Demoralization in acute coronary syndrome: Treatment and predictive factors associated with its persistence.

Background/objective: Although demoralization is associated with morbidity and mortality in cardiac settings, its treatment has been overlooked. The present randomized controlled trial aimed at 1) evaluating the effectiveness of sequential combination of Cognitive-Behavioral and Well-Being therapies (CBT/WBT), compared to Clinical Management (CM), on demoralization among Acute Coronary Syndromes (ACS) patients, at post-treatment and after 3 months; 2) examining ACS patients' characteristics predicting demoralization persistence at 3-month follow-up. Method: 91 demoralized ACS patients were randomized to CBT/WBT (N = 47) or CM (N = 44). Demoralization was assessed with an interview on Diagnostic Criteria for Psychosomatics Research at baseline, post-treatment and 3-month follow-up. Predictors of demoralization maintenance included cardiac parameters, psychological distress and well-being. Results: Compared to CM, CBT/WBT significantly reduced demoralization post-treatment. Somatization (odds ratio = 1.11; p = 0.027) and history of depression (odds ratio = 5.16; p = 0.004) were risk factors associated with demoralization persistence at follow-up, whereas positive relationships (odds ratio = 0.94; p = 0.005) represented protective factors. Conclusions: The study provides preliminary and promising evidence on the benefits of CBT/WBT in treating demoralization in ACS patients. Moreover, ACS patients with somatization or positive history of depression could be at higher risk for developing persistent demoralization.

Differential impact of resilience on demoralization and depression in Parkinson disease.

Objectives: The objective of this study was to study the interrelations of demoralization, depression, and resilience in patients with Parkinson disease, and, more specifically, to determine if higher resilience in patients with Parkinson disease is associated with lower demoralization, lower depression, or both. Methods: Outpatients with Parkinson disease (N = 95) were assessed for demoralization, depression, and resilience, as well as sociodemographic, clinical, and treatment-related variables. Bivariable associations, standard regressions, linear regression with copula correction, and correspondence analysis were used to analyze the data. Results: Although the bivariable association between resilience and depression was statistically significant, the association ceased to be significant when demoralization was taken into consideration in both standard regressions and linear regression with copula correction. By contrast, the association between resilience and demoralization was significant when depression was not taken into consideration and continued to be significant when depression was taken into consideration. Correspondence analysis revealed that low resilience was strongly related to demoralization combined with depression, whereas normal resilience was closely correlated with depression without demoralization. Conclusion: These results expand our understanding of resilience by suggesting that it is a mechanism evolved to reduce or prevent demoralization and not just depression. Reducing demoralization and strengthening resilience as part of a comprehensive treatment plan are likely to improve the prognosis of Parkinson disease.

Negative health outcomes in depressed cardiac patients are associated with both low and high psychological well-being dimensions.

Literature supports the positive effects of psychological well-being (P.W.B.) on health. However, most studies focused on the unitary construct of P.W.B., neglecting the different role played by distinct P.W.B. dimensions on health-related outcomes. The aim of this study was to determine whether unbalanced (i.e. low or high) levels of P.W.B. dimensions could differentially affect cardiac course after acute coronary syndrome (A.C.S.), in terms of participation in secondary prevention (S.P.) and/or survival. The sample included 136 depressed and/or demoralized A.C.S. patients referred for a S.P. program on lifestyle modification, in addition to routine cardiac visits provided by the hospital where they were admitted. Psychological assessment included validated interviews on depression and demoralization, Symptom Questionnaire and Psychological Well-Being scales. 100 patients joined the S.P. program, 36 did not. Logistic regression revealed that older age (B = 0.051; p < 0.05), higher autonomy (B = 0.070; p < 0.05) and lower personal growth (B = -0.073; p < 0.05) levels were associated with non-participation in S.P. Moreover, only among patients who did not join the program, those presenting with an impaired level of P.W.B. 'positive relations' dimension (i.e. below the 25th percentile) showed a worse cardiac prognosis (Log Rank: χ2(1) = 4.654; p = 0.031). Negative health outcomes in depressed cardiac patients, such as non-participation in S.P. and worse cardiac course, are associated with both high and low levels of certain P.W.B. dimensions. Psychotherapeutic approaches geared to a balance in P.W.B. dimensions could represent promising new additions to S.P. programs.

