Effectiveness of cloth face masks to prevent viral spread: a meta-analysis.

BACKGROUND: The effectiveness of cloth face masks to prevent viral spread has not yet been conclusively established. In this meta-analysis, we evaluate their effectiveness in comparison to standard medical/surgical and N95-typed masks against viral spread. METHODS: We identified literature through a systematic search in three databases and meta-analytically synthesized relevant studies by means of random-effects as well as multilevel modelling. RESULTS: Twelve studies comprising k = 28 effect sizes (N = 338) were included. Medical/surgical and N95-typed masks outperformed cloth masks, yielding a large effect (g = 1.40). This effect remained robust when data were grouped according to comparisons with medical/surgical masks (g = 1.25) and N95-typed masks (g = 1.29). However, effects were differentiated according to mask fit, indicating reversals of signs when cloth mask effects were compared with ill-fitting medical/surgical and N95-typed masks (gs = -12.50 and - 10.90, respectively). CONCLUSIONS: Cloth face masks were found to have significantly poorer filtering performance than medical/surgical masks and N95 masks, but only if non-cloth masks were properly fitted. Our results illustrate the necessity of using well-fitting medical/surgical or N95-typed masks to prevent viral spread, although some allowance should be made in circumstances where higher compliance with cloth mask mandates are expected.

Risk as a pattern over time: Delineation of time-dependent risk factors in biological, psychological, and social variables in cancer patients.

BACKGROUND: Survival in cancer patients is associated with a multitude of biological, social, and psychological factors. Although it is well established that all these factors add to overall mortality, it is not well understood how the predictive power of these parameters changes in a comprehensive model and over time. METHODS: Patients who attended the authors' outpatient clinic were invited to participate. The authors followed 5180 mixed cancer patients (51.1% female; mean age, 59.1 years [SD = 13.8]) for up to 16 years and analyzed biological (age, sex, cancer site, anemia), psychological (anxiety, depression), and social variables (marital status, education, employment status) potentially predicting overall survival in a Cox proportional hazards model. RESULTS: The median survival time for the entire sample was 4.3 years (95% confidence interval, 4.0-4.7). The overall survival probabilities for 1 and 10 years were 76.8% and 38.0%, respectively. Following an empirical approach, the authors split the time interval into five periods: acute, subacute, short-term, medium-term, and long-term. A complex pattern of variables predicted overall survival differently in the five periods. Biological parameters were important throughout most of the time, social parameters were either time-independent predictors or tended to be more important in the longer term. Of the psychological parameters, only depression was a significant predictor and lost its predictive power in the long-term. CONCLUSIONS: The findings of this study allow the development of comprehensive patient-specific models of risk and resilience factors addressing biopsychosocial needs of cancer patients, paving the way for a personalized treatment plan that goes beyond biomedical cancer care.

The impact of COVID-19 on cancer care of outpatients with low socioeconomic status.

Patients with low socioeconomic status (SES) are among the most underserved groups of people regarding cancer care. Analyzing the impact of the coronavirus-induced disease 2019 (COVID-19) pandemic on health care disparities and calling attention to inequalities in cancer care is crucial to justify and initiate adequate countermeasures. We aimed to determine whether the COVID-19 pandemic aggravated health care disparities of cancer outpatients related to their SES and analyzed patient data of the largest university center providing services for patients with hematologic and oncologic disorders in Austria from 2018 to 2021. SES was assessed using three indicators: monthly net household income, level of education and occupational prestige. In total, 1217 cancer outpatients (51.1% female) with a mean age of 59.4 years (SD = 14.2) participated. In the first year of the pandemic, the relative proportion of individuals with low income, low education level and low occupational prestige seeking cancer care at our outpatient center decreased significantly (P ≤ .015). The strongest indicator was income, with a consistent effect throughout the first pandemic year. Countermeasures and specific interventions to support cancer patients with low SES in their access to health care should be initiated and prioritized.

Prevalence of pain and its association with symptoms of post-traumatic stress disorder, depression, anxiety and distress in 846 cancer patients: A cross sectional study.

