Prevalence and factors associated with demoralization syndrome in patients with advanced disease: results from a cross-sectional Portuguese study
Open accessAbstract
Background: Demoralization syndrome (DS) within the context of the psychological experience at the end of life is an important and relevant medical issue and remains the subject of a growing area of research. Method: Ours was a cross-sectional study designed to assess the prevalence and associated demographic, physical, psychiatric, and psychosocial factors for demoralization syndrome in Portuguese patients with advanced disease. Results: Some 80 terminally ill patients were included in the analyses over a 28-month period of time. The prevalence of DS was found to be 52.5%. No statistical differences were observed among prevalence of DS within categories of all studied variables, with the exception of depression using DSM–IV criteria (prevalence ratio PR = 1.8, CI95% = [1.18–2.74]) and desire for death (PR = 1.8, CI95% = [1.25–2.56]). In the Poisson regression analyses predicting DS, none of the latter factors emerged as significant (DSM–IV criteria: PR = 1.6, CI95% = [0.84–3.08]; and desire for death: PR = 1.5, CI95% = [0.74–2.99]). Thirty percent of participants met both criteria for demoralization syndrome and depression using the DSM–IV. Significance of Results: Prevalence of demoralization syndrome was high in this patient sample. Based on our results, we cannot determine if DS and depression are two distinct psychological entities. Identifying factors associated with DS could help provide efficacious interventions capable of diminishing suffering in terminally ill patients.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Demoralization is highly prevalent (13-53%) among patients with serious medical illness.
“Demoralization is highly prevalent (13–53%) among patients with serious medical illness (e.g., advanced cancer and acquired immunodeficiency syndrome [AIDS], etc.) [2], [3], [4]”
From Psilocybin-assisted group therapy for demoralized older long-term AIDS survivor men: an open-label safety and feasibility pilot study. (2020) · cites this paper as [2]
Cites
Bruera, E. D., Kuehn, N., Miller, M. J., Selmser, P., & Macmillan, K. (1991) · Journal of Palliative Care · doi:10.1177/082585979100700202 · Cited by 2,686 · see citing works
Depression, Hopelessness, and Desire for Hastened Death in Terminally Ill Patients With Cancer
Breitbart, W. (2000) · JAMA · doi:10.1001/jama.284.22.2907 · Cited by 1,110 · see citing works
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)
Guzé, S. B. (1995) · American Journal of Psychiatry · doi:10.1176/ajp.152.8.1228 · Cited by 898 · see citing works
Validation study of a Portuguese version of the Hospital Anxiety and Depression Scale
Pais-Ribeiro, J., Silva, I., Ferreira, T., Martins, A., Meneses, R., & Baltar, M. (2007) · Psychology, Health & Medicine · doi:10.1080/13548500500524088 · Cited by 774 · see citing works
Desire for death in the terminally ill
Chochinov, H. M., Wilson, K. G., Enns, M. W., Mowchun, N., Lander, S., Levitt, M., & Clinch, J. (1995) · American Journal of Psychiatry · doi:10.1176/ajp.152.8.1185 · Cited by 742 · see citing works
The demoralization scale: a report of its development and preliminary validation
Kissane, D. W., Wein, S., Love, A., Lee, X. Q., Kee, P. L., & Clarke, D. M. (2004) · Journal of Palliative Care · doi:10.1177/082585970402000402 · Cited by 442 · see citing works
Robinson, S., Kissane, D. W., Brooker, J., & Burney, S. (2015) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2014.07.008 · Cited by 401 · see citing works
