Coping and depression in chronically ill hospitalized elderly patients MARY HARRIS KALFOSS

Kalfoss MH. Coping and depression in chronically ill hospitalized elderly patients. Nord J Psychiatry 1993;47:85-94. Oslo. ISSN 0803-9488.

The author hypothesized that depressive symptoms in chronically ill hospitalized elderly pa- tients would be related not only to descriptive factors but also to appraisal and individual coping responses. Eighty elderly hospitalized medical inpatients (50-98 years) with chronic physical diseases who were not expected to die during hospitalization were assessed by the Ways of Coping Checklist and the Montgomery-&berg Depression Rating Scale. No statis- tical significant relationships were found between illness variables, sociodemographic vari- ables, or problem-focused coping scores and depressive symptoms. There were, however, modest but significant correlations between secondary appraisals of having to hold oneself back from the situation, emotion-focused coping scores (r=0.27; p=0.01), perceived mental health the year before admittance, and depressive symptoms. This study suggests that de- pressive symptoms in chronically ill hospitalized elderly patients reflect an underlying ap- praisal of having to hold back from the situation (helplessness and powerlessness), which to a large extent reflects emotion-focused coping tendencies in responding to stressful events in general. This type of appraisal may reduce the probability that the staff will identify depres- sive symptoms in hospitalized medically ill elderly patients. Considering the increased mor- bidity and mortality associated with untreated depression in the medically ill, the use of trained nurses to detect depression may be the answer to this problem.

Adjustment, Chronic illness, Coping, Depression, Elderly, Nursirig.

H0gskolelektor Mary Harris Kalfoss, Ullevil Sykepleierh0gskole, Grunnutdanning i syke- pleie, PB 86 Ullevll sykehus, N-0407 Oslo, Norway; Accepted: 29 August 1992.

Depressive symptoms and psychologic disorders are the most frequent type of distress in hospital- ized patients in the general hospital. The preva- lence of depressive mood in medically ill popula- tions has been estimated to be in the range of 15- 50% depending on the type of measurement and the nature of the medical disease (1-4). A grow- ing body of research demonstrates that depres- sive mood hampers recovery, increases the num- ber of complications and risk of disability and death, and extends hospital stays (3, 5). Thus, the identification and treatment of clinically sig- nificant depressive symptoms in hospitalized pa- tients represents a major challenge for both con- sultationhaison psychiatrists and the nursing staff. The high prevalence of such disorders and the effectiveness of psychologic treatment alone in minor depression (6, 7) emphasize the need for nurses to identify potential risk factors and treat less severe depressive responses. This as- sessment requires increased knowledge about the relationship between individual depressive symp-

toms, on the one hand, and the patients’ ap- praisal and coping responses, on the other.

Review of previous research on coping and depres- sion Research focusing on medically ill populations has found that depressed persons appraise threat more readily than non-depressed persons (8, 9) and use less problem-solving, more attention deployment and avoidance behavior (10-12), more wishful thinking (13), greater emotional discharge and hostility (14-16), more self-blame (8), and more coping directed at self-control

Moreover, the type and severity of chronic ill- ness has also demonstrated disease-specific cop- ing effects. Persons diagnosed as having cancer and rheumatoid arthritis, for example, displayed more negative affect than patients with diabetes and hypertension (18), and patients with a myo- cardial infarct and cancer have been shown to

(17).

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86 Mary Harris Kalfoss NORD J PSYCHIATRY 4712 (1993)

use confrontive coping significantly more than patients with arthritis and dermatitis (3, 19).

All these studies, however, differed in sample characteristics, types of stressful events, and types of measurements. Among hospitalized, physically ill elderly patients the lack of studies on the relationships between depressive symp- toms and sociodemographic data is prominent. We also lack studies addressing the relationships between appraisal, coping, and depression. These relationships should be of particular inter- est to nursing personnel, to plan appropriate in- tervention strategies.

