SPIRITUAL AND PSYCHOLOGICAL DISTRESS IN PATIENTS (PDF)

1 ISSN 1803-4330 volume V/2 • October 2012 ISSN 1803-4330 • volume V/2 • October 2012 peer-reviewed journal for health professions Spiritual and Psychological Distress in Patients with Depression Ivan Farský Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava ABSTRACT Objectives: Th e study aimed to assess spiritual distress in patients with major depressive disorder and to identify the relationship between spiritual distress and mental distress. Methods: Spiritual distress was evaluated using Th e Meaning in Life Scale and Existential Well-Being, a subscale of the Spiritual Well-Being Scale. Mental distress was assessed with the SCL 90 questionnaire. Results: Th e study established that patients with depression are at a risk of experiencing spiritual distress. We found numerous negative signifi cant relationships between the variables of spiritual distress and the dimensions of psychological distress. Increased spiritual anguish was associated with increased mental distress. Conclusion: Despite its absence from nursing plans, spiritual distress is a serious problem, which, for instance, intensifi es mental problems in patients with depression. Th e inadequate diagnostics and approach to the diagnosis reduce the quality of nursing care. KEY WORDS spiritual distress, depression, psychological distress INTRODUCTION Major depressive disorder is one of the most serious psychiatric diseases. Apart from the adverse somatic, psychological, and social impacts it also aff ects the spir- itual well-being. It is oft en associated with feelings of loss of control, hopelessness, guilt, lack of life meaning. As stated by Roberts (2000, p 435), mental disorder represents a “crisis of a sense of meaning and purpose.” Individuals with mental problems experience feelings and thoughts that are troubling for themselves as well as their surroundings. Th ey struggle to fi nd a sense and meaning in their unusual experience, which are essen- tial for reaching their mental balance (Smale, 2000). All these problems are included in NANDA-I diagno- sis Spiritual Distress, which defi nes SD as a reduced ability of an individual to experience and integrate the meaning and purpose of life through a connection with oneself, others, art, nature and/or a higher force that transcends the person (NANDA, 2009, p 208). The diagnosis is missing from nursing documentation de- spite the consequences that spiritual distress has. As Nemčeková (2004, p 672) states: “An existential crisis, even a temporary one, is the most serious form of deg- radation of the quality of life; other problems as partial and relatively more easy to solve.” OBJECTIVES Th e study focuses on assessment of spiritual distress in patients with depression. Another objective was to identify the connection between the perception of spir- itual distress and mental distress. PARTICIPANTS The research sample consisted of 109 patients with major depressive disorder (mean age: 43.4 ± 11.8), of whom 48 were men and 61 were women. Th e inclusion criteria were: a diagnosed and treated mental disor- der of the depressive type, informed consent, patient cooperation, aged 18 and older. Th e exclusion criteria included a medium-severe to severe cognitive impair- ment (based on a psychiatric assessment), communi- cation disorder, acute mental disorder, acute somatic disease, severe chronic somatic disease. Th e participants were patients hospitalized at the Psychiatric Clinic, Jessenius Faculty of Medicine in Martin, Comenius University, recovering from an acute stage of the disease.  2 ISSN 1803-4330 • volume V/2 • October 2012 METHODS a) Spiritual/Existential Distress Th e selection of methods was based on the fact that although NANDA I defi nes spiritual distress, it does not mention any specifi c tools for its assessment. As the core of the definition is the meaning and purpose of life, we decided to measure them with an instrument that measures the sense of purpose in life and with Existential Well-Being, a subscale of the Spiritual Well-Being Scale. A low sense of pur- pose in life and low rates of existential well-being are symptoms of spiritual distress. Th e Meaning in Life Scale – MLS (Halama, 2002, p 265). Th e scale is based on a three-component un- derstanding of life’s meaning. Th e cognitive dimen- sion (MLSC) includes items concerning the overall life philosophy, direction, understanding or mission in life. Th e motivation dimension (MLSM) consists of items relating to goals, plans, and the strength and endurance the individual exerts to realize them. Th e aff ective