From Perceived Stress to Demoralization in Parkinson Disease: A Path Analysis.

Objectives: The objective of this study was to determine whether depression and anxiety are mediators between perceived stress and demoralization via a loss of the cognitive map to get out of the predicament manifesting as subjective incompetence. Methods: Ninety-five consecutive outpatients with Parkinson's disease were evaluated for perceived stress, depression, anxiety, subjective incompetence, and demoralization using reliable and valid scales. Inclusion criteria were ages 40-90, intact cognition, and no current history of substance use. The setting was a Movement Disorders Clinic at a university-affiliated hospital. The outcome variable was demoralization, selected a priori. Mediators between perceived stress and demoralization were examined using path analysis. Results: Depression, anxiety, and subjective incompetence were mediators between perceived stress and demoralization. Among all variables, subjective incompetence was the largest contributor to demoralization. Depression connected to demoralization indirectly via subjective incompetence (ß = 0.25, p < 0.001), whereas anxiety bypassed subjective incompetence (ß = -0.01, p = 0.882), connecting directly to demoralization (ß = 0.37, p = 0.008). Conclusion: Early treatment and reversal of subjective incompetence and anxiety could potentially prevent the escalation of demoralization and the associated disruption in health-related quality of life and eventual suicide.

Demoralization and Quality of Life of Patients with Parkinson Disease.

INTRODUCTION: Demoralization is quite prevalent in patients with Parkinson disease (PD). Unrecognized or untreated, demoralization may progress, at times, to demands for euthanasia and the desire for suicide. Typically, patients with PD do not complain of being "demoralized"; rather, they report disruptions in the quality of their lives. Hence, early identification of disruptions in health-related quality of life (HRQoL) specifically associated with demoralization may prompt earlier recognition and treatment. Published data on such associations, however, could not be found. Alleviation of demoralization in PD is likely to improve treatment outcomes. OBJECTIVE: This research aimed at identifying the disruptions of HRQoL specifically associated with the demoralization of patients with PD. METHODS: Consecutive general hospital outpatients with PD (n = 95) were assessed for: demoralization, with the Diagnostic Criteria for Psychosomatic Research Demoralization Scale (DCPR-D) and the Demoralization Scale (DS); depression, with the Patient Health Questionnaire-9 (PHQ-9); HRQoL, with the Parkinson Disease Questionnaire-Short Form (PDQ-8); sociodemographic variables; medical comorbidities; PD severity; and types of treatment. RESULTS: The prevalence of demoralization was 19%. Regression analyses showed that demoralization was significantly more likely to be experienced by participants who had difficulty with mobility and felt embarrassed in public due to having PD. Demoralization explained HRQoL over and above depression. CONCLUSIONS: Stigma and perceived difficulty with mobility are associated with demoralization of PD patients, and they may signal the need for psychotherapeutic and behavioral interventions to prevent the progression to helplessness, hopelessness, demands for euthanasia, and desire for suicide.

Demoralization in essential tremor: prevalence, clinical correlates, and dissociation from tremor severity.

OBJECTIVE: Essential tremor (ET) is associated with psychological difficulties, including anxiety and depression. Demoralization (feelings of helplessness, hopelessness, inability to cope), another manifestation of psychological distress, has yet to be investigated in ET. Our objectives are to (1) estimate the prevalence of demoralization in ET, (2) assess its clinical correlates, and (3) determine whether demoralization correlates with tremor severity. METHODS: We administered the Kissane Demoralization Scale (KDS-II) and several psychosocial evaluations (ie, scales assessing subjective incompetence, resilience, and depression [eg, Geriatric Depression Scale]) to 60 ET subjects. Tremor was assessed with a disability score and total tremor score. KDS-II >8 indicated demoralization. RESULTS: Among 60 ET subjects (mean age = 70.2 ± 6.8 years), the prevalence of demoralization was 13.3%, 95% confidence interval = 6.9-24.2%. Although there was overlap between demoralization and depression (10% of the sample meeting criteria for both), 54% of depressed subjects were not demoralized, and 25% of demoralized subjects were not depressed. Demoralization correlated with psychological factors, but demoralized subjects did not have significantly higher total tremor scores, tremor disability scores, or years with tremor. CONCLUSIONS: Demoralization has a prevalence of 13.3% in ET, similar to that in other chronic or terminal illnesses (eg, cancer 13-18%, Parkinson's disease 18.1%, coronary heart disease 20%). Demoralization was not a function of increased tremor severity, suggesting that it is a separable construct, which could dictate how a patient copes with his/her disease. These data further our understanding of the psychological and psychosocial correlates of ET.

