This is the first study on patients with oral cancer regarding the associations between demoralization and spiritual needs, quality of life, and suicidal ideation. We found that (a) patients with oral cancer were more likely to experience demoralization (35.5%) than those with other cancers, (b) high demoralization was associated with low satisfaction in spiritual needs, (c) high demoralization was associated with low quality of life, and (d) the odds ratio of suicidal ideation was 20 times more for patients with higher demoralization than for those with lower demoralization. Therefore, we propose that early assessment of demoralization is helpful in achieving holistic healthcare and preventing early suicide in these patients.
This study found that cancer status, treatment duration, and recurrence status were not significantly associated with demoralization. Clinically, major surgery has a negative impact not only on demoralization rates, but also on the quality of life, satisfaction of spiritual needs, and suicidal ideation. The participants in the present study comprised a higher proportion of those with demoralization than those in a previous study [12]. However, the mean demoralization scores in the present study were lower than those in a previous study among outpatients with head and neck cancer in Taiwan [13]. A possible reason for this is that most participants were in the advanced stage. They were admitted for major surgery and underwent assessment before surgery.
Suicide is an important clinical issue in chronic cancer care, and our study evaluated suicidal ideation using the DS-MV. In our study, we used two DS-MV statements to define suicidal ideation: “Life is no longer worth living” and “I would rather not be alive.” Demoralization was positively associated with suicidal ideation. Our results showed that the highly demoralized group experienced greater suicidal ideation. This finding is consistent with the literature on patients with cancer [13, 18]. For patients with high demoralization, suicidal ideation is suspected; therefore, early intervention is needed. Furthermore, demoralization is more likely to associate with depression [8, 31]. Therefore, patients with comorbidities of depression and hopelessness experience greater demoralization and require early suicide prevention and treatment.
In this study, we did not distinguish between depression and demoralization. Demoralization and depression have different clinical manifestations and treatments. Demoralization is associated with poorly controlled physical symptoms, inadequately treated depression and anxiety, reduced social functioning, unemployment, marital status [12], and, possibly, age and sex [9]. With regard to these parameters, we found no difference between the high- and low-demoralization groups in the relevant factors, including age, sex, education, marital status, religious affiliation, employment status, monthly income, cancer status (stage and location), and treatment. The roles of these factors, including the differences between inpatient and outpatient standing, cancer stage, and other complications, are still not fully understood. Follow-up research needs to include prospective research and establishment of important treatment time points as well as physical, psychological, and spiritual needs of the patients, and resources available for long-term care.
Currently, several scales are used to identify demoralized patients, including the Demoralization Scale [26], DS-II [9], and the Short Demoralization Scale (SDS) [32]. We used the Mandarin version of the Demoralization Scale; there is currently no Mandarin version of the DS-II or SDS for evaluating demoralization. Medical professionals have poor understanding of demoralization and require sensitization and training [33]. DS-MV is a self-report questionnaire for oral cancer patients and should be used as a routine screening tool to predict quality of life, suicidal ideation, comorbid depression, and spiritual needs. For those facing survival threats, demoralization is a clinically useful feature that guides clinicians in their efforts to restore morale, meaning, and purpose [9].
Another key point of this study was to evaluate which factors could predict high levels of demoralization in patients with cancer. The results of the C-SpIRIT and EORTC QLQ-C30, an overall quality of life score < 62.5, a functional score < 68.2, an asymptomatic score > 26.2, and a total score of spiritual needs < 3.7 were all predictors of high demoralization. Clinically, the C-SpIRIT and EORTC QLQ-C30 can be used to infer high demoralization in patients.
Our study revealed the values of 27.2 ± 16.8 for DS-MV and a 35.5% incidence of demoralization in our patients. Oral cancer is usually included among head and neck cancers. A study reported that among patients with head and neck cancer, 50% reported problems with eating, 28.5% had depressive symptoms, and 17.3% experienced substantial pain [5]. In a previous study in Taiwan, head and neck cancer outpatients had the highest score on DS-MV (38.4, SE = 13.6) when compared with other cancer outpatients [13]. A previous study reported that patients with head and neck cancer comprised higher proportions of those with depression and anxiety [34]. Patients likely have greater demoralization when specific attributes of oral cancer, i.e., disease severity and postoperative treatment, are considered, as verified by our results. High demoralization is significantly correlated with subscale scores of quality of life (fatigue, pain, dyspnea, constipation, and financial difficulties) as well as subscale scores of spiritual needs (positive attitude toward life, love shown to/from others, seeking the meaning of life, and a peaceful mind). In our study, all participants were inpatients, with most being men with full-time jobs and religious affiliations, and had a minimum education level of senior high school. The results may vary depending on country, culture, disease characteristics, and general conditions.
Limitations
This was a cross-sectional investigation based on patients from a single institute in Taiwan in which most oral cancer patients were men; therefore, the results are applicable mostly to male patients and the effects of sex remain unclear. Further, the reliability and validity of the DS-MV scale in identifying suicidal ideation have not yet been established. Therefore, suicidal ideation was the only descriptive statistical result.
A considerable amount of time is required to assess the overall needs of such patients and that the DS-MV is correlated with C-SpIRIT and EORTC QLQ-C3. Thus, high demoralization is negatively associated with low satisfaction with one’s spiritual needs as well as poor quality of life and high suicidal ideation. DS-MV may serve as an integrated assessment tool to help better understand the overall psychological care needs of these patients.