Barry Rosenfeld

Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients

BACKGROUND The importance of spirituality in coping with a terminal illness is becoming increasingly recognised. We aimed to assess the relation between spiritual well-being, depression, and end-of-life despair in terminally-ill cancer patients. METHODS 160 patients in a palliative care hospital with a life expectancy of less than 3 months were interviewed with a series of standardised instruments, including the functional assessment of chronic illness therapy-spiritual well-being scale, the Hamilton depression rating scale, the Beck hopelessness scale, and the schedule of attitudes toward hastened death. Suicidal ideation was based on responses to the Hamilton depression rating scale. FINDINGS Significant correlations were seen between spiritual well-being and desire for hastened death (r=-0.51), hopelessness (r=-0.68), and suicidal ideation (r=-0.41). Results of multiple regression analyses showed that spiritual well-being was the strongest predictor of each outcome variable and provided a unique significant contribution beyond that of depression and relevant covariates. Additionally, depression was highly correlated with desire for hastened death in participants low in spiritual well-being (r=0.40, p<0.0001) but not in those high in spiritual well-being (r=0.20, p=0.06). INTERPRETATION Spiritual well-being offers some protection against end-of-life despair in those for whom death is imminent. Our findings have important implications for palliative care practice. Controlled research assessing the effect of spirituality-based interventions is needed to establish what methods can help engender a sense of peace and meaning.

The memorial delirium assessment scale

We conducted two studies with medically hospitalized cancer and acquired immunodeficiency syndrome (AIDS) patients to assess the reliability and validity of a new measure of delirium severity, the Memorial Delirium Assessment Scale (MDAS). The first study used multiple raters who jointly administered the MDAS to 33 patients, 17 of whom met DSM III-R/DSM IV criteria for delirium, 8 met diagnostic criteria for another cognitive impairment disorder (for example, dementia), and 8 had non-cognitive psychiatric disorders (for example, adjustment disorder). Results indicate high levels of inter-rater reliability for the MDAS (0.92) and the individual MDAS items (ranging from 0.64 to 0.99), as well as high levels of internal consistency (coefficient alpha = 0.91). Mean MDAS ratings differed significantly between delirious patients and the comparison sample of patients with other cognitive impairment disorders or no cognitive impairment (P < 0.0002). The second study compared MDAS ratings of 51 medically hospitalized delirious patients with cancer and AIDS made by one clinician to ratings on several other measures of delirium (Delirium Rating Scale, clinicians ratings of delirium severely) and cognitive functioning (Mini-Mental State Examination) made by a second clinician. Results demonstrated a high correlation between MDAS scores and ratings on the Delirium Rating Scale (r = 0.88, p < 0.0001), the Mini-Mental State Examination (r = -0.91, P < 0.0001), and clinicians global ratings of delirium severity (r = 0.89, P < 0.0001). Thus, our findings indicate that the MDAS is a brief, reliable tool for assessing delirium severity among medically ill populations that can be reliably scored by multiple raters. The MDAS is highly correlated with existing measures of delirium and cognitive impairment, yet offers several advantages over these instruments for repeated assessments which are often necessary in clinical research.

Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial

Objectives: An increasingly important concern for clinicians who care for patients at the end of life is their spiritual well‐being and sense of meaning and purpose in life. In response to the need for short‐term interventions to address spiritual well‐being, we developed Meaning Centered Group Psychotherapy (MCGP) to help patients with advanced cancer sustain or enhance a sense of meaning, peace and purpose in their lives, even as they approach the end of life.

The undertreatment of pain in ambulatory AIDS patients.

