Relationship of Suicidal Ideation With Demoralization, Depression, and Anxiety: A Study of Cancer Patients in Mainland China

Demoralization: A concept analysis through a scoping review methodology

Background

Demoralization is a complex construct comprising of several clinical phenomena that has gained increasing interest in clinical practice and research; however, the concept needs to be sufficiently specified and clearly described. A concept analysis of demoralization is necessary to integrate previous research findings and establish the scientific foundation for future intervention research.

Aim

To analyze the concept of demoralization in terms of its antecedents, attributes, consequences, and empirical referents in health.

Methods

A concept analysis was performed using the Joanna Briggs Institute guidelines scoping review method and mapping information through the Walker and Avant concept analysis framework. Electronic databases, including PubMed, The Cochrane Library, Embase, PsycINFO, and Web of Science, were searched until September 15, 2024. The grey literature and other minor non-indexed publications were also reviewed.

Results

A total of 106 articles were included in the review. Antecedents included medical illness, symptom burden, low social support and coping difficulties. Attributes were identified as follows: dysphoria, disheartenment, helplessness, hopelessness, loss of meaning and purpose, and sense of failure. Consequences included poor quality of life, depression, anxiety, suicidal ideation and desire to die. The concept of demoralization was illustrated through a model case, one exhibiting borderline criterion and another displaying challenge.

Conclusion

This scoping review clarifies the clinical definition of demoralization, distinguishing it from common language usage and from other emotional symptoms frequently experienced by patients.

Implications for Practice

The identified attributes of demoralization play vital roles in health assessments and should guide nurses in providing appropriate patient care early on. Interventions should address the concept's antecedents and consequences.

Global prevalence and risk factors of suicidality among head and neck cancer patients-systematic review and meta-analysis

PURPOSE

Suicidality is a pertinent issue among head and neck cancer patients. Our primary aim is to investigate the current suicidality rate among head and neck cancer (HNC) patients and evaluate risk factors associated with suicidality.

METHODS

We thoroughly searched primary original research from January 2024 onwards across several databases, including PubMed, Embase, ScienceDirect, Web of Science, Scopus, and PsycINFO. Using a random-effects model, we calculated the odds ratio (OR) for risk factors and conducted a proportional meta-analysis to estimate prevalence and 95% confidence intervals (CI).

RESULTS

Out of 15 included studies, 305,146 head and neck cancer patients were included. The global prevalence of suicidality among head and neck cancer patients was estimated at 6.8% (95% CI 2.0-20.6%). Major depressive disorder (RR = 5.13, 95% CI 3.60-7.30), psychiatric disorders (RR = 3.73, 95% CI 2.65-5.25), alcohol abuse (RR = 2.67, 95% CI 1.71-4.16), substance abuse (RR = 2.47, 95% CI 1.58-3.85), smoking/nicotine dependence (RR = 2.03, 95% CI 1.60-2.58), and functional compromise (RR = 1.74, 95% CI 1.29-2.36) were identified as significant risk factors. Subgroup analysis by geographical location revealed variations in prevalence, with Asia reporting lower rates than Europe and North America.

CONCLUSION

This systematic review reports the current suicidality rate associated with head and neck cancer patients. Major depressive disorder and other psychiatric comorbidities pose substantial risks requiring early intervention in mitigating the burden of suicidality.

Factors correlated with demoralization among cancer patients: A systematic review and meta-analysis

OBJECTIVES

Demoralization isa common psychological problem in cancer patients. The purpose of this study is to systematically evaluate the correlated factors of demoralization among cancer patients. We also summarized the available evidence, effect estimates, and the strength of statistical associations between demoralization and its associated factors.

METHODS

We systematically searched PubMed, Web of Science, CINAHL, Embase, the Cochrane Library, PsycINFO, and 2 electronic databases to identify studies published up to October 2023 with data on the correlates of demoralization. Two researchers independently reviewed references, extracted data, and assessed data quality. Meta-analysis was performed using R4.1.1 software.

RESULTS

Thirty-eight studies were included in this meta-analysis. For the most studied sociodemographic correlates, demoralization was negatively correlated with income (z = -0.29, 95% CI: -0.51, -0.02), education (z = - 0.11, 95% CI: - 0.16, -0.05), and age (z = -0.45, 95%CI: -0.75, -0.01). For the most studied clinical correlates, demoralization was positively correlated with symptom burden (z = 0.37, 95% CI: 0.22, 0.50) and negatively correlated with quality of life (z = -0.40, 95% CI: -0.54, -0.24). For the most studied psychosocial correlates, demoralization was negatively correlated with social support (z = -0.39, 95% CI: -0.51, -0.26) and positively correlated with anxiety (z = 0.65, 95% CI: 0.56, 0.73), depression (z = 0.61, 95% CI: 0.54, 0.67), and suicidal ideation (z = 0.48, 95% CI: 0.34, 0.60).

SIGNIFICANCE OF RESULTS

Demoralization showed either positive or negative associations with sociodemographic, clinical, and psychological variables. More research is needed to explore the underlying mechanisms to develop effective interventions. This review provides information on the factors associated with demoralization in cancer patients, which can be used to inform strategies for clinical care providers.

Analysis of the relationship between antineoplastic drugs and suicide-related adverse events based on the food and drug administration adverse event reporting system database

Background

The potential association between new antineoplastic drugs and an increased risk of suicide-related adverse drug reactions remains unclear. This study aims to utilize the FAERS public database to analyze suicide-related adverse drug reactions associated with common antitumor drugs and to investigate potential risk signals for such adverse drug reactions.

Methods

This study was a retrospective analysis utilizing the FAERS database. The FAERS database was examined for reports of suicide-related adverse events associated with antitumor drugs, spanning from 2004 to 2023. To identify and verify adverse event signals, we employed reporting odds ratios, proportional reporting ratios, and Bayesian methods (Bayesian Confidence Propagation Neural Network). Additionally, logistic regression analysis was performed to assess outcomes in tumor patients.

Results

A total of 223,781 suicide-related adverse event reports were screened, of which 3790 involved common antitumor drugs. The top five drugs reported were tretinoin (n = 1220), methotrexate (n = 664), celecoxib (n = 505), rituximab (n = 107), and imatinib (n = 105). Risk signal analysis indicated that, with the exception of tretinoin (ROR = 6.317), the reporting odds ratio values for the other drugs were below 2. Among cancer patients, the most frequently reported adverse events included suicidal ideation (n = 233), completed suicide (n = 131), and suicide attempts (n = 97). Regression analysis revealed that risk factors for patient death included indication (OR = 0.967, p < 0.01), gender (OR = 0.57, p < 0.01), and type of adverse event (OR = 4.644, p < 0.01).

Conclusion

The findings suggest that antineoplastic drugs may not statistically increase the risk of suicide-related adverse events. However, specific tumor types and suicide-related adverse events may contribute to increased mortality in cancer patients. Further research is warranted to elucidate the risk of suicide-related adverse events in oncology patients.

