The interplay between mentalization, personality traits and burnout in psychiatry training: Results from a large multicenter controlled study.

BACKGROUND: A better characterization of educational processes during psychiatry training is needed, both to foster personal resilience and occupational proficiency. METHODS: An adequate coverage of medical residents at the national level was reached (41.86% of the total reference population, 29 out of 36 training centers-80.55%). Controls were recruited among residents in other medical specialties. All participants were assessed by questionnaires to evaluate early life experiences, attachment style, personality traits, coping strategies, emotional competencies. A Structural Equation Model (SEM) framework was employed to investigate the interplay between individual factors. RESULTS: A total sample of 936 people was recruited (87.9% response-rate; 645 residents in psychiatry, 291 other medical residents). Psychiatry trainees reported a higher prevalence of adverse childhood experiences (emotional abuse, emotional neglect, physical neglect), greater attachment insecurity (anxious or avoidant) in comparison to other medical trainees. Psychiatry residents also reported higher social support-seeking as a coping strategy, lower problem-orientation, and lower transcendence. Lower neuroticism, higher openness to experience, and higher emotional awareness were also observed in psychiatry trainees. Psychiatry training was associated with a redefinition of conflict management skills as a function of seniority. The SEM model provided support for an interplay between early traumatic experiences, mentalization skills (coping strategies, emotion regulation), interpersonal competencies and occupational distress. CONCLUSIONS: The findings of the present study supported a theoretical model based on mentalization theory for the interactions between personal and relational competencies in psychiatry training, thus providing potential target of remodulation and redefinition of this specific process of education.

Dignity in Medicine: Definition, Assessment and Therapy.

PURPOSE OF REVIEW: Over the last 20 years, dignity and dignity-conserving care have become the center of investigation, in many areas of medicine, including palliative care, oncology, neurology, geriatrics, and psychiatry. We summarized peer-reviewed literature and examined the definition, conceptualization of dignity, potential problems, and suggested interventions. RECENT FINDINGS: We performed a review utilizing several databases, including the most relevant studies in full journal articles, investigating the problems of dignity in medicine. It emerged that dignity is a multifactorial construct and that dignity-preserving care should be at the center of the health organization. Dignity should be also regularly assessed through the tools currently available in clinical practice. Among dignity intervention, besides dignity models of care, dignity intervention, such as dignity therapy (DT), life review and reminiscence therapy, have a role in maintaining both the extrinsic (preserved when health care professionals treat the patient with respect, meeting physical and emotional needs, honors the patient's wishes, and makes attempts to maintain privacy and confidentiality) and intrinsic dignity (preserved when the patient has appropriate self-esteem, is able to exercise autonomy and has a sense of hope and meaning). Unified trends across diverse medical contexts highlight the need for a holistic, patient-centered approach in healthcare settings. Challenges compromising dignity are pervasive, underscoring the importance of interventions and systematic efforts to address these issues. Future research and interventions should prioritize the multifaceted nature of dignity, striving to create healthcare environments that foster compassion, respect, and dignity across all medical settings.

The relationship between peritraumatic distress, mental health symptoms, and functioning impairment in healthcare workers during the COVID-19 emergency.

OBJECTIVE: Healthcare workers (HCWs) were considered a population at risk for developing psychiatric symptoms during the COVID-19 pandemic, such as anxiety, depression, and post-traumatic stress disorder (PTSD). Peritraumatic distress is associated with post-traumatic psychopathological symptoms; however, little is known about how it may affect functioning. The study aimed at evaluating the level of peritraumatic distress in a sample of HCWs during the first wave of the COVID-19 pandemic and at examining the relationship between peritraumatic distress, mental health symptoms, and functioning impairment. METHODS: A sample of 554 frontline HCWs were consecutively enrolled in major university hospitals and community services in Italy. The PDI, IES-R, PHQ-9, and GAD-7 were used to assess peritraumatic distress, symptoms of PTSD, depression, and anxiety, respectively, and the WSAS to investigate functioning impairment. PDI scores were higher among females, community services, physicians, and nurses. Furthermore, the PDI correlated significantly with the GAD-7, PHQ-9, IES-R, and WSAS. RESULTS: In a mediation analysis, the direct effect of PDI on WSAS and the indirect effects through the PHQ-9 and IES-R were statistically significant (P < .001). CONCLUSION: Peritraumatic distress reported by HCWs was associated with symptoms of PTSD, depression, and anxiety, but the association with reduced functioning may be only partially mediated through symptoms of depression and PTSD.

