Hayley Pessin

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.

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.

Meaning-Centered Group Psychotherapy: An Effective Intervention for Improving Psychological Well-Being in Patients With Advanced Cancer

PURPOSE To test the efficacy of meaning-centered group psychotherapy (MCGP) to reduce psychological distress and improve spiritual well-being in patients with advanced or terminal cancer. PATIENTS AND METHODS Patients with advanced cancer (N = 253) were randomly assigned to manualized eight-session interventions of either MCGP or supportive group psychotherapy (SGP). Patients were assessed before and after completing the treatment and 2 months after treatment. The primary outcome measures were spiritual well-being and overall quality of life, with secondary outcome measures assessing depression, hopelessness, desire for hastened death, anxiety, and physical symptom distress. RESULTS Hierarchical linear models that included a priori covariates and only participants who attended ≥ three sessions indicated a significant group × time interaction for most outcome variables. Specifically, patients receiving MCGP showed significantly greater improvement in spiritual well-being and quality of life and significantly greater reductions in depression, hopelessness, desire for hastened death, and physical symptom distress compared with those receiving SGP. No group differences were observed for changes in anxiety. Analyses that included all patients, regardless of whether they attended any treatment sessions (ie, intent-to-treat analyses), and no covariates still showed significant treatment effects (ie, greater benefit for patients receiving MCGP v SGP) for quality of life, depression, and hopelessness but not for other outcome variables. CONCLUSION This large randomized controlled study provides strong support for the efficacy of MCGP as a treatment for psychological and existential or spiritual distress in patients with advanced cancer.

Assessing Psychological Distress Near the End of Life

Psychological suffering is one of the most significant and potentially remediable impediments to the dying process for terminally ill patients and their families. This article reviews several of the most common psychological disorders that arise in the context of terminal illness, including depression, anxiety, delirium, and suicidal ideation. Issues related to assessment, measurement, and differential diagnosis are reviewed.

Burden and Benefit of Psychosocial Research at the End of Life

BACKGROUND The impact of psychosocial research participation has not been examined systematically in palliative care settings. Concerns are often raised regarding the potential for distress among terminally ill patients. This is particularly true when death and dying are the focus of research. Therefore, it is important to understand the specific ways psychosocial research could potentially harm or be helpful to participants. OBJECTIVE To assess the burden and benefits of participation in psychosocial research addressing end-of-life issues among patients receiving inpatient palliative care. DESIGN Sixty-eight terminally ill patients with cancer who had an average life expectancy of less than 2 months, were administered a brief self-report questionnaire to assess whether participation in psychosocial research was burdensome and/or beneficial. The specific factors that contributed to their perceptions were also identified. RESULTS The majority of patients reported no burden associated with participation (75%) and found the experience as moderately to highly beneficial (68%). Factors most frequently identified as burdensome included the length of the interview (21%), structure of the questionnaires (18%), and difficulty discussing end-of life issues (12%). Although some patients reported some distress while discussing end-of-life issues (19%), few endorsed a high level of distress (6%). Factors most frequently identified as beneficial were the social interaction (75%), sense of contributing to society (57%), and the opportunity to discuss their illness (47%). CONCLUSIONS Participants in psychosocial end-of-life research are unlikely to experience significant burden from participation and, in fact, may benefit.

Optimism, Social Support, and Mental Health Outcomes in Patients with Advanced Cancer

Optimism and social support serve as protective factors against distress in medically ill patients. Very few studies have specifically explored the ways in which these variables interact to impact quality of life (QOL), particularly among patients with advanced cancer. The present study examined the role of optimism as a moderator of the relationship between social support and anxiety, depression, hopelessness, and QOL among patients with advanced cancer.

