Sense of Meaning and Purpose; FHM: Preparing for the Future, Sustaining Hope and Facing Mortality). A random sample of 150 audio recordings (75 CALM, 75 SPI) were rated on a three-point Likert scale with 1 = "adherent to some extent," 2 = "adherent to a sufficient extent," 3 = "very adherent." RESULTS: All 19 treatment elements were applied, but in various frequencies. CALM therapists most frequently explored symptoms and/or relationship to health care providers (SC_1: n_applied = 62; 83%) and allowed expression of sadness and anxiety about the progression of disease (FHM_2: n_applied = 62; 83%). The exploration of CALM treatment element SC_1 was most frequently implemented in a satisfactory or excellent manner (n_sufficient or very adherent = 34; 45%), whereas the treatment element SMP_4: Therapist promotes acknowledgment that some life goals may no longer be achievable (n_sufficient or very adherent = 0; 0%) was not implemented in a satisfactory manner. In terms of treatment differentiation, no treatment elements could be identified which were applied significantly more often by CALM therapists than by SPI therapists. CONCLUSION: Results verify the application of CALM treatment domains. However, CALM therapists' adherence scores indicated manual deviations. Furthermore, raters were not able to significantly distinguish CALM from SPI, implying that overlapping treatment elements were delivered to patients.

Efficacy of the Managing Cancer and Living Meaningfully (CALM) individual psychotherapy for patients with advanced cancer: A single-blind randomized controlled trial.

OBJECTIVE: We aimed to determine whether the Managing Cancer and Living Meaningfully (CALM) therapy is superior to a non-manualized supportive psycho-oncological counselling intervention (SPI). METHODS: Adult patients with advanced cancer and ≥9 points on the PHQ-9 and/or ≥5 points on the DT were randomized to CALM or SPI. We hypothesized that CALM patients would report significantly less depression (primary outcome) on the BDI-II and the PHQ-9 6 months after baseline compared to SPI patients. RESULTS: From 329 eligible patients, 206 participated (61.2% female; age: M = 57.9 [SD = 11.7]; 84.5% UICC IV stage). Of them, 99 were assigned to CALM and 107 to SPI. Intention-to-treat analyses revealed significantly less depressive symptoms at 6 months than at baseline (P < .001 for BDI-II and PHQ-9), but participants in the CALM and SPI group did not differ in depression severity (BDI-II: P = .62, PHQ-9: P = .998). Group differences on secondary outcomes were statistically not significant either. CONCLUSIONS: CALM therapy was associated with reduction in depressive symptoms over time but this improvement was not statistically significant different than that obtained within SPI group.

Inter-professional teamwork and its association with patient safety in German hospitals-A cross sectional study.

BACKGROUND: Inter-professional teamwork is a prominent factor in quality of care and may lead to improved patient safety. Although team members' points of view are highly relevant when trying to improve inpatient procedures, there is a lack of systematic assessment of their perceptions. Therefore, study aims were to explore inter-professional teamwork, safety-related behavior, and patient safety in German hospitals from team members' point of view. Furthermore, we wanted to examine the association between inter-professional teamwork and safety-related behavior as well as the association between inter-professional teamwork and patient safety. METHODS: We used cross-sectional pre-intervention data of a multicenter longitudinal study (German KOMPAS project). We gathered descriptive statistics for sample characteristics and to describe the current state of inter-professional teamwork, safety-related behavior, and patient safety. We used one-way variance analyses to assess differences between groups, and linear regression analyses to examine the association between inter-professional teamwork and the outcomes safety-related behavior, and patient safety. RESULTS: 326 inpatient care team members participated in the study. Participants perceived a moderate to high level of inter-professional teamwork, and a moderate level of patient safety. Moreover, they reached rather high values in safety-related behavior. Professional group, work experience, and period of employment had an impact on the perceptions of inter-professional teamwork, and patient safety. Higher inter-professional teamwork was associated with better patient safety. We did not find an association between inter-professional teamwork and safety-related behavior. CONCLUSIONS: Based on the association between inter-professional teamwork and patient safety, we recommend the implementation of team interventions. Because professional group, period of employment, and work experience had an impact on the perceptions of inter-professional teamwork and patient safety, we suggest future qualitative research to explore reasons for caregivers' critical evaluation. Moreover, we recommend longitudinal studies to reveal causal relationships, and subsequently to determine areas of improvement for a safer health care.

Perceived relatedness, death acceptance, and demoralization in patients with cancer.

