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

Sophie Robinson, David W. Kissane, Joanne Brooker, Courtney Hempton, Natasha Michael, Jane Fischer, Michael Franco, Merlina Sulistio, David M. Clarke, Mehmet Ozmen, Susan Burney

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62 Citations (Scopus)


The recently refined Demoralization Scale-II (DS-II) is a 16-item, self-report measure of demoralization. Its 2 factors—Meaning and Purpose and Distress and Coping Ability—demonstrate sound internal validity, including item fit, unidimensionality, internal consistency, and test-retest reliability. The convergent and discriminant validity of the DS-II with various measures is reported here.
Patients who had cancer or other progressive diseases and were receiving palliative care (n = 211) completed a battery of questionnaires, including the DS-II and measures of symptom burden, quality of life, depression, and attitudes toward the end of life. Spearman ρ correlations were determined to assess convergent validity. Mann-Whitney U tests with calculated effect sizes were used to examine discriminant validity and establish the minimal clinically important difference (MCID). Cross-tabulation frequencies with chi-square analyses were used to examine discriminant validity with major depression.
The DS-II demonstrated convergent validity with measures of psychological distress, quality of life, and attitudes toward the end of life. It also demonstrated discriminant validity, as the DS-II differentiated patients who had different functional performance levels and high/low symptoms, with a difference of 2 points between groups on the DS-II considered clinically meaningful. Furthermore, discriminant validity was demonstrated, as comorbidity with depression was not observed at moderate levels of demoralization.
The DS-II has sound psychometric properties and is an appropriate measure of demoralization. Given its structural simplicity and brevity, it is likely to be a useful tool in meaning-centered therapies. Cancer 2016;122:2260–7. © 2016 American Cancer Society.
Original languageEnglish
Pages (from-to)2260-2267
Number of pages8
Issue number14
Publication statusPublished - 15 Jul 2016


  • cancer
  • construct validity
  • convergent validity
  • demoralization
  • discriminant validity
  • external validity
  • revalidation

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