Refinement and revalidation of the demoralization scale: The DS‐II—external validity

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BACKGROUND:The Demoralization Scale (DS) was initially validated in 2004 to enable the measurement of demoralization in patients with advanced cancer. Subsequent shortcomings indicated the need for psychometric strengthening. Here, the authors report on the refinement and revalidation of the DS to form the DS-II, specifically reporting the scale's internal validity. METHODS: Patients with cancer or other progressive diseases who were receiving palliative care (n 5 211) completed a revised version of the 24-item DS and a measure of symptom burden (the Memorial Symptom Assessment Scale). Exploratory factor analysis and Rasch modeling were used to evaluate, modify, and revalidate the scale, providing information about dimensionality, suitability of response format, item fit, item bias, and item difficulty. Test-retest reliability was examined for 58 symptomatically stable patients at a 5-day follow-up. RESULTS: Exploratory factor analysis supported a 22-item, 2-component model. Separate Rasch modeling of each component resulted in collapsing the response option categories and removing 3 items from each component. Both final 8-item subscales met Rasch model expectations and were appropriate to sum as a 16-item total score. The DS-II demonstrated internal consistency and test-retest reliability (Meaning and Purpose subscale: a 5 .84; intraclass correlation [ICC] 5 0.68; Distress and Coping Ability subscale: a 5 .82; ICC 5 0.82; total DS: a 5 .89; ICC 5 0.80). CONCLUSIONS: The DS-II is a 3-point response, self-report scale comprising 16 items and 2 subscales. Given its revalidation, psychometric strengthening, and simplification, the DS-II is an improved and more practical measure of demoralization for research and clinical use. External validation of the DS-II will be reported subsequently. Cancer 2016;122:2251-9. V C 2016 American Cancer Society.KEYWORDS: psychometrics, cancer, reliability, validity, adjustment, coping behavior, demoralization, Rasch modeling. INTRODUCTIONDemoralization has become increasingly recognized in palliative care as a clinical issue requiring assessment and treatment. 1,2 Understood as a state of maladaptive coping, demoralization develops with symptoms of hopelessness and helplessness associated with loss of purpose and meaning in life. 1 In a recent systematic review of 25 studies, clinical prevalence rates for demoralization ranged from 13% to 18% in patients with progressive diseases like cancer. 3 The morale of any patient fluctuates dimensionally from optimism to mild disheartenment, to greater despondency, and potentially to deep despair, which can be associated with a desire for hastened death. 4 Thus, the importance of measuring demoralization has been emphasized with reference to the risk of suicide and its potential relevance in end-of-life decision making. 1 Access to a psychometrically sound measure aids in the clinical assessment of demoralization. 5 Our preliminary validation of the Demoralization Scale (DS) in 2004 created a 24-item self-report scale that proved to be a use...

Section: Introductionmentioning

confidence: 95%

“…Its external validity (convergent and divergent) is reported in a companion article by Robinson et al in this issue of Cancer. 13…”

Section: Introductionmentioning

confidence: 99%

Refinement and revalidation of the demoralization scale: The DS‐II—internal validity

Robinson

Kissane

Brooker

et al. 2016

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“…[18][19][20][21][22][23][24][25] This is similar to mixed anxiety-depressive states. There is still limited evidence about the extent to which demoralization occurs independently of or in association with diagnosed mental disorders in individuals with cancer.…”

Section: Introductionmentioning

confidence: 99%

“…Previous work has shown moderate to high correlations between demoralization and self-reported depression (r 5 0.33-0.80) and selfreported anxiety (r 5 0.67-0.72). [18][19][20][21][22][23][24][25] This is similar to mixed anxiety-depressive states. The results of these studies do not, however, differentiate well between patients with and without a mental disorder and vary considerably because of the different self-report measures used.…”

Section: Introductionmentioning

confidence: 99%

The association of demoralization with mental disorders and suicidal ideation in patients with cancer

Vehling

Kissane

et al. 2017

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135

126

“…There have been several recent reports about the importance of demoralization, particularly in the settings of cancer and palliative care. [5][6][7] In this issue of Cancer, Robinson et al 8,9 explore the application of a new, refined, 16-item, self-report measure of demoralization (Demoralization Scale-II [DS-II]) in patients with cancer or other progressive diseases who were receiving palliative care. The analyses by Robinson and colleagues highlight the need for clinicians to consider demoralization as a significant clinical entity to be taken seriously into account in cancer settings.…”

mentioning

confidence: 99%

Demoralization syndrome: New insights in psychosocial cancer care

Grassi

Nanni

2016

The psychological reactions of patients in response to cancer have been the object of psycho-oncology research since the first studies carried out by Arthur M. Sutherland in the middle of the last century.1 Subsequent better designed investigations were carried out in many parts of the world using standardized psychiatric interviews according to the Diagnostic Statistical Manual for Mental Disorders (DSM) of the American Psychiatric Association and the International Classification of Diseases (ICD) of the World Health Organization. Meta-analyses of these studies are now available 2 and indicate that approximately 30% to 40% of patients with cancer meet the criteria for a psychiatric diagnosis-especially depressive disorders-that have extremely negative consequences for the patients and their families (eg, impairment of quality of life, longer rehabilitation processes, risk of suicide, reduction in adherence to treatment).It is clear that having a system to codify the psychiatric disorders observable in oncology, including depression, is extremely important for a whole-person-centered approach that includes psychosocial aspects as mandatory targets. However, the psycho-oncology literature has demonstrated that many other psychosocial dimensions not detectable with classical psychiatric nosology (ie, ICD and DSM) are extremely common and have a remarkable role in negatively influencing a patient's quality of life. 3,4 Demoralization is one of the most important among the aforesaid constructs. It can be clinically separated from depressive disorders, has a high prevalence in medical disorders, and thus needs to be carefully examined, correctly measured, and treated. There have been several recent reports about the importance of demoralization, particularly in the settings of cancer and palliative care. [5][6][7] In this issue of Cancer, Robinson et al 8,9 explore the application of a new, refined, 16-item, self-report measure of demoralization (Demoralization Scale-II [DS-II]) in patients with cancer or other progressive diseases who were receiving palliative care. The analyses by Robinson and colleagues highlight the need for clinicians to consider demoralization as a significant clinical entity to be taken seriously into account in cancer settings. Demoralization Syndrome and its AssessmentThe concept of demoralization