Pathways to Distress

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Social Science & Medicine 68 (2009) 562–569

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Social Science & Medicine

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Pathways to distress: The multiple determinants of depression,

hopelessness, and the desire for hastened death in metastatic cancer patients

Gary Rodin a, b, c, *, Christopher Lo a, b, c, Mario Mikulincer d,

Allan Donner e, Lucia Gagliese f, Camilla Zimmermann a, b, c


Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada

Psychosocial Oncology and Palliative Care Research Division, Ontario Cancer Institute, Toronto, Ontario, Canada

University of Toronto, Toronto, Ontario, Canada


New School of Psychology, Interdisciplinary Center Herzliya, Herzliya, Israel


Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada


School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada



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Available online 7 December 2008

We tested a model in which psychosocial and disease-related variables act as multiple protective and risk

factors for psychological distress in patients with metastatic cancer. We hypothesized that depression

and hopelessness constitute common pathways of distress, which mediate the effects of psychosocial

and disease-related factors on the desire for hastened death. This model was tested on a cross-sectional

sample of 406 patients with metastatic gastrointestinal or lung cancer recruited at outpatient clinics of

a Toronto cancer hospital, using structural equation modeling. The results supported the model. High

disease burden, insecure attachment, low self-esteem, and younger age were risk factors for depression.

Low spiritual well-being was a risk factor for hopelessness. Depression and hopelessness were found to

be mutually reinforcing, but distinct...