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Age and depression in patients with metastatic cancer: the protective effects of attachment security and spiritual wellbeing



Psychological distress in cancer patients is inversely related to age, although the reasons are unclear. The adult development literature suggests that ageing may be associated with the development of adaptive capacities, specifically greater attachment security (the sense that others will be available and supportive when needed) and spirituality (the capacity to view one's life as having meaning, purpose and value), that enable older people to cope better with disease. We examined whether age-related patterns in attachment security and spiritual wellbeing account for the protective effect of age against distress. Measures of depression, attachment security, spiritual wellbeing and disease burden were collected from 342 patients aged from 21 to 88 years with advanced, metastatic cancer. Attachment security and spiritual wellbeing were tested as mediators of the effect of age on depression, controlling for disease burden. It was found that age was associated inversely with depression and positively with spiritual wellbeing and attachment security. Depression was inversely related to attachment security and spiritual wellbeing, and the effect of age on depression was fully mediated by attachment security and spiritual wellbeing. The relative protection from psychological distress among older cancer patients may be the result of age-related developmental accomplishments and/or differences in the response to adverse life-events.


Corresponding author

Address for correspondence: Christopher Lo, Behavioural Sciences and Health Research Division, Toronto General Hospital, Eaton North 9-232, 200 Elizabeth Street, Toronto, Ontario M5G2C4, Canada. E-mail:


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Beck, A. T., Steer, R. A. and Brown, G. K. 1996. Manual for the Beck Depression Inventory-II. Psychological Corporation, San Antonio, Texas.
Bekelman, D. B., Dy, S. M., Becker, D. M., Wittstein, I. S., Hendricks, D. E., Yamashita, T. E. and Gottlieb, S. H. 2007. Spiritual well-being and depression in patients with heart failure. Journal of General Internal Medicine, 22, 4, 470–7.
Bouchardy, C., Rapiti, E., Blagojevic, S., Vlastos, A. and Vlastos, G. 2007. Older female cancer patients: importance, causes, and consequences of undertreatment. Journal of Clinical Oncology, 25, 14, 1858–69.
Brady, M. J., Peterman, A. H., Fitchett, G., Mo, M. and Cella, D. 1999. A case for including spirituality in quality of life measurement in oncology. Psycho-Oncology, 8, 5, 417–28.
Brandtstadter, J. and Greve, W. 1994. The aging self: stabilizing and protective processes. Developmental Review, 14, 1, 5280.
Breitbart, W. 2002. Spirituality and meaning in supportive care: spirituality – and meaning-centered group psychotherapy interventions in advanced cancer. Supportive Care in Cancer, 10, 4, 272–80.
Chochinov, H. M. and Cann, B. J. 2005. Interventions to enhance the spiritual aspects of dying. Journal of Palliative Medicine, 8, S1, S103–15.
Cleeland, C. S. 1989. Measurement of pain by subjective report. In Chapman, C. R. and Loeser, J. D. (eds), Advances in Pain Research and Therapy. Twelfth edition, Raven, New York, 391430.
Dalby, P. 2006. Is there a process of spiritual change or development associated with ageing? A critical review of research. Aging and Mental Health, 10, 1, 412.
Davila, J., Karney, B. R. and Bradbury, T. N. 1999. Attachment change processes in the early years of marriage. Journal of Personality and Social Psychology, 76, 5, 783802.
Edmondson, D., Park, C. L., Blank, T. O., Fenster, J. R. and Mills, M. A. 2008. Deconstructing spiritual well-being: existential well-being and HRQOL in cancer survivors. Psycho-Oncology, 17, 2, 161–9.
Ellis, J., Lin, J., Walsh, A., Lo, C., Shepherd, F. A., Moore, M., Li, M., Gagliese, L., Zimmermann, C. and Rodin, G. 2009. Predictors of referral for specialized psychosocial oncology care in patients with metastatic cancer: the contributions of age, distress and marital status. Journal of Clinical Oncology, 27, 5, 699705.
Exley, C. and Letherby, G. 2001. Managing a disrupted lifecourse: issues of identity and emotion work. Health, 5, 1, 112–32.
Gross, J. J., Carstensen, L. L., Pasupathi, M., Tsai, J., Skorpen, C. G. and Hsu, A. Y. C. 1997. Emotion and aging: experience, expression, and control. Psychology and Aging, 12, 4, 590–9.
Grossmann, K. E., Grossmann, K. and Waters, E. 2005. Attachment from Infancy to Adulthood: The Major Longitudinal Studies. Guilford, New York.
Holland, J. C. 2003. Psychological care of patients: psycho-oncology's contribution. Journal of Clinical Oncology, 21, 23S, 253s65s.
Hunter, M. J., Davis, P. J. and Tunstall, J. R. 2006. The influence of attachment and emotional support in end-stage cancer. Psycho-Oncology, 15, 5, 431–44.
Jorm, A. F., Windsor, T. D., Dear, K. B. G., Anstey, K. J., Christensen, H. and Rodgers, B. 2005. Age group differences in psychological distress: the role of psychosocial risk factors that vary with age. Psychological Medicine, 35, 9, 1253–63.
Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R. and Schimmel, H. 1983. Validation of a Short Orientation-Memory-Concentration Test of cognitive impairment. American Journal of Psychiatry, 140, 6, 734–9.
Lo, C., Walsh, A., Mikulincer, M., Gagliese, L., Zimmermann, C. and Rodin, G. 2009. Measuring attachment security in patients with advanced cancer: psychometric properties of a modified and brief ‘Experiences in Close Relationships’ scale. Psycho-Oncology, 18, 5, 490–9.
McClain, C. S., Rosenfeld, B. and Breitbart, W. 2003. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet, 361, 9369, 1603–7.
Mikulincer, M. and Shaver, P. R. 2007. Attachment in Adulthood: Dynamics, Structure, and Change. Guilford, New York.
Mosher, C. E. and Danoff-Burg, S. 2005. A review of age differences in psychological adjustment to breast cancer. Journal of Psychosocial Oncology, 23, 2/3, 101–14.
Muldoon, M. and King, N. 1995. Spirituality, health care, and bioethics. Journal of Religion and Health, 34, 4, 329–49.
Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L. and Cella, D. 2002. Measuring spiritual well-being in people with cancer: the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being Scale (FACIT-Sp). Annals of Behavioral Medicine, 24, 1, 4958.
Portenoy, R. K., Thaler, H. T., Kornblith, A. B., Lepore, J. M., Friedlander-Klar, H., Kiyasu, E., Sobel, K., Coyle, N., Kemeny, N., Norton, L. and Scher, H. 1994. The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress. European Journal of Cancer, 30A, 9, 1326–36.
Preacher, K. J. and Hayes, A. F. 2008. Asymptotic and re-sampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 3, 879–91.
Ries, L. A. G., Reichman, M. E., Lewis, D. R., Hankey, B. F. and Edwards, B. K. 2003. Cancer survival and incidence from the Surveillance, Epidemiology, and End Results (SEER) program. Oncologist, 8, 6, 541–52.
Rodin, G., Walsh, A., Zimmermann, C., Gagliese, L., Jones, J., Shepherd, F. A., Moore, M., Braun, M., Donner, A. and Mikulincer, M. 2007 a. The contribution of attachment security and social support to depressive symptoms in patients with metastatic cancer. Psycho-Oncology, 16, 12, 1080–91.
Rodin, G., Zimmermann, C., Rydall, A., Jones, J., Shepherd, F. A., Moore, M., Fruh, M., Donner, A. and Gagliese, L. 2007 b. The desire for hastened death in patients with metastatic cancer. Journal of Pain and Symptom Management, 33, 6, 661–75.
Schneider, R. A. 1998. Concurrent validity of the Beck Depression Inventory and the Multidimensional Fatigue Inventory-20 in assessing fatigue among cancer patients. Psychological Reports, 82, 3, part 1, 883–6.
Shepherd, F. 2000. Treatment of non-small cell lung cancer: chemotherapy. In Hansen, H. H. (ed.), Textbook of Lung Cancer. Martin Dunitz, London, 213–42.
Stanton, A. L. 2006. Psychosocial concerns and interventions for cancer survivors. Journal of Clinical Oncology, 24, 32, 5132–7.
Stefanek, M., McDonald, P. G. and Hess, S. A. 2005. Religion, spirituality and cancer: current status and methodological challenges. Psycho-Oncology, 14, 6, 453–63.
Strong, V., Waters, R., Hibberd, C., Rush, R., Cargill, A., Storey, D., Walker, J., Wall, L., Fallon, M. and Sharpe, M. 2007. Emotional distress in cancer patients: the Edinburgh Cancer Centre symptom study. British Journal of Cancer, 96, 6, 868–74.
Tan, A., Zimmermann, C. and Rodin, G. 2005. Interpersonal processes in palliative care: an attachment perspective on the patient–clinician relationship. Palliative Medicine, 19, 2, 143–50.
Torstam, L. 1996. Gerotranscendence: a theory about maturing into old age. Journal of Aging and Identity, 1, 1, 3750.
Wink, P. and Dillon, M. 2002. Spiritual development across the adult life course: findings from a longitudinal study. Journal of Adult Development, 9, 1, 7994.
Zhang, F. and Labouvie-Vief, G. 2004. Stability and fluctuation in adult attachment style over a 6-year period. Attachment and Human Development, 6, 4, 419–37.



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