The twofold purpose of this paper is to investi- gate in a group of hospitalized, chronically ill eld- erly patients the relationships between 1) de- scriptive and illness factors and depression and 2) appraisal, coping responses, and depression in coping with a stressful encounter. It was hy- pothesized that depressive symptoms would be more prominent among patients with longer ill- ness duration and greater illness severity. We also expected depressed patients to report more primary appraisals of harm and loss and more secondary appraisals of having to accept the situation, with less perceived options for change. The coping strategies of those less depressed should be more problem-focused, and among the depressed we would expect higher frequency of emotion-focused coping.

Subjects and methods Procedure The patients were inpatients in a department of internal medicine at a general municipal hospital in Oslo (Lovisenberg sykehus). This hospital serves a catchment area of elderly people from lower and middle socioeconomic classes. Study criteria restricted selection of individuals to those who fulfilled the following criteria: age 50 years or more, diagnosed as having onehany chronic illnesses (each patient had a disabling medical condition that was expected to continue for at least 6 months or would cause permanent disabil- ity) and had been hospitalized for at least 3 days and no more than 4 weeks at the time of the first interview. The patients should not be cognitively impaired, should have had no documented brain metastases or alcohol misuse, should be able to speak and hear clearly, and should not be termi-

nal (that is, they were expected to survive pres- ent hospitalization).

The hospital ethical board required that all pa- tients be cognitively screened by the nurse in charge and to have given verbal agreement to participate before inclusion in the study (for de- tails, see Ref. 20). Two consent forms describing the purpose and asking permission to tape-record interview sessions were obtained. The patients were interviewed over H consecutive days dur- ing their hospitalization, with each interview last- ing from 1 to 3 h. The data reported in this article were gathered during the first and second inter- views.

Sample The sample consisted of 36 men and 44 women with a mean age of 72.7 years (range 5C98 years). Educational level was quite low, as one- third of the patients had only completed primary school. More than one-third (38%) were not married, separated or divorced, 28% were mar- ried, and 35% were widowed. Patients were di- agnosed as having the following diseases: cancer (22.5%). metabolic diseases (16.3%), circulato- ry-respiratory disease (30%), and musculoskele- tal, genito-urinary, blood, or sense-organ dis- eases (31.3%). Diagnoses were categorized by three medical doctors in accordance with the World Health Organization Classification of Dis- eases (21). Illness duration was as follows: 35% of the patients had been diagnosed from 0 to 1 year, 31% for more than 1 and up to 5 years, 29% for more than 5 to 15 years, and 5% had been diagnosed as having an illness for more than 15 to 20 years. Patients had been hospital- ized for a mean length of 9.2 days.

Theoretical frame work Different ways of conceptualizing and measuring ways of coping have been proposed (22-24). The conceptualization and measurement of stress, ap- praisal, and coping in this study are based on a cognitive-phenomenologic theory of stress and coping (25). The person and the environment are viewed transactionally in terms of an ongoing causal relationship, each affecting and thus being affected by the other. Two processes mediate this relationship: appraisal and coping. Cognitive appraisal is the process by which people evaluate

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NORD PSYKIATR TlDSSKR 4712 (1993) Coping and depression 87

Coping Checklist (WCC) (25, 26). The WCC lists a broad range of cognitive and behavioral strategies that people use to manage the internal and external demands of a stressful encounter. The WCC is usually self-administered but was administered verbally in this study. The good psychometric properties of the scale have been confirmed (26-28). On the basis of a pilot study (n=8) and a review of the literature, 15 emotion- focused and 15 problem-focused strategies were selected for use in this study. These 30 items had an acceptable inter-item reliability (Chronbach’s alpha, 0.69) (see Tables 3 and 4). Coping respon- ses were rated by using a three-point numerical scale, where 0 indicated that the strategy was not used, 1 indicated that it was used somewhat, and 2 indicated that it was used a great deal.

both the personal significance of the event/what is at stake for the individual (primary appraisal) and the options available for coping (secondary appraisal). Coping is defined as constantly changing cognitive and behavioral efforts to manage external and/or internal demands that are appraised as taxing or exceeding the re- sources of the person (25, p. 141). In this model, coping serves two major functions: an emotion- regulating and a problem-regulating function.