Suicidal risk and demoralization in Parkinson disease.

OBJECTIVE: We aimed to determine suicide risk and lifetime suicidal ideation in Parkinson disease (PD) patients versus controls and how depression, demoralization, and insomnia are associated with suicidality. METHODS: In this case-control study, PD patients and matched controls were recruited from movement disorder clinics, Michael J. Fox Foundation, and Research Match websites. Suicide risk and suicidal ideation were assessed using the Suicidal Behavior Questionnaire-revised (SBQ-R) and Columbia-Suicide Severity Rating Scale. Lifetime depression was assessed using the Brief Lifetime Depression Scale, sleep using Insomnia Severity Index (ISI), demoralization using Diagnostic Criteria for Psychosomatic Research and Kissane Demoralization Scales, and non-motor symptoms using UPDRS Non-Motor Aspects of Experiences of Daily Living scale (nM-EDL). RESULTS: 186 PD participants and 177 controls were matched for age (64.2 ± 7.7 years), sex (48.8% female), and socioeconomics. PD participants were not more likely than controls to have high suicide risk (SBQ-R ≥ 7) (7.5% vs. 11.3%; p = 0.22) or to have had a lifetime suicide plan or attempt (2.7% vs. 5.1%; p = 0.24), but were less likely to have had lifetime suicidal ideation (23.1% vs. 35.0%; p = 0.01). PD participants were more likely than controls to have lifetime depression history (34.4% vs. 20.9%; p = 0.004), and demoralization (19.9% vs. 10.7%; p = 0.02), and had higher ISI scores (8.7 ± 5.8 vs. 5.1 ± 4.5; p < 0.0001). PD patients with high versus normal suicide risk had higher nM-EDL scores (16.5 ± 6.8 vs. 10.7 ± 5.9; p = 0.002), and more demoralization (71.4% vs. 21.5%; p < 0.0001). CONCLUSIONS: Suicide risk is not elevated and suicidal ideation is uncommon in PD, despite the high prevalence of depression and demoralization.

Demoralization in Parkinson disease.

OBJECTIVE: To determine the prevalence and associated features of demoralization in Parkinson disease (PD). METHODS: Participants with PD and controls were prospectively recruited from outpatient movement disorder clinics and the community. Demoralization was defined as scoring positively on the Diagnostic Criteria for Psychosomatic Research, Demoralization questionnaire or Kissane Demoralization Scale score ≥24. Depression was defined as Patient Health Questionnaire-9 score ≥10. Forward stepwise logistic regression was used to determine the odds of having demoralization in the overall, control, and PD cohorts. RESULTS: Demoralization occurred in 18.1% of 94 participants with PD and 8.1% of 86 control participants (p = 0.05). These 2 groups were otherwise comparable in age, sex, education, economics, race, and marital status. Although demoralization was highly associated with depression, there were individuals with one and not the other. Among participants with PD, 7 of 19 (36.8%) depressed individuals were not demoralized, and 5 of 17 (29.4%) demoralized individuals were not depressed. In the overall cohort, having PD (odds ratio 2.60, 95% confidence interval 1.00-6.80, p = 0.051) was associated with demoralization, along with younger age and not currently being married. In the PD cohort, younger age and Unified Parkinson's Disease Rating Scale, part III score (per score 1) were associated with demoralization (odds ratio 1.06, 95% confidence interval 1.01-1.12, p = 0.02). CONCLUSIONS: Demoralization is common in PD and is associated with motor dysfunction. In demoralization, there is a prominent inability to cope, making it somewhat distinct from depression. Treatment approaches are also different, making it important to identify demoralization in patients with PD.