OBJECTIVE: Pain depicts a severe physical symptom but its relationship to mental health problems is not well studied in cancer patients. The aim of this study was to investigate the prevalence of pain and its correlation with symptoms of post-traumatic stress disorder (PTSD), depression, anxiety and psychological distress in a large sample of cancer patients. METHODS: From 2010 to 2019, cancer patients who received outpatient treatment at the Medical University of Vienna were assessed with the Post-Traumatic Symptom Scale (PTSS-10) and the Hospital Anxiety and Depression Scales. A visual analogue scale was used to assess pain perception. For statistical analysis, linear regression models were applied to log-transformed data. RESULTS: Of the 846 cancer patients included in the study, 63.5% experienced pain (mild 43.5%, moderate 13.6%, severe 6.4%). About a third (31.2%) of the total sample presented with significant PTSD symptoms. Significant symptoms of depression, anxiety and distress were present in 13.9%, 15.1% and 25.3%, respectively. Women more often reported symptoms of PTSD, anxiety and distress. Pain scores were significantly related to symptoms of PTSD, depression and psychological distress (all with p < .001), but not to anxiety. CONCLUSIONS: Results show a high prevalence of experienced pain and indicate a clear association of elevated pain levels with psychiatric symptoms in oncological patients in a large Austrian sample. In order to decrease experienced pain and to enable better treatment of mental health problems in cancer patients, diagnostic procedures and interventions based on a biopsychosocial model need to be intensified.

Onset of effects of non-pharmaceutical interventions on COVID-19 infection rates in 176 countries.

BACKGROUND: During the initial phase of the global COVID-19 outbreak, most countries responded with non-pharmaceutical interventions (NPIs). In this study we investigate the general effectiveness of these NPIs, how long different NPIs need to be in place to take effect, and how long they should be in place for their maximum effect to unfold. METHODS: We used global data and a non-parametric machine learning model to estimate the effects of NPIs in relation to how long they have been in place. We applied a random forest model and used accumulated local effect (ALE) plots to derive estimates of the effectiveness of single NPIs in relation to their implementation date. In addition, we used bootstrap samples to investigate the variability in these ALE plots. RESULTS: Our results show that closure and regulation of schools was the most important NPI, associated with a pronounced effect about 10 days after implementation. Restrictions of mass gatherings and restrictions and regulations of businesses were found to have a more gradual effect, and social distancing was associated with a delayed effect starting about 18 days after implementation. CONCLUSIONS: Our results can inform political decisions regarding the choice of NPIs and how long they need to be in place to take effect.

Lateral preferences for hand clasping and arm folding are associated with handedness in two large-sample latent variable analyses.

Hand clasping (HC) and arm folding (AF) are bilateral limb postures which are subject to lateral preferences. Previous research suggested that left HC and left AF are "canonical" among European populations, i.e., generally preferred by right-handers. However, evidence on the associations of handedness with HC and AF to date is sparse and inconsistent, with studies mostly relying on relatively small sample sizes and arbitrary classifications of handedness. Utilizing latent class analysis for handedness classification, we present data from two large and independent middle-European samples, a discovery (n = 7,658) and replication (n = 5,062) sample. Our results indicate that right HC, not left HC, is overall preferred and that right-handedness is associated with right HC/left AF, and left- and mixed-handedness with left HC/right AF. Moreover, lateral preferences increased with age, and men had a higher preference of right HC, independent of handedness. We discuss our findings with regard to the generalizability of previous results.

On dying alone in prison and the social responsibility of medicine: a pilot interview study of physicians caring for terminally ill incarcerated patients in Austria and the United States.

BACKGROUND: This group of physicians is difficult to reach and small in number. While studies of palliative care and end-of-life (EOL) issues in prison have increased, especially in the United States and since the coronavirus disease 2019 (COVID-19) pandemic, they are still limited due to the constraints of carrying out research in carceral contexts. At present, there is very little knowledge of the experiences of physicians providing EOL care in prisons. The aim of this pilot study was to examine the experiences of doctors caring for terminally ill patients inside prisons. METHODS: Three expert qualitative interviews were conducted in March and April 2021 with physicians working in carceral institutions in New York State and Austria. The interviews were audio-recorded and transcribed verbatim. Braun and Clarke's thematic analysis was used to examine the data. RESULTS: The following five themes were found: (I) a lack of training and support; (II) interrupted relationships; (III) limitations on visits and saying one's goodbyes; (IV) security as a main concern; and (V) the possibility of release. CONCLUSIONS: The study reveals the difficulties physicians face when caring for dying incarcerated patients. Provider-patient relationships are hardly continuous. The findings represent a starting point for further research. Support from the medical and palliative care community is needed for adequate provision of EOL care within prisons, improved post-release conditions, and help for physicians working in existing structures.