Problem-focused coping refers to efforts to deal with the source of stress directly, such as changing conditions in the environment or changing one’s own behavior. Emotion-focused coping refers to coping efforts aimed at reducing emotional distress. An important consequence of this theory emphasizes a person-environmental approach to depression. Depression is regarded as part of an individual’s transaction with her en- vironment and is maintained by specific appraisal and coping responses and is not regarded as purely a consistent perceptual-cognitive struc- ture.

Measurement of ways of coping Perceived stress and cognitive appraisals In an open-ended question, patients were first asked to describe the most stressful episode that they had experienced during the past 3 days.

Primary appraisal (of what was at stake) con- cerning the stressful event was then assessed by the question as to whether it represented a threat, a harm, a loss, or a challenge. The pa- tients were allowed to give only one response.

Secondary appraisal of the event in question was then assessed with four items that described coping options. Patients indicated with a yesho answer whether the stressful situation was “one that you could change or do something about?”, “that you had to accept?”, “that you needed to know more about before you could act?”, and “in which you had to hold yourself back from do- ing what you wanted to do?”. Patients were asked to give only one response to these ques- tions.

Coping responses In assessing coping responses to this specific stressful event, patients completed a shortened 30-item version of the 67-item revised Ways of

Assessment of depression Depression was assessed by a semi-structured clinical interview utilizing the Montgomery As- berg Depression Rating Scale (MADRS) (29). The inter-rater reliabilities of these items have been reported elsewhere (20). The MADRS has a considerable advantage of brevity and there- fore provides ease of administration. The scale is also robust and has been found to provide reli- able ratings when used by non-psychiatric health personnel (20, 30). The scale has been recom- mended specifically in the assessment of depres- sion in the setting of physical illness (31, 32).

Mental health status On a three-point scale patients were asked to rate their mental health status the past year as compared with earlier (33). Answer alternatives were change to the better, unchanged, and change to the worse.

Illness severity Severity of illness was evaluated by the doctor in charge in accordance with the following catego- ries: 1) death not likely, 2) death possible but not likely, 3) death possible in 1-5 years, 4) death possible within a year, 5) death possible in Wj months, 6) death possible in 1-3 months, and 7) will die within 4 weeks.

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Illness duration

Duration of illness was evaluated by the doctor in charge on the basis of the following categories: the patient had lived with his illness 1) less than 3 months; 2) more than 3 months and up to 6 months; 3) more than 6 months and up to 12 months; 4) over 1 year and up to 3 years; 5) over 3 years and up to 5 years; 6) over 5 years and up to 10 years; 7) over 10 years and up to 15 years; and 8) over 15 years and up to 20 years.

Statistical analysis The bivariate relationships between demo- graphic and illness variables was examined by analysis of variance (ANOVA) and table analy- ses. These factors were categorized for analyses in accordance with their presentation in Table 1. Additionally, the relationship between illness se- verity and degree of depression was examined by a 3x3 table analysis, using Goodman and Kru- skal’s gamma coefficient.

The bivariate relationships between cognitive appraisalkoping strategies and depression were examined by ANOVA and linear regression analysis. Cognitive appraisals were coded by ca- tegorizing responses as listed in Table 2 . Coping strategies were coded by aggregating response options into two categories: whether the strategy was not used or whether the strategy was used somewhat/or a great deal.

For additional analysis, the 15 individual pro- blem-focused strategies and the 15 individual emotion-focused strategies were summed to form two separate scores: a problem-focused score (Cronbach’s alpha = 0.67) and an emotion-fo- cused score (Cronbach’s alpha = 0.41).

All analyses were calculated on PC versions of the statistical programs BMDP and SPSS at the Department of Geriatrics, University of Oslo, Ullevil sykehus.

Results No statistically significant relationships were found between sociodemographic and illness variables and depressive symptoms except for a nonsignificant tendency for patients with cancer to have higher depression scores. However, pa- tients who evaluated their mental health as be- coming worse the past year had higher MADRS scores (P=O.OOl ) (Table 1).

