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Palliative Medicine, Vol. 20, No. 8, 779-789 (2006)
DOI: 10.1177/0269216306072347

Measurement of psychological distress in palliative care

Brian Kelly

Centre for Rural and Remote Mental Health, University of Newcastle, Orange, Australia, brian.kelly{at}newcastle.edu.au

Susan McClement

Faculty of Nursing, University of Manitoba, Manitoba, Canada

Harvey Max Chochinov

Department of Psychiatry, University of Manitoba, Manitoba, Canada

Research investigating the psychological distress of palliative care patients has contributed to our understanding of the needs and experiences of individuals approaching death. This paper aims to provide a brief review of such measurement of psychological distress in palliative care, focusing on established psychiatric and psychological research tools, and quantitative research methods. This includes clinical screening and diagnostic assessment instruments used to identify key distress-related symptoms and the presence of common clinical syndromes, such as depression, anxiety, delirium, as well as the broader psychological dimensions of suffering, such as existential concerns, spirituality, hope and demoralisation. There are important considerations in undertaking psychological research in palliative care, such as maintaining a balance between the methods and measurements that will address key research questions, and sensitivity to the range of physical and emotional demands facing individuals at the point of receiving palliative care. The clinical application of psychological and psychiatric research tools and methods can aid the detection of psychological distress, aid the thorough assessment of the psychological dimension of the patients’ illness and care, aid the identification of individuals who would benefit from specific psychotherapeutic or pharmacologic interventions, and the evaluation of response to treatments.

Key Words: anxiety • depression • palliative care • psychological distress • research

