Lee et al.

BMC Palliative Care (2015) 14:69

DOI 10.1186/s12904-015-0067-2

RESEARCH ARTICLE Open Access

The relationship between pain

management and psychospiritual distress
in patients with advanced cancer following
admission to a palliative care unit
Ya-Ping Lee1,2, Chih-Hsun Wu2,3, Tai-Yuan Chiu2, Ching-Yu Chen2,4, Tatsuya Morita5, Shou-Hung Hung6,
Sin-Bao Huang7,8, Chia-Sheng Kuo6 and Jaw-Shiun Tsai2,9*

Abstract
Background: Although many cross-sectional studies have demonstrated the association between cancer pain and
psychospiritual distress, the time-dependent relationship has not been fully explored. For that reason, this study
aims to investigate the time-dependent relationship between psychospiritual distress and cancer pain management in
advanced cancer patients.
Methods: This is a prospective observational study. Two hundred thirty-seven advanced cancer patients were recruited
from a palliative care unit in Taiwan. Demographic and clinical data were retrieved at admission. Pain and
psychospiritual distress (i.e.: anxiety, depression, anger, level of family and social support, fear of death) were
assessed upon admission and one week later, by using a “Symptom Reporting Form”. Patients were divided
into two groups according to the pain status one week post-admission (improved versus not improved groups).
Results: One hundred sixty-three (68.8 %) patients were assigned to the improved group, and 74 (31.2 %) patients were
assigned to the not improved group. There were no differences in the psychospiritual variables between groups upon
admission. In overall patients, all psychospiritual variables improved one week post-admission, but the improvement of
depression and family/social support in the not improved group was not significant. Consistent with this, for depression
scores, there was a statistically significant pain group x time interaction effect detected, meaning that the pain group
effect on depression scores was dependent on time.
Conclusions: We demonstrated a time-dependent relationship between depression and pain management in
advanced cancer patients. Our results suggest that poor pain management may be associated with intractable
depression. The inclusion of interventions that effectively improve psychospiritual distress may contribute to
pain management strategies for advanced cancer patients.
Keywords: Cancer pain, Psychospiritual distress, Advanced cancer, Hospice palliative care

* Correspondence: [email protected]
2
Department of Family Medicine, Hospice and Palliative Care Unit, College of
Medicine and Hospital, National Taiwan University, 7 Chung-Shan South
Road, Taipei, Taiwan
9
Center for Complementary and Integrated Medicine, National Taiwan
University Hospital, Taipei, Taiwan
Full list of author information is available at the end of the article

© 2015 Lee et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Lee et al. BMC Palliative Care (2015) 14:69 Page 2 of 7

