A qualitative exploration of the feasibility and acceptability of Meaning-Centered Psychotherapy for Cancer Caregivers.

OBJECTIVE: Caregivers of patients with cancer are at significant risk for existential distress. Such distress negatively impacts caregivers' quality of life and capacity to serve in their role as healthcare proxies, and ultimately, contributes to poor bereavement outcomes. Our team developed Meaning-Centered Psychotherapy for Cancer Caregivers (MCP-C), the first targeted psychosocial intervention that directly addresses existential distress in caregivers. METHOD: Nine caregivers of patients with glioblastoma multiforme (GBM) enrolled in a pilot randomized controlled trial evaluating the feasibility, acceptability, and effects of MCP-C, and completed in-depth interviews about their experience in the therapy. One focus group with three MCP-C interventionists was also completed. RESULTS: Four key themes emerged from interviews: (1) MCP-C validated caregivers' experience of caregiving; (2) MCP-C helped participants reframe their "caregiving identity" as a facet of their larger self-identity, by placing caregiving in the context of their life's journey; (3) MCP-C enabled caregivers to find ways to assert their agency through caregiving; and (4) the structure and sequence of sessions made MCP-C accessible and feasible. Feedback from interventionists highlighted several potential manual changes and overall ways in which MCP-C can help facilitate caregivers' openness to discussing death and engaging in advanced care planning discussions with the patient. SIGNIFICANCE OF RESULTS: The overarching goal of MCP-C is to allow caregivers to concurrently experience meaning and suffering; the intervention does not seek to deny the reality of challenges endured by caregivers, but instead to foster a connection to meaning and purpose alongside their suffering. Through in-depth interviews with caregivers and a focus group with MCP interventionists, we have refined and improved our MCP-C manual so that it can most effectively assist caregivers in experiencing meaning and purpose, despite inevitable suffering.

Efficacy of meaning-centered group psychotherapy for cancer survivors: a randomized controlled trial.

BACKGROUND: The aim of this study was to assess the efficacy of meaning-centered group psychotherapy for cancer survivors (MCGP-CS) to improve personal meaning, compared with supportive group psychotherapy (SGP) and care as usual (CAU). METHOD: A total of 170 cancer survivors were randomly assigned to one of the three study arms: MCGP-CS (n = 57); SGP (n = 56); CAU (n = 57). The primary outcome measure was the Personal Meaning Profile (PMP; total score). Secondary outcome measures were subscales of the PMP, psychological well-being (Scales of Psychological Well-being; SPWB), post-traumatic growth (Posttraumatic Growth Inventory), Mental Adjustment to Cancer (MAC), optimism (Life Orientation Test-Revised), hopelessness (Beck's Hopelessness Scale), psychological distress (anxiety and depression, Hospital Anxiety and Depression Scale; HADS) and quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; EORTC QLQ-C30). Outcome measures were assessed before randomization, post-intervention, and after 3 and 6 months of follow-up (FU). RESULTS: Linear mixed model analyses (intention-to-treat) showed significant differences between MCGP-CS, SGP and CAU on the total PMP score, and on (sub)scales of the PMP, SPWB, MAC and HADS. Post-hoc analyses showed significantly stronger treatment effects of MCGP-CS compared with CAU on personal meaning (d = 0.81), goal-orientedness (d = 1.07), positive relations (d = 0.59), purpose in life (d = 0.69); fighting spirit (d = 0.61) (post-intervention) and helpless/hopeless (d = -0.87) (3 months FU); and distress (d = -0.6) and depression (d = -0.38) (6 months FU). Significantly stronger effects of MCGP-CS compared with SGP were found on personal growth (d = 0.57) (3 months FU) and environmental mastery (d = 0.66) (6 months FU). CONCLUSIONS: MCGP-CS is an effective intervention for cancer survivors to improve personal meaning, psychological well-being and mental adjustment to cancer in the short term, and to reduce psychological distress in the long run.

Mental health care in oncology. Contemporary perspective on the psychosocial burden of cancer and evidence-based interventions.

