Facing haematopoietic stem-cell transplantation: do patients and their physicians agree regarding the prognosis?

OBJECTIVE: To evaluate the correlation and concordance between patients' and physicians' estimations of prognoses before initiation of the conditioning regimen for allogeneic haematopoietic stem-cell transplantation. METHODS: A total of 123 patients and their attending physicians were asked to estimate a prognosis on a six-point scale. The patients were also asked to fill out questionnaires addressing their psychological state and coping. RESULTS: The mean prognostic estimations differed by 1.17 points (p<0.001), with the patients being more optimistic than the physicians. With respect to concordance: Pearson correlation r=0.024 (ns); unweighted kappa and kappa with linear weighting are 0.115 and 0.068, respectively. The prognostic estimates of the patients correlated with their psychological state, but not with the objective disease- or treatment-related variables, whereas the physicians' estimates were partially based on such objective factors. CONCLUSIONS: A clear significant association between actual survival and the physicians' estimates, but not the patients' estimates, was observed. If agreement regarding the prognosis exists, the relationship between physicians' and patients' estimates is probably non-linear. Assessing one's chances of being cured is a highly emotional task, and psychological processes such as denial or repression most likely play a decisive role. Moreover, collusion between the patient and physician may be inevitable in this situation. Whether it is desirable to gain concordance and who will benefit from such efforts must be discussed and empirically studied.

Pre-transplant depression as risk factor for survival of patients undergoing allogeneic haematopoietic stem cell transplantation.

INTRODUCTION: Depression is discussed as a possible risk factor for survival in cancer patients. We explored this relationship for patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT). PATIENTS AND METHODS: The depression subscale of the Hospital Anxiety and Depression Scale (HADS) served as a measure for depression. One hundred and thirty-eight patients (mean age 41 years; different diagnoses) participating in a psycho-oncology study filled in the HADS after admission for allogeneic HSCT. They were followed-up for at least two years; 72 patients died during follow-up. RESULTS: Depression scores were not correlated with medical and psychosocial objective factors with the exception of having under-aged children. Controlling for medical factors that showed up as predictors for survival in our sample (patient's age at HSCT, having had a transplant before, risk for treatment failure) the HADS depression score (range 0-21) emerged as an independent predictor (Cox regression): hazard ratio = 1.087, 95% CI = 1.018-1.161. CONCLUSION: Depression is probably not a simple indicator of a worse health status. Further research is needed to decide if depression must be considered as an independent risk factor for survival when diagnosed in the pre-transplant period.

Physicians' prognostic estimates of survival for patients undergoing allogeneic hematopoietic stem cell transplantation.

OBJECTIVE: Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) often demand a single estimate of their prognosis from their treating physician. Little is known about the validity of and the factors influencing these estimates. PATIENTS AND METHODS: We explored physicians' prognostic estimates (six-point scale from very good to very poor) in a sample of 136 patients participating in a psycho-oncology study. Patients (mean age, 41 years) were followed-up for at least 2 years, and 72 patients died during the follow-up period. RESULTS: Physicians' estimates were clearly associated with overall survival (univariate Cox regression: hazard ratio=1.51, 95% confidence interval=1.24-1.82). In a multivariate Cox regression model, these estimates were independent predictors for survival in addition to previous treatment (former HSCT) and donor type (related vs. unrelated). DISCUSSION: Physicians on transplant units are able to give a concise prognostic estimate that corresponds to real outcomes. Patients often do not have a sufficient understanding of the risks of their treatment. Obtaining such condensed information instead of a complex prognostic estimate might be easier to understand. For the physician, it might be helpful to reflect his/her individual method of condensing information to be able to give a concise prognosis and to achieve informed consent with the patient. A systematic description of the extensive implicit and explicit experiences regarding objective and subjective data and its respective weight could help to improve the training of future hematologists and should be explored in further studies.

[Fighting spirit--a key to survival in cancer patients?]. / "Fighting Spirit" gegen Krebs. Ein Schlüssel für längeres Uberleben?

The conviction that mental factors have an influence on the development and course of malignant diseases is widely held. However, earlier results indicating that a fighting spirit or a never-say-die attitude has a life-prolonging effect have not so far been compellingly confirmed. Clinically speaking, a patient might even consider it a relief not to find himself involved in a seemingly never-ending fight.