References

  • Ridner SH. Psychological distress: concept analysis . J Adv Nurs 2004; 45(5): 536-545 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Vachon M. Psychosocial distress and coping after cancer treatment . Am J Nurs 2006; 106(Suppl 3): 26-31 .[ISI][Medline] [Order article via Infotrieve]
  • Rodin GM, Nolan RP, Katz MR. Depression. In Levenson JL ed. Textbook of psychosomatic medicine. American Psychiatric Publishing Inc ., 2005: 193-217.
  • Ryan H, Schofield P, Cockburn J, et al. Howto recognize and manage psychological distress in cancer patients . Eur J Cancer Care 2005; 14: 7-15 .[CrossRef]
  • Zabora J, Brintzenhofeszoc K, Curbow B, et al. The prevalence of psychological distress by cancer site . Psychooncology. 2001 Jan-Feb; 10(1); 19-28 .[CrossRef][Medline] [Order article via Infotrieve]
  • Wilson K, Chochinov HM, de Faye BJ, et al. Diagnosis and management of depression in palliative care. In Chochinov M, Breitbart W eds. Handbook of psychiatry in palliative medicine. Oxford University Press , 2000: 25-49.
  • Gruneir A, Smith TF, Hirdes J, et al. Depression in patients with advanced illness: an examination of Ontario complex continuing care using the Minimum Data Set 2 .0. Palliat Support Care 2005; 3(2): 99-105 .[Medline] [Order article via Infotrieve]
  • Addington-Hall JM, Higginson IJ eds. Palliative care for non-cancer patients. Oxford University Press , 2001.
  • Robinson RG. Poststroke depression: prevalence, diagnosis, treatment and disease progression . Biol Psychiatry 2003; 54: 376-387 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Lagopoulos J, Nalhi GS, Ivanovski B, et al. A matter of motion or an emotional matter? Management of depression in Parkinson’s disease . Expert Rev Neurother 2005; 5(6): 803-810 .
  • Lyketsos CG, Lopez O, Jones B, et al. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study . JAMA 2002; 288: 1475-1483 .[Abstract/Free Full Text]
  • Murillo M, Holland JC. Clinical practice guidelines for the management of psychosocial distress at the end of life . Palliat Support Care 2004; 2: 65-77 .[Medline] [Order article via Infotrieve]
  • Kristeller JL, Zumbrun CS, Schilling RF. ‘I would if I could:’ how oncologists and oncology nurses address spiritual distress in cancer patients . Psychooncology 1999; 8(5): 451-458 .[CrossRef][Medline] [Order article via Infotrieve]
  • Breitbart W, Chochinov HM, Passik SD. Psychiatric symptoms in palliative medicine. In Doyle D, Hanks G, Cherny N, Calman K eds. Oxford textbook of palliative medicine, third edition. Oxford University Press , 2004: 750-755.
  • Chochinov HM. Thinking outside the box: depression, hope, and meaning at the end of life . J Palliat Med 2003; 6: 973-977 .[CrossRef][Medline] [Order article via Infotrieve]
  • Pessin H, Rosenfeld B, Breitbart W. Assessing psychological distress near the end of life . Am Behav Sci 2002; 46(3): 357-372 .[Abstract/Free Full Text]
  • Breitbart W, Bruera E, Chochinov H, et al. Neuropsychiatric syndromes and psychological symptoms in patients with advanced cancer . J Pain Symptom Manage 1995; 10(2): 131-141 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Morita T, Kawa M, Honke Y, et al. Existential concerns of terminally ill cancer patients receiving specialized palliative care in Japan . Support Care Cancer 2004; 12(2): 137-140 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Moadel A, Morgan C, Fatone A, et al. Seeking meaning and hope: self-reported spiritual and existential needs among an ethnically-diverse cancer patient population . Psychooncology 1999; 8(5): 378-385 .[CrossRef][Medline] [Order article via Infotrieve]
  • Chochinov HM, Wilson KG, Enns M, et al. ‘Are you depressed?’ Screening for depression in the terminally ill . Am J Psychiatry 1997; (154): 674-676 .
  • Holland J. NCCN practical guidelines for the management of psychosocial distress . Oncology 1999; 13(5A): 113-147 .
  • Ransom S, Jacobsen PB, Booth-Jones M. Validation of the distress thermometer in bone marrow transplant patients . Psychooncology 2006; 15: 739-747 .[CrossRef][Medline] [Order article via Infotrieve]
  • Steinhauser KE, Voils CI, Clipp EC, et al. ‘Are you at peace?’: one item to probe spiritual concerns at the end of life . Arch Intern Med 2006; 166(1): 101-105 .[Abstract/Free Full Text]
  • Peterman AH, Fitchett G, Brady MJ, et al. Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy -Spiritual Well-being Scale (FACIT-Sp) . Ann Behav Med 2002; 24(1): 49-58 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Bruera E, Kuehn N, Miller MJ, et al. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients . J Palliat Care 1991; 7(2): 6-9 .[Medline] [Order article via Infotrieve]