Background pain and psychospiritual distress in advanced cancer pa-

Moderate to severe pain affects 70–80 % of advanced tients. The aim of this study was to examine the time-
cancer patients [1]. Although the World Health Organi- dependent relationship between pain management and
zation’s (WHO’s) analgesic ladder has been reported to psychospiritual distress in advanced cancer patients ad-
provide adequate pain relief in 80–90 % of cancer pa- mitted to a palliative care unit.
tients [2, 3], more recent reports have brought this per-
centage into question. In fact, pain may be undertreated Methods
in as many as 43 % of cancer patients [4]. Regardless of Study design, patients and palliative care setting
pharmacological treatment, most advanced cancer pa- This is a prospective observational study. Participants
tients still experience pain and report that their quality were selected from patients with advanced cancer, not
of life is significantly compromised [5, 6]. Thus, pain responsive to any caner therapy administrated by on-
management is still unsatisfactory in this patient popula- cologists and consecutively admitted to the Palliative
tion, and remains a core issue in cancer patient care. Care Unit of the National Taiwan University Hospital
Advanced cancer patients often exhibit symptoms of between October 2006 and December 2007. All patients
weakness, pain, anorexia, and cachexia [7]. There is a provided informed consent. The conscious levels of pa-
high prevalence of these symptoms in advanced cancer tients were divided into six categories by primary care
patients regardless of the primary cancer site [7]. We physicians: alertness (normal response to orders), lethargy
have reported that 81 % of patients with advanced can- (sleepy but normal response to orders), obtundation (slow
cer admitted to a palliative care unit in Taiwan reported response to orders), delirium (confusion), stupor (near-un-
having pain [7]. Furthermore, we have reported that the consciousness) and coma (unconsciousness). The inclu-
constellation of symptoms associated with advanced can- sion criteria is that the individual’s level of consciousness
cer can be grouped according their pattern of expression had to be clear enough (alert or lethargic consciousness)
(i.e.: symptom patterns) at the end stage of life [8]. Pain to report symptoms both on admission and one week after
and depression severity followed the same “decrease- admission. The participants were under active, total care,
static” symptom pattern, which is characterized by only provided by a multidisciplinary team of physicians, nurses,
an initial improvement in symptoms after admittance psychologists, social workers, clinical Buddhist chaplains,
into palliative care, followed by a maintenance of that and volunteers. The physicians managed the patients’
level until death [8]. Therefore, it is crucial to make symptoms by pharmacologic and non-pharmacologic
great progress in pain management in these patients. strategies and coordinated the care team. The nurses
Although advanced cancer patients experience both provided routine nursing care. The psychologists pro-
psychological and physical pain, treatment is mostly tar- vided psychotherapy, such as cognitive behavioral ther-
geted at alleviating the physical symptoms [9]. However, apy, positive thinking, problem solving, relaxation
cultural and psychosocial factors can hinder pain man- strategies and so on. The social workers provided psy-
agement [10]. Psychological factors such as depression, chosocial and financial support. The clinical Buddhist
anxiety and a fear of catastrophes are associated with chaplains provided spiritual support including life re-
more severe pain [11]. Indeed, cancer pain can be- view, fulfillment of spiritual needs, and prayer for the
come intractable, particularly in the presence of psy- patients and their family. Team meetings were held on
chological distress [12]. Unrecognized psychosocial a weekly basis. This study was approved by the ethical
variables that cause distress can worsen pain severity committee at the National Taiwan University Hospital.
and increase the use of medications [12]. Besides,
spiritual distress can also aggravate the physical/psy- Symptom assessment and data collection
chological symptoms of cancer patients [13]. Thus, Patient demographics (age, gender, primary site of
cancer pain is a multidimensional phenomenon and a cancer, and survival days) were obtained from routine
complex subjective experience. records. The symptom assessment tool was a “Symp-
Advanced cancer patients often experience suffering of tom Reporting Form” which was used to assess phys-
the whole person. Thus, in order to better manage can- ical, psychosocial and spiritual distress using different
cer pain, it is important to consider not only biomedical scale systems [7, 8]. Information was gathered from
factors but also the level of psychosocial and spiritual the “Symptom Reporting Forms” at the time of admission
distress of the patient [14]. There have several cross- and one week after admission. Pain scores were rated on a
sectional studies reporting that pain is associated with 10 point likert scale of 0–10 (0 = none, and 10 = extreme).
psychosocial distress [15–17]. Despite literatures re- A psychosocial evaluation was conducted by the psycholo-
ported that psychological distress complicates cancer gists to assess the severity of depression, anxiety, and
pain considerably [12], there is lack of quantitative evi- anger on a scale of 1–5 (1, almost none; 2, mild; 3, moder-
dence showing the time-dependent relationship between ate; 4, severe; 5, extreme); the degrees of family and social
Lee et al. BMC Palliative Care (2015) 14:69 Page 3 of 7