Perceived Control as a Potential Protective Factor for Suicidal Thoughts and Behaviors in Cancer Patients and Survivors: A Systematic Review With Meta-Analysis

OBJECTIVE

Individuals affected by cancer have an elevated risk of experiencing suicidal crises. Aligning established suicide theories with social-cognitive theories, perceived control and related constructs emerge as potential protective factors for suicidal thoughts and behaviors in cancer patients. As perceived control is potentially modifiable, it holds great potential for prevention and intervention efforts. We aimed to comprehensively synthesize the evidence on perceived control and its link with suicidal thoughts and behaviors in cancer patients.

METHODS

The search term and procedures were registered in PROSPERO (CRD42023391048). We systematically searched the databases PubMed/MEDLINE, CINAHL, PsycInfo, Web-of-Science Core Collection, Cochrane Library, adding a grey literature search. In addition to the narrative review, pooled effect sizes, moderation and subgroup analysis were calculated.

RESULTS

The systematic search yielded 1986 original reports of which 36 were included in the systematic review and 25 in the meta-analysis. Demoralization, help-/hopelessness, and self-efficacy were the most commonly studied facets of control, showing a relatively large, pooled correlation with suicidal ideation overall (r = 0.45, [95% CI = 0.38-0.52], Q = 346.15, p < 0.01, I2 = 91.2%) and across operationalisations (demoralisation: r = 52; hopelessness: r = 45; self-efficacy: r = 0.40). Moderation analyses revealed no effect of cancer stages; but more directly cancer-associated variables (demoralisation, hopelessness) were more closely related to suicidal ideation (QM = 5.40, p = 0.02) than general self-efficacy.

CONCLUSION

The findings underscore the pivotal role of perceived control in shaping severe distress in cancer patients. More studies are needed examining perceived control in a narrower sense.

Single Question for Screening Suicide Risk in Patients With Cancer in Nursing Routine Work: A Retrospective Cross-Sectional Study

AIM

To examine the efficacy of the Single Suicide Question, a tactful single-item tool, in assessing suicide risk among cancer patients.

BACKGROUND

Suicide risk screening in cancer patients faces challenges such as cultural, the degree of attention given and the complexity and diversity of assessment methods. An efficient and simple suicide screening tool is needed within the nursing and treatment process.

DESIGN

A retrospective cross-sectional study.

DATA SOURCES

All data utilised in this study were obtained from assessments conducted by researchers at our institution between March 2018 and August 2023.

METHODS

Retrospectively analysed Single Suicide Question scores from 9703 patients (March 2018-August 2023), with 229 undergoing additional using other established tools (the Patient Health Questionnaire-9, Generalised Anxiety Disorder-7, Distress Thermometer) alongside the Mini International Neuropsychiatric Interview Suicidal Subscale (MINI Suicidal Subscale). These 229 patients were divided into the cut-off determination dataset (174/229) and the validation dataset (55/229) to analyse, validate and compare the screening efficacy, consistency and optimal cut-off points of the tools relative to the MINI Suicidal subscale (golden standard). K-fold cross-validation was employed to assess the stability of the Single Suicide Question and to revalidate its screening efficacy.

RESULTS

In cut-off determination dataset, the Single Suicide Question exhibited good screening efficacy and substantial agreement relative to the MINI Suicidal subscale, as validated in the validation dataset, outperforming other tools. The optimal cut-off points of Single Suicide Question for screening moderate or higher and high suicide risk as 2 and 3 respectively. Its stability in K-fold cross-validation further supported its screening efficacy.

CONCLUSION

The Single Suicide Question shows potential as a preliminary screening tool for suicide risk. Furthermore, it has also demonstrated the potential of a simple, tactful, culturally fitting question in assessing suicide risk, providing insight for the development of relevant tools in different cultural and linguistic backgrounds.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Our study demonstrates the potential of the Single Suicide Question as a screening tool for identifying suicide risk among cancer patients, which may facilitate efficient suicide screening. Furthermore, it reveals that tactful, culturally fitting, yet simple tools can achieve good screening efficacy, providing insights for the development of similar tools in different cultural and linguistic contexts.

IMPACT

This study investigated the effectiveness of using a culturally contextualised, specific single question to screen for suicide risk in Chinese cancer patients, demonstrating high screening efficacy and stability. With further research, this method may provide a tactful, culturally informed and efficient suicide screening approach to address the critical issue of suicide risk in cancer care, and it also serves as a reference for developing similar tools in diverse cultural and linguistic contexts.

REPORTING METHOD

The study followed the STROBE checklist guidelines for cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

The data provided by patients were the foundation of this study. Nurses played a central role in conducting the majority of assessments and contributing to the research design in this study.

Prevalence of and factors associated with demoralization among family caregivers of palliative care patients in Hong Kong

OBJECTIVES

This study aims to examine (1) the prevalence of demoralization among family caregivers of palliative care patients (PCP) in Hong Kong, (2) the percentage of caregivers who are demoralized but not depressed, (3) the factors associated with demoralization, and (4) the differences in caregivers' support needs between high and low levels of demoralization groups.

METHODS

Ninety-four family caregivers were recruited and completed a questionnaire that included measures of demoralization, depression and caregiving strain, caregivers' support needs, and demographic information.

RESULTS

The prevalence of demoralization among family caregivers of PCP was found to be 12.8% (cutoff score = 50) and 51.1% (cutoff score = 30). Although 27.7% of caregivers met the criteria of depression and demoralization, 12.8% of demoralized caregivers were not depressed. Depression and caregiving strain were identified as the predictors of demoralization. Caregivers with a poorer subjective physical status and a lower education level are more prone to demoralization. The three major caregivers' needs for support reported were (1) knowing what to expect in the future (77.7%); (2) knowing who to contact (74.5%); and (3) understanding your relative's illness (73.4%). Those who experienced a high level of demoralization often reported more need for support in end-of-life caregiving.

SIGNIFICANCE OF RESULTS

This is the first study that focused on the demoralization of family caregivers of PCP in the East Asian context. Demoralization is prevalent among these caregivers. We recommend that early assessment of demoralization among family caregivers of PCP be considered, especially for those who are more depressed and have a higher level of caregiving stress.