With cancer incidence increasing over time worldwide, attention to the burden of psychiatric and psychosocial consequences of the disease is now mandatory for both cancer and mental health care professionals. Psychiatric disorders have been shown to affect at least 30-35% of cancer patients during all phases of the disease trajectory, and differ in nature according to stage and type of cancer. Other clinically relevant distressing psychosocial and existential conditions (e.g. demoralisation, health anxiety, loss of meaning and existential distress) not included as 'disorders' in the usual diagnostic and nosological systems (i.e. meta-diagnostic conditions) have also been shown to be present in another 15-20% of cancer patients. In this editorial, we will present a summary of the extensive literature regarding the epidemiology of the several psychosocial disorders affecting cancer patients as a cause of distress and burden to be taken into consideration and addressed in cancer care through evidence-based intervention.

Cancer-related fatigue: prevalence of proposed diagnostic criteria in a United States sample of cancer survivors.

PURPOSE: To evaluate the proposed cancer-related fatigue (CRF) diagnostic criteria in a sample of cancer survivors. More accurate prevalence estimates of CRF may result in improved diagnosis and management of one of the most common symptoms associated with cancer and its treatment. METHODS: Three hundred seventy-nine individuals who had been treated with chemotherapy, either alone or in combination with radiation therapy, were surveyed. Patients were asked background questions about their current condition, their medical history, and the frequency of fatigue during their chemotherapy. Additionally, patients who reported experiencing fatigue at least a few days each month during treatment were asked a series of questions about the impact of fatigue on their daily functioning. RESULTS: One hundred forty-one (37%) individuals reported at least 2 weeks of fatigue in the previous month. Of the respondents who had received their last treatment more than 5 years ago, 33% still reported at least a 2-week period of fatigue in the month before the interview. Evaluation of the proposed criteria revealed that 17% of respondents met at least two criteria for CRF. CONCLUSION: The prevalence of diagnosable CRF in the individuals in this sample, most of whom had completed treatment more than 1 year ago, was 17%-lower than expected based on previous reports that have used less-strict criteria. In a sizable number of people, CRF persists well beyond active treatment and should be a focus of intervention. Although they will require replication in other samples and clinical validation, these formal diagnostic criteria can be a step toward common language and a better understanding of the severity range and persistence of CRF.

A randomized clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms.

A randomized nonblinded study was performed in three cancer centers to test over a 10-day period the efficacy of (1) a triazolobenzodiazepine, alprazolam, 0.5 mg three times a day and (2) use of a behavioral technique in which patients were trained in progressive muscle relaxation at an initial session with a behavioral psychologist and then asked to listen at home to an audiotape of the session three times a day. Of 147 cancer patients who met entry levels of distress and completed the study, uncontrolled for site or disease stage, 70 were randomized to drug, 77 to relaxation. Four measures of anxiety and depression were used: Covi, Raskin, Affects Balance, and Symptoms Checklist-90 (SCL-90). Results showed that both treatment arms resulted in significant (P less than .001) decrease in observer and patient-reported anxious and depressed mood symptoms. Although both treatment arms were effective, patients receiving the drug showed a slightly more rapid decrease in anxiety and greater reduction of depressive symptoms. These findings confirm efficacy of both alprazolam and relaxation to reduce cancer-related anxiety and depression. As safe, inexpensive, and effective interventions, physicians should consider their use in cancer patients experiencing anxiety and depressive symptoms.

A randomized, double-blind, placebo-controlled trial of psychostimulants for the treatment of fatigue in ambulatory patients with human immunodeficiency virus disease.