Depression, Hopelessness, and Suicidal Ideation in the Terminally Ill
Chochinov, H. M., Wilson, K. G., Enns, M., & Lander, S. (1998) · Psychosomatics · doi:10.1016/s0033-3182(98)71325-8 · Cited by 363 · see citing works
Depression in advanced disease: a systematic review Part 1. Prevalence and case finding
Hotopf, M. H., Chidgey, J., Addington-Hall, J. M., & Ly, K. L. (2002) · Palliative Medicine · doi:10.1191/0269216302pm507oa · Cited by 359 · see citing works
Depression in advanced disease: a systematic review. Part 1: Prevalence and case finding
Hotopf, M. H., Chidgey, J., Addington-Hall, J. M., & Ly, K. L. (2002) · Palliative Medicine · doi:10.1191/02169216302pm507oa · Cited by 344 · see citing works
Diagnostic criteria for psychosomatic research and psychosocial variables in breast cancer patients
Grassi, L., Rossi, E., Sabato, S., Cruciani, G., & Zambelli, M. (2004) · Psychosomatics · doi:10.1176/appi.psy.45.6.483 · Cited by 133 · see citing works
Julião, M., Oliveira, F., Nunes, B., Vaz Carneiro, A., & Barbosa, A. (2014) · Journal of Palliative Medicine · doi:10.1089/jpm.2013.0567 · Cited by 117 · see citing works
Self-citationVehling, S., Lehmann, C., Oechsle, K., Bokemeyer, C., Krüll, A., Koch, U., & Mehnert, A. (2012) · Psycho-Oncology · doi:10.1002/pon.1866 · Cited by 97 · see citing works
Validation of the Demoralization Scale in an Irish advanced cancer sample
Mullane, M., Dooley, B., Tiernan, E., & Bates, U. (2009) · Palliative and Supportive Care · doi:10.1017/s1478951509990253 · Cited by 93 · see citing works
Family Focused Grief Therapy: A Model of Family-Centred Care during Palliative Care and Bereavement
Kissane, D. W., & Bloch, S. (2002) · Medical Entomology and Zoology · Cited by 82 · see citing works
Julião, M., Barbosa, A., Oliveira, F., Nunes, B., & Carneiro, A. V. (2013) · Palliative & Supportive Care · doi:10.1017/s1478951512000892 · Cited by 81 · see citing works
Self-citationPsychospiritual and existential distress. The challenge for palliative care.
Kissane, D. W. (2000) · PubMed · Cited by 79 · see citing works
Jacobsen, J., Vanderwerker, L., Block, S., Friedlander, R., Maciejewski, P., & Prigerson, H. (2006) · Indian Journal of Palliative Care · doi:10.4103/0973-1075.25913 · Cited by 61 · cited 3× · see citing works
“Patients presenting clinically significant DFD were 1.8 times more likely to have DS when compared to participants without DFD.”
ResultInfluentialJulião, M., Barbosa, A., Oliveira, F., & Nunes, B. (2013) · Psychosomatics · doi:10.1016/j.psym.2013.01.006 · Cited by 23 · see citing works
Self-citationHopelessness and Suicidal Behavior: An Overview
Beck, A. T. (1975) · JAMA · doi:10.1001/jama.1975.03260240050026 · Cited by 11 · see citing works
Julião, M., Nunes, B., Sobral, M. A., Dias, D., Inocêncio, I., & Barbosa, A. (2015) · Palliative & Supportive Care · doi:10.1017/s1478951515000474 · Cited by 9 · see citing works
Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
Anderson, B. T., Danforth, A., Daroff, P. R., Stauffer, C., Ekman, E., Agin-Liebes, G., Trope, A., Boden, M. T., Dilley, P. J., Mitchell, J., et al. (2020) · EClinicalMedicine · doi:10.1016/j.eclinm.2020.100538 · Cited by 284 · see citing works
Julião, M., Oliveira, F., Nunes, B., Carneiro, A. V., & Barbosa, A. (2017) · Palliative & Supportive Care · doi:10.1017/s1478951516001140 · Cited by 86 · see citing works
Self-citationNanni, M. G., Caruso, R., Travado, L., Ventura, C., Palma, A., Berardi, A. M., Meggiolaro, E., Ruffilli, F., Martins, C., Kissane, D., et al. (2018) · Psycho-Oncology · doi:10.1002/pon.4824 · Cited by 78 · see citing works
