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Interventions Can Alleviate Demoralization

Asking demoralized medically ill patients some existential questions can help foster their resistance.

Some evidence from American studies buttresses that from Italian research that demoralization is common among persons who have heart disease, cancer, or other kinds of medical conditions (see story above).

The American evidence comes from James Griffith, M.D., and Lynne Gaby, M.D., of the consultation-liaison psychiatry faculty at George Washington University Medical Center in Washington, D.C.

Griffith told Psychiatric News that several years ago he and Gaby reviewed 100 psychiatric consultations that had been conducted either by themselves or by psychiatry residents they supervised. All of the consultations had been undertaken in response to medical and surgical colleagues' request to "evaluate and treat a patient's depression," which is the most common reason why medical colleagues ask them to consult on their cases.

Griffth and Gaby found that in 52 of the 100 consultations, patients had been given "a depressive disorder" as the primary psychiatric diagnosis (the average Hamilton Depression Rating Scale score was 20), whereas in the remaining 48 consultations, patients had been given "demoralization" as the primary psychiatric descriptor (the average Hamilton score was 11, which is just higher than the normal range).

Thus, demoralization rather than a mood disorder was the major problem for many of these patients, Griffith said.

Moreover, Griffith continued, "We have learned that these patients respond quickly and robustly to two kinds of interventions.... [The interventions are] taking immediate steps at the bedside to relieve either physical or emotional suffering and helping patients regain a sense of hope or dignity or purpose in living that they lost."

For example, Griffith explained, a psychiatrist can do the following:

• Normalize the patient's distress. State to the patient, "I do not believe that you have a psychiatric disorder. You are someone coping normally with a hard situation. Almost anyone would feel as badly as you are feeling in this situation."
  
• Inquire about the patient's priority of concerns. Ask, for example, "What are you most concerned about?"
  
• Partner with the patient in managing some aspect of the situation. This might be relieving physical suffering, such as physical pain, nausea, or insomnia; mobilizing friends or family to visit; or making a phone call to get financial affairs in order.
  
• Ask existential questions that mobilize resilience. For example: "During hard times like this, from where do you draw hope?" "Which people or what things give you reason to want to live?"
  

Griffith and Gaby offered other suggestions on how to help demoralized patients, as well as vignettes illustrating those suggestions, in the April Psychosomatics.

The article "Brief Psychotherapy at the Bedside: Countering Demoralization From Medical Illness" is posted online at <http://psy.psychiatryonline.org/cgi/content/full/46/2/109>.

Psychosomatics 2005 46 109[Abstract/Free Full Text]

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