BACKGROUND: Fatigue is a commonly encountered symptom of human immunodeficiency virus (HIV) disease, associated with significant psychological and functional morbidity and poor quality of life. Preliminary studies on the treatment of fatigue from the cancer and multiple sclerosis literature suggest that psychostimulants may be effective in reducing fatigue. OBJECTIVE: To compare the efficacy of 2 psychostimulant medications, methylphenidate hydrochloride (Ritalin) and pemoline (Cylert), with a placebo intervention for the treatment of fatigue in patients with HIV disease. METHODS: In this double-blind trial, 144 ambulatory patients with HIV disease and persistent and severe fatigue were randomized to treatment with methylphenidate, pemoline, or placebo. Medications were titrated up to a maximum dose of 60 mg of methlyphenidate hydrochloride, 150 mg of pemoline, or 8 capsules of placebo daily. Fatigue was measured using 2 self-reported rating scales, the Piper Fatigue Scale (PFS) and the Visual Analogue Scale for Fatigue (VAS-F). We also used the timed isometric unilateral straight leg-raising task, a measure of muscular endurance. Quality-of-life and psychological well-being measures included the Beck Depression Inventory, the Brief Symptom Inventory, and the 36-Item Short-Form Medical Outcomes Study Health Status Survey. Side effects were monitored using the Systematic Assessment for Treatment Emergent Events and the Extra-pyramidal Symptom Rating Scale. All measures were rated weekly. RESULTS: One hundred nine subjects completed the 6-week trial; 15 patients (41%) receiving methylphenidate and 12 patients (36%) receiving pemoline demonstrated clinically significant improvement compared with 6 patients (15%) receiving placebo. Patients receiving methylphenidate or pemoline demonstrated significantly more improvement in fatigue on several self-reported rating scales (PFS total score, P=.04; affective subscale, P=.008; sensory subscale, P=.04; and VAS-F energy subscale, P=.02). Analysis of the regression slopes by means of hierarchical linear modeling demonstrated a significantly greater rate of improvement in PFS total scores among patients receiving psychostimulants compared with the placebo group (P=.02). There were no significant differences in the efficacy between methlyphenidate and pemoline on any outcome measure studied. Improvement in fatigue was also significantly correlated with improvement in measures of depression, psychological distress, and overall quality of life. Severe side effects were relatively uncommon among this sample, and only hyperactivity or jitteriness occurred significantly more often among subjects receiving active medication. CONCLUSIONS: Many patients with HIV- and acquired immunodeficiency syndrome-unrelated fatigue respond favorably to treatment with methylphenidate or pemoline. Both psychostimulants appear to be equally effective and significantly superior to placebo in decreasing fatigue severity with minimal side effects. Moreover, improvement of fatigue was significantly associated with improved quality of life and decreased levels of depression and psychological distress.

Patient, caregiver, and oncologist perceptions of cancer-related fatigue: results of a tripart assessment survey. The Fatigue Coalition.

Although fatigue is the most common symptom reported by cancer patients and has serious adverse effects on quality of life, it remains poorly understood. A survey was designed to characterize the epidemiology of cancer-related fatigue from the perspectives of the patient, primary caregiver, and oncologist. A telephone survey included 419 cancer patients recruited from 100,000 randomly selected households nationwide. Patients provided access to 200 primary caregivers (usually family members) who were also interviewed by telephone. In a separate mail survey, 197 of 600 randomly sampled oncologists (unrelated to the patients) responded to a questionnaire that assessed perceptions and attitudes concerning fatigue in cancer patients who had received chemotherapy or radiotherapy and their caregivers. The median patient age was 65 years, and the principal cancer diagnoses were breast (females) and genitourinary (males). Fifty-nine percent of the patients had received chemotherapy, 63% radiation therapy, and 24% both; 20% of patients received their last treatment within 6 weeks, 31% within 7 weeks to 1 year, and 49% more than 1 year ago. More than three quarters of patients (78%) experienced fatigue (defined as a general feeling of debilitating tiredness or loss of energy) during the course of their disease and treatment. Thirty-two percent experienced fatigue daily, and 32% reported fatigue significantly affected their daily routines. Caregivers reported observing fatigue in 86% of the index patients, and oncologists perceived that 76% of their patients experienced fatigue. Although oncologists believed that pain adversely affected their patients to a greater degree than fatigue (61% v 37%), patients felt that fatigue adversely affected their daily lives more than pain (61% v 19%). Most oncologists (80%) believed fatigue is overlooked or undertreated, and most patients (74%) considered fatigue a symptom to be endured. Fifty percent of patients did not discuss treatment options with their oncologists, and only 27% reported that their oncologists recommended any treatment for fatigue. When used, treatments for fatigue were generally perceived by patients and caregivers to be successful. These data confirm the high prevalence and adverse impact of cancer-related fatigue, although it is seldom discussed and infrequently treated. For patients and oncologists, improving the quality of life of cancer patients requires a heightened awareness of fatigue, a better understanding of its impact, and improve communication and familiarity with interventions that can reduce its debilitating effects.