PURPOSE: Close relationships can be strained by losses related to independence, autonomy, and separation after diagnosis of severe illness. The perceived quality of their close relationships affects individuals' psychological adaptation in this context. We explored the level of perceived relatedness and its impact on demoralization and death acceptance. We further examined a possible protective effect of perceived relatedness on the association between tumor stage and death acceptance. METHODS: For this observational study, we consecutively recruited gynecology outpatients and general surgery inpatients at the University Cancer Center Hamburg-Eppendorf and oncological inpatients at the LungenClinic Grosshansdorf, Germany. At baseline, 307 patients (age M = 59.6, 69% female, 69% advanced cancer) participated. At 6- and 12-month (T3) follow-up, 213 and 153 patients responded, respectively. Patients completed self-report questionnaires including a modified version of the Posttraumatic Growth Inventory assessing perceived relatedness, the Life Attitude Profile-Revised assessing death acceptance, the Demoralization Scale, and the Memorial Symptom Assessment Scale assessing symptom burden. We calculated multiple linear regression analyses controlling for demographic and disease-related factors. RESULTS: Participants reported a stronger perceived relatedness at baseline (M = 3.04, SE = 0.03, possible range 0-4) than at T3 (M = 2.93, SE = 0.04; p = 0.02). Perceived relatedness significantly predicted lower demoralization at T3 but did not moderate the relationship between tumor stage and demoralization. Apart from male gender, none of the predictor or moderator variables had a significant impact on death acceptance at T3. CONCLUSIONS: The strong impact of perceived relatedness on existential distress emphasizes the importance of strengthening interpersonal relationships within psychosocial interventions.

Spiritual well-being mediates the association between attachment insecurity and psychological distress in advanced cancer patients.

PURPOSE: The diagnosis of a terminal disease bears existential challenges, which activate the attachment system. Attachment insecurity, as well as existential resources, such as spiritual well-being, influences patients' extent of psychological distress. Knowledge about the interrelation of these constructs is limited. Based on current research, we assume spiritual well-being to mediate the association of attachment insecurity and psychological distress. METHODS: We obtained data from the baseline measurement of a randomized controlled trial in advanced cancer patients. Patients were sampled from the University Medical Centers of Hamburg and Leipzig, Germany. Main outcome measures included the Patient Health Questionnaire (PHQ-9), the Death and Dying Distress Scale (DADDS), the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp), and the Experience in Close Relationships Scale (ECR-M16) for assessing attachment insecurity. We tested the mediation hypothesis with two regression analyses using bootstrapping procedure. RESULTS: A total of 190 patients were included. Spiritual well-being mediated the association of attachment insecurity and depression (R2 = 11%), as well as death anxiety (R2 = 15%), in fearful-avoidant attached patients. Neither dismissingly nor preoccupied attached patients differ in terms of spiritual well-being and psychological distress in comparison with secure attached patients. CONCLUSION: Spiritual well-being plays a relevant role in advanced cancer patient's mental health through mediating the association of attachment and psychological distress. Developing a better understanding of the interdependency of the constructs of spiritual well-being and attachment can help to develop individually tailored advanced cancer care programs and psychotherapeutic interventions. TRIAL REGISTRATION: NCT02051660.

Characterizing death acceptance among patients with cancer.

OBJECTIVE: Death acceptance may indicate positive adaptation in cancer patients. Little is known about what characterizes patients with different levels of death acceptance or its impact on psychological distress. We aimed to broaden the understanding of death acceptance by exploring associated demographic, medical, and psychological characteristics. METHODS: At baseline, we studied 307 mixed cancer patients attending the University Cancer Center Hamburg and a specialized lung cancer center (age M = 59.6, 69% female, 69% advanced cancer). At 1-year follow-up, 153 patients participated. We assessed death acceptance using the validated Life Attitude Profile-Revised. Patients further completed the Memorial Symptom Assessment Scale, the Demoralization Scale, the Patient Health Questionnaire, and the Generalized Anxiety Disorder Questionnaire. Statistical analyses included multinomial and hierarchical regression analyses. RESULTS: At baseline, mean death acceptance was 4.33 (standard deviation [SD] = 1.3, range 1-7). There was no change to follow-up (P = 0.26). When all variables were entered simultaneously, patients who experienced high death acceptance were more likely to be older (odds ratio [OR] = 1.04; 95% confidence interval [CI], 1.01-1.07), male (OR = 3.59; 95% CI, 1.35-9.56), widowed (OR = 3.24; 95% CI, 1.01-10.41), and diagnosed with stage IV (OR = 2.44; 95% CI, 1.27-4.71). They were less likely to be diagnosed with lung cancer (OR = 0.20; 95% CI, 0.07-0.58), and their death acceptance was lower with every month since diagnosis (OR = 0.99; 95% CI, 0.98-0.99). High death acceptance predicted lower demoralization and anxiety at follow-up but not depression. CONCLUSIONS: High death acceptance was adaptive. It predicted lower existential distress and anxiety after 1 year. Advanced cancer did not preclude death acceptance, supporting the exploration of death-related concerns in psychosocial interventions.