Effects of electroconvulsive therapy on cortical thickness in depression: a systematic review.

OBJECTIVE: Electroconvulsive therapy (ECT) is one of the most studied and validated available treatments for severe or treatment-resistant depression. However, little is known about the neural mechanisms underlying ECT. This systematic review aims to critically review all structural magnetic resonance imaging studies investigating longitudinal cortical thickness (CT) changes after ECT in patients with unipolar or bipolar depression. METHODS: We performed a search on PubMed, Medline, and Embase to identify all available studies published before April 20, 2023. A total of 10 studies were included. RESULTS: The investigations showed widespread increases in CT after ECT in depressed patients, involving mainly the temporal, insular, and frontal regions. In five studies, CT increases in a non-overlapping set of brain areas correlated with the clinical efficacy of ECT. The small sample size, heterogeneity in terms of populations, comorbidities, and ECT protocols, and the lack of a control group in some investigations limit the generalisability of the results. CONCLUSIONS: Our findings support the idea that ECT can increase CT in patients with unipolar and bipolar depression. It remains unclear whether these changes are related to the clinical response. Future larger studies with longer follow-up are warranted to thoroughly address the potential role of CT as a biomarker of clinical response after ECT.

Depressive symptom complexes of community-dwelling older adults: a latent network model.

Late-life depression has multiple, heterogeneous clinical presentations. The aim of the study was to identify higher-order homogeneous clinical features (symptom complexes), while accounting for their potential causal interactions within the network approach to psychopathology. We analyzed cross-sectional data from community-dwelling adults aged 65-85 years recruited by the European MentDis_ICF65+ study (n = 2623, mean age 74, 49% females). The severity of 33 depressive symptoms was derived from the age-adapted Composite International Diagnostic Interview. Symptom complexes were identified using multiple detection algorithms for symptom networks, and their fit to data was assessed with latent network models (LNMs) in exploratory and confirmatory analyses. Sensitivity analyses included the Partial Correlation Likelihood Test (PCLT) to investigate the data-generating structure. Depressive symptoms were organized by the Walktrap algorithm into eight symptom complexes, namely sadness/hopelessness, anhedonia/lack of energy, anxiety/irritability, self-reproach, disturbed sleep, agitation/increased appetite, concentration/decision making, and thoughts of death. An LNM adequately fit the distribution of individual symptoms' data in the population. The model suggested the presence of reciprocal interactions between the symptom complexes of sadness and anxiety, concentration and self-reproach and between self-reproach and thoughts of death. Results of the PCLT confirmed that symptom complex data were more likely generated by a network, rather than a latent-variable structure. In conclusion, late-life depressive symptoms are organized into eight interacting symptom complexes. Identification of the symptom complexes of late-life depression may streamline clinical assessment, provide targets for personalization of treatment, and aid the search for biomarkers and for predictors of outcomes of late-life depression.

A comparison of Dignity Therapy narratives among people with severe mental illness and people with cancer.