Table 1. Relationships between demographiciill- ness variables and the Montgomery-Asberg De- pression Rating Scale (MADRS). Mean scores and standard deviations in 80 hospitalized chronically ill elderly.

MADRS mean score

Descriptive factors Mean SD Sex

Male Female

Age, years 50-69 70-98

Civil status Not married? Married Widowed

Diagnosis7 Neoplasms Cardio-respiratory Endocrine Other5

Illness duration < I year 1-5 years 5->15 years

Mental health Better Unchanged Worse

11.7 7.0 11.3 6.8

11.9 8.1 11.3 6.8

11.9 6.5 10.6 5.3 13.1 7.0

13.6 7.0 9.2 5.6

12.6 8.5 11.6 7.7

12.6 8. I 12.2 5.7 11 .o 5.0

7.8 I .9 8.7 5.3

16.3; 7.7

* P=0.01 as compared with other categories of the

t Includes unmarried, divorced, separated. 7 Diagnoses categorized by doctor in charge in accord-

I Musculoskeletal, genito-urinary, blood and blood-

variable (ANOVA).

ance with WHO Classification of Diseases.

forming, nerve and sense organs.

The primary and secondary appraisals and their relationships with the MADRS scores are presented in Table 2. No statistically significant relationships were found between primary ap- praisals and depression, although threat apprai- sals were associated with the highest mean scores. However, patients who appraised an event as having to hold themselves back from do- ing what they really wanted to do in the situation (secondary appraisal) displayed a statistically sig- nificantly higher MADRS score.

Individual coping strategies and their relation- ship with MADRS mean scores are presented in Tables 3 and 4. Depression was positively related to the problem-focused strategy of trying to ana-

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NORD PSYKlATR TIDSSKR 4712 (1993) Coping and depression 89

revealed a somewhat different picture. The use of all but three emotion-focused coping respon- ses was associated with higher numerical depres- sion scores. However, only the emotion-focused strategy of “wishing one could change what has happened or how one felt” reached statistical sig- nificance (p=0.04).

The sum score of all problem-focused items did not correlate with depressive symptoms as measured by the MADRS. However, the emo- tion-focused sum score was positively related to depression (R=0.265, p=O.Ol).

Table 2. The relationship between cognitive ap- praisals of a stressful event within the hospital and Montgomery-Asberg Depression Scale (MADRS) mean scores in 80 hospitalized chroni- callv i l l elderlv. ~

MADRS mean score

Cognitive appraisals Mean SD

Threat 12.7 7.8 Harm 11.1 10.8 Loss 11.8 5.6 Challenge 7.0 3.8

Can change 9.0 6.3 Must accept 10.9 6.7 Hold yourself back 16.4“’ 8.1 Need information 8.7 4.5

Primary appraisal

Secondary appraisal

“’P=0.01 when compared with all other categories in the group (ANOVA analysis).

lyze the problem (p=0.04). Except for this cop- ing response, no statistically significant relation- ships were found between problem-focused strat- egies and depressive symptoms (Table 3).

The use of emotion-focused coping strategies

Discussion Elderly patients with chronic illnesses constitute a major part of the inpatients in most general hospitals. The presence of depressive symptoms increases functional disability, the risks of phys- ical complications and is associated with pro- longed hospitalization and a complicated reha- bilitation process (1, 4, 34, 35). The present study suggests that the presence of depression in this hospital population was unrelated to physical diagnosis, illness duration, or severity of illness. However, the severity of depressive symptoms

Table 3. Montgomery-Asberg Depression Rating Scale (MADRS) means scores by problem-focused strategies according to a shortened version of the Ways of Coping Checklist (WCC) in 80 hospitalized chronically ill elderly patients (the responses “used somewhat” and “used a great deal” are com- bined).