[Assessment of Couples' Communication in Patients with Advanced Cancer: Validation of a German Version of the Couple Communication Scale (CCS)]. / Die Erfassung der Paarkommunikation bei Patienten mit einer fortgeschrittenen Krebserkrankung: Validierung einer deutschen Version der Couple Communication Scale (CCS).

BACKGROUND: There are only a few valid instruments measuring couples' communication in patients with cancer for German speaking countries. The Couple Communication Scale (CCS) represents an established instrument to assess couples' communication. However, there is no evidence regarding the psychometric properties of the German version of the CCS until now and the assumed one factor structure of the CCS was not verified for patients with advanced cancer yet. METHOD: The CCS was validated as a part of the study "Managing cancer and living meaningfully" (CALM) on N=136 patients with advanced cancer (≥18 years, UICC-state III/IV). The psychometric properties of the scale were calculated (factor reliability, item reliability, average variance extracted [DEV]) and a confirmatory factor analysis was conducted (Maximum Likelihood Estimation). The concurrent validity was tested against symptoms of anxiety (GAD-7), depression (BDI-II) and attachment insecurity (ECR-M16). RESULTS: In the confirmatory factor analysis, the one factor structure showed a low, but acceptable model fit and explained on average 49% of every item's variance (DEV). The CCS has an excellent internal consistency (Cronbachs α=0,91) and was negatively associated with attachment insecurity (ECR-M16: anxiety: r=- 0,55, p<0,01; avoidance: r=- 0,42, p<0,01) as well as with anxiety (GAD-7: r=- 0,20, p<0,05) and depression (BDI-II: r=- 0,27, p<0,01). CONCLUSION: The CCS is a reliable and valid instrument measuring couples' communication in patients with advanced cancer.

Effectiveness of metacognitive interventions for mental disorders in adults-A systematic review and meta-analysis (METACOG).

We evaluated the effectiveness and acceptability of metacognitive interventions for mental disorders. We searched electronic databases and included randomized and nonrandomized controlled trials comparing metacognitive interventions with other treatments in adults with mental disorders. Primary effectiveness and acceptability outcomes were symptom severity and dropout, respectively. We performed random-effects meta-analyses. We identified Metacognitive Training (MCTrain), Metacognitive Therapy (MCTherap), and Metacognition Reflection and Insight Therapy (MERIT). We included 49 trials with 2,609 patients. In patients with schizophrenia, MCTrain was more effective than a psychological treatment (cognitive remediation, SMD = -0.39). It bordered significance when compared with standard or other psychological treatments. In a post hoc analysis, across all studies, the pooled effect was significant (SMD = -0.31). MCTrain was more effective than standard treatment in patients with obsessive-compulsive disorder (SMD = -0.40). MCTherap was more effective than a waitlist in patients with depression (SMD = -2.80), posttraumatic stress disorder (SMD = -2.36), and psychological treatments (cognitive-behavioural) in patients with anxiety (SMD = -0.46). In patients with depression, MCTherap was not superior to psychological treatment (cognitive-behavioural). For MERIT, the database was too small to allow solid conclusions. Acceptability of metacognitive interventions among patients was high on average. Methodological quality was mostly unclear or moderate. Metacognitive interventions are likely to be effective in alleviating symptom severity in mental disorders. Although their add-on value against existing psychological interventions awaits to be established, potential advantages are their low threshold and economy.

Perceived doctor-patient relationship and its association with demoralization in patients with advanced cancer.

BACKGROUND: Advanced diseases pose a great burden on patients and go hand in hand with existential concerns. Demoralization is considered as a syndrome of existential distress with a perceived inability to cope with loss of meaning in life and feelings of helplessness and hopelessness. Professional health care providers play an important role in providing support for patients and unfavorable conversational styles in their relationship can increase patient's distress. In this study, we examine the association between the patient's perceived relationship to health care providers and demoralization. METHODS: We used baseline data of a randomized control trial intervention study for advanced cancer patients (UICC-Stage ≥ III; PHQ ≥ 9 and/or Distress-Thermometer ≥5). We used a subscale of the QUAL-EC-P for assessing doctor-patient relationship, Beck Depression Inventory-II for depressive symptoms, a modified version of the MSAS as physiological symptom checklist, and the Demoralization Scale to assess demoralization. A hierarchical regression analysis was calculated. RESULTS: In our sample of 187 patients with stage III or IV cancer (62% women), demoralization was present in 53.4% (16% moderate demoralization; 37.4% high demoralization) of the patients. Relationship to health care provider was an independent predictor (ß = -.33, t(186) = -6.70, P < .001) of demoralization. CONCLUSIONS: Our findings underline the importance of the physician-patient relationship in the context of coping with existential challenges in advanced cancer patients. Trainings on how to communicate and build a sustainable relationship with patients and their specific needs may increase the buffering effect of social support by the physicians on patient's existential distress.

Existential distress and meaning-focused interventions in cancer survivorship.