support were rated on a scale of 1–6 (1, extreme not fit; 2, reported no improvement in cancer pain (not improved
not fit; 3, somewhat not fit; 4, somewhat fit; 5, fit; 6, very group). The demographic and diagnostic data were not
fit). Clinical Buddhist chaplains conducted the fear of significantly different between the two groups (Table 1).
death assessment on a scale of 1–5 (1, very little fear, Table 2 compares the pain scores and assessments of
peaceful, and happy; 2, little fear but can be managed and psychospiritual distress between the two groups at each
no company required; 3, fear and company is required but assessment time point. At admission, pain scores were
the fear can be managed; 4, extreme fear, company re- significantly higher in the group that would later report
quired, and fear of sleeping at night; 5, confusion, losing an improvement in pain one week later (5.49 ± 2.10 vs
autonomy, and rejecting help from others) [18]. 2.20 ± 2.48, p < 0.001). However, measures of the psy-
The “Symptoms Reporting Form” was designed by ex- chospiritual variables were not significantly different
perienced specialists and has been used in our previous between the two groups. One week after admission,
studies [7–9, 19–21]. A content validity index was used pain scores were no longer significantly different be-
to determine the validity of the structured question- tween the two groups. It is important to note, however,
naire and yielded an index of 0.96. A pilot study further that depression scores were significantly higher in the not
confirmed the instrument’s content validity and ease of improved group one week after admission (p = 0.016).
application [19]. Death fear scale in the study was also Table 3 compares the time-dependent assessment of
designed by experienced specialists and has been used pain and psychospiritual distress between the two as-
in our previous studies [18, 21, 22]. A content validity sessment time points for each group. One week after
index was used to determine the validity of the struc- admission, a significant improvement in pain scores
tured questionnaire and yielded a score of 0.93. Ten and all the psychospiritual distress parameters was re-
volunteers (bereaved family members) filled out the ported by the improved group (all p’s < 0.05). However,
questionnaire to confirm the questionnaire’s face valid- in the not improved group, the improvement of depres-
ity and ease of application [22]. sion and family/social support was not significant.
We used a mixed designed ANOVA, with one be-
Statistical analysis tween subject factor “pain group” and one within sub-
Participants were assigned to one of two groups based ject factor “time”, to examine the relationships between
on whether their pain scores were lower one week cancer pain and the variables used to reflect psychos-
after admission or not (improved versus not improved piritual distress. No main effect of pain control status
groups). The patients whose pain scores reported one was detected for any of the factors of psychospiritual
week after admission were lower than those on admission distress. However, a main effect of time was observed
were assigned to the improved group; the other patients
were assigned to the not improved group. Descriptive Table 1 Descriptive statistics of demographic and primary
measures of data were summarized as frequencies and cancer sites in different pain control groups
percentages for categorical and interval variables, and Group by pain control status
mean ± standard deviation (SD) for non-categorical vari- Variable Improved Not improved Statistics p
ables. The t test and mixed designed analysis of variance (n = 163) (n = 74) (t-test/χ2test)
(ANOVA) with one between-subject factor “pain group” Age (years) 63.62 ± 13.76 64.73 ± 13.99 −0.57 .567
and one within-subject factor “time” were used to ex- Survival (days) 40.98 ± 40.97 32.58 ± 37.62 1.41 .161
plore the relationships between cancer pain and psy-
Gender 0.01 .924
chospiritual factors. Statistical significance was defined
as a p value less than 0.05. All data were analyzed by Male 76(46.6 %) 35(47.3 %)
using SAS 9.2 statistical software. Female 87(53.4 %) 39(52.7 %)
Primary Cancer Site 2.53 .960
Results Lung 31 (19.0 %) 15 (20.3 %)
Based on the inclusion criteria, 237 patients were en- Liver 30 (18.4 %) 12 (16.2 %)
rolled in this study. There were 111 (46.8 %) men and
Colon and rectum 14 (8.6 %) 7 (9.5 %)
126 (53.2 %) women. The mean age of all patients was
64.05 ± 13.87 years. The most common primary cancer Head and neck 13 (8.0 %) 4 (5.4 %)
sites included lung (19.4 %), liver (17.7 %), and colon/ Breast 11 (6.7 %) 3 (4.1 %)
rectum (8.9 %). The mean survival was 39.54 ± Stomach 10 (6.1 %) 7 (9.5 %)
47.72 days. The median survival was 22.5 days (ranging Pancreas 9 (5.5 %) 3 (4.1 %)
from 7 to 418 days). One week after admission, 163 Cervix/uterine 6 (3.7 %) 3 (4.1 %)
(68.8 %) patients reported an improvement in cancer
Others 39 (23.9 %) 20 (27.0 %)
pain (improved group) and 74 (31.2 %) patients
Lee et al. BMC Palliative Care (2015) 14:69 Page 4 of 7