Effectiveness of telephone-based aftercare case management for adult patients with unipolar depression compared to usual care: A randomized controlled trial.

BACKGROUND: Patients with depression often have limited access to outpatient psychotherapy following inpatient treatment. The objective of the study was to evaluate the long-term effectiveness of a telephone-based aftercare case management (ACM) intervention for patients with depression. METHODS: We performed a prospective randomized controlled trial in four psychotherapeutic inpatient care units with N = 199 patients with major depression or dysthymia (F32.x, F33.x, F34.1, according to the ICD-10). The ACM consisted of six phone contacts at two-week intervals performed by trained and certified psychotherapists. The control group received usual care (UC). The primary outcome was depressive symptom severity (BDI-II) at 9-month follow-up, and secondary outcomes were health-related quality of life (SF-8, EQ-5D), self-efficacy (SWE), and the proportion of patients initiating outpatient psychotherapy. Mixed model analyses were conducted to compare improvements between treatment groups. RESULTS: Regarding the primary outcome of symptom severity, the groups did not significantly differ after 3 months (p = .132; ES = -0.23) or at the 9-month follow-up (p = .284; ES = -0.20). No significant differences in health-related quality of life or self-efficacy were found between groups. Patients receiving ACM were more likely to be in outpatient psychotherapy after 3 months (OR: 3.00[1.12-8.07]; p = .029) and 9 months (OR: 4.78 [1.55-14.74]; p = .006) than those receiving UC. CONCLUSIONS: Although telephone-based ACM did not significantly improve symptom severity, it seems to be a valuable approach for overcoming treatment barriers to the clinical pathways of patients with depression regarding their access to outpatient psychotherapy.

Coping and survival in patients with leukemia undergoing allogeneic bone marrow transplantation--long-term follow-up of a prospective study.

OBJECTIVE: The exploratory study examined the relationship between coping and survival in patients undergoing bone marrow transplantation (BMT). METHODS: Patients scheduled for BMT were recruited from 1990 until 1995 at the University Hospital of Ulm, Germany. They were interviewed before transplantation, and the corresponding records were checked in December 2002. Seventy-two audiotaped interviews could be analyzed for 34 coping strategies as defined in the Ulm Coping Manual (UCM). Main outcome measure was survival time post-BMT. RESULTS: On average, the patients were 35 years old, 65% were male, and 56% diagnosed acute leukemia (AL). Four coping strategies were found to show a clear trend towards an association with survival time: emotional support, acceptance, taking control, and compensation. The last strategy was associated with shorter, the others with longer survival. CONCLUSION: We found further evidence for an association between coping and survival. Because of the possible wide-reaching consequences for clinical management, replication of the data is essential.

Distress in patients undergoing allogeneic haematopoietic stem cell transplantation is correlated with distress in nurses.

PURPOSE: To date, no studies have reported on the relationship between the emotional distress of patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) and the distress of their nurses. METHODS: 113 patients rated their distress by means of a daily questionnaire during their inpatient hospitalisation for HSCT. At the same time, nurses were asked to assess their distress caused by the additional care needs and increased emotional demands placed on them by the patients. Surveys covered a treatment period from day -5 to day +29 post-HSCT. RESULTS: The correlation between the distress level of the patients and that of the nurses was r=0.40 (p<0.001). The partial coefficient of this correlation was r=0.43 (p<0.001) when an indicator of the physical state of the patients, as assessed by their treating physicians, was controlled. CONCLUSIONS: Distress, as experienced by patients and nurses, is positively correlated. We assume that such a relation holds beyond other individual, organisational, structural, and occupational influences that play decisive and limiting roles in the patient-nurse relationship. Reducing the distress of one of these parties could also positively affect the distress levels of the other party. Therefore, patient distress should be monitored since it may add to nurse distress. Types of patient interventions, as well as the people responsible for performing these interventions, must be discussed. On the other hand, interventions aimed at reducing nurse distress (regardless of the cause of the distress) could reduce patient distress and improve their satisfaction with the treatment, and their quality of life.

Ambivalence over Emotional Expressiveness: psychometric evaluation of the AEQ-G18 in a representative German survey.