PURPOSE OF REVIEW: Cancer can challenge fundamental assumptions about security, controllability and life priorities, which may lead to clinically relevant existential distress. We review recent studies on the prevalence of existential distress in cancer survivors, its distinctness from other distress concepts and interventions to address cancer-specific existential challenges. We further describe psychological mechanisms that may underlie change resulting from such interventions. RECENT FINDINGS: One-third to one-half of cancer survivors experienced existential fears and concerns related to reduced control, identity and uncertainty about the future. Clinically relevant levels of demoralization (a state comprising loss of meaning and a sense of poor coping) were found in one in four to five cancer patients in mixed samples. Existential interventions have shown positive effects in facilitating personal meaning and promoting psychological adaptation. SUMMARY: Existential distress can be understood as a distinct dimension of cancer-related distress requiring attention from healthcare professionals. Psychosocial interventions can facilitate dealing with existential challenges during and while transitioning to longer term survivorship. Such interventions can effectively support survivors to manage uncertainty, link cancer to their life story and engage in meaningful activity despite an uncertain and potentially foreshortened future.

Insecure attachment predicts depression and death anxiety in advanced cancer patients.

ABSTRACTObjective:The prevalence of depression as well as adjustment and anxiety disorders is high in advanced cancer patients, and research exploring intraindividual factors leading to high psychological distress is underrepresented. Cancer patients' feelings about security and trust in their healthcare providers have a significant influence on how they deal with their disease. The perception of social support is affected by patients' attachment styles and influences their reactions to feelings of dependency and loss of control. We therefore aimed to explore attachment and its association with psychological distress in patients with advanced cancer. METHOD: We obtained data from the baseline measurements of a randomized controlled trial in advanced cancer patients. Patients were sampled from the university medical centers of Hamburg and Leipzig, Germany. The main outcome measures included the Patient Health Questionnaire, the Death and Dying Distress Scale, the Memorial Symptom Assessment Scale, and the Experience in Close Relationships Scale for assessing attachment insecurity. RESULTS: A total of 162 patients were included. We found that 64% of patients were insecurely attached (fearful-avoidant 31%, dismissing 17%, and preoccupied 16%). A dismissing attachment style was associated with more physical symptoms but did not predict psychological distress. A fearful-avoidant attachment style significantly predicted higher death anxiety and depression, whereas preoccupied attachment predicted higher death anxiety only. Overall, insecure attachment contributed to the prediction of depression (10%) and death anxiety (14%). SIGNIFICANCE OF RESULTS: The concept of attachment plays a relevant role in advanced cancer patients' mental health. Healthcare providers can benefit from knowledge of advanced cancer patients' attachment styles and how they relate to specific mental distress. Developing a better understanding of patients' reactions to feelings of dependency and distressing emotions can help us to develop individually tailored advanced cancer care programs and psychotherapeutic interventions.

Measuring the Psychosocial Dimensions of Quality of Life in Patients With Advanced Cancer: Psychometrics of the German Quality of Life at the End of Life-Cancer-Psychosocial Questionnaire.

CONTEXT: Quality of life (QoL) is a central focus of care in advanced cancer. Specialized instruments, such as the Quality of Life at the End of Life-Cancer (QUAL-EC), may be useful to assess psychosocial issues associated with QoL unique to this population. OBJECTIVES: To evaluate the measurement of the psychosocial dimensions of QoL using the German translation of the QUAL-EC-Psychosocial (QUAL-EC-P) questionnaire, including factor structure and psychometrics. METHODS: About 183 patients with advanced cancer from the University Medical Center Hamburg-Eppendorf and University Medical Center Leipzig completed the QUAL-EC-P questionnaire. We conducted exploratory factor analysis as well as item and reliability analysis. We examined convergent validity with correlations between the scale and relevant psychological constructs. RESULTS: The sample was 60% female with mean age of 57.7 (SD = 11.7). We extracted three factors accounting for 44% of the variance aligning with the structure of the instrument. The QUAL-EC-P questionnaire showed good to acceptable internal consistency for the QoL-psychosocial total score (α = 0.77), the Life completion subscale (α = 0.77), and the Relationship with health care provider subscale (α = 0.81). The Preparation for end of life subscale had adequate albeit low internal consistency (α = 0.64) because concerns about family were less associated with financial worry and fear of death than expected. The psychosocial dimensions of QoL correlated negatively with depression (r = -0.27, P ≤ 0.001), anxiety (r = -0.32, P ≤ 0.001), demoralization (r = -0.63, P ≤ 0.001), and attachment insecurity (r = -0.51, P ≤ 0.001) and positively with spiritual well-being (r = 0.63, P ≤ 0.001). CONCLUSION: The QUAL-EC-P questionnaire may be used to assess the psychosocial aspects of QoL and promote their clinical discussion in patients with advanced cancer.