Interest in physician-assisted suicide among ambulatory HIV-infected patients.

OBJECTIVE: This study surveyed HIV-infected patients' attitudes toward physician-assisted suicide and examined the relationship between interest in physician-assisted suicide and physical and psychosocial variables. METHOD: Three hundred seventy-eight ambulatory HIV-infected patients, 90% of whom met the criteria of the Centers for Disease Control for AIDS, were recruited from several sites in New York City. Self-report measures were used to assess pain, physical symptoms, psychological distress, depression, and social supports. Attitudes toward, and interest in, physician-assisted suicide were assessed through responses to a questionnaire. RESULTS: Sixty-three percent of the patients supported policies favoring physician-assisted suicide, and 55% acknowledged considering physician-assisted suicide as an option for themselves. The strongest predictors of interest in physician-assisted suicide were high scores on measures of psychological distress (depression, hopelessness, suicidal ideation, overall psychological distress) and experience with terminal illness in a family member or friend. Other strong predictors were Caucasian race, infrequent or no attendance at religious services, and perceived low level of social supports. Interest in physician-assisted suicide was not related to severity of pain, pain-related functional impairment, physical symptoms, or extent of HIV disease. CONCLUSIONS: HIV-infected patients supported policies favoring physician-assisted suicide at rates comparable to those in the general public. Patients' interest in physician-assisted suicide appeared to be more a function of psychological distress and social factors than physical factors. These findings highlight the importance of psychiatric and psychosocial assessment and intervention in the care of patients who express interest in or request physician-assisted suicide.

Measuring desire for death among patients with HIV/AIDS: the schedule of attitudes toward hastened death.

OBJECTIVE: As physician-assisted suicide is debated, a need for standardized measurement of desire for death among medically ill individuals has emerged. The authors present preliminary validation data for a new self-report instrument, the Schedule of Attitudes Toward Hastened Death. METHOD: The participants were 195 patients with HIV/AIDS from two sites: 148 ambulatory patients and 47 patients who had been recently admitted to a facility for end-of-life care. The ambulatory participants completed the 20-item Schedule of Attitudes Toward Hastened Death and several other instruments, including the Beck Depression Inventory and Brief Symptom Inventory. The terminally ill patients also completed the Schedule of Attitudes Toward Hastened Death, along with other measures, and were assessed by clinicians with the Hamilton Depression Rating Scale and the Desire for Death Rating Scale, a global clinician rating of the patient's desire for death. RESULTS: The Schedule of Attitudes Toward Hastened Death demonstrated high reliability. The total score significantly correlated with the clinician rating on the Desire for Death Rating Scale and with ratings of depression and psychological distress. In addition, the Schedule of Attitudes Toward Hastened Death score significantly correlated with pain intensity and physical symptom distress. Factor analysis supported a single factor structure for the instrument. CONCLUSIONS: These results indicate that the Schedule of Attitudes Toward Hastened Death is a reliable, valid measure of desire for death among patients with HIV/AIDS. Further research with this measure may help address many of the unanswered questions emerging from the ongoing debates regarding legalization of assisted suicide.

A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients.