OBJECTIVE: The present study evaluates a questionnaire on ambivalence over emotional expressiveness, the AEQ-G18 [1], [2], with regard to its statistical parameters, the influence of socio-demographic variables, and its interrelationship with depression and quality of life. METHODS: A representative German sample (1009 participants from East Germany and 1034 participants from West Germany) completed the AEQ-G18 [1], [2], the depression screener DEP-2 [3], the Profile of Mood States POMS [4], the revised Beck Depression Inventory BDI [5], the short form of the Patient Health Questionnaire PHQ-9 [6] and the SF-36 health survey questionnaire [7]. RESULTS: Our study was only partially able to confirm the two factors effect ambivalence and competence ambivalence postulated by Traue et al. [1], [2]. Women scored somewhat higher on the scale effect ambivalence. Participants with a higher educational background exhibited less emotional ambivalence. Emotional ambivalence correlated positively with depression and reduced psychological state of health (depression, fatigue, and anger), whereas it correlated negatively with health-related quality of life and positive attitude (vigor). In addition to the scales of the AEQ-G18, we developed a short form, the AEQ-G10, and provide normative data for the AEQ-G18 and the AEQ-G10. CONCLUSION: This study presents normative data for two variations of a clinically relevant, valid, and time-efficient diagnostic instrument used for the evaluation of ambivalence over emotional expressiveness, the AEQ-G18 and its short form, the AEQ-G10.

Mental adjustment to cancer and survival of patients admitted for allogenic hemopoietic stem cell transplantation - a prospective cohort study.

OBJECTIVE: The Mental Adjustment to Cancer Scale (MAC scale) has evolved to a standard measure in the field of psycho-oncology. In this context an attitude called "fighting spirit" gained much attention as a coping style. Some reports suggest that coping efforts as measured by the MAC scale are predictive for survival of breast cancer patients. We explored the predictive power of the MAC scale by using a sample of patients with haematological malignancies undergoing allogenic hemopoietic stem cell transplantation (HSCT). METHODS: Between 9/1999 and 12/2001 127 patients were administered the MAC scale prior to HSCT. Follow-up data of overall survival and event-free survival were obtained in December 2003 and analyzed using Cox-regression models. RESULTS: At the time of the follow-up, 68 patients had died (overall survival), 75 patients had experienced a relapse or had died (event-free survival). We failed to find significant results for the MAC subscales with and without adjustment for prognostic factors. CONCLUSION: In the special situation of patients facing HSCT the MAC scale seems not to be of predictive value. In general, with respect to survival the empirical evidence is not very convincing.

[Validation and standardization of the "Questionnaire for Assessing Subjective Physical Well-Being" by Kolip and Schmidt in a representative German sample]. / Validierung und Normierung des "Fragebogen zur Erfassung des körperlichen Wohlbefindens" (FEW-16) von Kolip und Schmidt an einer repräsentativen deutschen Bevölkerungsstichprobe.

The "Questionnaire for Assessing Subjective Physical Well-Being" by Kolip and Schmidt is examined using data drawn from a nationally representative survey of 573 former East and 1900 former West Germans. In this non-clinical sample the construct "subjective physical well-being" assessed by the "Questionnaire for Assessing Subjective Physical Well-Being" seems to have just one dimension. As women and probands with growing age score lower for "subjective physical well-being" a differentiated standardization was done for gender and age. Connections between "subjective physical well-being" and body-image assessed by the "Body Image Questionnaire" (FKB-20), quality of life ("EURO-HIS-QOL"), and questions for concerns about financial situation, family and health give hints for validity of the questionnaire.

Two-question depression-screeners - the solution to all problems?

UNLABELLED: Depression constitutes a considerable issue in medicine and it is anticipated that the amount of people suffering from affective disorders will increase significantly. It would be useful to have a simple, fast screening procedure which would help detect depression. In four recently published articles a two-question depression-screener is recommended. METHOD: Sensitivity, specificity, likelihood ratios, negative and positive predictive values were compared. RESULTS: For four different clinical samples and one sample that was representative of the German population the prevalence for depression ranged from 6.9 % to 18.1 %. Sensitivity and specificity reached values from 72.6 % to 96.6 % and from 56.9 % to 90.0 % respectively. All negative predictive values were high (< 97 %) opposed to positive predictive values (17.8 % to 38.5 %). CONCLUSION: Overall, it seems that the two-question screenings are well suited for the exclusion of a major depression. It is possible that regular screening could further lower the percentage of undiagnosed cases.

