Assessing demoralization in medically ill patients: Factor structure of the Italian version of the demoralization scale and development of short versions with the item response theory framework

Martino Belvederi Murri, Luigi Zerbinati, Heifa Ounalli, David Kissane, Beatrice Casoni, Marta Leoni, Giorgia Rossi, Riccardo Dall'Olio, Rosangela Caruso, Maria Giulia Nanni, Luigi Grassi

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Objective: Demoralization has been mostly investigated in oncology but is also relevant for patients with other physical illnesses. Our aims were to investigate the psychometric properties of the 24-item Italian version of the Demoralization Scale (DS-24) among medically ill inpatients, and to develop shorter versions for screening. Methods: Four-hundred and seventy-three participants were recruited from medical wards of the University Hospital of Ferrara. Patients were assessed using the Diagnostic Criteria for Psychosomatic Research-Demoralization module (DCPR/D), Demoralization Scale (DS-24), Patient Health Questionnaire-9 (PHQ-9), Brief-Symptom Inventory-18, Anxiety subscale (BSI-Anx) and EuroQol Group (EQ-5D). Confirmatory factor analyses of previous structures and exploratory factor analyses were conducted using an Item Response Theory approach, including a bifactor model. Results: According to DCPR/D criteria, the prevalence of demoralization was 40%. Confirmatory analyses revealed that none out of seven factor structures from oncology studies adequately fitted data from hospital inpatients. Exploratory Item Factor Analysis uncovered a four-factor model comprising Disheartenment, Dysphoria, Sense of Failure, Loss of Meaning and Purpose, or a bifactor model, comprising similar factors with the addition of a general factor accounting for 45% of the variance. Moreover, we developed 13 and 6-item versions of the DS, both retaining high correlation with DS-24 scores (r = 0.98 and r = 0.95, respectively) and concordance with DCPR/D criteria (AUC-ROC 0.82 and 0.81). Conclusion: The DS factor structure differs between general hospital and cancer patients. Differences may depend on intrinsic disease features and cultural-geographic factors. The short versions of the DS-24 may aid clinicians in identifying demoralized patients in hospital settings.

Original languageEnglish
Article number109889
Number of pages8
JournalJournal of Psychosomatic Research
Publication statusPublished - Jan 2020


  • Chronic diseases
  • Demoralization
  • Depression
  • Distress
  • General hospital
  • Screening

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