OBJECTIVE: The purpose of this study was to examine the efficacy and side effects of haloperidol, chlorpromazine, and lorazepam for the treatment of the symptoms of delirium in adult AIDS patients in a randomized, double-blind, comparison trial. METHOD: Nondelirious, medically hospitalized AIDS patients (N = 244) consented to participate in the study and were monitored prospectively for the development of delirium. Patients entered the treatment phase of the study if they met DSM-III-R criteria for delirium and scored 13 or greater on the Delirium Rating Scale. Thirty patients were randomly assigned to treatment with haloperidol (N = 11), chlorpromazine (N = 13), or lorazepam (N = 6). Efficacy and side effects associated with the treatment were measured with repeated assessments using the Delirium Rating Scale, the Mini-Mental State, and the Extrapyramidal Symptom Rating Scale. RESULTS: Treatment with either haloperidol or chlorpromazine in relatively low doses resulted in significant improvement in the symptoms of delirium as measured by the Delirium Rating Scale. No improvement in the symptoms of delirium was found in the lorazepam group. Cognitive function, as measured by the Mini-Mental State, improved significantly from baseline to day 2 for patients receiving chlorpromazine. Treatment with haloperidol or chlorpromazine was associated with an extremely low prevalence of extrapyramidal side effects. All patients receiving lorazepam, however, developed treatment-limiting adverse effects. Although only a small number of patients had been treated with lorazepam, the authors became sufficiently concerned with the adverse effects to terminate that arm of the protocol early. CONCLUSIONS: Symptoms of delirium in medically hospitalized AIDS patients may be treated efficaciously with few side effects by using low-dose neuroleptics (haloperidol or chlorpromazine). Lorazepam alone appears to be ineffective and associated with treatment-limiting adverse effects.

The undertreatment of pain in ambulatory AIDS patients.

Pain is highly prevalent in individuals with HIV disease, yet is often overlooked as a symptom requiring clinical intervention. We evaluated the adequacy of analgesic management for pain and identified predictors of pain undertreatment in a sample of 366 ambulatory AIDS patients using a prospective cross-sectional survey design. Two hundred and twenty-six of the 366 ambulatory AIDS patients surveyed reported "persistent or frequent" pain over the 2 week period prior to the survey. Adequacy of analgesic therapy was assessed using the Pain Management Index (PMI - a measure derived from the Brief Pain Inventory) and the type and frequency of analgesic medications prescribed for pain. Results indicated that nearly 85% of patients were classified as receiving inadequate analgesic therapy based on the PMI. Less that 8% of the 110 patients who reported "severe" pain were prescribed a "strong" opioid (e.g., morphine), as suggested by published guidelines. Adjuvant analgesic drugs (e.g., antidepressant medications) were prescribed in only 10% of the patients. Women, less educated patients, and patients who reported injection drug use as their HIV transmission risk factor were most likely to have received inadequate analgesic therapy. These results demonstrate the alarming degree of undertreatment of pain in ambulatory patients with AIDS, and indicates the need to improve the management of AIDS-related pain in this underserved population. Future research should elucidate the factors that impede adequate pain management in order to overcome obstacles to adequate treatment.

A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse.

Concerns are often raised regarding the credibility of patients' report of pain and this concern is heightened among individuals with AIDS, where many patients have a history of injection drug use. This study compared the pain experience, adequacy of pain management and psychological well-being among patients with AIDS who reported a history of injection drug use (IDU) as their HIV transmission risk factor and patients with other HIV transmission risk factors. Five hundred and sixteen ambulatory AIDS patients participating in a quality of life study completed a series of self-report instruments including the Brief Pain Inventory, the Beck Depression Inventory, the Brief Symptom Inventory, the Functional Living Inventory and the Social Support Questionnaire. Results demonstrated that IDU and non-IDU subjects did not differ significantly in their report of pain prevalence, pain intensity or pain-related functional interference. However, IDU patients were significantly more likely to receive inadequate analgesic medications, reported lower levels of pain relief and a greater degree of psychological distress. There was also no difference in report of pain intensity, pain relief or functional interference among patients who acknowledged continued drug use, those who denied any recent drug use and patients participating in a methadone maintenance program. These data support the validity of AIDS patients' report of pain, at least in research settings, and suggest that undertreatment of pain is not restricted to patients who actively abuse drugs.

Pain syndromes and etiologies in ambulatory AIDS patients.

