The Transcultural Psychiatry Section was awarded one of the two inaugural grants approved for funding by the World Psychiatric Association for research on topics related to the interrelations of psychiatry and medicine. The subjects in the study will be cancer patients recruited in participating centers located in the United States, Italy, and Australia. John M.de Figueiredo, MD, ScD, Associate Clinical Professor of Psychiatry at Yale University School of Medicine, will be the Principal Investigator. Giovanni Fava, MD, Professor of Psychiatry and Psychology at the University of Bologna, Italy, and David Clarke, Ph.D., Professor of Psychology, Psychiatry and Psychological Medicine at Monash University, Melbourne, Australia, will be Co-Principal Investigators.
Numerous studies have assessed depression in cancer patients, reporting widely variable prevalence rates . The study of depression in cancer patients can be quite challenging, partly because the symptoms range from sadness to major depressive disorder, partly because patients are exposed to a life threatening illness and its complications, and partly because it may be difficult to distinguish what may be homeostatic response to stress from a mental disorder or a result of cancer or its treatment . A critical issue is the interpretation of the clinical presentation. Are the symptoms of depression of a cancer patient a sign of normal (“understandable”) reaction to stress, of non-specific (sub-threshold) distress, of clinical (supra-threshold) depression, or of demoralization? How is a normal (“understandable”) reaction to cancer influenced by culture? 
The distinction between depression and demoralization brings us closer to an understanding of the psychological distress of cancer patients. Demoralization has been described as the state of mind of a person deprived of spirit or courage, disheartened, bewildered, and thrown into disorder or confusion. Jerome D. Frank proposed that all forms of psychotherapy attempt to relieve demoralization and that the majority of patients who seek psychotherapy are demoralized, whatever their diagnostic label. Moreover, he pointed out that all psychotherapies share at least four effective features: a therapeutic alliance between the helper and the sufferer; a context or healing setting; a rationale, conceptual scheme or myth that provides a plausible explanation for the patient’s symptoms; and a ritual or procedure that requires the active participation of the healer and the sufferer and that is believed by both to be the means of restoring the patient’s health. According to Frank, these four features are the nonspecific ingredients of the process of healing . Frank recognized that improvement in psychotherapy is multidimensional and that the key element in improvement is the patient’s own restorative process rather than the specific form of psychotherapy, thus highlighting the importance of the patient’s degree of resilience in his or her attempts to overcome demoralization .
Demoralization has been observed not only in psychiatric outpatients but also in medically ill patients, first described by George Engel as the “giving up-given up syndrome”  and in acutely ill patients in emergency departments, where it was called “crisis” by Gerald Kaplan . A state of chronic demoralization was described as “social breakdown syndrome” by Ernest Gruenberg in patients with chronic mental illness . The prevalence of demoralization in a community has been shown to be inversely associated with the degree of sociocultural integration. That is, persons less integrated in their social groups are more demoralized and more likely to suffer from psychiatric disorders than those more integrated; even when the former have fewer stressful life events than the latter [9, 10]. Furthermore, the former are also more likely to see a doctor or to be hospitalized for physical illness than the latter .
To further characterize the concept of demoralization, Dr. de Figueiredo, who had been a student of Dr. Frank, proposed several years ago that the clinical hallmark of demoralization is “subjective incompetence”, a self-perceived incapacity to perform tasks and express feelings deemed appropriate in a stressful situation, resulting in pervasive uncertainty and doubts about the future. Depression and other forms of distress may or may not be associated with subjective incompetence. Demoralization is viewed as involving both non-specific distress and subjective incompetence [12-14].
The objectives of the proposed research are to determine if: (a) subjective incompetence is directly correlated with functional impairment and predicts functional impairment; (b) subjective incompetence is a necessary component of demoralization; and (c) depression and subjective incompetence are separate components of demoralization. Cross-national and cross-cultural differences in the pattern of results will be examined and interpreted.
Due to lack of measures of subjective incompetence, while demoralization has been documented in cancer patients, the relevance of subjective incompetence to this patient population has not yet been demonstrated. Two scales for subjective incompetence have recently been developed by Dr. de Figueiredo and his colleagues and shown to have reliability and validity, thus opening up the possibility for studying the relationship of distress and subjective incompetence to perceived stress and social support . The now-funded WPA-TPS study will be using those two subjective incompetence scales as well as other measures such as the demoralization criteria that are part of the Diagnostic Criteria for Psychosomatic Research (DCPR) , the demoralization scales developed by Bruce Dohrenwend  and David Kissane , and scales to measure perceived stress, level of social support, resilience, and quality of life. The Karnofsky performance status criteria and index will be used to measure functional impairment .
It is anticipated that this project will be carried out from March, 2010 tihrough July, 2011. Reports on the methods and results of this study will be submitted for publication in professional journals and presented at cultural psychiatry conference in 2011 and 2012.