A Biobehavioral Perspective on Caring for Allogeneic Hematopoietic Stem Cell Transplant Survivors with Graft-Versus-Host Disease

Among the potential complications of allogeneic hematopoietic stem cell transplantation (HSCT), graft-versus-host disease (GVHD) is common and associated with significant physical and psychosocial symptom burden. Despite substantial advances in GVHD treatment, the global immune suppression that frequently accompanies GVHD treatment also contributes to high rates of physical and emotional suffering and mortality. The complex manifestations of GVHD and its treatment warrant a multidisciplinary team-based approach to managing patients' multi-organ system comorbidities. A biobehavioral framework can enhance our understanding of the complex association between medications, physical symptoms, and psychosocial distress in patients with GVHD. Hence, for this perspective, we highlight the importance of addressing both the physical and psychosocial needs experienced by patients with GVHD and provide guidance on how to approach and manage those symptoms and concerns as part of comprehensive cancer care.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

To what extent are psychological variables considered in the study of risk and protective factors for suicidal thoughts and behaviours in individuals with cancer? A systematic review of 70 years of research

Psychological variables substantially shape the risk of suicidal thoughts and behaviours (STBs). However, it is unclear to what extent they are considered in individuals with cancer. We synthesized the quantitative research landscape concerning psychological risk/protective factors of STBs in the (psycho-) oncological context. This pre-registered review (PROSPERO-ID CRD42022331484) systematically searched the databases PubMed/Medline, CINAHL, PsycInfo, Cochrane Library, and Web of Science (as well as the grey literature and preprints). Risk of bias (RoB) was estimated using the ROBINS-I tool. Of 11,159 retrieved records, 319 studies were eligible for inclusion. Of those, 163 (51.1%) had investigated psychological factors (affective: n = 155; social: n = 65; cognitive: n = 63; personality/individual differences: n = 37; life events: n = 6), in a combined 3,561,741 participants. The most common STBs were suicidal ideation (n = 107) or death wishes (n = 20) rather than behaviour (suicide deaths: n = 26; attempts: n = 14). Most studies had a serious RoB. Thus, a large body of research investigated STBs in cancer patients/survivors, but it rarely aligned with the theoretical or clinical developments in suicide research. We propose a conceptual model of STBs in cancer delineating moderation and mediation effects to advance the integration of the fields, and to inform future research and practice.

Risk factors associated with suicidal ideation among cancer patients: a systematic review and meta-analysis

Objective

The objective of this review was to provide a comprehensive summary and analysis of the risk factors associated with suicidal ideation among cancer patients.

Methods

This review adhered to the PICO/S framework and guidelines outlined in the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) framework (PROSPERO CRD42023433639). We searched Web of Science, PubMed, Embase, Scopus, PsycINFO, and Cochrane Library from the establishment date of the databases until June 9, 2023 for observational studies that reveal risk factors associated with suicidal ideation among cancer patients. Software Review Manager 5 (vision 5.4) was used for Meta-analyses.

Results

4,921 studies were obtained through the search of the databases, 40 of which were eligible. Meta-analysis revealed that suicidal ideation in cancer patients was significantly associated with marital status, living alone, post-traumatic stress disorder (PTSD), panic disorder, education, psychiatric illness history, social functioning, childhood adversity experience, financial problems, pain, depression, demoralization, vomiting, residence and anxiety.

Conclusion

Being unmarried, living alone, less educated, living in rural, financial problems, pain, vomiting, PTSD, psychiatric illness history, lower social functioning, childhood adversity experience, anxiety, depression, demoralization, panic disorder were risk factors for suicidal ideation among cancer patients. This review provided evidence-based information for identifying and reducing the risk of suicide in cancer survivors.Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, CRD42023433639.

Demoralization in cancer survivors: an updated systematic review and meta-analysis for quantitative studies

BACKGROUND

Demoralization can cause impairments across all life aspects of cancer patients. Cancer patients are also vulnerable during their survivorship. The purpose of this review is to examine the risk of demoralization and associated risk factors among cancer survivors who have completed their primary anti-cancer treatment or time since diagnosis ≥5 years without recurrence.

METHODS

We searched databases of PubMed, Cochrane, Embase, PsycINFO and ClinicalTrial.gov to identify eligible studies which reported the demoralization level among cancer survivors. A random-effect meta-analysis model was used for calculating mean demoralization level. Heterogeneity was evaluated by I2 statistics. Funnel plots and Egger's regression tests were performed for checking publication bias. We used one-study-removed method for sensitivity analysis. Subgroup analysis was also done to examine the difference of demoralization level between cancer types. Meta-regression was performed to reveal risk factors of demoralization.

RESULTS

A meta-analysis of 12 articles involving 2902 cancer survivors was conducted. The mean demoralization score among cancer survivors was 25.98 (95% CI: 23.53-28.43). Higher demoralization level was seen in participants with older age, higher female ratio, higher married/living together status ratio and higher patient health questionnaire-9 score. The literature review revealed correlations between demoralization and suicide risk, anxiety and quality of life. No consistent correlation between demoralization and post-traumatic stress symptoms could be seen.

CONCLUSIONS

High demoralization level is noticed among cancer survivors. Risks for females, elder patients or breast cancer survivors are identified. More longitudinal or interventional studies for cancer survivors' demoralization are expected in the future.

Prevalence, Associated Factors and Adverse Outcomes of Demoralization in Cancer Patients: A Decade of Systematic Review

Demoralization has been extensively studied in oncology and palliative care settings, and is characterized by a loss of meaning and purpose in life, a sense of powerlessness over life events, and a sense of helplessness. The objective of this systematic review is to synthesize the prevalence, associated factors, and adverse outcomes of demoralization in cancer patients by reviewing the literature of the last decade. Seven databases (PubMed, PsycINFO, Embase, Web of Science, Medline, CINAHL and Cochrane Library databases) were systematically searched from January 2012 to June 2022. Roughly speaking, the prevalence of demoralization in cancer patients ranges from 13.50% to 49.4%. A total of 45 factors are associated with demoralization, of which psychological factors have been studied more frequently in the last decade. There are nine outcomes related to demoralization, with the strongest evidence for the correlation between demoralization and suicidal ideation. The study emphasizes the complexity of factors associated with demoralization in cancer patients. There appears to be a intersection between the constructs of demoralization and depression, anxiety, and suicidal ideation, which may explain the correlation between them.

Distinguishing and treating demoralization syndrome in cancer: A review

IMPORTANCE

Demoralization, characterized by a persistent inability to cope, as well as helplessness, hopelessness, and despair, is highly prevalent in oncology, with between 36% to 52% of patients exhibiting demoralization syndrome. Given established evidence linking demoralization in patients with cancer to physical symptom burden, quality of life, sleep disturbance, and suicidality, assessment and treatment of demoralization syndrome is critical for optimizing clinical and psychosocial outcomes.

OBSERVATIONS

The term "demoralization" is highly relevant to the care of patients with cancer facing life-limiting illnesses. Indeed, demoralization can be conceptualized as a feeling state characterized by the perception of being unable to cope with some pressing problems and/or of lack of adequate support from others. Despite a considerable overlap in symptoms, demoralization and depression should be regarded as distinct and independent clinical syndromes. Patients who are demoralized but not clinically depressed often describe a sense of subjective incompetence and do not report anhedonia (i.e., loss of interest and inability to enjoy things). Although the definition of demoralization is now included as a distinct syndrome in the International Classification of Diseases (ICD)-11, it has been neglected by the current U.S. official nosology in psychiatry, such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). As such, demoralization syndrome may be under- or misdiagnosed and treated ineffectively in the oncology setting, potentially prolonging suffering and influencing cancer outcomes.