  • Wilson KG, Graham ID, Viola RA, et al. Structured interview assessment of symptoms and concerns in palliative care . Can J Psychiatry 2004; 49: 350-358 .[Medline] [Order article via Infotrieve]
  • Aminoff BZ, Purits E, Noy S, et al. Measuring the suffering of end-stage dementia: reliability and validity of the Mini-Suffering State Examination . Arch Gerontol Geriatr 2004; 38(2): 123-130 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Akechi T, Okuyama T, Akizuki N, et al. Course of psychological distress and its predictors in advanced non-small cell lung cancer patients . Psychooncology 2006; 15(6): 463-473 .[CrossRef][Medline] [Order article via Infotrieve]
  • Nelson CJ, Rosenfeld B, Breitbart W, et al. Spirituality, religion, and depression in the terminally ill . Psychosomatics 2002; 43(3): 213-220 .[Abstract/Free Full Text]
  • McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients . Lancet 2003; 361: 1603-1607 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill . Am J Psychiatry 1995; 152(8): 1185-1191 .[Abstract/Free Full Text]
  • Chochinov HM, Tataryn D, Clinch JJ, et al. Will to live in the terminally ill . Lancet 1999; 354: 816-819 .[ISI][Medline] [Order article via Infotrieve]
  • Rosenfeld B, Breitbart W, Stein K, et al. Measuring desire for death among patients with HIV/AIDS: the schedule of attitudes toward hastened death . Am J Psychiatry 1999; 156: 94-100 .[Abstract/Free Full Text]
  • Rosenfeld B, Breitbart W, Galietta M, et al. The schedule of attitudes toward hastened death: measuring desire for death in terminally ill cancer patients . Cancer 2000; 88: 2868-2875 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Webster K, Odom L, Peterman A, et al. The Functional Assessment of Chronic Illness Therapy (FACIT) measurement system: validation of version 4 of the core questionnaire . Qual Life Res 1999; 8: 604-604 .
  • Byock I, Merriman M. Measuring quality of life for patient with terminal illness: The Missoula Quality of Life Index (MVQOLI) . Palliative Medicine 1998; 12: 231-244 .[Abstract/Free Full Text]
  • Cohen SR, Mount BM, Bruera E, et al. Validity of the McGill Quality of Life Questionnaire in the palliative care setting: a multi-centre Canadian study demonstrating the importance of the existential domain . Palliat Med 1997; 11: 3-20 .[ISI][Medline] [Order article via Infotrieve]
  • Steinhauser KE, Clipp EC, Bosworth HB, et al. Measuring quality of life at the end of life: validation of the QUAL-E . Palliat Support Care 2004; 2(1): 3-14 .[Medline] [Order article via Infotrieve]
  • Groenvold M, Petersen MA, Aaronson NK, et al.; EORTC Quality of Life Group. The development of the EORTC QLQ-C15-PAL: a shortened questionnaire for cancer patients in palliative care . Eur J Cancer 2006; 42(1): 55-64 . Epub 12 September 2005. EORTC questionnaires/(QLQ-C15-PAL).[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure . J Clin Oncol 1993; 11(3): 570-579 .[Abstract/Free Full Text]
  • Graham KY, Longman AJ. Quality of life and persons with melanoma. Preliminary model testing . Cancer Nurs 1987; 10(6): 338-346 .[ISI][Medline] [Order article via Infotrieve]
  • Stiefel R, Die Trill M, Berney A, et al. Depression in palliative care: a pragmatic report from Expert Working Group of the European Association for Palliative Care . Support Care Cancer 2001; 9(7): 477-488 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Hotopf M, Chidgey J, Addington-Hall J, et al. Depression in advanced disease: a systematic review. Part 1. Prevalence and case finding . Palliat Med 2002; 16(2): 81-97 . http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf [Abstract/Free Full Text]
  • Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity and comorbidity of 12 month DSM-IV disorders in the National Comorbidity Survey Replication . Arch Gen Psychiatry 2005; 62: 617-627 .[Abstract/Free Full Text]
  • Alonso J, Angermeyer MC, Bernet S, et al.; The ESEMed/MHEDEA 2000 Investigators. The prevalence of mental disorders in Europe: results of the European Study of the Epidemiology of Mental Disorders (ESEMed) project . Acta Psychiatr Scand 2004; S109: 21-27 .
  • Robins LN, Helzer JE, Croughan J, et al. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics and validity . Arch Gen Psychiatry 1981; 38: 381-389 .[Abstract]