OBJECTIVE: To examine Dignity Therapy (DT) narratives in patients with severe mental illness (SMI) and a control group of cancer patients. METHODS: 12 patients with SMI (schizophrenia, bipolar disorders, sever personality disorders) and 12 patients with non-advanced cancer individually participated to DT interviews. DT was tape-recorded, transcribed verbatim and shaped into a narrative through a preliminary editing process. A session was dedicated to the final editing process along with the participant, with a final written legacy (generativity document) provided to the participant. Interpretative Phenomenological Analysis was used to qualitatively analyze the generativity documents. RESULTS: Patients with SMI and patients with cancer presented similar main narrative categories relative to dignity, such as "Meaning making", "Resources", "Legacy", "Dignity"; in addition, inpatients with SMI "Stigma" and inpatients with cancer "Injustice" emerged as separate categories. Patients in both groups strongly appreciated DT as an opportunity to reflect on their life story and legacy. CONCLUSIONS: The study showed that DT is a valuable intervention for people with SMI, grounded in a practical, person-centered approach. All patients found DT as an opportunity to describe their past and present, highlighting changes in the way they relate to themselves and others. These results can guide implementation of DT in mental health settings for people with SMI, as it is for people with cancer.

Insomnia and related factors in patients with pre-existing psychiatric disorders compared to the general population during the COVID-19 lockdown: Findings from the multicentric COMET study.

BACKGROUND: The COVID-19 pandemic has heavily impacted social, economic and health systems worldwide. Necessary confinement measures have, in turn, contributed to the occurrence of several stress-related conditions and deterioration of pre-existing mental conditions, including insomnia. OBJECTIVE: The present study sought to investigate the occurrence and severity of insomnia during the COVID-19 lockdown among psychiatric patients and in the general population in the largest Italian sample examined to date. Potential factors associated with a risk of developing insomnia in the global sample were examined as well. METHODS: A sample of 20,720 people (5.5% of them being psychiatric patients) was assessed through an online survey conducted during lockdown between March and May 2020. To investigate the occurrence and severity of sleep related issues, the Insomnia Severity Index (ISI) was used. In order to evaluate factors associated with the severity of insomnia in the global sample, multivariate linear regression models were performed. RESULTS: During the lockdown, patients with pre-existing mental disorders reported a mean higher score on the ISI scale (p < 0.001) compared to the general population. According to the multivariate regression models, the first three weeks of lockdown were significantly associated with a higher risk of insomnia, but the risk disappeared in the fourth week. Other associated factors included: the presence of a pre-existing mental disorder, ages 24 to 64 years old, and/or being female (p < 0.001). CONCLUSIONS: Although containment measures represent essential public health strategies to avoid the spread of the COVID-19 pandemic, sleep was one of the aspects affected during the early stages of the lockdown in both people with pre-existing mental disorders and general population. As an integral part of COVID-19 intervention, it is useful to raise awareness about these issues and to adopt both preventive and therapeutic interventions.

Use of social network as a coping strategy for depression among young people during the COVID-19 lockdown: findings from the COMET collaborative study.

BACKGROUND: Use of social media (SM) has exponentially grown particularly among youths in the past two years, due to COVID-19-related changing lifestyles. Based on the Italian COvid Mental hEalth Trial (COMET), we investigated the association between SM use and depressive symptoms among Italian young adults (aged 18-24). METHODS: The COMET is a nationwide multi-center cross-sectional study that investigated socio-demographic data, social networking addiction (BSNAS), depression, anxiety, and stress (DASS-21), as well as impulsiveness (BIS-15) and aggressiveness (AQ) in a large sample of youngsters, in order to assess the association between BSNAS and DASS-21 indices. Mediation analyses were performed to evaluate the role of impulsiveness and aggressive personality traits in the association between SM use (SMU) and depression. RESULTS: 75.8% of the sample (n = 491) had a problematic SMU. SMU was reduced by high AQ and high DASS-21 scores (F = 42.338, p < 0.001, R2 = 0.207). Mediation analyses showed that SMU negatively predicted depressive symptomatology with the interaction mediated by AQ total (ß = - 0.1075), physical (ß = - 0.207) and anger (ß = - 0.0582), BIS-15 total (ß = - 0.0272) and attentional (ß = - 0.0302). High depressive levels were predicted by high AQ scores, low SMU levels, low verbal and physical AQ, and low attentional BIS-15 (F = 30.322, p < 0.001, R2 = 0.273). Depressive symptomatology negatively predicted SMU with their interaction mediated by AQ total (ß = - 0.1640), verbal (ß = 0.0436) and anger (ß = - 0.0807), BIS-15 total (ß = - 0.0448) and attentional (ß = - 0.0409). CONCLUSIONS: SMU during the early phases of the COVID-19 pandemic could have a beneficial role in buffering negative consequences linked to social isolation due to quarantine measures, despite this association being mediated by specific personality traits.

