"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 Psychiatry.

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 psychosomatic research.

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 demoralized.

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 demoralized?

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>.▪