MADRS mean score (SD)

Strategy Strategy used Coping strategy not used

1. Looked for the silver lining, so to speak; tried to look on the bright side of things 11.7 (5.2) 11.4 (7.5)

2. I knew what had to be done so I doubled my efforts to make things work ( P =0.09) 13.9 (7.4) 10.7 (7.0)

3. I waited to see what happened before I did anything 12.6 (8.0) 11.0 (6.9) 4. I came out of the experience better than I went in 11.5 (5.5) 11.5 (7.8) 5. Drew on past experiences; I was in a similar situation before 12.5 (7.3) 11.0 (7.2) 6. Rediscovered what was important in life 11.5 (6.4) 11.5 (7.6) 7. I tried to see things from the other person’s point of view 12.1 (7.3) 11.2 (7.2) 8. Bargained or compromised to get something positive from the situation 13.0 (7.1) 10.6 (7.1) 9. Asked a relative or friend I respected for advice 10.2 (4.7) 12.3 (8.4)

10. Tried to analyze the problem to understand it better 9.6 (6.6) 12.8 (7.3)’

11. Talked to someone to find out more from the situation 11.6 (6.9) 11.4 (7.5) 12. I made a plan of action and followed i t 12.6 (6.6) 10.5 (7.6) 13. I was inspired to do something creative 11.5 (6.9) 11.5 (7.6) 14. 10.8 (7.0) 12.6 (7.4) 15. Changed something about myself 11.4 (6.3) 11.6 (8.6)

0, = 0.04)

Tried to get the person responsible to change his or her mind

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Table 4. Montgomery- Asberg Depression Rating Scale (MADRS) mean scores by emotional-focused strategies according to a shortened version of the Ways of Coping Checklist (WCC) in 80 hospitalized chronically ill elderly patients (the responses “used somewhat” and “used a great deal” are com- bined).

MADRS mean score

Strategy Strategy

1. 8.3 (6.0) 11.9 (7.3) 2. 12.5 (6.0) 11.3 (7.4) 3. Maintained my pride and kept a stiff upper lip 10.6 (5.0) 11.6 (7.6) 4. Accepted it since nothing could be done 9.7 (8.4) 11.9 (6.9) 5. Tried to keep my feelings to myself 9.8 (6.5) 11.9 (7.3) 6. Tried to forget the whole thing 10.7 (7.6) 11.8 (7.0) 7. Went on as if nothing was happening 12.9 (7.2) 10.8 (7.1) 8. Criticized or lectured myself 9.9 (6.3) 12.5 (7.6) 9. Reminded myself how much worse things could be 10.1 (6.9) 12.6 (7.3)

10. Kept others from knowing how bad things are 10.9 (5.8) 12.0 (8.2) 11. Wished that I could change what has happened or how I felt

12. I daydreamed or imagined a better time or place than the one I was in 10.2 (5.6) 12.6 (8.2) 13. I thought about how a person 1 admired would handle this situation and used

that as a model 11.0 (7.0) 12.2 (7.4) 14. Avoided being with people in general 11.3 (5.8) 11.8 (9.0) 15. Took it out on other people 12.0 (7.4) 8.6 (4.9)

Coping strategy not used used

Got away from it awhile, tried to rest or take a vacation Wished the situation would go away or somehow be over with

9.8 (6.2) 13.0 (7.7)* (p =o .04)

was significantly but moderately related to the secondary appraisal of holding oneself back from the situation and to specific coping strategies. The key coping features of depressed elderly pa- tients with a chronic illness are their general use of emotion-focused coping strategies like rumi- nation and wishful thinking. Additionally, de- pressed patients perceived their prehospitali- zation mental health status as significantly worse.

Whether a specific disease type, phase, dura- tion, or seventy of illness is related to emotional distress has been the subject of much research (11, 18, 36, 37). Other authors have maintained that there exists a direct relationship between psychologic distress and age (38), civil status (39), and sex (40, 41). It was‘interesting to note that depression is not significantly related to any of the above factors. Assumptions of diagnosis and stage-specific emotional responses may be neither tenable nor clinically meaningful. De- pression seems largely independent of diagnosis. Instead, the findings point to the importance of the appraisal demands in a specific stressful event.