Prevalence and biopsychosocial indicators of fatigue in cancer patients.

INTRODUCTION: Symptoms of cancer-related fatigue (CRF) can have a significant impact on patients' quality of life and treatment adherence. We aimed to investigate the relationship between CRF and multiple psychosocial and somatic indicators within a large mixed cancer sample. METHODS: In this cross-sectional study, N = 1787 outpatients with cancer were assessed for CRF, pain, anxiety, and depression using validated screening instruments. We further obtained clinical parameters (Hb, CRP, creatinine, leukocytes, ASAT, and ALAT), sociodemographic data (age, gender, income, education level, marital status, parenthood, and living area), and lifestyle factors. Multivariate linear regression models were applied to estimate the impact of each indicator on CRF. RESULTS: Overall, 90.6% of patients experienced some CRF, with 14.8% experiencing severe CRF. No gender difference was found in the prevalence of CRF. Patients with higher levels of pain, depressive symptoms, and lower Hb levels had significantly higher levels of CRF (ps <0.001). Lower levels of CRF were observed in patients who had children (p = 0.03), had less education (p < 0.001), and were physically active for more than 2 h per week before their oncological diagnosis (p = 0.014). The latter was only a significant indicator in the male subsample. CONCLUSION: The present results demonstrate a high prevalence of CRF and highlight that not only somatic and psychosocial factors, but also lifestyle factors prior to diagnosis appear to be associated with the etiology and persistence of CRF. To effectively treat CRF, a biopsychosocial, personalized approach is recommended.

Statements of Austrian hospices and palliative care units after the implementation of the law on assisted suicide : A qualitative study of web-based publications.

BACKGROUND: Since January 2022, assisted suicide (AS) in Austria is legal under certain conditions. One of these conditions is informative consultations with two physicians, one of whom must be qualified in palliative medicine. Patients who are thinking about AS can approach palliative care institutions. This study aims to assess the availability and nature of Austrian palliative care institutions' web-based statements about AS. METHODS: In this qualitative study, the websites of all Austrian palliative care units (n = 43) and all Austrian inpatient hospices (n = 14) were searched for possible statements on AS once in February 2022 and once in August 2022 using the three search terms "suicide", "assisted", and "euthanasia". The findings were subsequently evaluated using thematic analysis and NVivo software. RESULTS: Statements or texts that included positions on AS were found on the websites of 11 institutions (19%). The results covered three main themes 1) demarcation: denial of involvement and judgment about AS, 2) duty: handling of requests and describing the target group of care recipients, and 3) explanation: experience, values, concerns, and demands. CONCLUSION: The results of this study indicate that people in Austria who wish to have AS and who may use the internet as their first source of information largely find no relevant information. There is no online statement of a palliative care or hospice institution that endorses AS. Positions on AS are mostly lacking, while reluctant attitudes of Christian institutions are predominant.

Concepts of good mental health and wellbeing in people with intellectual disability: Study protocol for a systematic review.

Introduction: Good mental health is an indispensable aspect of good general health and different definitions of good mental health have been developed for the general population. However, it is not clear how these definitions can be applied to people with intellectual disabilities (ID), as they may have difficulties in many facets encompassed in existing definitions. Yet, people with ID can be mentally healthy or mentally ill just as people without ID. Objective: The aim of this systematic review is to summarize existing concepts, definitions, and measurement approaches of good mental health and wellbeing for people with ID. Methods: A comprehensive, systematic literature review will be conducted in 11 databases, including ASSIA, CINAHL, Cochrane Library, ERIC, MedRxiv, OSF preprints, ProQuest Dissertations & Theses Global, PsycINFO, PubMed, Scopus, and Web of Science. By including preprints and theses servers in the search strategy, we will also consider grey and unpublished literature. The quality of included studies will be rated using standardized checklists. All steps of the literature search, data extraction, and quality rating will be performed independently by two trained researchers. Disagreements will be resolved through discussion between these researchers and, if required, by consulting a third team member. In a narrative synthesis, existing approaches to good mental health and wellbeing for people with ID will be systematically described and linked to current research in mental health for people with and without ID. Discussion: The findings of this study will provide researchers and practitioners with an evidence-based overview of current approaches to good mental health and wellbeing of people with ID. We will explore and discuss the individual facets of the definitions, concepts, and measurement approaches and identify possible gaps which need to be addressed. This will strengthen future research on this topic and focus research activities on important and unresolved themes that need to be targeted to promote health equity for people with ID.