Explaining the 'immigration advantage' and the 'biculturalism paradox': an application of the theory of demoralization.

BACKGROUND: Recent immigrants have better mental health than the natives ('immigration advantage'). Biculturals have better mental health than the monoculturals ('biculturalism paradox'). MATERIAL: Mexican immigrants have lower rates of psychopathology than the U.S. population. This is less true for Cubans and not true for Puerto Ricans. The 'advantage' also occurs in other groups. Biculturals have better mental health and endorse both cultures. DISCUSSION: The theory of demoralization predicts that borrowing values from both cultures and applying them judiciously are more conducive to mental health than indiscriminately subscribing to either culture. CONCLUSION: The findings are consistent with the theory of demoralization.

Culture and demoralization in psychotherapy.

In most societies, members of a culture have attempted to help each other in times of trouble with various types of healing methods. Demoralization - an individual experience related to a group phenomenon - responds to certain elements shared by all psychotherapies. This article has three objectives: (1) to review the theoretical background leading to our current views on culture and demoralization in psychotherapy, (2) to discuss the methodological challenges faced in the cross-cultural study of demoralization and psychotherapy, and (3) to describe the clinical applications and research prospects of this area of inquiry. Demoralization follows a shattering of the individual's assumptive world and it is different from homeostatic responses to a stressful situation or from depressive disorders. Only a few comparative studies of this construct across cultures have been undertaken. The presentation of distress may vary widely from culture to culture and even within the same culture. To avoid 'category fallacy', it is important to understand the idioms of distress peculiar to a cultural group. A cultural psychiatrist or psychotherapist would have to identify patient's values and sentiments, reconstruct his/her personal and collective ambient worlds, and only then study demoralization. The limitations of our current diagnostic systems have resulted in methodological challenges. Cultural clinicians should consider using a combination of both 'clinimetric' and 'perspectivistic' approaches in order to arrive at a diagnosis and identify the appropriate intervention. The presenting problem has to be understood in the context of the patient's individual, social and cultural background, and patients unfamiliar with Western-type psychotherapies have to be prepared to guide their own expectations before the former are used. Future research should identify the gaps in knowledge on the effectiveness of cultural psychotherapy at reversing or preventing demoralization.

Prevention of demoralization in prolonged bicultural conflict and interaction: the role of cultural receptors II - genesis of hybridization.

BACKGROUND: The objective of this article is to show that bicultural hybridization for the prevention of demoralization is anchored on the discovery of certain thematic areas (cultural receptors) in which social roles or cultural mandates are missing, unclear, ambiguous or congruent. MATERIAL: The specific setting is the history of Goa, a former Portuguese territory on the western coast of India. Both published and unpublished sources of information were studied. DISCUSSION: Education, occupation and income, the three dimensions of social class, were less dominant than other aspects of the Hindu caste system, such as birth into a group viewed as a caste, observance of marriage circles, regulations of kinship and inheritance, and identification with a location. These other aspects were preserved as much as possible. The result was the conversion of the caste system into a system more akin to social class. Other examples of cultural receptors were found. CONCLUSIONS: A key step in the adaptation to acculturative stress is the discovery of cultural receptors in both cultures and the development of meaningful interconnections among those receptors. Psychotherapy attempts the restoration of morale. To be effective, therapists should consider the hierarchical organization of symbols and sentiments in the patient's culture.

Prevention of demoralization in prolonged bicultural conflict and interaction: the role of cultural receptors I - description of a natural experiment.

BACKGROUND: This article examines how symbols and sentiments are exchanged to produce a synthesis of two cultures in the context of prolonged bicultural conflict and interaction, thereby minimizing or preventing sociocultural disintegration and the resulting demoralization. This process will be shown to be anchored on the discovery of certain thematic areas (cultural receptors) in which social roles or cultural mandates are missing, unclear, ambiguous or congruent. MATERIAL: The setting of this research is the history of Goa, a former Portuguese state on the western coast of India, where the exchange between the Portuguese and Indian cultures lasted longer than four centuries (1510-1961). Both published and unpublished sources were studied. DISCUSSION: From 1510, the year of the beginning of the Portuguese rule, until 1540, the local traditions and leadership patterns were respected. This was followed by a period of religious intolerance during which attempts were made to encourage Hindus to convert to Christianity and to wipe out the bicultural interaction. Finally a new era of tolerance and cultural integration started around 1773 and continued until 1961. The bicultural interaction persisted and a hybrid culture developed around cultural receptors. CONCLUSIONS: The history of Portuguese Goa is a natural experiment that allows us to examine the role played by cultural receptors in the adaptation to acculturative stress.