How should these findings be interpreted, and what are the clinical implications with regard to

patient care? Three different explanations may be provided. First, reports of more frequent use of emotion-focused coping strategies may be caused by the presence of depressive symptoms. An alternative explanation may be that depres- sive symptoms are the result of emotion-focused coping strategies. Finally, both depressive symp- toms and emotion-focused coping may be two different ways of measuring the same underlying phenomenon - that is, maladjustment to life stress. In the following section all three interpre- tations will be discussed with reference to other studies of coping with stressful events.

Do depressive symptoms cause increased use of emotion-focused coping strategies? The higher depression scores reported by those who had perceived their mental health as becom- ing worse the last year before admission might suggest that emotion-focused coping is caused by depression. Within this context, the secondary appraisal of holding oneself back may thus re- flect depressive mood or other psychiatric prob- lems present before admittance. Furthermore, passivity and holding oneself back are typical re-

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NORD PSYKIATR TIDSSKR 4712 (1YY3) Coping and depression 91

sponses to stressful events in depressive patients. This finding that depressed persons significantly appraised a stressful encounter as holding no coping potential except of holding oneself back also corresponds to the results found by others (8,251.

Several factors may explain feelings of depres- sion and the subsequent use of emotion-focused coping strategies: living with a chronic and pos- sibly painful and disabling illness, facing inter- mittent threatening illness exacerbations, per- sonal-physical ineptness, uncertainty, appraisal of other responses as being too costly for one’s well being, and/or feelings of situational power- lessness due to hospital structure and routines. The use of emotion-focused strategies may function to potentiate rather than alleviate feel- ings of distress.

It has been contended that when first respond- ing to stressful events, persons will cope with in- vigorated efforts to enhance control, a form of reactance that is characterized by increased con- centration, vigilant searching, and perseverance (42). Findings seem to suggest that persons may become trapped in a vicious circle of thoughts and feelings without finding resolution or con- trol. The increased depressive scores among those who “tried to analyze the problem in order to understand it better” and “wished that they could change what had happened or how they felt” may support this explanation.

A significant relationship was found between those persons who assessed their mental health the past year as becoming worse and being de- pressed. Although coping efforts may affect well- being independent of prior mental health status, it is logical that people in poor mental health use different and less effective strategies than those in better mental health (43). Those in poorer mental health may also experience a greater multitude, frequency, and intensity of stressful life events and therefore cope in maladaptive ways. Study findings provide additional evidence for the observation by Felton et al. (18) of what they also called a mutually reinforcing cycle be- tween poor mental health and maladaptive cop- ing. The greater the initial level of emotional dis- tress and the greater the severity of the problem, the more likely it is that persons will use mal- adaptive coping, further increase emotional dis- tress, and possibly increase the probability of problems occurring in the future.

Does emotion-focused coping cause depressive symptoms? The presence of emotion-focused coping among patients with increased depressive symptoms could be related to various factors such as feel- ings of helplessness, slowed reaction time, and the cautious behavior tendencies of the elderly (44). Other factors may include altered levels of consciousness such as decreased ability to think systematically and memory decrements ( 4 3 , bio- chemical changes or situational disturbances such as sensory overload or sensory deprivation, or minimal information on which to act or make de- cisions. Depression might be the ultimate conse- quence of these factors. However, there are sev- eral findings from previous studies that do not support the “depression followed by emotion- focused coping” interpretation. Recent coping studies have found that some patients use various coping strategies whereas others use very few. Furthermore, there was little change in the num- ber of coping responses used in relation to the time since diagnosis (46). The incidence of de- pression, however, is greater when closer related to the time of diagnosis (2, 4), a tendency also seen in our study (Table 1).

Studies have found that problem-focused cop- ing is more situation-dependent than emotion-fo- cused coping, which is more stable and situation- independent. These observations raise the pos- sibility that our findings are less predicted by the hospital situation or the chronic illness per se and are more likely associated with premorbid fac- tors. These findings also correspond to the re- sults found by others (47). This increases the likelihood that the individual will appraise the coping options to any stressful life situation as one in which they have to hold back.