CONCLUSIONS AND RELEVANCE

Optimization of methods to diagnose and assess demoralization syndrome is critical to underpin rigorous studies evaluating the efficacy of psychotherapeutic and pharmacological interventions for patients with cancer experiencing demoralization. Our review supports the use of specific diagnostic criteria for demoralization in cancer patients, introduces methodological considerations relevant to treatment studies, and presents a novel measurement approach to the assessment of demoralization severity with the Clinical Interview for Demoralization (CIDE).

Distress Thermometer Score Is Useful For Predicting Suicidal Ideation in Patients With Cancer

PURPOSE

Suicidal ideation (SI) and depressive symptoms are common in patients with cancer. A Distress Thermometer (DT) is an effective tool to screen depression and anxiety in such cohorts. We investigated the value of the DT for predicting SI and the prevalence and associated risk factors of SI in the study population.

METHODS

This cross-sectional study enrolled a total of 162 heterogeneous patients with cancer. Information regarding sociodemographic and clinical characteristics, the Hospital Anxiety and Depression Scale, DT score, and the past month SI were collected. Receiver operating characteristic (ROC) analysis was performed to find accuracy and the optimal cutoff score for predicting risk of SI. The significance of difference between DT scores was obtained using the median independence test. Likelihood of risk was analyzed through odds ratio.

RESULTS

DT possesses good overall accuracy (area under the ROC curve = 0.797) for predicting SI in patients with cancer. The DT had a sensitivity of 0.929 and a specificity of 0.522 with a cutoff score of ≥4. The patients with SI had significantly higher DT scores than the patients without SI (7 [5,8] v 3 [1,6]; P < .001). The 1-month prevalence of SI was 17.3%. Depression, anxiety, and psychological distress were the predictive factors of SI.

CONCLUSION

SI is a global issue in patients with cancer. The DT scores may be a rapid predicting tool for identifying SI in patients with cancer. Higher DT scores and patients with psychosocial problems need to be routinely screened for SI, which may help to prevent suicidal risk.

Contribution of coping style to the association between illness uncertainty and demoralisation in patients with breast cancer: a cross-sectional mediation analysis

OBJECTIVE

Demoralisation is a common psychological issue in patients with cancer and aggravates depression, reduces the quality of life and even causes suicidal ideation. There is a lack of knowledge about illness uncertainty, coping style and demoralisation in patients with breast cancer. The current study explored the relationship between illness uncertainty and demoralisation among those patients, as well as the potential mediating role of coping style.

DESIGN

A cross-sectional study.

SETTING

Participants were recruited from the Breast Tumor Center in a tertiary hospital in Shijiazhuang, Hebei province.

PARTICIPANTS

A total of 211 patients with breast cancer completed the survey.

OUTCOME MEASURES

A total of 211 patients with breast cancer completed the Mishel's Uncertainty in Illness Scale, Trait Coping Style Questionnaire and the Mandarin version of Demoralization Scale (DS-MV).

RESULTS

Of the patients, 47.40% exhibited symptoms of demoralisation (DS-MV>30), and the mean of demoralisation score was (29.55±13.21). The results demonstrated that illness uncertainty and negative coping styles were positively related to demoralisation (p<0.001), while active coping styles were negatively related to demoralisation (p<0.001). Importantly, coping styles could partially mediate the relationship between illness uncertainty and demoralisation (p<0.01).

CONCLUSION

Our study illustrated that illness uncertainty was associated with demoralisation in patients with breast cancer, and coping style acted as a mediator in this relationship. The findings highlighted the critical role of reducing negative coping styles to the early prevention and efficient treatment of demoralisation among those patients.

The prevalence of depression and suicidal ideation among cancer patients in mainland China and its provinces, 1994-2021: A systematic review and meta-analysis of 201 cross-sectional studies

To evaluate the national prevalence depression of Chinese cancer patients and clarify its potential associated factors. Twelve databases were searched from database inception through October 31, 2022 for relevant studies published in English (PubMed MEDLINE, Ovid MEDLINE, Embase, Scopus, PsycINFO, and Cochrane and Web of Science) and Chinese (China National Knowledge Infrastructure, Wanfang, Weipu, Chinese Biomedical Literature Service System, Duxiu) that estimated point or period prevalence of depression, depressive disorder, or suicidal ideation as assessed by self-report scale or structured interview. 201 studies were eligible for inclusion in our meta-analyses. We found the national pooled prevalence rates of depression and suicidal ideation were 44.63 % (95 % CI 42.24 %-47.01 %) and 24.95 % (95 % CI 10.96 %-38.95 %), respectively. The pooled prevalence of depression was associated with study location, cancer type, comorbid chronic disease, and female sex (all P < 0.05). The distribution of the depression prevalence among cancer patients in mainland China was characterized by significant geographical variation and clustering. The highest pooled prevalence of depression was among gynecologic oncology patients. We recommend that more attention and resources be given to mental health problems such as depression and suicidal ideation among Chinese cancer patients, and that prevention programs be developed, especially in areas with a high prevalence of depression.

Multi-omics data reveals the important role of glycerophospholipid metabolism in the crosstalk between gut and brain in depression

BACKGROUND

Gut microbiota plays a critical role in the onset and development of depression, but the underlying molecular mechanisms are unclear. This study was conducted to observe the characteristics of gut microbiota, lipid metabolism and neurotransmitters in Gut-Liver-Brain axis in depressed mice (DM), and identify some novel perceptions on relationships between gut microbiota and depression.

METHODS

A mouse model of depression was built used chronic unpredictable mild stress (CUMS). Fecal samples (measuring gut microbiota compositions, microbial genes and lipid metabolites), liver samples (measuring lipid metabolites), and hippocampus (measuring neurotransmitters) were collected. Both univariate and multivariate statistical analyses were used to identify the differential gut microbiota, metabolic signatures and neurotransmitters in DM.

RESULTS

There were significant differences on both microbial and metabolic signatures between DM and control mice (CM): 71 significantly changed operational taxonomic units (OTUs) (60.56% belonged to phylum Firmicutes) and 405 differential lipid metabolites (51.11% belonged to Glycerophospholipid (GP) metabolism) were identified. Functional analysis showed that depressive-like behaviors (DLB)-related differential microbial genes were mainly enriched in GP metabolism. Weighted correlation network analysis (WGCNA) showed that DLB-related differential metabolites mainly belonged to GPs. Meanwhile, seven differential neurotransmitters were identified. Comprehensive analysis found that Lachnospiraceae and gamma-aminobutyric acid (GABA) were significantly correlated with 94.20% and 53.14% differential GPs, respectively, and GABA was significantly correlated with three main DLB phenotypes.