Reflecting on meaning in an existential-reorientation group psychotherapy approach for cancer patients: A qualitative thematic analysis.

OBJECTIVE: The objectives of this study were to evaluate, in the Italian cultural context, breast cancer patients' main meaning themes related to the experience of the disease, on the one side, and to be part of an existentially oriented group intervention, on the other. METHOD: A short reorientation-existential (RET) group intervention, structured by using some tools and background from cognitive analytic therapy (CAT) and based on the meaning-centered psychotherapy (MCP) existential framework, was delivered to 29 breast cancer patients. The sessions were audio-recorded and transcribed verbatim, with the narratives from reflective exercises (meaning of the journey cancer, meaning of the journey of intervention) uploaded to computer software NVivo 11. Analysis of the transcripts emerged from reflective exercises on the personal meaning of cancer and the letters of meaning (goodbye letter) written by the patients to express the meaning of their experience in the group was conducted through the interpretative phenomenological analysis (IPA) framework. RESULTS: Four superordinate themes were identified in the exercise meaning of the experience of cancer, namely "sense of stigma and loneliness (the foreigner)," "guilt (unjust guilt and anticipatory guilt)," "reconsidering one's own life and nostalgia," and "rebirth (a new life, life after life)." Three superordinate themes were found in the meaning of the group experience in the letters, namely "togetherness and gratitude," "legacy," and "acceptance." SIGNIFICANCE OF RESULTS: The study confirmed that a short group intervention, based on the existentially oriented framework and delivered in a public clinical healthcare setting, was enriched by focusing on the personal meaning of cancer. Some themes, such as loneliness, nostalgia, and rebirth, emerged during reflection giving, in written letters to participants, the sense of the group therapeutic experience.

Knowledge about risk factors for cancer and cancer risk behavior among patients with severe mental illness.

OBJECTIVE: To examine knowledge about, perception of and current risk factors for cancer, among patients with severe mental illness (SMI) and to compare these variables with patients without SMI. METHODS: A series of patients affected by SMI (i.e., schizophrenia spectrum disorders, bipolar disorders and severe personality disorders) and a matched (gender, age) control group of primary care attenders were assessed, by using an ad hoc semi-structured interview and a short true/false 17-item questionnaire, about family history of cancer, cancer risk-related lifestyles, personal perception and knowledge of risk for cancer. RESULTS: Patients with SMI (n = 185, mainly schizophrenia spectrum disorders, 48%, and mood disorders, 33%) significantly differed from primary care attenders (n = 173) for: lower participation to occult stool blood screening test, Pap smear test and mammography; higher prevalence of current and past smoking habits; lower awareness towards their own physical symptoms and their perception of risks for cancer; lower physical exercise practicing; lower knowledge about risk factors for cancer (e.g. familiarity for cancer, smoke-habits, breast and uterine cancer). CONCLUSIONS: Patients suffering from SMI had higher at-risk behavior for cancer and showed fewer concerns and less knowledge about risk for cancer than primary care attendees. These findings can guide to implement screening for cancer (e.g., Pap test, blood) and to design evidence-based interventions to reduce cancer risk (e.g., educational and behavioral change for smoking cessation, dietary habits) among patients with SMI.

Hostility in cancer patients as an underexplored facet of distress.

