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

Abstract

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.

Psycho-Existential Symptom Assessment Scale (PeSAS) Screening in Palliative Care

“…The data are noteworthy for the precision involved in prevalence estimates of these symptoms, especially in the severe category. These prevalences are consistent with formal studies of psycho-existential distress (20)(21)(22)(23)(24). Around one half of patients felt trapped by their illness, a clear signifier of distress.…”

“…Early observations by Morita and colleagues in Japan (20) highlighted the prominence of existential distress. Four systematic reviews of studies assessing demoralization in palliative care have revealed prevalences that include 13-18% in 2295 patients using the validated Demoralization Scale (DS) (21), 20-33% in 959 patients using a demoralization interview (22), 18.3% in 1279 cancer patients using the DS (23), and 24-35% in 11,670 oncology and non-oncology patients across 52 more recent studies (24).…”

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

“…1 In 2021, Gan et al reviewed 52 studies and reported that burdensome physical symptoms, psychological factors, reduced quality of life, and risk of suicide were strongly correlated with demoralization in contexts of both oncology and non-oncology. 4 These three systematic reviews provided important insights into demoralization. However, several limitations should not be ignored.…”

“…Regarding physical factors, our review further supports that more physical symptoms predicted increased demoralization for people with cancer. 1,4,17 Effect sizes ranged from small to moderate, and the overall mean effect size was moderate. In the majority of cancer patients, demoralization may be due to stressors related to the occurrence and threat of cancer, pre-existing psychological vulnerabilities, as well as being a direct consequence of biological causes either by physical changes induced by cancer or side effects of treatment.…”

“…The former is a sense of subjective incompetence and hopelessness looking forward, whereas the latter is a preoccupation with anhedonia in the present moment 3 . However, demoralization can be both a precursor of depression or coexist with it; patients with demoralization have a high possibility of developing depression, or a large proportion of patients meet the criteria of comorbidity of demoralization and depression 4 . Globally, the pooled average of the mean demoralization score in cancer patients was higher than in non‐neoplastic patients from 2014 to 2020 4 .…”