Ambulatory AIDS patients participating in a quality of life study were recruited for an assessment of pain syndromes. Of 274 patients with pain, 151 (55%) consented to the assessment which included a clinical interview, neurologic examination, and review of medical records. The number, type, and etiology of pains were evaluated in terms of risk factors, age, sex, CD4+ lymphocyte count, and performance status. The average number of pains per patient was 2.7 (range, 1-7), yielding a total of 405 pains. The most common pain diagnoses were headache (46% of patients; 17% of all pains), joint pain (31% of patients; 12% of pains), pain due to polyneuropathy (28% of patients; 10% of pains), and muscle pain (27% of patients; 12% of pains). Pathophysiology was inferred for all pain syndromes (except for headache), 45% of pain syndromes were somatic in nature, 15% were visceral, 19% were neuropathic, and 4% were unknown, psychogenic, or idiopathic; 17% of pains were classified as headache, hence pathophysiology could not be determined. Pain resulted from diverse etiologies, including the direct effects of HIV/AIDS-related conditions (30%) pre-existing unrelated conditions (24%), and therapies for HIV/AIDS and related conditions (4%). The latter category, pain related to HIV therapies, occurred in 11% of patients. In 37% of the pains, the etiology could not be determined from the information available. In univariate analyses, lower CD4+ cell counts were significantly associated with polyneuropathy (P < 0.05) and headache (P < 0.05), and female gender was significantly associated with the presence of headache (P < 0.05) and radiculopathy (P < 0.001). These data confirm the diversity of pain syndromes in AIDS patients, clarify the prevalence of common pain types, and suggest associations between specific patient characteristics and pain syndromes. The large proportion of patients who could not be given a diagnosis underscores the need for a careful diagnostic evaluation of pain in this population.

Pain in ambulatory AIDS patients. II: Impact of pain on psychological functioning and quality of life.

The relationships among pain, psychological distress and other quality of life concerns were examined through a prospective cross-sectional survey of 438 ambulatory AIDS patients recruited from health care facilities in New York City. In this sample, 274 (62.6%) patients reported frequent or persistent pain during the prior 2 wks. Patients with and without pain completed a questionnaire packet that included measures of psychological symptom distress (Brief Symptom Inventory and the Psychological Distress Subscale of the Memorial Symptom Assessment Scale), depression (Beck Depression Inventory and Beck Hopelessness Scale), social support (Social Support Questionnaire), and overall quality of life (Functional Living Index-Cancer, modified for AIDS). Multivariate analyses (MANOVA, multiple regression) revealed significant associations between the presence and intensity of pain and scores on the measures of psychological distress, depression, hopelessness, and quality of life (P < 0.0001 for most analyses). Perceived adequacy of social support was also significantly associated with lower levels of psychological distress and depression, and better quality of life. These results demonstrate the significant relationships between pain, psychological well-being, and quality of life, and affirm the need to provide adequate treatment of pain in patients with AIDS.

Patient-related barriers to pain management in ambulatory AIDS patients.

A number of studies have demonstrated that pain is dramatically undertreated among patients with AIDS and that opioids in particular are rarely prescribed. To date, however, there has been no systematic attempt to examine patient-related barriers to the management of pain in AIDS. This study examines potential patient-related barriers to pain management in patients with AIDS using the Barriers Questionnaire (Ward et al., Pain, 52 (1993) 319-324), and assesses gender, racial, and other demographic differences in the endorsement of these barriers. We surveyed 199 ambulatory patients with AIDS, recruited from numerous sites in New York City, as part of an ongoing study of pain and quality of life in ambulatory AIDS patients. In addition to obtaining demographic and medical data, we administered a number of self-report questionnaires including the Brief Pain Inventory (BPI), the Brief Symptom Index (BSI), the Beck Depression Inventory (BDI), and the Memorial Symptom Assessment Scale (MSAS). Barriers to pain management were assessed using a modified version of the Barriers Questionnaire (BQ), including the original 27 questions from this self-report instrument along with an additional 12 items developed for an AIDS population. Results indicated that the most frequently endorsed BQ items were those concerning the addiction potential of pain medications and physical discomfort associated with opioid administration (e.g. injections) or side effects (e.g. nausea, constipation). There were no associations between age, gender, or HIV transmission risk factor and total scores on the BQ; however, Caucasian patients endorsed significantly fewer BQ items than did non-Caucasian patients and years of education was negatively correlated with BQ scores. Scores on the BQ were also significantly correlated with number of physical symptoms (MSAS) and scores on several self-report measures of psychological distress (the BSI Global Distress Index, BDI total scores). Patient-related barriers (i.e. BQ total scores) were significantly associated with undertreatment of pain (as measured by the Pain Management Index), and added significantly to the prediction of undertreatment in a logistic regression analysis, even after controlling for the impact of gender, education and IDU transmission risk factor. These data suggest that patient-related barriers to pain management may add to the already considerable likelihood of undertreatment of AIDS-related pain.