  • Kessler RC, Ustun TB. The World Mental Health (WMH) Survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) . Int J Methods Psychiatr Res 2004; 13(2): 93-121 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Endicott, J, Spitzer R. A diagnostic interview: the schedule for affective disorders and schizophrenia . Arch Gen Psychiatry 1978; 35: 837-844 .[Abstract]
  • Spitzer RL, Williams JBW, Biggon M, et al. Structure clinical interview for DSM-III-R. American Psychiatric Press , 1990.
  • von Ammon Cavanaugh S. Depression in the medically ill. Critical issues in diagnostic assessment . Psychosomatics 1995; 36(1): 48-59 .[Abstract/Free Full Text]
  • Endicott J. Measurement of depression in patients with cancer . Cancer 1984; 53: 2243-2248 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Zabora JR. Screening procedures for psychosocial distress. In Holland J ed. Psycho-oncology. Oxford University Press , 1998: 653-661.
  • Lloyd-Williams. Screening for depression in palliative care patients: a review . Eur J Cancer Care 2001; 10: 31-35 .[CrossRef]
  • Lloyd-Williams M, Dennis M, Taylor F, et al. Is asking patients in palliative care, ‘Are you depressed?’ appropriate? Prospective study . BMJ 2003; 327: 372-373 .[Free Full Text]
  • Akechi T, Okyama T, Sugawara Y, et al. Screening for depression in terminally ill cancer patients in Japan . J Pain Symptom Manage 2006; 31(1): 5-12 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Radloff LS. The CES-D: a self-report depression scale for research in the general population . Appl Psychol Meas 1977; 3: 385-401 .
  • Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale . Acta Psychiatry Scand 1983; 67: 361-370 .[ISI][Medline] [Order article via Infotrieve]
  • Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. Psychological Corporation , 1996.
  • Clarke DM, Kissane DW, Trauer T, et al. Demoralization, anhedonia and grief in patients with severe physical illness . World Psychiatry 2005; 4(2): 96-105 .[Medline] [Order article via Infotrieve]
  • Kissane DW, Wein S, Love A, et al. The Demoralization Scale: a report of its development and preliminary validation . J Palliat Care 2004; 20(4): 269-276 .[ISI][Medline] [Order article via Infotrieve]
  • Kristjanson LJ. Conceptual issues related to measurement in family research . Can J Nurs Res 1992; 24(3): 37-51 .[Medline] [Order article via Infotrieve]
  • Snaith P. What do depression rating scales measure? Br J Psychiatry 1993; 163: 293-298 .[Abstract/Free Full Text]
  • Ewing G, Todd C, Rogers M, et al. Validation of a symptom measure suitable for use among palliative care patients in the community: CAMPAS-R . J Pain Symptom Manage 2004; 27(4): 287-299 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Kadan-Lottick NS, Vanderwerker LC, Block SD, et al. Psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study . Cancer 2005; 104: 2872-2881 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Hearn J, Higgins IJ. Development and validation of a core outcome measure for palliative care: the palliative care outcome scale . Qual Health Care 1999; 8: 219-227 .[Abstract]
  • Aaronson NK, Ahmedzai S, Bergman B, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology . J Nat Cancer Inst 1993; 85(5): 365-376 .[Abstract/Free Full Text]
  • Portenoy RK, Thaler HT, Kornblith AB, et al. The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress . Eur J Cancer 1994; 30A: 1326-1336 .
  • Stromgren AS, Goldschmidt D, Groenvold M, et al. Self-assessment in cancer patients referred to palliative care: a study of feasibility and symptom epidemiology . Cancer 2002; 94(2): 512-520 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Lloyd-Williams M, Friedman T, Rudd N. An analysis of the validity of the Hospital Anxiety and Depression Scale as a screening tool in patients with advanced metastatic cancer . J Pain Symptom Manage 2001; 6: 990-996 .
  • Le Fevre P, Devereux J, Smith S, et al. Screening for psychiatric illness in the palliative care inpatient setting: a comparison between the Hospital Anxiety and Depression Scale and the General Health Questionnaire-12 . Palliat Med 1999; 13: 399-407 .[Abstract/Free Full Text]
  • Harter M, Woll S, Wunsch A, et al. Screening for mental disorders in cancer, cardiovascular and musculoskeletal diseases. Comparison of HADS and GHQ-12 . Soc Psychiatry Psychiatr Epidemiol 2006; 41: 56-62 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Carlson LE, Blutz BD. Cancer distress screening: needs, models and methods . J Psychosom Res 2003: 55(5); 403-409 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Akechi T, Okuyama T, Sugawara Y, et al. Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors . J Clin Oncol 2004; 22: 1957-1965 .[Abstract/Free Full Text]