Routine laboratory parameters to support decision on parenteral nutrition in palliative care.

Introduction: Parenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN. Methods: The laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time. Results: The final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0). Discussion: The decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN.

The impact of COVID-19 and socioeconomic status on psychological distress in cancer patients.

Objective: We aimed to investigate the impact of the COVID-19 pandemic on psychological symptom burden against the socioeconomic background of cancer patients using data from routine assessments before and during the pandemic. Method: In this cross-sectional study, standardised assessment instruments were applied in N = 1,329 patients to screen for symptoms of anxiety, depression, post-traumatic stress, and fatigue from 2018 to 2022. Two MANOVAs with post-hoc tests were computed. First, only time was included as predictor to examine the isolated impact of the pandemic. Second, income level and education level were included as further predictors to additionally test the predictive power of socioeconomic factors. Results: In the final model, only income had a significant impact on all aspects of psychological symptom burden, with patients with low income being highly burdened (partial η² = .01, p = .023). The highest mean difference was found for depressive symptoms (MD = 0.13, CI = [0.07; 0.19], p < .001). The pandemic had no further influence on psychological distress. Conclusions: Although the pandemic is a major stressor in many respects, poverty may be the more important risk factor for psychological symptom burden in cancer outpatients, outweighing the impact of the pandemic.

Sexual violence by occupational forces during and after World War II: influence of experiencing and witnessing of sexual violence on current mental health in a sample of elderly Austrians.

BACKGROUND: Wartime rape is an atrocity with long-lasting impacts not only on victims but whole societies. In this brief report, we present data on experience and witness of sexual violence during World War II (WWII) and subsequent time of occupation and on indicators of mental health in a sample of elderly Austrians. METHODS: Interviews of 298 elderly Austrians from a larger epidemiological study on WWII traumatization were analyzed for the impact of experience and witness of sexual violence during the wartime committed by occupational forces. Interviews comprised a biographical/historical section and psychological measures (BSI, TLEQ, PCL-C). Participants were recruited in all nine provinces of Austria with respect to former zones of occupation (Western Allied/Soviet). RESULTS: Twelve persons reported direct experience of sexual violence, 33 persons witnessed such atrocities. One third of the victims and 18.2% of the witnesses reported post-traumatic stress disorder (PTSD full/subthreshold). Sexual violence occurred more often in the former Soviet zone. Victims and witnesses displayed higher odds of post-traumatic symptoms and symptoms of depression and phobic fear than non-victims. Furthermore, witnesses displayed higher levels of aggression compared to victims and non-witnesses. CONCLUSIONS: Our results corroborate previous findings that wartime rape has long-lasting effects over decades on current mental health and post-traumatic distress in victims and witnesses. We recommend integration of psychotraumatological knowledge on consequences of sexual violence on mental health into geriatric care and the education of dedicated personnel.

Is There a "Gifted Personality"? Initial Evidence for Differences between MENSA and General Population Members in the HEXACO Personality Inventory.