Ross, S., Agrawal, M., Griffiths, R. R., Grob, C. S., Berger, A. M., & Henningfield, J. E. (2022) · Neuropharmacology · doi:10.1016/j.neuropharm.2022.109174 · Cited by 71 · see citing works
Bovero, A., Botto, R., Adriano, B., Opezzo, M., Tesio, V., & Torta, R. (2019) · Palliative & Supportive Care · doi:10.1017/s1478951519000191 · Cited by 63 · see citing works
Gan, L. L., Gong, S., & Kissane, D. W. (2021) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674211060746 · Cited by 57 · see citing works
Iani, L., Vincenzo, F. D., Maruelli, A., Chochinov, H. M., Ragghianti, M., Durante, S., & Lombardo, L. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.01468 · Cited by 56 · see citing works
Clinical utility of demoralization: A systematic review of the literature
Woźniewicz, A., & Cosci, F. (2023) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102227 · Cited by 44 · see citing works
Relationship between demoralization and quality of life in end‐of‐life cancer patients
Bovero, A., Opezzo, M., & Tesio, V. (2023) · Psycho-Oncology · doi:10.1002/pon.6095 · Cited by 42 · see citing works
The Wish to Hasten Death in Patients With Life-Limiting Conditions. A Systematic Overview
Rodríguez‐Prat, A., Pergolizzi, D., Crespo, I., Julià-Torras, J., Balaguer, A., Kremeike, K., Voltz, R., & Monforte‐Royo, C. (2024) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2024.04.023 · Cited by 35 · see citing works
Reich, M., Bondenet, X., Laurence, R., Ait-Kaci, F., Sedda, A.-L., Silva, A. D., Villet, S., & Gamblin, V. (2019) · Palliative & Supportive Care · doi:10.1017/s1478951519000816 · Cited by 25 · see citing works
Li, J., Liu, X., Xu, L., & Jin, Z. (2020) · The European Journal of Psychiatry · doi:10.1016/j.ejpsy.2020.06.007 · Cited by 24 · see citing works
Galiana, L., Rudilla, D., Oliver, A., & Barreto, P. (2017) · Palliative & Supportive Care · doi:10.1017/s1478951516000973 · Cited by 25 · see citing works
Exploring and assessing demoralization in patients with non-psychotic affective disorders
Grassi, L. G., Pasquini, M., Kissane, D. W., Zerbinati, L., Caruso, R., Sabato, S., Nanni, M. G., Ounalli, H., Maraone, A., Roselli, V., et al. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.05.043 · Cited by 22 · see citing works
Wish to die and hasten death in palliative care: a cross-sectional study factor analysis
Belar, A., Martínez, M., Centeno, C., López–Fidalgo, J., Santesteban, Y., Lama, M., & Arantzamendi, M. (2021) · BMJ Supportive & Palliative Care · doi:10.1136/bmjspcare-2021-003080 · Cited by 22 · see citing works
Li, Y., Ho, C., & Wang, H. (2017) · Asian Nursing Research · doi:10.1016/j.anr.2017.07.001 · Cited by 19 · see citing works
Marina, S., Wainwright, T. W., & Ricou, M. (2020) · International Journal of Psychology · doi:10.1002/ijop.12680 · Cited by 13 · see citing works
Chan, W. C. H., Yu, C. T. K., Kwok, D. K. S., & Wan, J. K. M. (2022) · Palliative & Supportive Care · doi:10.1017/s1478951522001171 · Cited by 13 · see citing works
Belar, A., Arantzamendi, M., Santesteban, Y., López–Fidalgo, J., Martínez, M., Lama, M., Rullán, M., Olza, I., Breeze, R., & Centeno, C. (2020) · BMJ Supportive & Palliative Care · doi:10.1136/bmjspcare-2020-002234 · Cited by 12 · see citing works
de Oliveira, S. G., Pacheco, S. T. D. A., Nunes, M. D. R., Caldas, C. P., da Cunha, A. L., & Peres, P. L. P. (2020) · Revista Enfermagem UERJ · doi:10.12957/reuerj.2020.47321 · Cited by 12 · see citing works
Lai, Q., Huang, H., Zhu, Y., Shu, S., Chen, Y., Luo, Y., Zhang, L., & Yang, Z. (2022) · Supportive Care in Cancer · doi:10.1007/s00520-022-07386-8 · Cited by 10 · see citing works
Demoralization in breast cancer survivors