  • Kangas M, Henry JL, Bryant RA. Predictors or post-traumatic stress disorder following cancer . Health Psychol 2005; 24: 579-585 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Smith MY, Redd WH, Peyser C, et al. Post-traumatic stress disorder in cancer: a review . Psychooncology 1999; 8: 521-537 .[CrossRef][Medline] [Order article via Infotrieve]
  • Baider L, Holland JC, Russak SM, et al. System of Belief Inventory . Psychooncology 2001; 10: 534-540 .[CrossRef][Medline] [Order article via Infotrieve]
  • Gagnon P, Allard P, Masse B, et al. Delirium in terminal cancer: a prospective study using daily screening, early diagnosis, and continuous monitoring . J Pain Symptom Manage 2000; 19: 412-426 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Lawlor PG, Faisinger RL, Bruera, ED. Delirium at the End of Life. Critical Issues in Clinical Practice and Research . J Am Med Assoc 2000; 284(19): 2427-2429 .[Free Full Text]
  • Smith MJ, Breitbart WS, Platt MM. A critique of instruments and methods to detect, diagnose and rate delirium . J Pain Symptom Manage 1995; 10: 35-77 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC , 1994.
  • Hjermstad MJ, Loge JH, Kaasa S. Methods for assessment of cognitive failure and delirium in palliative care patients: implications for practice and research . Palliat Med 2004; 18: 494-506 .[Abstract/Free Full Text]
  • Klepstad P, Hilton P, Moen J, et al. Self-reports are not related to objective assessments of cognitive function and sedation in patients with cancer pain admitted to a palliative care unit . Palliat Med 2002; 16: 13-19 .[Abstract/Free Full Text]
  • Folstein MF, Folstein SE, McHugh PR. ‘Minimental state’: a practical method of grading the cognitive state of patients for the clinician . J Psychiatry Res 1975; 12: 189-198 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Fayers PM, Hjermstad MJ, Ranhoff AH, et al. Which mini-mental state exam items can be used to screen for delirium and cognitive impairment? J Pain Symptom Manage 2005; 30: 41-50 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Stillman MJ, Rybicki LA. The bedside confusion scale: development of a portable bedside test for confusion and its application to the palliative medicine population . J Palliat Med 2003; 3(4): 449-456 .
  • Breitbart W, Rosenfeld B, Roth A, et al. The Memorial Delirium Assessment Scale . J Pain Symptom Manage 1997; 13: 128-137 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Lawlor PG, Faisinger RL, Bruera, ED. Delirium at the end of life . Crit Iss Clin Pract Res, J Am Med Assoc 2000; 284(19): 2427-2429 .
  • Inouye S, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method: a new method for detection of delirium . Ann Intern Med 1990; 113: 941-948 .[ISI][Medline] [Order article via Infotrieve]
  • Caraceni A, Nanni O, Maltoni M, et al. Impact of delirium on the short term prognosis of advanced cancer patients, Italian Multicenter Study Group on Palliative Care . Cancer 2000; 89: 1145-1149 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Inouye S, van Dyck CH, Alessi CA, et al. Clarifying Confusion: The Confusion Assessment Method: A new Method for Detection of Delirium . Ann Int Med 1990; 113: 941-948 .[ISI][Medline] [Order article via Infotrieve]
  • Turkel SB, Braslow K, Tavare CJ, et al. The Delirium Rating Scale in children and adolescents . Psychosomatics 2003; 44: 126-129 .[Abstract/Free Full Text]
  • Morita T, Tsunoda J, Inoue S, et al. Communication Capacity Scale and Agitation Distress Scale to measure the severity of delirium in terminally ill cancer patients: a validation study . Palliat Med 2001; 15: 197-206 .[Abstract/Free Full Text]
  • Breitbart W, Gibson C, Tremblay A. The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer; their spouses/caregivers, and their nurses . Psychosomatics 2004; 43: 183-194 .
  • Caraceni A, Nanni O, Maltoni M, et al. Impact of delirium on the short term prognosis of advanced cancer patients. Italian Multicenter Study Group on Palliative Care . Cancer 2000, 89: 1145-1149 .[CrossRef][ISI][Medline] [Order article via Infotrieve]
  • Stagno D, Gibson C, Breitbart W.et al. Delirium sub-types . Palliat Support Care 2004; 2: 171-179 .[CrossRef][Medline] [Order article via Infotrieve]
  • Trzepacz PT. The Delirium Rating Scale: its use in consultation-liaison psychiatry research . Psychosomatics 1999; 40: 193-204 .[Abstract/Free Full Text]

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