Contrary to the common notion that personality and intelligence are unrelated constructs, numerous correlational studies have demonstrated substantial associations between the two domains. Moreover, samples of intellectually gifted individuals have been found to differ from the general population in specific aspects of their personalities. However, most studies so far have relied on the Five-Factor Model of Personality (FFM), while none have investigated this phenomenon using the HEXACO personality framework. We recruited 617 adult members of the international high-IQ society MENSA and compared them to 3 reference samples (combined N = 112,637) regarding their personalities as measured by the HEXACO-60 personality inventory. We found that gifted persons scored higher in Honesty-Humility and Conscientiousness but lower in Emotionality compared to reference samples. Interestingly, gifted individuals scored only slightly higher in Openness to Experience, and no consistent differences emerged for Agreeableness. We demonstrate that some known personality differences between gifted and non-gifted persons translate from the FFM to the HEXACO model, while others do not. Our results indicate that within the HEXACO factor structure differences in sociability are more pronounced, while intellect-related differences are comparatively weak.

Satisfaction with life in Special Olympic athletes: the role of autonomy support and basic need fulfilment.

Aims: Athletes in the general population report higher satisfaction of basic needs when coaches are providing an autonomy supportive sport climate (ASSC). Our study aims at investigating whether ASSC is associated with satisfaction with life in athletes with intellectual disabilities (ID) and whether this association is mediated by basic need satisfaction. Method: During the Special Olympics World Winter Games 2017, 168 athletes with ID (M = 33.86 years; SD = 10.47) completed questionnaires measuring ASSC, basic need satisfaction (autonomy, competence, and relatedness), and satisfaction with life. Multiple linear regression analyses and mediation analyses were performed. The mediation model was controlled for the potential impact of participating in team vs. individual sports. Additionally, gender effects were explored. Results: ASSC was significantly associated with satisfaction with life (ß = .38, p < .001). This association was mediated by competence (indirect effect: ab1 = .15; CI [.05; .32]) but not by autonomy or relatedness. No effects were found related to participating in team vs. individual sports or gender. Conclusions: Our study provides evidence that an ASSC is associated with athletes perceiving themselves as more competent and reporting more satisfaction with life.

Challenges in Palliative Care Nursing at a University Hospital: A Qualitative Interview Study.

We examined the perception of palliative care nurses regarding challenges, coping strategies, resources, and needs when working in a university hospital in Austria. A qualitative descriptive design was applied, using semistructured interviews with 8 female and 2 male nurses. All interviews were recorded as digital audio and transcribed verbatim. We used thematic analysis and MAXQDA. In our analysis, 6 themes emerged: Four themes related to challenges: ( a ) lack of a supporting structural framework, ( b ) conflict in interdisciplinary work, ( c ) conflict with caregivers, and ( d ) dealing with death in a highly specialized university environment. One theme related to ( e ) individual solutions and coping strategies, and 1 theme comprised ( f ) needs and suggestions for improvements. Taking care of the family of a dying person, handling threatening situation, and working with inexperienced physicians were among the most important challenges reported by nurses. A supportive team, professional counseling, and training related to communication skills and to culturally specific needs of families are perceived to be necessary to provide high-quality palliative care. Addressing the needs of nurses can substantially improve their working condition and has an impact not only on the nurses themselves but also on the quality of patient care.

Informant-based assessment instruments for dementia in people with intellectual disability: A systematic review and standardised evaluation.

BACKGROUND: Dementia in people with intellectual disability (ID) is frequent but hard to recognise. Evidence-based recommendations for suitable instruments are lacking. AIMS: The present study set out to evaluate informant-based dementia assessment instruments and to provide evidence-based recommendations for instruments most suitable in clinical practice and research. METHOD AND PROCEDURES: A systematic review was conducted across ten international electronic databases. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines, including a risk of bias assessment, was applied to extract information and to evaluate measurement properties and the quality of available evidence. OUTCOMES AND RESULTS: In total, 42 studies evaluating 18 informant-based assessment instruments were analysed. For screening purposes, we recommend the Behavioral and Psychological Symptoms of Dementia in Down Syndrome Scale (BPSD-DS), the Cognitive Scale for Down Syndrome (CS-DS), and the Dementia Screening Questionnaire for Individuals with Intellectual Disabilities (DSQIID). For a more thorough dementia assessment, we recommend the Cambridge Examination for Mental Disorders of Older People with Down's Syndrome and Others with Intellectual Disabilities (CAMDEX-DS). CONCLUSIONS AND IMPLICATIONS: Our study informs clinicians and researchers about adequate, well-evaluated dementia assessment instruments for people with ID, and highlights the need for high quality studies, especially regarding content validity.