Sender, A., Hinz, A., Broemer, L., Mehnert, A., Strauss, B. M., Briest, S., & Rosendahl, J. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1523164 · Cited by 9 · see citing works
Rabinowitz, J. A., Ellis, J. D., Strickland, J. C., Hochheimer, M., Zhou, Y., Young, A. S., Curtis, B. L., & Huhn, A. S. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.05.029 · Cited by 7 · see citing works
YuYu, L., Shan, Z., & JingJun, P. (2023) · Medicine · doi:10.1097/md.0000000000032719 · Cited by 7 · see citing works
Chan, W. C. H., Yu, C. T. K., Kwok, D. K.-S., & Wan, J. K. M. (2023) · Palliative & Supportive Care · doi:10.1017/s1478951523000950 · Cited by 6 · see citing works
Christiansen, E., Hallas, J., Stenager, E. N., & Reilev, M. (2025) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2025.112326 · Cited by 5 · see citing works
Mai, S. S., Vogt, A. R., Schmidtmann, I. M., Maier, B. O., Wagner, B., Dvir, M., & Weber, M. (2020) · Supportive Care in Cancer · doi:10.1007/s00520-020-05555-1 · Cited by 5 · see citing works
Demoralisation in Cancer Patients: The Association with Distress, Depression and Positive Emotion
Thong, K. S. (2021) · Medicine & health · doi:10.17576/mh.2021.1601.10 · Cited by 4 · see citing works
Advances in the Understanding of Demoralization in Oncology and Palliative Care
Grass, L., & de Figueiredo, J. M. (2018) · Psycho-Oncologie · doi:10.3166/pson-2018-0049 · Cited by 4 · see citing works
Pollo, D. R., Rubiales, Á. S., Aragón, M. L. V., Canedo, J. A. M., Alonso‐Sardón, M., & Sagrado, M. G. (2018) · Medicina Paliativa · doi:10.1016/j.medipa.2017.05.006 · Cited by 3 · see citing works
Li, Y., Liu, Z., Lu, X., Chai, X., Bai, N., & Chen, Y. (2025) · Patient Preference and Adherence · doi:10.2147/ppa.s535288 · Cited by 2 · see citing works
Late-Life Depression: Portuguese Research Trends over the last Decade (2007-2017)
Kisieliūtė, G., Ribeiro, Ó. M., & Paúl, C. (2018) · The Psychologist Practice & Research Journal · doi:10.33525/pprj.v1i1.51
Grant, D. (2004)
Le-Berre, R. (2020) · Dunod eBooks · doi:10.3917/dunod.centr.2020.01.0411
Nogueda, I. A. A., & Castro, S. G. Q. (2024) · LATAM Revista Latinoamericana de Ciencias Sociales y Humanidades · doi:10.56712/latam.v5i4.2555
Rodríguez-Mayoral, O., Monreal-Carrillo, E. A., Contreras-Yáñez, I., Allende‐Pérez, S., Agazzi, É., & Pascual‐Ramos, V. (2025) · PLoS ONE · doi:10.1371/journal.pone.0329736
- Authors
- Julião, M., Nunes, B., & Barbosa, A.
- Affiliations
- University of Lisbon (PT)
- Corresponding author
- Julião, Miguel
- Venue
- Palliative and Supportive Care
- Publisher
- Cambridge University Press (CUP)
- Published
- 2016-01-06
- Volume
- 14
- Issue
- 5
- Pages
- 468-473
- ISSN
- 1478-9515 (ISSN-L)
- 1478-9523
- OpenAlex
- W2467323865
- Cited by
- 36
- References
- 21
- Citations by year
- 2025: 4 · 2024: 2 · 2023: 4 · 2022: 4 · 2021: 3 · 2020: 9 · 2019: 2 · 2018: 4 · 2017: 3
- FWCI
- 2.98
- Type
- journal article
- Language
- en
- Open access
- green
- hdl.handle.net
- Licence
- Locations
- Palliative & Supportive Care (publishedVersion)
- PubMed (publishedVersion)
- Portuguese National Funding Agency for Science, Research and Technology (RCAAP Project by FCT) (submittedVersion, cc-by-nc)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Social Sciences › Health › Religion, Spirituality, and Psychology
- Keywords
- demoralization syndrome, advanced disease, dying patients, depression, desire for death, prevalence, risk factors, psychosocial factors, palliative care
- MeSH terms
- Adult, Aged, Aged, 80 and over, Cross-Sectional Studies, Depressive Disorder, Female, Humans, Male, Middle Aged, Palliative Care, Portugal, Stress, Psychological, Prevalence
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