Pain in ambulatory AIDS patients. I: Pain characteristics and medical correlates.

The characteristics and impact of pain were evaluated in a prospective cross-sectional survey of 438 ambulatory AIDS patients recruited from health care facilities in New York City. More than 60% of the patients reported 'frequent or persistent pain' during the 2 wks preceding the study. Patients with pain reported an average of 2.5 different pains. On the 0-10 numerical scale of the Brief Pain Inventory (BPI), mean pain intensity 'on average' was 5.4 (SD = 2.2; range = 0-10), and mean pain 'at its worst' was 7.4 (SD = 2.0; range = 1-10). The pain-related functional interference index (sum of the seven item BPI subscale) was 42.6 (SD = 17.2; range = 0.70). Demographic variables were not associated with the presence of pain, but the number of current HIV-related symptoms, treatment for HIV-related infections, and the absence of antiretroviral medications were significantly associated with the presence of pain. Female gender, non-Caucasian race, and number of HIV-related physical symptoms were significantly associated with pain intensity. Presence of pain and increasing pain intensity were significantly associated with greater impairment in functional ability (Karnofsky Performance Status, BPI functional interference index) and physical symptom distress (Memorial Symptom Assessment Scale). Results demonstrate high levels of pain and pain-related functional impairment among patients with AIDS. The presence and intensity of pain are associated with more advanced HIV disease and pain intensity is also associated with demographic factors (gender, race).

Psychosocial aspects of head and neck cancer.

The major psychosocial issues in managing the patient with a head and neck tumor are dealing with the emotional reactions to structural and functional deficits, recognizing and treating preexisting personality problems, especially those related to alcohol and tobacco abuse, which frequently complicate their treatment course. These factors influence the rehabilitation process which should begin in the preoperative period with careful attention to psychologic and social assessment and psychiatric evaluation; if an alcoholic history is elicited. Important continuity in rehabilitation can be accomplished by contact with the rehabilitative team members before surgery, preoperative chemotherapy or radiation. Attention to appropriate adaptation to facial prostheses and dealing early with communication disorders requires a specialized staff and a rehabilitative team which can call on a range of skills including a psychiatric consultant. While the ordeal of the head and neck cancer patient is psychologically difficult and challenging, most patients are able, with the proper help, to resume full and productive lives.

Psychiatric emergencies in terminally ill cancer patients.

Delirium, depression, suicidal ideation, and severe anxiety are among the most commonly occurring psychiatric complications encountered in cancer pain patients. When severe, these disorders require as urgent and aggressive attention as do other distressing physical symptoms, such as escalating pain. Early diagnosis and treatment can result in effective management of these psychiatric emergencies.

Psychosocial Aspects of Palliative Care.

BACKGROUND: Relief of suffering is a central goal for palliative care. Achievement of this goal can be difficult, however, due to the complex nature of suffering. METHODS: A psychosocial perspective is used to understand suffering and to identify interventions to relieve suffering in patients with advanced disease. RESULTS: Clinical experience and research suggest that attending to the psychosocial aspects as well as the medical aspects of palliative care has the potential of further reducing the suffering experienced by patients with advanced disease. CONCLUSIONS: Suffering is best viewed as a subjective phenomenon t hat can be influenced by biological, psychological and social processes. Interventions in each of these areas can help to relieve patient suffering.