OBJECTIVE: In the present study, we aimed to assess hostility and to examine its association with formal psychiatric diagnosis, coping, cancer worries, and quality of life in cancer patients. METHODS: The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to make an ICD-10 (International Classification of Disease) psychiatric diagnosis was applied to 516 cancer outpatients. The patients also completed the Brief Symptom Inventory-53 to assess hostility (BSI-HOS), and the Mini-Mental Adjustment to cancer scale (Mini-MAC). A subset of patients completed the Cancer Worries Inventory (CWI), the Openness Scale, and the Quality of Life Index. RESULTS: By analyzing the distribution of the responses 25% of the patients had moderate and 11% high levels of hostility, with about 20% being BSI-HOS "cases." Hostility was higher in patients with a formal ICD-10 psychiatric diagnosis (mainly major depression, other depressive disorders, anxiety disorders) than patients without ICD-10 diagnosis. However, about 25% of ICD-10-non cases also had moderate-to-high hostility levels. Hostility was associated with Mini-MAC hopelessness and anxious preoccupation, poorer quality of life, worries (mainly problems sin interpersonal relationships), and inability to openly discuss these problems within the family. CONCLUSIONS: Hostility and its components should be considered as dimensions to be more carefully explored in screening for distress in cancer clinical settings for its implications in negatively impacting on quality of life, coping and relationships with the family, and possibly the health care system.

Mortality from cancer in people with severe mental disorders in Emilia Romagna Region, Italy.

OBJECTIVE: To examine cancer-related mortality in patients with severe mental disorders (SMI) in the Emilia Romagna (ER) Region, Northern Italy, during the period 2008-2017 and compare it with the regional population. METHODS: We used the ER Regional Mental Health Registry identifying all patients aged ≥18 years who had received an ICD-9CM system diagnosis of SMI (i.e., schizophrenia or other functional psychosis, mania, or bipolar affective disorders) during a 10-year period (2008-2017). Information on deaths (date and causes of death) were retrieved through the Regional Cause of Death Registry. Comparisons were made with the deaths and cause of deaths of the regional population over the same period. RESULTS: Amongst 12,385 patients suffering from SMI (64.1% schizophrenia spectrum and 36.9% bipolar spectrum disorders), 24% (range 21%-29%) died of cancer. In comparison with the general regional population, the mortality for cancer was about 50% higher among patients with SMI, irrespective if affected by schizophrenia or bipolar disorders. As for the site-specific cancers, significant excesses were reported for stomach, central nervous system, respiratory, and pancreas cancer with a variability according to psychiatric diagnosis and gender. CONCLUSIONS: Patients suffering from SMI had higher mortality risk than the regional population with some differences according to cancer type, gender, and psychiatric diagnosis. Proper cancer preventive and treatment interventions, including more effective risk modification strategies (e.g., smoking cessation, dietary habits) and screening for cancer, should be part of the agenda of all mental health departments in conjunction with other health care organizations, including psycho-oncology.

Association between Type-D Personality and Affective (Anxiety, Depression, Post-traumatic Stress) Symptoms and Maladaptive Coping in Breast Cancer Patients: A Longitudinal Study.

