"It's too much." "It's no use." "I can't take
it anymore." "I give up!" These comments come from
individuals who feel beaten down by adversity, demoralized. Demoralization is
common among persons with heart disease, cancer, gastrointestinal disorders,
and other kinds of general medical conditions, an Italian study has found. In
fact, it is more prevalent than major depression.
The study was headed by Giovanni Fava, M.D., a University of Bologna
psychiatrist. Results appeared in the March Journal of Clinical
Fava and his colleagues recruited about 800 patients from various medical
centers and various types of outpatient clinics—cardiology,
endocrinology, gastroenterology, and oncology—for their study. Each
subject was interviewed by clinical psychologists with extensive experience in
The psychologists used the Structured Clinical Interview for
DSM-IV to obtain a DSM-IV diagnosis for major depression and
the Structured Interview for the Diagnostic Criteria for Psychosomatic
Research (DCPR) to assess for the presence of demoralization in conjunction
with a general medical condition.
The DCPR was developed by an international group of investigators to
translate psychosocial variables that were derived from psychosomatic research
into operational tools by which individual conditions could be identified.
To receive a DSM-IV diagnosis of major depression, an individual
must exhibit, during the same two-week period, five or more symptoms such as
feeling depressed most of the day and nearly every day, experiencing markedly
diminished interest or pleasure in almost all activities most of the day and
nearly every day, losing a marked amount of weight, thinking often about
death, and so forth. But to receive a DCPR assessment of demoralization in
conjunction with a general medical condition, an individual must meet the
following three criteria: (1) feeling as though one has failed to meet his or
her own expectations (or those of others) or that one is unable to cope with
some pressing problems, leading to a sense of helplessness, hopelessness, or
giving up; (2) experiencing the above emotions for at least one month; and (3)
experiencing the feelings closely before the manifestation of a general
medical condition or having the feelings exacerbate one's symptoms.
Fava and his co-workers then analyzed the interview results to determine
how many of their subjects had a major depression and how many were
demoralized. Seventeen percent had a major depression, and 30 percent were
Moreover, the investigators learned, not all subjects with a major
depression were demoralized, and not all demoralized subjects had a major
depression, although subjects often experienced both conditions.
Finally, the prevalence of demoralization was about the same in subjects
regardless of the general medical condition they had. Demoralization was found
in 23 percent of gastroenterology subjects; 32 percent of heart-transplant
subjects; 33 percent of myocardial-infarction subjects; 33 percent of
endocrinology subjects, and 33 percent of oncology subjects.
"These findings suggest a high prevalence of demoralization in the
medically ill and the feasibility of a differentiation between demoralization
and depression," Fava and his team concluded.
The findings, they believe, also point to several questions. For example,
does demoralization thwart a patient's recovery from an illness? If a patient
is both demoralized and seriously depressed, is recovery harder to achieve
than if the patient had only one of these conditions? Finally, can
antidepressants or specific types of psychotherapy help patients who are
The study was funded by the Italian National Research Council and Ministry
of the University and Research.
The study, "Assessing Demoralization and Depression in the
Setting of Medical Disease," is posted online at<www.psychiatrist.com/privatepdf/2005/v66n03/v66n0317.pdf>.▪