Table 2 Descriptive statistics of psychosocial spiritual variables in different pain control groups
Group by pain control status
Improved Not improved
Variable N Mean ± SD N Mean ± SD t(df ) p
At admission
Pain 163 5.49 ± 2.10 74 2.20 ± 2.48 10.54(235) <.001*
Anxiety 156 2.35 ± 0.98 72 2.29 ± 0.86 0.40(226) .686
Depression 156 2.29 ± 1.02 73 2.32 ± 1.01 −0.19(227) .853
Anger 155 1.63 ± 0.88 72 1.76 ± 0.99 −1.01(225) .312
Family support 157 4.61 ± 1.05 73 4.48 ± 1.04 0.89(228) .374
Social support 157 4.46 ± 1.22 73 4.29 ± 1.22 1.03(228) .305
Fear of death 143 2.78 ± 0.75 68 2.79 ± 0.78 −0.16(209) .873
1 week after admission
Pain 163 2.37 ± 1.45 74 2.58 ± 2.65 −0.63(235) .530
Anxiety 153 2.04 ± 0.92 72 2.08 ± 0.75 −0.35(223) .723
Depression 153 1.90 ± 0.97 73 2.25 ± 1.04 −2.44(224) .016*
Anger 151 1.42 ± 0.76 72 1.63 ± 0.88 −1.75(221) .081
Family support 156 4.72 ± 1.01 73 4.55 ± 1.00 1.23(227) .219
Social support 156 4.62 ± 1.22 73 4.37 ± 1.11 1.50(227) .136
Fear of death 140 2.38 ± 0.80 70 2.59 ± 0.81 −1.76(208) .081
*significant at 0.05 level

for all the psychospiritual factors (all p’s < 0.05), indicat- depression scores was dependent on time (p = 0.005)
ing that, being in palliative care for one week, patients (Table 4 and Fig. 1).
reported an improvement in psychospiritual distress
(Table 4). Finally, for depression scores, there was a Discussion
statistically significant pain group x time interaction ef- For overall patients, we demonstrated that psychospiri-
fect detected, meaning that the pain group effect on tual distress improved under our active total care. In

Table 3 Descriptive statistics of psychosocial spiritual variables at different time points

Variable At admission 1 week after admission t(df ) p
Improved
Pain 163 5.49 ± 2.10 2.37 ± 1.45 21.98(162) <.001*
Anxiety 153 2.33 ± 0.98 2.04 ± 0.92 4.36(152) <.001*
Depression 153 2.27 ± 1.01 1.90 ± 0.97 5.97(152) <.001*
Anger 151 1.62 ± 0.87 1.42 ± 0.76 3.52(150) .001*
Family support 156 4.61 ± 1.05 4.72 ± 1.01 −2.40(155) .018*
Social support 156 4.46 ± 1.22 4.62 ± 1.22 −3.64(155) <.001*
Fear of death 139 2.76 ± 0.75 2.39 ± 0.79 7.44(138) <.001*
Not improved
Pain 74 2.20 ± 2.48 2.58 ± 2.65 −4.13(73) <.001*
Anxiety 72 2.29 ± 0.86 2.08 ± 0.75 2.42(71) .018*
Depression 73 2.32 ± 1.01 2.25 ± 1.04 0.82(72) .415
Anger 72 1.76 ± 0.99 1.63 ± 0.88 2.44(71) .017*
Family support 73 4.48 ± 1.04 4.55 ± 1.00 −1.40(72) .167
Social support 73 4.29 ± 1.22 4.37 ± 1.11 −1.10(72) .276
Fear of death 68 2.79 ± 0.78 2.60 ± 0.79 2.14(67) .036*
*significant at .05 level
Lee et al. BMC Palliative Care (2015) 14:69 Page 5 of 7