Background: Type-D (distressed) personality has not been prospectively explored for its association with psychosocial distress symptoms in breast cancer patients. Objective: The objective of the study was to test the hypothesis that Type-D personality can be associated with psychosocial distress variables in cancer over a 2-point period (6 month-follow-up). Aims: The aim of the study was to analyze the role of Type-D personality in relation to anxiety, depression, post-traumatic stress symptoms, general distress, and maladaptive coping among cancer patients. Methods: 145 breast cancer patients were assessed within 6 months from diagnosis (T0) and again 6 months later (T1). The Type-D personality Scale, the Hospital Anxiety and Depression Scale, Depression subscale (HAD-D), the Brief Symptom Inventory (BSI-18) Anxiety subscale, the Distress Thermometer (DT), the Post-traumatic Symptoms (PTS) Impact of Event Scale (IES), and the Mini Mental Adjustment to Cancer (Mini-MAC) Anxious Preoccupation and Hopelessness scales were individually administered at T0 and T1. Results: One-quarter of cancer patients met the criteria for Type-D personality, which was stable over the follow-up time. The two main constructs of Type-D personality, namely social inhibition (SI) and negative affectivity (NA), were related to anxiety, depression, PTS, BSI-general distress and maladaptive coping (Mini-MAC anxious preoccupation and hopelessness). In regression analysis, Type-D SI was the most significant factor associated with the above-mentioned psychosocial variables, both at T0 and T1. Conclusion: Likewise other medical disorders (especially cardiology), Type-D personality has been confirmed to be a construct significantly related to psychosocial distress conditions and maladaptive coping that are usually part of assessment and intervention in cancer care. More attention to personality issues is important in oncology.

Quality of life, level of functioning, and its relationship with mental and physical disorders in the elderly: results from the MentDis_ICF65+ study.

BACKGROUND: An ageing population worldwide needs to investigate quality of life (QoL) and level of functioning (LoF) in the elderly and its associated variables. We aimed to study the relationship between Quality of Life (QoL) and Level of Functioning (LoF) in an elderly population in Europe. METHOD: As part of the Ment_Dis65+ European Project, 3142 community-dwelling adults aged 65-84 years in six countries were assessed by using the adaptation for the elderly of the Composite International Diagnostic Interview (CIDI65+) to provide psychiatric diagnosis according to the International Classification of Diseases (10th edition) (ICD-10 Classification of Mental and Behavioural Disorders). Socio-demographic and clinical interviews, and two self-report tools, the World Health Organization QoL assessment (WHO QoL BREF), to assess QoL, and the WHO Disability Assessment Schedule -II (WHODAS-II), to assess LoF, were also administered. RESULTS: Most subjects reported good levels of QoL (56.6%) and self-rated health (62%), with no or mild disability (58.8%). There was a linear decrease of the QoL and the LoF by increase of age. Elderly with ICD-10 mental disorder (e.g. somatoform, affective and anxiety disorders) had poorer QoL and lower LoF. There were a number of predictors of lower levels of QoL and disability, including both socio-demographic variables (e.g. male gender, increase in age, poor financial situation, retirement, reduced number of close significant others), ICD-10 psychiatric diagnosis (mainly anxiety, somatoform disorders) and presence of medical disorders (mainly heart and respiratory diseases). CONCLUSIONS: The study indicates that QoL and LoF were quite acceptable in European elderly people. A series of variables, including psychiatric and somatic disorders, as well as socio-demographic factor influenced in a negative way both QoL and LoF. More specific links between mental health, social and health services dedicated to this segment of the population, should be implemented in order to provide better care for elderly people with conditions impacting their QoL and functioning.

How to improve adherence to antidepressant treatments in patients with major depression: a psychoeducational consensus checklist.

Studies conducted in primary care as well as in psychiatric settings show that more than half of patients suffering from major depressive disorder (MDD) have poor adherence to antidepressants. Patients prematurely discontinue antidepressant therapy for various reasons, including patient-related (e.g., misperceptions about antidepressants, side-effects, and lack of tolerability), clinician-related (e.g., insufficient instruction received by clinicians about the medication, lack of shared decision-making, and follow-up care), as well as structural factors (e.g., access, cost, and stigma). The high rate of poor adherence to antidepressant treatments provides the impetus for identifying factors that are contributing to noncompliance in an individual patient, to implement a careful education about this phenomenon. As adherence to antidepressants is one of the major unmet needs in MDD treatment, being associated with negative outcomes, we sought to identify a series of priorities to be discussed with persons with MDD with the larger aim to improve treatment adherence. To do so, we analyzed a series of epidemiological findings and clinical reasons for this phenomenon, and then proceeded to define through a multi-step consensus a set of recommendations to be provided by psychiatrists and other practitioners at the time of the first (prescription) visit with patients. Herein, we report the results of this initiative.