CONCLUSION

Our results provided novel perceptions on the role of Gut-Liver-Brain axis in the onset of depression, and showed that GP metabolism might be the bridge between gut microbiota and depression. "Lachnospiraceae-GP metabolism-GABA" held the promise as a potential way between gut microbiota and brain functions in DM.

Clinical utility of demoralization: A systematic review of the literature

Demoralization is a complex clinical phenomenon which has raised a growing interest in clinical and research realms. The present systematic review of the literature aimed at (1) updating on demoralization prevalence in different populations, (2) identifying the instruments more largely used to assess demoralization, and (3) verifying whether new tools of assessment have been proposed. PubMed and Web of Science were searched from inception to April 2022. Search terms were: demoralization/demoralized/demoralizing/demoralised/demoralising. PRISMA guidelines were followed. GRADE rating system was used. A total of 188 papers were included. Demoralization appeared to be a distinctive psychological state common in medical, psychiatric, and non-clinical settings, thus not limited to life-threatening diseases. Diagnostic Criteria for Psychosomatic Research (DCPR) and Demoralization Scale (DS) are the most commonly used tools to assess it. DCPR allow to diagnose demoralization as a manifestation of dealing with chronic stress. DS captures dimensionally a psychological distress related to end of life. Demoralization is associated with clinical features encompassing allostatic overload, quality of life, wellbeing/euthymia. Implications on health outcomes and treatment are discussed. Demoralization warrants careful consideration in clinical contexts through valid assessment procedures. DCPR are recommended to diagnose it, DS can be helpful to capture clinical details.

Dignity and Related Factors in Patients with Cancer: A Cross-Sectional Study

PURPOSE

Dignity is a basic human right that is related to psychological distress factors in patients with cancer such as depression and demoralization. Hence, the dignity issue is of great importance to healthcare professionals. The present study aimed to advise healthcare professionals regarding the related distress factors of dignity in patients with cancer by investigating its relationship with patients' demographics, disease characteristics, and psychological distress.

METHODS

This was a cross-sectional study design. A convenience sample of 267 patients with cancer from a medical center was recruited into this study. Each patient completed demographics and disease characteristics questionnaires, the Patient Dignity Inventory Mandarin Version, the Demoralization Scale Mandarin Version (DS-MV), and the Patient Health Questionnaire-9 (PHQ-9). Data were analyzed with SPSS 22.0 software.

RESULTS

Dignity was significantly correlated with age, demoralization, and depression. Cancer patients aged 65 or above were more likely to have a lower sense of dignity. In the present study, the sensitivity and specificity of the Patient Dignity Inventory Mandarin Version for demoralization (DS-MV≥30) were 84.8% and 79.1% and for depression (PHQ-9≥10) were 73.8% and 70.9% in patients with cancer with an aggregate score of 35 or above.

CONCLUSIONS

Dignity is significantly correlated with personal demographic characteristics and psychological distress in patients with cancer. The results provide reference data for healthcare professionals to understand and enable dignity in patients with cancer and aid in the development of methods that promote their dignity.

Understanding factors influencing demoralization among cancer patients based on the bio-psycho-social model: A systematic review

OBJECTIVE

Demoralization is a prevalent psychological problem among cancer patients and reflects a sense of subjective incompetence. This systematic review aims to identify factors influencing demoralization among cancer patients.

METHODS

Eleven databases were systematically searched from database inception to 31 December 2020. Google Scholar and relevant reference lists were supplementarily searched. Studies reporting demoralization measured by Demoralization Scale and its influencing factors among cancer patients were included. A qualitative synthesis was conducted owing to the heterogeneity of the study outcome.

RESULTS

A total of 49 studies involving 10,712 participants were included in this review. The results showed substantial effect size variation, but the psychological factors showed the strongest magnitude of association. Among the biological factors, the number of physical symptoms (mean r values [rs]: 0.331) was associated with increased demoralization. Among the psychological factors, negative psychological factors include hopelessness (mean rs: 0.633), desire for death (mean rs: 0.620), dignity-related distress (mean rs: 0.595), depression (mean rs: 0.593), anxiety (mean rs: 0.589), psychological distress (mean rs: 0.465), and suicidal ideation (mean rs: 0.460) were related to increased demoralization; whereas positive psychological factors including hope (mean rs: -0.565), attachment security (mean rs: -0.530), and sense of coherence (mean rs: -0.453) were related to decreased demoralization. Among the social factors, social support (mean rs: -0.330) was negatively related to demoralization, and the demographic factors were still controversial. Quality of life was considered to be at the intersection of biopsychosocial factors and negatively associated with demoralization (mean rs: -0.599).

CONCLUSIONS

Demoralization is a consequence of the interaction of physical, psychological, and social factors among cancer patients. Factors with a significant effect should not be overlooked when designing an intervention to reduce demoralization. It is necessary to distinguish demoralization from other negative psychological states and further explore positive psychological factors influencing demoralization among cancer patients.

The Demoralization Interview: Reliability and validity of a new brief diagnostic measure among medically ill patients

BACKGROUND

Demoralization is a state of low morale and poor coping that is being increasingly recognized in stressful circumstances, such as illness. Meta-analyses show prevalence of 30% in the medically and 50% in the mentally ill. A brief structured diagnostic interview is needed to assess for and diagnose demoralization.

METHODS

The Demoralization Interview (DI) was designed from items of the Demoralization Scale-II (DS-II) and common items used in other clinical interviews. The resultant 26 items were administered to 264 patients with serious progressive medical illnesses, together with the DS-II, measures of depression, anxiety, and quality of life. Rasch analysis was used to co-calibrate the DI against the DS-II. Sensitivity, specificity, and area under the receiver operating characteristics curve (AUROC) were assessed. Concurrent validation was conducted against measures of anxiety, depression, and quality of life.

RESULTS

A 14-item Demoralization Interview (DI) with a diagnostic threshold of 6 symptoms generated sensitivity of 78.0%, specificity of 90.9%, and AUROC of 0.84 against the DS-II. Unidimensionality was indicated, with a Cronbach's alpha of 0.81. For respondents with 6 or more symptoms on the DI, 98% recognized a current stressor and 66% described significant distress or functional impairment. Demoralized respondents carried significantly lower quality of life, higher physical disability, and higher depressive and anxiety symptoms.

CONCLUSIONS

The DI has good reliability and validity, with a threshold of 6 symptoms supporting a diagnosis of demoralization. It could be used as a stand-alone diagnosis, or as a specifier for adjustment disorder or depression.