Table 4 Interaction of pain control group and time on However, pain in some patients did not improve but
psychosocial spiritual distress worsened, even under holistic care provided by a multi-
Pain group Time Pain group x time disciplinary team. Although the level of psychospiritual
Variable F(df1,df2) p F(df1,df2) p F(df1,df2) p distress was not significantly different between the two
Anxiety 0.01(1,223) .969 19.29(1,223) <.001* 0.49(1,223) .484 groups upon admission, depression did not improve sig-
Depression 2.18(1,224) .141 16.83(1,224) <.001* 7.89(1,224) .005*
nificantly one week after admission in the not improved
group. Mori et al. recently reported on three advanced
Anger 2.33(1,221) .129 14.04(1,221) <.001* 0.36(1,221) .548
cancer patients with intractable pain, the cause of
Family support 1.18(1,227) .278 5.57(1,227) .019* 0.36(1,227) .548 which was attributed to severe psychosocial distress
Social support 1.65(1,227) .200 8.67(1,227) .004* 0.90(1,227) .344 [12]. Although the causality between depression and
Fear of death 1.38(1,205) .241 35.16(1,205) <.001* 3.68(1,205) .056 pain relief is hard to establish, our findings suggest
*significant at .05 level that depression is an important psychological factor
in determining whether cancer patients will experience ef-
the improved group, all parameters of psychospiritual fective pain management, especially when depression is
distress were simultaneously significantly ameliorated. difficult to manage. The reason why depression and pain
However, the improvement of certain psychosocial vari- are sometimes difficult to manage simultaneously may be
ables was not significant in the not improved group. associated with the individual’s psychosocial profile [12].
This effect was particularly dramatic for depression; In addition to signs of physical deterioration, more atten-
while other measures of psychological distress, such as tion should be directed to documenting over-time changes
anxiety and anger, improved significantly in the not im- in psychospiritual distress. Successfully recognizing the
proved group, depression scores did not. In the improved risk factors underlying poor pain management, including
group, however, depression improved significantly within both physical condition and psychospiritual distress, may
one week following admission. To our knowledge, this is be very important for effective cancer pain management
the first study to report that improvement in cancer pain strategies.
is associated with an improvement in depression. Pain is a complex multidimensional subjective experi-
It is very interesting that in the improved group pain ence and psychosocial components play an important
was significantly ameliorated one week after admission role in cancer pain management [8]. Zaza and Baine
even though pain scores were significantly higher upon systematically reviewed the relationship between cancer
admission in these individuals. Since the severities of pain and psychological distress [23]. The authors found
psychospiritual distress of the two groups at admission that increased pain was significantly associated with
were similar, physical distress may contribute to the sig- increased psychological distress [23]. Kane et al. and
nificant difference of pain severities in two groups at ad- Kelsen et al. both reported that there was a signifi-
mission. Consequently, the outcome that pain in the cant cross-sectional association between pain and de-
improved group significantly improved may result from pression [24, 25]. Pain is a symptom in advanced cancer
that most physical distress were relieved by pharmaco- patients that is expressed in the same symptom pattern as
logical therapy such as opioid analgesics. This is consist- depression [8]. Possible biological mechanism linking pain
ent with our previous observations that better pain and depression is inflammation, such as elevated eosino-
management could be achieved following the implemen- phil counts [26]. Neuroimaging studies also reveal that
tation of educational programs on opioid analgesia in brain activity, especially in the cingulate gyrus, is associ-
1990 in Taiwan [7]. ated with pain, depression and social distress [27, 28], and
the similar findings also exist in the cancer popula-
tion [29, 30]. Recently, genetic researchers have re-
ported that polymorphisms in some cytokines genes
are potential markers for pain and depression in can-
cer patients [31, 32]. Psychospiritual factors linking
pain and depression includes demoralization [33], loss
of dignity [34], loss of hope [35], loss of help [36]
and poor family/social support [37, 38]. These studies
may support our findings.
Although pain and depression are highly prevalent in
cancer patients [39] and literatures emphasize that pain
and depression should be managed simultaneously for
better outcomes [40], our study revealed more than
Fig. 1 Interaction of pain control group and time on depression
30 % of cancer patients still have unsatisfied pain
Lee et al. BMC Palliative Care (2015) 14:69 Page 6 of 7