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

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

&NA; The characteristics and impact of pain were evaluated in a prospective cross‐sectional survey of 438 ambulatory AIDS patients recruited from health care facilities in New York City. More than 60% of the patients reported ‘frequent or persistent pain’ during the 2 wks preceding the study. Patients with pain reported an average of 2.5 different pains. On the 0–10 numerical scale of the Brief Pain Inventory (BPI), mean pain intensity ‘on average’ was 5.4 (SD = 2.2; range = 0–10), and mean pain ‘at its worst’ was 7.4 (SD = 2.0; range = 1–10). The pain‐related functional interference index (sum of the seven item BPI subscale) was 42.6 (SD = 17.2; range = 0–70). Demographic variables were not associated with the presence of pain, but the number of current HIV‐related symptoms, treatment for HIV‐related infections, and the absence of antiretroviral medications were significantly associated with the presence of pain. Female gender, non‐Caucasian race, and number of HIV‐related physical symptoms were significantly associated with pain intensity. Presence of pain and increasing pain intensity were significantly associated with greater impairment in functional ability (Karnofsky Performance Status, BPI functional interference index) and physical symptom distress (Memorial Symptom Assessment Scale). Results demonstrate high levels of pain and pain‐related functional impairment among patients with AIDS. The presence and intensity of pain are associated with more advanced HIV disease and pain intensity is also associated with demographic factors (gender, race).

Symptom Prevalence, Characteristics, and Distress in AIDS Outpatients ☆

Symptom distress is an important but poorly characterized aspect of quality of life in AIDS patients. To assess and characterize the symptoms and symptom distress associated with AIDS, 504 ambulatory patients with AIDS were evaluated between December, 1992 and December, 1995. The assessment included measures of symptom distress, physical and psychosocial functioning, and demographic and disease-related factors. Patients described symptoms during the previous week using the Memorial Symptom Assessment Scale Short Form (MSAS-SF), a validated measure of physical and psychological symptom distress. The mean age was 38.6 years (range 18-69); 56% were male. African-Americans comprised 40% of the sample, Caucasians 35%, and Hispanics 23%. Ninety-three percent had CD4+ T-cell counts below 500, and 66% had counts below 200; 69% were classified in CDC category C (history of AIDS-defining conditions). Fifty-two percent reported intravenous drug use. Karnofsky performance status was > or = 70 in 80% of the patients. No patients were taking protease inhibitors. The mean (+/- SD) number of symptoms was 16.7 +/- 7.3. The most prevalent symptoms were worrying (86%), fatigue (85%), sadness (82%), and pain (76%). Patients with Karnofsky performance scores < 70 had more symptoms and higher symptom distress scores than patients with scores > or = 70 (21.2 +/- 6.5 vs. 15.6 +/- 7.1 symptoms/patient; 2.3 +/- 0.8 vs. 1.6 +/- 0.8 on the Global Distress Index [GDI] of the MSAS-SF; P < 0.0001 for both). Patients who reported intravenous drug use as an HIV transmission factor reported more symptoms and higher overall and physical symptom distress than those who reported homosexual or heterosexual contact as their transmission factor (17.8 +/- 7.5 vs. 15.4 +/- 6.9 symptoms/patient, P = 0.0002; 1.9 +/- 0.9 vs. 1.6 +/- 0.8 on the MSAS-GDI, P = 0.002). Both the number of symptoms and symptom distress were highly associated with psychological distress and poorer quality of life; for example, r = -0.69 (P < 0.0001) between GDI scores and scores on a validated measure of quality of life. Neither gender nor CD4+ T-cell count was associated with symptom number or distress. Responses from this self-referred sample of AIDS outpatients indicate that AIDS patients experience many distressing physical and psychological symptoms and a high level of distress. Both the number of symptoms and the distress associated with them are associated with a variety of disease-related factors and disturbances in other aspects of quality of life. Symptom assessment provides information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life.

Court-ordered treatment of spouse abuse

A growing societal awareness of the frequency and seriousness of spouse abuse has brought with it increased reliance on clinical interventions. Over the past decade, the use of court-ordered psychotherapeutic treatments as a pretrial diversion or dispositional alternative has increased dramatically. Currently, little published research has documented the effectiveness of these court-ordered treatments. The studies reviewed here cast doubt on the assumption that mandatory psychotherapeutic treatments are effective in reducing future incidents of violence between spouses. The incremental benefit of court-ordered treatment over the deterrent effects of traditional criminal justice system remedies is unclear. Differences in abuse recidivism between subjects court-ordered into treatment and subjects arrested and untreated have been small. In addition, subjects withdraw from treatment despite a court order to attend, indicating that legal system involvement does not motivate many unwilling subjects. Furthermore, subjects who discontinue treatment prematurely remain violence-free almost as often as subjects who complete treatment programs, thus drawing into question the, specific impact of clinical treatment for men who abuse their spouses. Future research is necessary to elucidate the precise benefits and appropriate focus of court-ordered treatment programs.