Demoralization and Its Association with Quality of Life, Sleep Quality, Spiritual Interests, and Suicide Risk in Breast Cancer Inpatients: A Cross-Sectional Study

With decreasing mortality, the quality of life, spiritual needs, and mental health of breast cancer patients have become increasingly important. Demoralization is a poor prognostic factor for cancer patients. The extent of demoralization in breast cancer patients and its association with these factors remains unclear. This cross-sectional study was conducted at a Taiwanese medical center. We enrolled 121 participants (34 with high demoralization and 87 with low demoralization, as per the Mandarin Version of Demoralization Scale). High demoralization was associated with reduced quality of life, sleep quality, and spiritual interests. Multivariate analyses revealed that the scores of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire ≥ 62.5 (OR = 0.21, p = 0.002) and Spiritual Interests Related to Illness Tool Chinese Version ≥ 3.66 (OR = 0.11, p < 0.001) were associated with low demoralization. Demoralized patients with depression had a poorer quality of life and sleep quality. Although not statistically significant, depressed and demoralized participants were at a higher risk of suicide. Cancer patients with both depression and demoralization had the worst prognosis. Breast cancer patients exhibited demoralization when they had unmet bio-psycho-social-spiritual needs. An early assessment of demoralization may improve holistic healthcare for breast cancer patients.

Mental state of demoralisation across diverse clinical settings: A systematic review, meta-analysis and proposal for its use as a 'specifier' in mental illness

OBJECTIVE

Demoralisation is a state of poor coping characterised by low morale, hopelessness, subjective incompetence, and loss of meaning and purpose in life. While studied extensively in oncology and palliative care, there has been recent exploration in broader medical and mental health settings. The aim was to investigate the prevalence of demoralisation and associated sociodemographic and psychological factors across these clinical settings.

METHOD

Six electronic databases were used to locate articles from January 2014 to March 2020. A pre-publication update of non-oncology populations was completed in September 2021. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled prevalence of demoralisation was determined through % prevalence and mean demoralisation score; this was synthesised through meta-analysis of single means to determine pooled mean prevalence of Demoralisation Scale scores using the 'R' statistical software.

RESULTS

Demoralisation has been examined in 52 studies (n = 11,670) and found to be prevalent in 24-35% of oncology and non-oncology, including mental health, populations. The mean score on the Demoralisation Scale was 24.3 (95% confidence interval, CI = [21.3, 27.3]). There was evidence of divergent validity in addition to significant comorbidity between depression, demoralisation and suicidal ideation. Burdensome physical symptoms, and psychological and demographic factors are strongly correlated with demoralisation.

CONCLUSION

There remains a need to recognise demoralisation in various clinical and cultural settings and to strongly consider its inclusion as a 'specifier' within formal nosological systems for adjustment and depressive disorders. This is important to initiate targeted interventions and prevent significant morbidity.

Suicidal ideation and attempted suicide among cancer patients during the COVID-19 pandemic

This study aimed to understand the suicidal ideation and suicidal attempts among cancer patients during the COVID-19 pandemic. The data were collected from patients diagnosed with cancer while attending the largest cancer center in the south of China. A structured questionnaire was used to investigate patients' demographic data, suicidal behavior, and factors related to COVID-19. Mental health conditions were measured by the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, and the Brief Symptom Inventory. Comorbidities and medical conditions of cancer patients were extracted from the electronic healthcare records. Among the 5670 cancer patients, 755 (13.3%) reported suicidal ideation, and 266 (4.7%) reported suicidal attempts during the COVID-19 pandemic. The age group with the highest risk of suicidal ideation was 20-24 years (23.9%). Lifetime history of suffering from mental disorders, longer time since cancer diagnosis, regional and distant tumor stage, depression, anxiety, hostility, having a higher frequency of worrying about cancer management due to COVID-19, higher frequency feeling of overwhelming psychological pressure due to COVID-19, having a higher level of barriers to manage cancer due to COVID-19, and higher barriers to continue treatment of cancer due to inconveniences caused by COVID-19, were all significantly associated with increased risk of suicidal ideation. We also identified the risk factors of suicide attempts. This is the first study investigating the prevalence and risk factors associated with suicidal ideation and suicidal attempts in Chinese cancer patients during the COVID-19 pandemic. Our findings suggest that it is essential to monitor the mental health conditions of this vulnerable population, especially for cancer patients who have comorbidity with a history of mental disorders. Also, government policymakers should take action to protect cancer patients to avoid any interruption of their continued treatment. Further efforts are urgently required to develop specific psychological interventions to reduce the risk factors among cancer patients during the COVID-19 pandemic.

Demoralization level fluctuated at various time frame of radiotherapy for patients with different cancers: a longitudinal observational study

Background

Demoralization is a psychological response that is frequently observed in patients with cancer or advanced diseases. It is affected by national characteristics, culture, disease characteristics and general conditions of the patient such as individual cultural features, nature of stress, personal expression preferences and social behavior. Compared with the results of previous studies on demoralization syndrome, patients with cancer in Taiwan exhibit a higher prevalence of demoralization. We aimed to investigate the prevalence of high demoralization and the changes in the level of demoralization in cancer patients during radiotherapy to explore the associated factors and the contributing factors to the high level of demoralization.

Methods

We used the Demoralization Scale-Mandarin Version to evaluate the demoralization level at six-time points in patients admitted for radiotherapy in a 3-month observational period. 101 patients allocated to three groups by cancer region completed the study. We applied the generalized estimating equation (GEE) to analyze the changes in the demoralization level among the three groups. The variables associated with the changes in the demoralization level were also investigated.

Results

In the analysis using univariate GEE, only patients in the chest and breast group exhibited significant changes at two different time points. The results obtained using multivariate GEE revealed that sociodemographic variables, stage of disease and use of surgery or chemotherapy had no impact on the changes in demoralization across three months.

Conclusion

The demoralization level certainly fluctuated in an extremely high range. The higher prevalence of demoralized patients may indicate that if medical staff neglect the importance of demoralization, demoralized patients with cancer may not receive appropriate care.

Demoralization in suicide: A systematic review

OBJECTIVE

In psychiatric literature, few original studies exist on the topic of demoralization in suicide. In this review, we aim to identify original studies on suicidal ideation (SI)/suicidal behavior (SB) and demoralization in populations of community-dwellers and patients with somatic or psychiatric disorders.

METHODS

We employed a systematic approach that followed PRISMA guidelines, searching through four major electronic databases (PubMed/MEDLINE, Scopus, Science Direct, and PsychINFO) for relevant titles/abstracts published from January 1980-June 2021. We included original studies that explicitly mentioned the investigation of a potential association between SI/SB and demoralization.