control. Pain scores were low in the not improved group and symptom issues. Fourth, all participants in the
at admission, whereas this does not mean that pain was study were Taiwanese, so the results should be con-
easy to treat with analgesics in these patients particularly firmed in other ethic background. Fifth, our pain as-
when psychospiritual factors were difficult to manage. In sessment tool was a single-dimensional numerical rating
the not improved group, depression and family/social scale. A multidimensional tool such as the Melzack Pain
support did not significantly improve. Demoralization, Questionnaire will give more information related to the
one of the troublesome psychological distress, is very components of pain.
common in cancer patients in Taiwan with the reported
prevalence of 49.1 % [33]. Joblessness is associated with Conclusion
demoralization because it may cause a sense of use- There is a time-dependent relationship between pain
lessness [33]. Although most medical expenses of pa- relief and improvement of psychospiritual distress in
tients is paid by National Health Insurance which has advanced cancer patients. Routine assessment of psy-
been formed since 1995 [41], family caregivers still chospiritual distress factors should be considered in
face the caring burden such as their own health prob- cancer pain management. More aggressive psychos-
lems, financial difficulties, and disruption of daily rou- piritual support may improve pharmacological pain
tine at home [42]; indeed, the caring burden of family management strategies in advanced cancer patients.
certainly makes a significant impact on quality of life
among terminally ill cancer patients [42]. These psy- Abbreviation
chosocial factors make the management of cancer WHO: World Health Organization.
pain and depression more difficult.
The concept of total care provided by a palliative Competing interests
The authors declare that they have no competing interests.
care team will result in an increased likelihood of im-
proving depression, especially when pain is success- Authors’ contributions
fully controlled [43]. Furthermore, our results suggest Conceived and designed the study: TYC, CYC, JST. Analyzed the data: YPL,
that treating comorbid depression concomitantly with CHW, JST. Commented on the data analysis: TM, SHH, SBH, CSK. Wrote the
paper: YPL, JST. All authors read and approved the final manuscript.
pharmacological and non-pharmacological manage-
ments may be beneficial in ameliorating pain. Most
Acknowledgments
importantly, considering an individual’s psychosocial The authors are indebted to the participants, the staff of the Eighth Core
profile in cancer pain management is crucial, particu- Laboratory, and the faculty of the Department of Family Medicine at the
National Taiwan University Hospital for their full support of this study. This
larly when it is proving difficult to treat. The concept
study was supported by the National Science Council (NSC 91-2314-B-002-224;
of total pain, pain consisting of physical, psycho- NSC 95-2314-B-002-145), the Department Of Health (DOH92-HP-1506), and the
logical, social and spiritual components, is very im- National Health Research Institutes (NHRI-102A1-PDCO-0100028), Executive
Yuan, Taipei, Taiwan.
portant in the care of advanced cancer patients [44].
Palliative and hospice care can continuously relieve Author details
1
psychosocial distress and fear of death while physical Division of Family Medicine, Taipei Hospital, Ministry of Health and Welfare,
New Taipei City, Taiwan. 2Department of Family Medicine, Hospice and
condition deteriorates gradually [21]. Unquestionably,
Palliative Care Unit, College of Medicine and Hospital, National Taiwan
patients with advanced cancer can have a better qual- University, 7 Chung-Shan South Road, Taipei, Taiwan. 3Department of
ity of life and experience a more peaceful death under Psychology, National Chengchi University, Taipei, Taiwan. 4Division of
Geriatric Research, Institute of Population Health Science, National Health
palliative and hospice care [21].
Research Institutes, Ju-Nan, Taiwan. 5Palliative and Supportive Care Division,
Our study has some limitations. First, only individuals Seirei Mikatahara Hospital, Mikatahara, Kita, Hamamatsu, Japan. 6Department
whose level of consciousness was clear enough (alert or of Community and Family Medicine, National Taiwan University Hospital
Yun-Lin Branch, Yun-Lin, Taiwan. 7Department of Palliative Care, Changhua
lethargic consciousness) to report symptoms were re-
Christian Hospital, Changhua, Taiwan. 8Department of Family Medicine,
cruited. Second, this study was conducted in a palliative Changhua Christian Hospital, Changhua, Taiwan. 9Center for Complementary
care unit where active total care was provided. We did and Integrated Medicine, National Taiwan University Hospital, Taipei, Taiwan.
not assess other advanced cancer patients in other types
Received: 2 August 2015 Accepted: 26 November 2015
of wards, or at home. Third, this is an observational
study, and the findings therefore cannot confirm causal-
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