Italian Validation of the Screen for Cognitive Impairment in Psychiatry.

Cognitive impairments have profound implications for the management of severe mental disorders; however, they are rarely assessed in everyday clinical practice due to constraints in time, resource and expertise. Novel and short instruments, such as the Screen for Cognitive Impairment in Psychiatry (SCIP), which overcome such limitations are greatly needed. The study aims to assess the validity and reliability, among healthy subjects, of the Italian translation of the SCIP, a brief, accessible tool to detect cognitive impairments among individuals suffering from mental disorders, as the first step to validate the instrument in clinical settings. One-hundred and twenty healthy subjects completed two of the three alternative forms of the SCIP. Cronbach Alpha (0.70) supported the reliability of the SCIP scores. Correlation coefficients supported the test-retest reliability of the tool. Learning effects were observed despite the use of alternative forms. Factor analysis indicated a two-factor solution explaining 55.4% of the total variance: the first factor ("memory") loading for VLT-I and VLT-D and less for WMT; the second factor ("executive function") loading for VFT and PST and less for WMT. The study proved the validity and reliability of the Italian version of the SCIP as a reliable and simple instrument to screen for cognitive impairment in the general population.

Screening for emotional disorders in patients with cancer using the Brief Symptom Inventory (BSI) and the BSI-18 versus a standardized psychiatric interview (the World Health Organization Composite International Diagnostic Interview).

BACKGROUND: Given the adverse consequences of psychiatric and psychosocial morbidity on the quality of life for patients with cancer, prompt detection of psychological symptoms is mandatory. The authors examined the properties and accuracy of the Brief Symptom Inventory (the 53-item version [BSI] and the 18-item version [BSI-18]) for the detection of psychiatric morbidity compared with the World Health Organization Composite International Diagnostic Interview (CIDI) for International Classification of Diseases-10th Revision psychiatric diagnoses. METHODS: A convenience sample of 498 patients with newly diagnosed cancer who were recruited in cancer outpatient services participated in the CIDI interview and in BSI and BSI-18 assessments. RESULTS: The prevalence of psychiatric morbidity was 39.75%. When participants were classified as cases using the BSI standard case rule, agreement with the CIDI was potentially acceptable (sensitivity, 72.7%; specificity, 88.7%). In contrast, the accuracy of the BSI-18 in identifying cases was poor according to the standard case rule, with very low sensitivity (29.3%) (misclassification rate, 28.7%). By using a first alternative case-rule system (a BSI-18 global severity index [GSI] T-score ≥57), sensitivity marginally improved (45%), whereas a second alternative case-rule system (a GSI T-score ≥50) significantly increased sensitivity (77.3%). In receiver operating characteristic curve analysis, a further cutoff GSI T-score ≥48 exhibited good discrimination levels (sensitivity, 82.3%; specificity, 72.4%). There were some differences in GSI cutoff T-scores according to the International Classification of Diseases-10th Revision diagnosis and sex. CONCLUSIONS: The BSI appeared to have acceptable diagnostic accuracy compared with a standardized psychiatric interview. For the BSI-18, it is mandatory to use alternative case-rule systems, to identify patients with psychiatric morbidity. Cancer 2018;124:2415-26. © 2018 American Cancer Society.

Relationship of demoralization with anxiety, depression, and quality of life: A Southern European study of Italian and Portuguese cancer patients.