RESULTS

A total of 18 studies met our inclusion criteria. Their synthesis revealed that demoralization can be associated with SI/SB in a wide range of populations (community dwellers, patients with somatic or psychiatric disorders) and lead to significantly higher suicide risk (odds ratios of >6 were encountered in community dwellers experiencing financial hardship or isolation). Moreover, demoralization alone (about half the patients who were demoralized did not meet the criteria for an affective disorder nor were they clinically depressed) or together with depression has been identified as a major risk factor for SI/SB. Regarding the crucial issue of progression from SI to SA, in the context of the "ideation-to-action" frame, some authors found that the interaction of demoralization and over-arousal could be a useful predictor for this progression, while others found that depression alone was sufficient to differentiate attempters from non-attempters or the interaction with shutdown (helplessness and low positive emotions).

CONCLUSION

These results emphasize the possibility to identify demoralization as an independent risk factor for suicide. In patients with psychiatric disorders, the association between demoralization and SI/SB may be transnosographic. Overall, from the clinical implications perspective, our findings highlight that: i. Assessment of demoralization may contribute to a more comprehensive suicide risk detection. This appears particularly relevant in Emergency Departments (EDs) where heterogeneous population typologies are usually admitted and a clinical diagnosis of depression is often difficult to be defined. ii. Additionally, since meaninglessness is considered one of the demoralization subcomponents, meaning-centered psychotherapeutic approaches prove to be indicated and they can be initiated already at the EDs upon first contact with the patient. Further studies are necessary to confirm these findings.

A cross-sectional study on demoralization in prostate cancer patients: the role of masculine self-esteem, depression, and resilience

Purpose

The current cross-sectional study had three objectives: (1) to assess the prevalence of depression and demoralization in a sample of prostate cancer (PCa) patients; (2) to examine whether masculine self-esteem and depression were associated with demoralization; and (3) to evaluate the role of resilience as a factor buffering the effects of masculine self-esteem and depression on demoralization.

Methods

197 PCa patients aged 48 to 79 years (M = 67.19; SD = 6.83) answered questions about masculine self-esteem, depression, resilience, and demoralization. An ANOVA was conducted to examine whether the association between demoralization and depressive symptoms was linear. A chi-square test was calculated to determine differences between depression and demoralization. Finally, a hierarchical multiple linear regression analysis with interaction terms was conducted to examine the associations between masculine self-esteem, depression, resilience, and demoralization.

Results

Depression scores increased linearly with demoralization severity, but demoralization scores were higher than depression scores (21.3% vs. 15.2%). Lower scores on masculine self-esteem and higher scores on depressive symptoms were associated with greater demoralization. Resilience significantly moderated the association between masculine self-esteem and demoralization, but not between depression and demoralization.

Conclusion

Assessment of depression, masculine self-esteem, resilience, and demoralization in the clinical setting is critical for improving the mental health status of PCa patients.

Development and validation of a model for predicting the risk of suicide in patients with cancer

OBJECTIVE

The objective of this study was to establish a nomogram model to predict SI in patients with cancer and further evaluate its performance.

METHOD

This study was performed among 390 patients in oncology departments of Affiliated Hospital of Nantong University from April 2020 to January 2021. Of these, eligible patients who were diagnosed with cancer were split into training and validation cohorts according the ratio of 2:1 randomly. In the training cohort, multivariate regression was performed to determine the independent variables related to SI. A nomogram was built incorporating these variables. The model performance was evaluated by an independent validation cohort.

RESULTS

The prevalence of SI in patients with cancer was 22.31% and 19.23% in training and validation cohorts, respectively. The nomogram model suggested independent variables for SI, including depression, emotional function, time after diagnosis, family function and educational status. The area under the curve (AUC) was 0.93 (95%CI, 0.90-0.97) and 0.82 (95%CI, 0.74-0.90) in training and validation cohorts respectively, which indicated good discrimination of the nomogram in predicting SI in cancer patients. The p-value of the goodness of fit (GOF) test was 0.197 and 0.974 in training and validation cohorts respectively, suggesting our nomogram model has acceptable calibration power, and the calibration curves further indicated good calibration power.

CONCLUSION

In conclusion, the nomogram model for predicting individualized probability of SI could help clinical caregivers estimate the risk of SI in patients with cancer and provide appropriate management.

Predictive value of the Distress Thermometer score for risk of suicide in patients with cancer

PURPOSE

This study aimed to assess the association between the Distress Thermometer (DT) score and risk of suicide in patients with cancer. In addition, we aimed to determine the best cutoff score to predict patients at risk of suicide.

METHODS

From 2015 to 2016, we retrospectively collected data on patients with cancer. DT scores were collected, and the association between DT score and risk of suicide (suicide ideation or death ideation) was analyzed. Furthermore, receiver operating characteristic (ROC) analysis was performed to identify the appropriate cutoff score for predicting risk of suicide.

RESULTS

A total of 260 patients with cancer were included, and suicidal ideation was identified in 33 cases referred for psychological intervention. The DT scores of the patients with suicidal ideation were significantly higher than those of patients without suicidal ideation (6.30±2.11 vs. 4.29±1.72, p<0.05). In addition, the area under the ROC curve for predicting risk for suicide was 0.758. The cutoff DT score of 3 had the highest sensitivity of 1.00 to rule out suicidal ideation, while 9 had the highest specificity of 1.00 to rule in suicidal ideation. Moreover, the appropriate cutoff DT score to predict patients with suicidal ideation was 5, with a sensitivity of 0.52, specificity of .84, positive likelihood ratio of 3.24, and negative likelihood ratio of 0.58.

CONCLUSION

The DT score may be a helpful clinical tool to evaluate emotional distress and risk of suicide in patients with cancer. Clinically, for DT scores greater than 5 in patients with cancer, the risk of suicide greatly increases. In view of the DT's widespread use internationally by non-mental health clinicians in cancer to guide the need for specialist mental health interventions, its potential utility in also predicting suicide risk is of great interest.

Incidence and risk factors for suicidal ideation in a sample of Chinese patients with mixed cancer types

PURPOSE

Suicidal ideation (SI) is often overlooked as a risk factor for people with cancer. Because it is often a precursor for suicidal behavior, it is critical to identify and address SI in a timely manner. This study investigated SI incidence and risk factors in a cohort of Chinese patients with mixed cancer types.

METHODS

Data from this cross-sectional study were collected from 588 patients receiving medical therapy for tumors at Nanfang Hospital and the Integrated Hospital of Traditional Chinese Medicine at Southern Medical University. SI was measured using the Self-rating Idea of Suicide Scale (SIOSS). Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). The Chinese version of the Demoralization Scale II (DS-II-C) was used to assess demoralization. Univariate and correlation analyses were used to identify correlative factors of SI and multiple stepwise linear regression analysis was used to characterize potential risk factors.

RESULTS

SI was reported in 24.7% of participants and the SIOSS score was 14.00 (13.00, 15.00) in the SI group. Multiple linear regression results showed that demoralization, medical financial burden, cancer type, living condition, caretaker, working state, residence, gender, and marital status explained 32.1% of the SI in this cohort (F = 28.705, P < 0.001).

