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

Abstract

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...

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

“…Although this reflects the population distribution of illness severity among German cancer patients, the results may not be generalizable to individuals with more advanced disease. 47 The results of this study indicate that demoralization is a relevant and distinct dimension of distress in patients with cancer. 21,45 Furthermore, we used a distribution-based cutoff score to identify clinically relevant demoralization; a gold standard based on a structured clinical interview for demoralization, against which a cutoff score could be evaluated, has yet to be defined.…”

The differences and the relationship between demoralization and depression in Chinese cancer patients

“…The DS‐MV assesses status over the preceding 2 weeks. It contains 24 items using a five‐point scoring method, ranging from “strong disagreement” to “strong agreement” . Items 1, 6, 12, 17, and 19 are reverse scored.…”

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

“…The DS‐II is comprised of 16 items rated on a 3‐point Likert scale, including 0 ( never ), 1 ( sometimes ), and 2 ( often ), with higher scores indicative of higher levels of demoralization (score range, 0‐32) . It contains two 8‐item factors: Meaning and Purpose and Distress and Coping Ability .…”

“…The Demoralization Scale‐II (DS‐II) is a recently refined and revalidated 16‐item, self‐report measure of demoralization . Demoralization is a maladaptive coping response conceptualized as a loss of meaning and purpose, with feelings of hopelessness and helplessness .…”

“…In our recent systematic and conceptual reviews, we provided a discussion on the differences between demoralization and depression and highlighted the finding that there is a level of overlap between these constructs. In a companion to this article in this issue of Cancer , we report the internal validity of the DS‐II as a 2‐factor model (comprising two 8‐item factors: Meaning and Purpose and Distress and Coping Ability ) that demonstrated psychometrically sound item fit, unidimensionality, and reliability in patients receiving palliative care . The reduced number of items and the simplified response format make the DS‐II more user‐friendly in the advanced cancer setting than the original 24‐item Demoralization Scale (DS) …”