dimension (MLSA) of the meaning of life comprises items relating to life satisfaction, ful- fi lment, optimism, or, on the negative level, feel- ings of disgust, monotony, etc. Th e scale features 18 statements, with 6 on each subscale. Th e items are rated on a 5-point Likert scale from 1 – strongly disagree to 5 – strongly agree, based on the partici- pant’s agreement with the statements. Scores evalu- ated include the subscale score that ranges from 6 to 30 and the total score, which ranges from 18 to 90. Higher scores indicate a higher sense of purpose in life of the respondent. Existential Well-Being (SWSE) – a subscale of the Spiritual Well-Being Scale (Ellison, 1983). Existen- tial well-being constitutes a “horizontal” dimension of spirituality, which focuses on how well the person is adjusted to self, community, and surroundings. Th is subscale includes the existential notions of life purpose, life satisfaction, and positive and negative life experiences. Th e subscale has 10 items rated on a 6-point Likert scale, where respondents express to what degree they agree with the statement, from 1 – strongly agree to 6 – strongly disagree. Scores range from 10 to 60. Th e higher the spiritual well- being is, the higher the score. b) Psychological Distress Psychological distress was assessed using the tool Symptom Checklist 90 (SCL-90) (Baštecký, Šavlík, Šimek, 1990). Th is self-report assessment scale tar- geted at monitoring the intensity of the occurrence of subjective psychological and behavioural symp- toms. SCL-90 measures the current (point-in-time) mental condition, and not the permanent features of personality. SCL-90 contains 90 items that are grouped into nine dimensions: somatization (So), obsessive-compulsive (OC), interpersonal sensi- tivity (IS), depression (De), anxiety (An), hostility (Ho), phobic anxiety (PA), paranoid ideation (Pa), psychoticism (Ps) + unclassifi ed items (UI) – with the view to covering the full symptomatic behaviour in patients. In addition to the dimensions, the GSI (General Symptomatic Index) – the total index of symptoms, and the PSDI (Positive Symptom Dis- tress Index) – the average intensity of symptoms, were evaluated. Th e generated data were processed in the programme Statistica v.7. Relationships between variables were identifi ed with the help of descriptive statistics and a nonparametric test (Spearman’s rank correlation co- effi cient). RESULTS Patients attributed the highest score to the cognitive dimension of the meaning (Table 1). Th e highest number of mental problems in patients with depression was found in the dimensions of depres- sion and obsessive compulsion and the lowest number in psychoticism and hostility (Table 2). Every spiritual variable correlated with at least 5 dimensions of psychological distress and all corre- lated signifi cantly with the General Symptomatic In- dex (GSI), as well as the intensity of symptoms (PSDI) (Table 3). DISCUSSION Th e sense of purpose in life in patients with depression scored about 60% and existential well-being 52% of the maximum score. Farský (2011, p 60) argued that in his sample of 249 adult respondents without any mental disorders, the sense of purpose in life was at 75% of the possible maximum and existential well-being at 66% on average. Similar results in a healthy population are also re- ported by Halama et al. (2010, p 50), where the mean- ing of life was at about 74% and existential well-being at 67%. Th e study established that patients with de- pression are at a risk of experiencing spiritual distress. Our fi ndings are only confi rmed by the results of other studies (Mascaro, Rosen, 2005, p 1003; Ondrejka, 2006; Farský, 2008; Halama et al., 2010). Th e assessment of the relationship between the vari- ables of spiritual distress showed multiple negative sig- nifi cant correlations. Th e cognitive dimension of life meaning was the highest correlated variable (except the general sense of purpose). As mentioned in the results,  3 ISSN 1803-4330 • volume V/2 • October 2012 Table 1 Spiritual distress 109 tSZZ SZZK SZZM SZZA SWSE x 60,61 21,02 19,99 19,61 36,39 sd 12,38 4,26 4,56 5,23 7,78 Table 2 Psychological distress n 109 So OK IS De Uz Ho Fo Pa Ps NP GSI PSDI x 0,95 1,25 1,12 1,37 0,99 0,6 0,75 0,85 0,68 1,11 1 1,75 sd 0,9 0,73 0,77 0,93 0,8 0,61 0,8 0,67 0,66 0,76 0,66 0,66 Table 3 Relationships between spiritual distress and psychological distress n tSZZ SZZK SZZM SZZA SWSE So –0,093 –0,021 –0,131 –0,064 –0,028 OK –0,346 –0,317 –0,294 –0,288 –0,279 IS –0,382 –0,378 –0,332 –0,278 –0,335 De –0,525 –0,51 –0,408 –0,445 –0,487 Uz –0,266 –0,234 –0,185 –0,244 –0,19 Ho –0,226 –0,195 –0,173 –0,196 –0,132 Fo –0,23 –0,284 –0,144 –0,168 –0,206 Pa –0,247 –0,274 –0,241 –0,129 –0,109 Ps –0,254 –0,244 –0,182 –0,215 –0,21 NP –0,354 –0,303 –0,269 –0,325 –0,279 GSI –0,399 –0,375 –0,319 –0,33 –0,303 PSDI –0,293 –0,259 –0,267 –0,223 –0,26 P ≤ 0,05 this dimension was rated the highest by the patients. Th e cognitive dimension expresses how oriented the person feels in the world and in life. Th is understand- ing of life, overall direction, may help patients give a meaning to life even despite unfavourable conditions and reduce their spiritual distress. While the correla- tion analysis by itself can not accurately determine which of the variables is primary and which second- ary in terms of its eff ects, selected characteristics of the variables provide some insight. Despite their dynamic character, constructs such as purpose in life and exis- tential well-being may be considered more permanent characteristics. In terms of the meaning of life relation- ships are likely reciprocal. With deteriorating orienta- tion to the sense of purpose, general mental hygiene, the number of frustration symptoms and the tendency to noogenic depression increases (Frankl, 1997, p 21). Measurements taken by Mascara and Rosena (2005) over two periods of time showed that although depres- sion at the fi rst period was the strongest predictor of depression at the second period, the purpose of life at the fi rst measurement was another factor which can explain to a certain degree the residual variance. Th e level of life’s meaning may thus be seen as a rather in- dependent clinical phenomenon. Likewise, it is possible that high rates of psychopathology decrease the rate of life-meaning, as already indicated by Yalom (2006). He pointed out that the purpose in life rises with the decrease in levels of psychopathology, even in the case of a biologically-based intervention. In contrast, SCL-90 measures the current (point-in-time) mental condition, a less permanent variable in terms of time. Consequently, experiencing a spiritual distress or well- being is likely to aff ect psychological distress, and not vice versa. Th e use of spirituality as a coping mecha- nism belongs to the described eff ects of spirituality on mental health. Yi et al. (2006, p 24) note that higher levels of spiritual well-being may enhance positive and “healthier” personal and social behaviours, provide an umbrella and unifying framework that helps the person solve unexpected and problematic situations, and may give a greater sense of coherence between the person and their environment; all this may provide protection against depression and other mental health problems. Th e relationship between spiritual variables and psy- chological distress may then theoretically function as follows (Fig. 1):  4 ISSN 1803-4330 • volume V/2 • October 2012 Although the sense of meaning in life, including ex- istential well-being, correlated with mental distress, the correlations were moderately strong. Likewise, although spirituality reduces psychological distress, it cannot eliminate it. Symptoms of obsession-compul- sion, depression, and interpersonal sensitivity were among dimensions that had the highest response rates to the monitored spiritual variables. Moomal (1999, p 42) and Tsang et al. (2003, p 180) report similar re- sults. Moomal found that the meaning of life corre- lated negatively with the majority of these tendencies (depression, paranoia, anxiety, psychasthenia, hypo- chondria, schizophrenia, social introversion). Tsang reported negative correlations of meaning of life and depression, anxiety, somatic problems, and general psychopathology. CONCLUSION Th e absence of the diagnosis Spiritual Distress from nursing records is not due to the fact that it would be in practice non-existent in patients. Our study estab- lished that patients with depression are at a risk of ex- periencing spiritual distress. 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Peering through the darkness: the subjective experience of clinical depression. Journal of Psychiatric and Mental Health Nursing. 2000, vol. 7, no. 3, p. 227–283. ISSN 1365-2850. YALOM, I. D. 2006. Existenciální psychoterapie. 1st ed. Prague: Portál, 2006. 527 p. ISBN 978-80-7367-147-6. YI, M. S. et al. 2006. Religion, Spirituality, and Depressive Symptoms in Patients with HIV/AIDS. Journal of General Internal Medicine. 2006, vol. 21, no. 5, p. 21–27. ISSN 1525-1497. CONTACT DETAILS OF AUTHOR Ivan Farský Department of Nursing Jessenius Faculty of Medicine in Martin Comenius University in Bratislava Malá Hora 5 SK-036 32 MARTIN [email protected]