The potential of medical comics to teach palliative care skills: a cross-sectional study of 668 medical students.

BACKGROUND: Palliative care (PC) skills are important when caring for patients with advanced illness in a broad range of settings. Students need to be trained in communication and empathy, both representing essential PC skills. Therefore, creative approaches could promote the understanding of relevant PC skills. METHODS: In an online lecture about graphic medicine, different medical comics (MC) were used to introduce the field of graphic medicine and to illustrate relevant skills in PC. After the lecture, an online survey was conducted. The survey consisted of each respondent`s sociodemographic profile and a questionnaire on multiple aspects related to the field of MC. Spearman correlation coefficients and Cohen's effect sizes were used for statistical analysis. RESULTS: The survey respondents comprised 668 students, 337 female, 326 male and 5 diverse. The results showed that the students had never (27.2%) or had very rarely (31.9%) been involved in with the field of MC. The largest number would rate their interest as somewhat or very interested (58.8%). When considering the use of MC to understand different perspectives, the students mainly rated them as useful (54.6%) or very useful (23.4%). Women had a more positive attitude towards MC than men (P<0.001). Students who placed more importance on PC skills were more likely to recommend the use of MC in general medical education (r=0.11, P=0.005). The majority of the students (58.8%) moderately or strongly agreed on the use of MC as a teaching method in PC. CONCLUSIONS: After a single lecture on graphic medicine, the students were positive about using MC for teaching PC skills. Since the lecture was short and the majority of the medical students stated that they had not been previously exposed to the field of MC, this study demonstrates that it is promising to further use and evaluate a set of visual and narrative illustrations as a teaching method in PC.

Latent structure and measurement invariance of the Hospital Anxiety and Depression Scale in cancer outpatients.

Background/Objective: The aim of the present study was to compare competing psychometric models and analyze measurement invariance of the Hospital Anxiety and Depression Scale (HADS) in cancer outpatients. Method: The sample included 3,260 cancer outpatients. Latent structure of the HADS was analyzed using confirmatory factor analysis (CFA) with robust maximum likelihood estimation (MLR). Measurement invariance was tested for age, time of response, gender, and cancer type by comparing nested multigroup CFA models with parameter restrictions. Results: Except for the one-factor solutions, all models showed acceptable model fit and measurement invariance. The model with the best fit was the originally proposed two-factor model with exclusion of two items. The one-factor solutions showed inacceptable model fit and were not invariant for age and gender. Conclusions: The HADS has a robust two-factor structure in cancer outpatients. We recommend excluding item 7 and 10 when screening for anxiety and depression.

The cancer survival index-A prognostic score integrating psychosocial and biological factors in patients diagnosed with cancer or haematologic malignancies.

OBJECTIVE: We aimed to investigate whether (1) psychological and social indicators influence survival in patients diagnosed with cancer or haematologic malignancies when important biological aspects are controlled for, (2) psychological, social and biological indicators can be utilised to design one collated index for survival, usable in clinical practice to identify patients at risk of shorter survival and to improve personalised healthcare provision. METHODS: In this cross-sectional study, 2263 patients with cancer or haematologic malignancies participated. We analysed 15 biological, psychological and social indicators as risk factors for survival with a Cox proportional hazards model. Indicators significantly associated with survival were combined to compute models for the identification of patient groups with different risks of death. The training sample contained 1122 patients. Validation samples included the remaining 1141 patients, the total sample, as well as groups with different cancer entities. RESULTS: Five indicators were found to significantly impact survival: Cancer site (HR: 3.56), metastatic disease (HR: 1.88), symptoms of depression (HR: 1.34), female sex (HR: 0.73) and anaemia (HR: 0.48). Combining these indicators to a model, we developed the Cancer Survival Index, identifying three distinct groups of patients with estimated survival times of 47.2 months, 141 months and 198.2 months (p < 0.001). Post hoc analysis of the influence of depression on survival showed a mediating effect of the following four factors, related to both depression and survival: previous psychiatric conditions, employment status, metastatic disease and haemoglobin levels. CONCLUSIONS: Psychosocial and biological factors impact survival in various malignancies and can be utilised jointly to compute an index for estimating the survival of each patient individually-the Cancer Survival Index.