[Standardization of the German short version of "profile of mood states" (POMS) in a representative sample--short communication]. / Normierung der deutschen Kurzform des Fragebogens "Profile of Mood States" (POMS) anhand einer repräsentativen Bevölkerungsstichprobe--Kurzbericht.

The questionnaire "Profile of Mood States (POMS)" is recommended as a measure of mood states in patients and non-clinical samples. On the basis of a representative sample (2043 subjects) reference values for the four scales (DEPRESSION/ANXIETY, FATIGUE, VIGOR, ANGER) of the German short version of the "Profile of Mood States" (POMS--35 items, 7 point scale, instruction "How you have been feeling during the past 24 hours?") are presented. The scale ANGER was independent from variables gender, age, education and current residence. In contrast to the other three scales these differentiations were necessary and detailed reference values are reported.

Worrying about one's job, family, financial situation and health - results of a population-representative study.

OBJECTIVE: Worrying about one's job, family, financial situation and health is distressing. How intense are these worries in the general population? METHODS: An inquiry representative of the German population (N=2473, age>14 years) was performed. The total score of the "Questionnaire for Assessing Subjective Physical Well-Being" (FEW) and the screening scale of the "Trier Inventory for the Assessment of Chronic Stress" (TICS) were correlated with the four above mentioned items addressing worries (range 1-4). RESULTS: Worries about one's financial situation were scored highest (mean=2.04, SD=0.92), followed by worries about one's health (mean=1.94; SD=0.87), one's family (mean=1.85; SD=0.86) and worries about one's job (mean=1.69; SD=0.92). Health worries increased with age. Those without a job and single parents showed the highest grades of solicitude. Increasing income decreased worrying. The correlations with chronic stress were moderate (.24

[The German short version of "Profile of Mood States" (POMS): psychometric evaluation in a representative sample]. / Uberprüfung der Gütekriterien der deutschen Kurzform des Fragebogens "Profile of Mood States" (POMS) in einer repräsentativen Bevölkerungsstichprobe.

The German short version of "Profile of Mood States" (POMS) was psychometrically tested in a representative sample (1009 subjects in Eastern Germany and 1034 subjects in Western Germany). The 35 items (7 point scale, instruction "How you have been feeling during the past 24 hours?") form the following scales: Depression/Anxiety, Fatigue, Vigor, Hostility. The POMS appears to be an internally consistent instrument (Cronbach's Alpha from 0.89 to 0.95). Replication of the postulated 4 factors was limited. There are hints for convergent validity of POMS-Scales using two questions: "1. Over the past two weeks, have you felt down, depressed, or helpless?" and "2. Over the past two weeks, have you felt little interest or pleasure in doing things?"

[Screening for depression -- two questions practically oriented]. / Depressivitäts-Screening -- zwei Fragen für die Praxis.

Despite the high epidemiological relevance of depressive disorders in daily clinical practice, they are insufficiently diagnosed. For screening, the U.S. Preventive Services Task Force proposed two questions aiming at finding depressive core symptoms: "Over the past two weeks, have you felt down, depressed, or helpless?" and "Over the past two weeks, have you felt little interest or pleasure in doing things?". We tested comparable questions in a representative sample from the German population. The correlations between the screening and validated questionnaires for depression point towards the validity of the screener. Relevant indices are satisfying: For major depression the sensitivity is 72.6% and specificity is 87.4%.

[Religious and spiritual beliefs - validation of the German version of the "Systems of Belief Inventory" (SBI-15R-D) by Holland et al. in a population-based sample]. / Erfassung religiöser und spiritueller Einstellungen - Psychometrische Uberprüfung der deutschen Version des "Systems of Belief Inventory" (SBI-15R-D) von Holland et al. in einer repräsentativen Bevölkerungsstichprobe.

The present study describes the German version of the "Systems of Belief Inventory (SBI-15R)" developed by Holland et al. The questionnaire was used in a representative sample of 954 eastern and 1031 western Germans. The SBI met tests of internal consistency and demonstrated discriminant validity. But the two factors of the original version could not clearly be replicated. For the relevance of religious beliefs we found that women score higher than men, older score higher than younger, persons with lower education score higher than persons with higher education, western Germans score higher than eastern Germans. Connections between the SBI-15R-D and self-evaluation as being religious and importance of faith during childhood give hints to the instrument's validity. The SBI-15R-D can serve as a valid and economic tool to explore the role of religious and spiritual beliefs.