BACKGROUND: Demoralization syndrome is a significant condition that has not been greatly studied in Southern European countries. AIMS: To extend the knowledge of demoralization in Southern Europe by examining its prevalence according to different methods of assessment, its relationship with anxiety and depression, and its impact on quality of life (QoL) among cancer patients. METHODS: A convenience sample of 195 cancer outpatients from two oncology centers (102 from Lisbon, Portugal, and 93 from Ferrara, Italy) participated in an observational, cross-sectional study using the Diagnostic Criteria of Psychosomatic Research-Demoralization interview (DCPR/D) and psychometric tools (Demoralization scale-DS; Patient Health Questionnaire-9/PHQ-9; Hospital Anxiety Depression Scale-HADS; and European Quality of Life-5-EQ-5D). RESULTS: A 25.1% prevalence (CI 95%, 0.19-0.31) of clinically relevant demoralization was reported on the DCPR/D interview. A total demoralization score cutoff score ≥ 25 maximized sensitivity (81.6%), and specificity (72.6%) in identifying DCPR/D demoralized patients. The DCPR/D and DS were associated with poorer levels of QoL. About half of the patients who were demoralized were not clinically depressed (PHQ-9). Self-reported suicidal ideation (PHQ-9 item 9) was found in a minority of patients (8.2%), most of whom (77%) were cases of depression (PHQ-9), but one-quarter (23%) were not depressed, yet moderately/severely demoralized (DCPR/D and DS). CONCLUSIONS: This Southern European study confirms the importance of demoralization in cancer patients as a different condition with respect to depression and its relationship with poor QoL and suicidal ideation.

The factor structure and use of the Demoralization Scale (DS-IT) in Italian cancer patients.

OBJECTIVE: Demoralization is a commonly observed syndrome in cancer patients, deserving to be carefully assessed in cross-cultural contexts. AIMS: To examine the factor structure and concurrent and divergent validity of the Italian version of the Demoralization Scale (DS-IT) in cancer patients. METHODS: The sample included 194 Italian cancer outpatients who were assessed by using the DS-IT and the Diagnostic Criteria of Psychosomatic Research-Demoralization module to examine demoralization. The Patient Health Questionnaire-9 (PHQ-9) to explore depression and the Mini-Mental Adjustment-to-Cancer-Hopelessness/Helplessness scale (Mini-MAC-HH) to explore maladaptive coping were also administered. RESULTS: Four factors were extracted by exploratory factor analysis on the DS-IT (disheartenment, α = .87; sense of failure, α = .77; dysphoria, α = .73; loss of meaning/purpose, α = .72; total = 0.91), accounting for 57.1% of the variance. The DS-IT factors shared between 17% and 36% of the variance. Patients reporting a diagnosis of demoralization on the Diagnostic Criteria of Psychosomatic Research-Demoralization module (23.7%) had higher scores on DS-IT loss of meaning/purpose, sense of failure, dysphoria, and DS-IT total. About half of those who were highly demoralized were not depressed and among those who had moderate or moderately severe demoralization, about 80% were not depressed on the PHQ-9. The DS-IT was significantly associated with PHQ-9 and Mini-MAC-HH. CONCLUSIONS: The study presents further evidence that demoralization is a significant clinical condition and that the DS-IT demonstrates satisfactory levels of validity and reliability to support its use in patients in the ambulatory cancer setting.

A person-centred approach in medicine to reduce the psychosocial and existential burden of chronic and life-threatening medical illness.

The psychiatric, psychosocial, and existential/spiritual pain determined by chronic medical disorders, especially if in advanced stages, have been repeatedly underlined. The right to approach patients as persons, rather than symptoms of organs to be repaired, has also been reported, from Paul Tournier to Karl Jaspers, in opposition and contrast with the technically-enhanced evidence-based domain of sciences that have reduced the patients to 'objects' and weakened the physician's identity deprived of its ethical value of meeting, listening, and treating subjects. The paper will discuss the main psychosocial and existential burden related to chronic and advanced medical illnesses, and the diagnostic and therapeutic implications for a dignity preserving care within a person-centred approach in medicine, examined in terms of care of the person (of the person's whole health), for the person (for the fulfilment of the person's health aspirations), by the person (with physicians extending themselves as total human beings), and with the person (working respectfully with the medically ill person).