Is emotion-focused coping and depressive symp- toms predicted by the same underlying premorbid factor? The use of emotion-focused coping strategies by depressive persons outside hospital settings is well documented (8, 48, 49). Previous studies have also demonstrated a clear-cut relationship among emotion-focused coping, depression, and poor adjustment to illness (8, 16, 18, 50, 51). When the above factors are considered together with the lack of significant relationships found between depression scores and sociodemo-

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graphic and disease variables (Table l), results may indicate that the severity of depressive symptoms and coping strategies is related more to personality variables than to the actual stressful hospital event.

This interpretation of our data fits well with a recent follow-up study of hospitalized acciden- tally injured males (47) and the results of a genetic epidemiologic investigation of coping in which the WCC was used to assess coping ( 5 2 ) . The lower overall emotion-focused coping scores reported by the patients with fewer depressive symptoms may reflect their ability to perceive and act on several coping options in a specific en- counter. Thus, they do not have to hold them- selves back and rely on the use of emotion-fo- cused strategies.

The results of this study provide only tenative support for the cognitive theoretical coping framework of Lazarus and colleagues, whereby the person and the environment are viewed transactionally in terms of an ongoing process (51). The coping of depressed persons was char- acterized by suppressed emotions and general use of emotion-focused strategies. Only one sig- nificant relationship was found between descrip- tive factors and depression which also lends sup- port to the fact that distressing reactions may be reflected by personality factors or cognitive as- sessment of the stressful situation than by the ill- ness per se.

Methodologic aspects

To a large extent, coping theory suggests that coping responses are situation-specific. In this study, the time from hospital admission to the time of the interview varied. This may theoreti- cally influence the coping results. However, one study suggested that strategies in coping with cancer were rather consistent and displayed little variation over time (46). Therefore, it is not like- ly that the present findings are invalidated by the minor differences in time elapsing from hospital admittance to the time of interview.

Limitations in cross-sectional studies concern questions about causation and effect of influ- ence. It should be stressed that this study has identified certain patterns of association, not causal relationships. Although the issue of cau- sality has been discussed, it still remains unclear whether ineffective appraisals and coping re-

sponses were the cause o r the result of depressive symptoms. It has been argued that a network of reciprocal effects most certainly exists. The rela- tionships between coping and emotion are com- plex, and the correlations found in this study are rather modest. Thus, although the findings fit with other studies of coping, including recent genetic studies (53) , this study underlines the need for research focused on longitudinal data.

Implications for consultationlliaison psychiatry

It is imperative that nurses understand their pa- tients’ perceptions of stress, can predict their adaptive capacities, and can deliberately select those interventions that will increase the coping capacities for those at risk. The findings of this study may stress the value of including nurses in the consultation/liaison work. I t has repeatedly been found that a system based on direct consul- tation identifies only a limited number of those patients who are depressed (3). By using nurses in liaison work who are trained in reliable assess- ments (20), it should be possible to detect an even larger group of patients who are depressed or suffer from other psychiatric problems, and offer them specific inpatient treatment and dis- charge follow-up.

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Acknowledgement - This paper is part of a study finan- cially supported by The Norwegian Cancer Society and the Norwegian Research Council for Sciences and the Humanities (NAVF). The study was also supported by the Norwegian Nurses Association. The author would like to thank nurses and doctors at the Department of Internal Medicine, Lovisenberg Hospital, Oslo, for help and support in conducting the study. The author is grateful for the critical comments and suggestions for improvement made by the professors Knut Laake and Ulrik Malt, Faculty of Medicine, University of Oslo, Norway.

Mary Harris Kalfoss, MA, Department of Geriatrics, University of Oslo, Ullevll sykehus, and Department of Psychosomatic and Behavioural Medicine, Univer- sity of Oslo, The National Hospital, Oslo, Norway.

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