Anxiety in Terminally Ill Cancer Patients

CONTEXT Anxiety in terminal cancer is linked to diminished quality of life, yet overall it is poorly understood with regard to prevalence and relationship to other aspects of psychological distress. OBJECTIVES This study examines anxiety in terminally ill cancer patients, including the prevalence of anxiety symptoms, the relationship between anxiety and depression, differences in anxiety between participants receiving inpatient palliative care and those receiving outpatient care, and characteristics that distinguish highly anxious from less anxious patients. METHODS Participants were 194 patients with terminal cancer. Approximately half (n=103) were receiving inpatient care in a palliative care facility and half (n=91) were receiving outpatient care in a tertiary care cancer center. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression, and was administered along with measures of hopelessness, desire for hastened death, and social support. RESULTS Moderately elevated anxiety symptoms were found in 18.6% of participants (n=36) and 12.4% (n=24) had clinically significant anxiety symptoms. Level of anxiety did not differ between the two treatment settings. However, participants receiving palliative care reported significantly higher levels of depression and desire for hastened death. A multivariate prediction model indicated that belief in an afterlife, social support, and anxiolytic and antidepressant use were unique, significant predictors of anxiety. CONCLUSION Severity of anxiety symptoms did not differ between the study sites, suggesting that anxiety may differ from depression and desire for hastened death in the course that it takes over the duration of terminal cancer.

Measuring depression at the end of life: is the Hamilton Depression Rating Scale a valid instrument?

Depression at the end of life is a common mental health issue with serious implications for quality of life and decision making. This study investigated the reliability and validity of one of the most frequently used measures of depression, the Hamilton Depression Rating Scale (HAM-D) in 422 patients with terminal cancer admitted to a palliative care hospital. The HAM-D demonstrated high reliability and concurrent validity with depression diagnosis, based on Structured Clinical Interview for DSM-IV Axis I Disorders, non-patient research version (SCID-I/NP Depression Module). Receiver Operating Characteristic (ROC) analyses generated an area under the curve of .91, indicating high sensitivity and specificity. The HAM-D strongly correlated with several measures of distress (e.g., hopelessness, desire for hastened death, and suicidal ideation). Factor analysis generated 4 factors (anxiety, depressed mood, insomnia, and somatic symptoms), accounting for 42% of the variance. Implications for assessing depression in this population are discussed.

On sinking and swimming: the dialectic of hope, hopelessness, and acceptance in terminal cancer.

For terminally ill cancer patients, hope and hopelessness are constructs that significantly impact quality of life. The aim of this study was to examine the relationship between hope and hopelessness in advanced cancer and to identify factors that maintain hope and increase vulnerability to hopelessness. Semistructured interviews were conducted with 22 terminally ill cancer patients. Interview transcripts were analyzed using thematic content analysis to identify patient definitions of these terms and associated cognitions and emotions. Hope and hopelessness were identified as distinct, often co-occurring, and dialectically interacting constructs. The relationship between hope and hopelessness often balanced on acceptance, perceived as diametrically opposed to hopelessness, and conducive to redirecting hope toward new goals. Positive interpersonal relationships enhanced hope, and uncontrolled physical pain increased vulnerability to hopelessness.

Impact of treatment for depression on desire for hastened death in patients with advanced AIDS.

BACKGROUND Despite the development of multi-drug regimens for HIV, palliative care and quality-of-life issues in patients with advanced AIDS remain important areas of clinical investigation. OBJECTIVE Authors assessed the impact of treatment for depression on desire for hastened death in patients with advanced AIDS. METHOD Patients with advanced AIDS (N=372) were interviewed shortly after admission to a palliative-care facility, and were reinterviewed monthly for the next 2 months. Patients diagnosed with a major depressive syndrome were provided with antidepressant treatment and reinterviewed weekly. Desire for hastened death was assessed with two questionnaire measures. RESULTS Desire for death was highly associated with depression, and it decreased dramatically in patients who responded to antidepressant treatment. Little change in desire for hastened death was observed in patients whose depression did not improve. Although improved depression was not significantly associated with the use of antidepressant medication, those individuals prescribed antidepressant medication showed the largest decreases in desire for hastened death. DISCUSSION Successful treatment for depression appears to substantially decrease desire for hastened death in patients with advanced AIDS. The authors discuss implications of these findings for palliative-care treatment and the physician-assisted suicide debate.