CONCLUSION

Approximately one-quarter of cancer patients in this study reported SI influenced by both external and internal factors. Characterizing these factors can be informative for prevention and treatment efforts.

Prevalence and risk factors for suicidality in cancer patients and oncology healthcare professionals strategies in identifying suicide risk in cancer patients

PURPOSE OF REVIEW

The aim of this study was to summarize the literature on prevalence and risk factors for suicidality in cancer patients and to document the research on oncology healthcare professionals' strategies in identifying this risk.

RECENT FINDINGS

Cancer patients exhibit increased risk of suicidality compared with the general population. Various risk factors have been identified including sociodemographic factors such as poverty, being male and elderly as well as disease-related attributes such as cancer type and stage. The literature on how healthcare professionals identify suicide risk is sparse. Ten articles were found that focused on two main themes. These included information on systematic strategies in identifying suicide risk and factors that affect healthcare professionals' ability to identify risk in their patients.

SUMMARY

Although there is an immense amount of literature documenting the problem of suicidality among patients, the research on how healthcare professionals identify and respond to these indications in patients is nearly nonexistent. Cancer centres should implement standardized and systematic screening of cancer patients for suicidality and research on this patient population should collect and report these data. Ongoing training and education for healthcare professionals who work in the oncology setting on how to identify and respond to suicide risk among cancer patients is urgently needed.

Severe Suicidality in Athletes with Chronic Traumatic Encephalopathy: A Case Series and Overview on Putative Ethiopathogenetic Mechanisms

Chronic traumatic encephalopathy (CTE) results from repetitive brain injuries and is a common neurotraumatic sequela in contact sports. CTE is often accompanied by neuropsychiatric symptoms, which could escalate to suicidal ideation (SI) and suicidal behaviour (SB). Nevertheless, fairly limited emphasis about the association between suicidality and CTE exists in medical literature. Here, we report two cases of retired professional athletes in high contact sports (boxing and ice hockey) who have developed similar clinical trajectories characterized by progressive neuropsychiatric symptoms compatible with a CTE diagnosis and subsequent SB in its severe forms (medical serious suicide attempt (SA) and completed suicide). In addition to the description of outlining clinical, neuropsychological, neuroimaging, and differential diagnosis elements related to these cases, we also hypothesized some mechanisms that might augment the suicide risk in CTE. They include those related to neurobiological (neuroanatomic/neuroinflammatory) dysfunctions as well as those pertaining to psychiatry and psychosocial maladaptation to neurotraumas and retirement from professional competitive activity. Findings described here can provide clinical pictures to improve the identification of patients with CTE and also potential mechanistic insights to refine the knowledge of eventual severe SB development, which might enable its earlier prevention.

Suicidality in Patients with Brain Tumors: A Brief Literature Review with Clinical Exemplar

Background: Suicidality and brain tumors are two life-threatening conditions and, somewhat unexpectedly, the associations between them have scarcely been reported. Objective: In this study, we aimed to provide a brief literature review of epidemiological studies on suicidal ideation (SI) and suicidal behavior (SB) in patients with brain tumors. To illustrate various aspects of brain tumors that potentially underlie the emergence of suicidality, the review is supplemented with a clinical exemplar of a long-term survivor of brain tumor (glioblastoma) who experienced persistent SI. Furthermore, we discuss putative both neurobiological (including anatomical and immunological) and psychosocial mechanisms that might be accountable for the development of SI and SB in patients with brain tumors. Conclusions: While the etiology of this phenomenon appears to be multifactorial and still remains a subject of much debate, it is of critical importance to identify patients for which a psychiatric evaluation could recognize, in a timely manner, a possible suicide risk and alleviate the deep related suffering, by appropriate psychopharmacological and supportive and psychotherapeutic interventions.

Serial multiple mediation of demoralization and depression in the relationship between hopelessness and suicidal ideation

OBJECTIVE

Suicidal ideation is common in cancer patients and may be associated with hopelessness, demoralization, and depression. This study aims to investigate the serial multiple mediation of demoralization and depression in the relationship between hopelessness and suicidal ideation in cancer patients.

METHODS

A total of 244 cancer patients were investigated by using the following standardized self-reported questionnaires: self-rating idea of suicide scale, Beck hopelessness scale, demoralization scale-Mandarin version, and patient health questionnaire depression scale-9. The mediation hypothesis was tested with a serial multiple mediation model (PROCESS model 6). An exploratory graph analysis was performed to detect the correlations among the dimensions of the mental conditions measured by these instruments.

RESULTS

Bootstrap analyzes indicate that there were direct and indirect effects of hopelessness on suicidal ideation mediated solely by demoralization (B = 2.3074, SE = 0.1724, P < .001) or by demoralization together with depression (B = 0.1605, SE = 0.0303, 95% confidence interval [CI] = 0.1102 to 0.2303). The mediation of depression alone in the relationship between hopelessness and suicidal ideation was insignificant (B = 0.1541, SE = 0.0519, 95% CI = -0.0565 to 0.0715). The exploratory graph analysis suggests that the strongest edge of dimensions between demoralization and suicidal ideation was desperation-disheartenment (0.62).

CONCLUSIONS

The results of the study support the hypothesis that demoralization and depression mediate between hopelessness and suicidal ideation. The early identification of and interventions for hopelessness, demoralization, and depression may prevent cancer patients from developing suicidal ideation.

Suicidal Ideation in Newly-Diagnosed Chinese Cancer Patients

OBJECTIVE

Suicide is one of the main reasons cited behind the death rate of cancer, and suicidal ideation (SI) is the first step toward it. This study aimed to investigate the prevalence and associates of suicidal ideation in newly-diagnosed Chinese cancer patients.

METHODS

This multicenter study was conducted from January 2018 to September 2019. Eligible participants were asked to complete a Case Record Form (CRF), the Patient Health Questionnaire (PHQ-9), General Anxiety Disorder Questionnaire (GAD-7), Fear of Cancer Recurrence Questionnaire (FCRQ-7), and McGill Pain Questionnaire-Visual Analogue Scale (MPQ-VAS). Univariate analyses and multivariate logistic regression analyses were conducted for assessment.

RESULTS

Out of 603 patients, 91 (15.1%, 95%CI: 12.23%-17.96%) reported suicidal ideation in the last 2 weeks. Physical comorbidities (OR=1.808, P=0.039), childhood adversity experience (OR=5.999, P=0.001), cancer pain (OR=1.828, P=0.047), depression (OR=2.811, P=0.013), and anxiety (OR=6.532, P<0.001) were significantly associated with suicidal ideation. It was also found that patients who regularly exercised were less likely to report suicidal thoughts (OR=0.172, P=0.007).

CONCLUSION

Physical comorbidities, body ache, and mood disturbances are possible risk factors for suicidal ideation that warrant further attention in clinical practice. Preventive measures, such as systematic screening and arrangement for regular check-ups, could be beneficial to lower the risk of suicide.