Pilot Randomized Controlled Trial of Individual Meaning-Centered Psychotherapy for Patients With Advanced Cancer

PURPOSE Spiritual well-being and sense of meaning are important concerns for clinicians who care for patients with cancer. We developed Individual Meaning-Centered Psychotherapy (IMCP) to address the need for brief interventions targeting spiritual well-being and meaning for patients with advanced cancer. PATIENTS AND METHODS Patients with stage III or IV cancer (N = 120) were randomly assigned to seven sessions of either IMCP or therapeutic massage (TM). Patients were assessed before and after completing the intervention and 2 months postintervention. Primary outcome measures assessed spiritual well-being and quality of life; secondary outcomes included anxiety, depression, hopelessness, symptom burden, and symptom-related distress. RESULTS Of the 120 participants randomly assigned, 78 (65%) completed the post-treatment assessment and 67 (56%) completed the 2-month follow-up. At the post-treatment assessment, IMCP participants demonstrated significantly greater improvement than the control condition for the primary outcomes of spiritual well-being (b = 0.39; P <.001, including both components of spiritual well-being (sense of meaning: b = 0.34; P = .003 and faith: b = 0.42; P = .03), and quality of life (b = 0.76; P = .013). Significantly greater improvements for IMCP patients were also observed for the secondary outcomes of symptom burden (b = -6.56; P < .001) and symptom-related distress (b = -0.47; P < .001) but not for anxiety, depression, or hopelessness. At the 2-month follow-up assessment, the improvements observed for the IMCP group were no longer significantly greater than those observed for the TM group. CONCLUSION IMCP has clear short-term benefits for spiritual suffering and quality of life in patients with advanced cancer. Clinicians working with patients who have advanced cancer should consider IMCP as an approach to enhance quality of life and spiritual well-being.

Use of the Zung Self‐Rating Depression Scale in cancer patients: Feasibility as a screening tool

The feasibility, utility and reliability of the Zung Self‐Rating Depression Scale (ZSDS) was examined in a large sample of ambulatory cancer patients. This tool and a brief 11‐item version of the ZSDS (excluding nine items concerning somatic symptoms), which was developed during the course of the survey, were used to estimate the prevalence of self‐reported depressive symptoms. Patient characteristics that may be associated with an increased risk of clinically significant depressive symptoms were also explored. Twenty‐five ambulatory oncology clinics affiliated with Community Cancer Care, Inc. enrolled and surveyed 1109 subjects. The alpha coefficients for the ZSDS (0.84) and the Brief ZSDS (0.84) indicated high levels of internal consistency. The overall prevalence of clinically significant depressive symptoms as defined by the ZSDS was 35.9% and by the Brief ZSDS was 31.1%. The ZSDS and the Brief ZSDS were highly correlated (r=0.92). The medical and demographic variables most associated with clinically significant depressive symptoms were more advanced stage of disease at time of diagnosis, lung cancer as primary tumor type, higher ECOG rating (greater degree of physical disability), and having been prescribed antidepressant medications. The high prevalence of depressive symptoms observed in this study is consistent with rates found in other studies of self‐report depression instruments in cancer patients. The initial indicators of internal consistency and validity suggest that the Zung SDS or the brief version may be useful screening tools to identify depressive symptoms in oncology patients.

The Memorial Anxiety Scale for Prostate Cancer Validation of a New Scale to Measure Anxiety in Men with Prostate Cancer

The psychological difficulties facing men with prostate cancer are acknowledged widely, yet identifying men who may benefit from mental health treatment has proven to be a challenging task. The authors developed the Memorial Anxiety Scale for Prostate Cancer (MAX‐PC) to facilitate the identification and assessment of men with prostate cancer‐related anxiety. This scale consists of three subscales that measure general prostate cancer anxiety, anxiety related to prostate specific antigen (PSA) levels in particular, and fear of recurrence.