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2008; Volume 9, No 1, January

Carla Ripamonti, MD


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Article of the Month

Reviewed by: Gian Domenico Borasio, MD (Germany)

Cross-cultural variation in mental health at end of life in patients with ALS

Authors: Albert SM, Wasner M, Tider T, Drory VE, Borasio GD  

Journal: Neurology 2007; 68: 1058-1061


The study set out to examine mental health at the end of life among patients with amyotrophic lateral sclerosis (ALS) in three countries: Israel, Germany, and the United States. Patients completed nonsomatic items from the Beck Depression Inventory and several visual analogue rating scales. The three sites contributed a total of 92 patients who were considered to be near the end of life on clinical grounds; 60 died during follow-up. Patients at the three sites did not differ significantly in sociodemographic features or ALS Functional Rating Scale scores. However, patients at the three sites differed significantly in their reports on issues relevant to mental health.

The main findings were:

  1. American patients reported the least distress/pessimism and Israeli patients the most.
  2. The wish to live was highest in German patients (8.2 on a scale of 0-10), followed by American (6.9) and Israeli patients (5.4).
  3. Suicidal thoughts were rare in all three settings.
  4. Spirituality and religiousness were significantly more important for patients in Germany and the US as compared to Israel.
  5. Differences in disability were not responsible for the variation in distress experienced at the end of life.
  6. The perceived burden of family caregivers was very high in all three countries.
  7. In an analyses limited to the people who died, similar patterns emerged, with the wish to live greatest in Americans and Germans and least among Israelis.

Despite similarities in disease severity and proximity to death, ALS patients in the three countries differed significantly in indicators of distress as well as in the wish to live. In the full set of patients, differences were significant for pessimism and suffering in pairwise comparisons between American and Israeli patients. More generally, Israeli patients reported the most distress and Americans the least. These differences were robust in that they persisted even with adjustment for disability and the use of non-invasive ventilation. The study indicates that cultural factors may significantly affect mental health at the end of life in patients with ALS.


Why I chose this article

First of all, I would like to apologize for choosing an article on which I am a co-author.

The reasons why I choose this article are:

  1. It is not published in the palliative care literature and therefore may be more easily overlooked.
  2. It concerns a neurological disorder, an area that is still underrepresented in palliative care.
  3. It highlights the need for close attention to cross-cultural issues at the end of life.

Cross-cultural studies are still rare in palliative care. This study indicates the difficulty of extrapolating results obtained in a particular sociocultural setting to other settings. Comparing attitudes and practices in palliative care across cultures can be very helpful when trying to tailor palliative care interventions to a specific sociocultural environment. It would be interesting to expand these types of studies to include non-Western cultures, which may have very different perspectives on the quality of life, meaning in life and mental health at the end of life.

by Gian Domenico Borasio, MD, DipPallMed
Professor and acting chairman of the Interdisciplinary Center for Palliative Medicine, and head of the motor neurone disease research group at the Department of Neurology, University of Munich, Germany.

Dr. Borasio is a member of the IAHPC Board of Directors.

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