The making of a multicultural psychiatrist.

The author grew up in Goa, a unique bicultural setting on the western coast of India. Goa came under Portuguese rule in 1510 AD and remained under the Portuguese until 1961 when it became part of India. The Indian and Portuguese cultures interacted in Goa and led the Goans to create an interesting blend in which elements of both cultures were made to reconcile. The author reviews his experiences in this setting and describes how his family background, his search for roots, and his exposure to two religions, two languages, and two cultures fostered his decision to study medicine, his passion for transcultural psychiatry, and eventual pursuit of an academic career in this field in the United States. Research and reflections are presented on the impact of colonization, migration, and acculturation, and the importance of the construct of demoralization.

Diagnosis and measurement of subjective incompetence: the clinical hallmark of demoralization.

BACKGROUND: This article presents the development and application of a method to diagnose and measure subjective incompetence, the clinical hallmark of demoralization. METHODS: The subjects (n = 112) were patients with cancer at a consultation clinic of a cancer center. They completed a questionnaire on general background information, the Brief Cope Scale, and a newly developed scale to measure subjective incompetence. The development and psychometric properties of this scale were studied. Data analysis included both univariate and bivariate statistical tests and an examination of the intercorrelations between the subjective incompetence scores and the scores on the Brief Cope Scale. RESULTS: The scale for subjective incompetence was found to have adequate reliability and validity. CONCLUSIONS: The proposed scale will allow us to determine if the distinction between depression and demoralization has practical implications and to what extent and to further clarify the role of demoralization in the etiology and pathogenesis of both physical illnesses and mental disorders. The combined use of this scale with the existing criteria and scales for demoralization will highlight the role of subjective incompetence in converting what might have been a normal response to stress into an abnormal state requiring intervention.

Recent treatment history vs clinical characteristics in the prediction of use of outpatient psychiatric services.

BACKGROUND: The use of outpatient psychiatric services has been shown to be a complex function of sociodemographic, clinical, and pathway variables. The relative contribution of each variable or groups of variables in explaining the variability in the use of outpatient psychiatric services, however, remains poorly documented. METHODS: The subjects (N=382) were all patients admitted to an outpatient psychiatric clinic serving mostly a minority and low-income population. The charts of the patients were reviewed for sociodemographic, clinical, and pathway variables and the number of outpatient visits. The pathway variables studied were source of referral and most recent psychiatric treatment service used. Both bivariate and multivariate statistics were used to analyze the data. RESULTS: Pathway variables were better predictors of the number of outpatient visits than clinical variables after controlling for sociodemographic variables. CONCLUSION: Patients recently hospitalized may be sicker or have fewer social supports and therefore require more outpatient visits. Recent treatment history stands out as an important variable in the prediction of the number of outpatient mental health visits. More research is needed to examine the influence of pathway variables on treatment decisions.

Pathways of low-income minority patients to outpatient psychiatric treatment.

OBJECTIVE: Low-income outpatients with scheduled appointments ("scheduled patients") were compared with those who sought treatment without appointments ("walk-ins"). METHOD: The charts of scheduled patients and walk-ins at an outpatient mental health clinic serving a low-income group were reviewed to determine sociodemographic and clinical characteristics and patients' pathways to treatment. RESULTS: Walk-ins (N=241) outnumbered scheduled patients (N=141). The two groups differed significantly in type of presenting complaint and source of referral. A higher proportion of walk-ins sought help with social relationships, while more scheduled patients had complaints involving social performance. Self-referrals were more common among the scheduled patients, and family members were more likely to have motivated the walk-ins. CONCLUSIONS: The two groups have more in common than might be expected. Scheduled patients are probably more motivated to seek treatment and therefore more likely to initiate appointments. Walk-ins appear to postpone asking for help until their families urge them to do so.