Psychological Characterization of Demoralization in the Setting of Heart Transplantation

Objective: The aims of this study were to examine the psychological features of demoralization and its overlap with major depressive disorder in a sample of cardiac transplant recipients, with special reference to psychological well-being, quality of life, and psychological distress. We also tested whether demoralization was significantly associated with demographic characteristics and clinical parameters, including survival status at a 6-year follow-up.

Method: From May to December 2002, 95 heart transplanted patients were administered the Structured Clinical Interview for DSM-IV and the Diagnostic Criteria for Psychosomatic Research, leading to the identification of major depressive disorder and demoralization, respectively. Patients also completed Ryff’s Scales of Psychological Well-Being, Kellner’s Symptom Questionnaire, and the World Health Organization Quality of Life-Brief Version scale.

Results: Demoralization was related to impairments in physical, psychological, social, and environmental quality of life and in psychological well-being, especially self-acceptance and environmental mastery (all P ≤ .05). It was also associated with higher levels of psychological distress, and it was more frequent in women (P = .027) and in single patients (P = .038). The co-occurrence of a major depressive episode did not alter this pattern of associations. The addition of demoralization to major depressive disorder resulted in decreased Scales of Psychological Well-Being autonomy, positive relations, and self-acceptance (all P ≤ .05). Demoralization and major depressive disorder were identified in 31 (32.6%) and 14 (14.7%) patients, respectively. Among depressed subjects, 5 (35.7%) were not demoralized, and 22 (71%) of those with demoralization did not satisfy the criteria for major depressive disorder. Nine patients were both depressed and demoralized.

Conclusion: Diagnostic Criteria for Psychosomatic Research-defined demoralization has some distinctive features that confirm previous phenomenological observations.

J Clin Psychiatry

Submitted: March 6, 2009; accepted October 22, 2009.

Online ahead of print: December 14, 2010 (doi:10.4088/JCP.09m05191blu).

Corresponding author: Giovanni A. Fava, MD, Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy (giovanniandrea.fava@unibo.it).