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

doi:10.1016/j.jpsychores.2019.109889

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

J Psychosom Res. 2020 Jan:128:109889. doi: 10.1016/j.jpsychores.2019.109889. Epub 2019 Nov 29.

Affiliations

¹ Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara, Italy. Electronic address: martino.belvederimurri@unife.it.
² Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara, Italy.
³ Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy.
⁴ University of Notre Dame Australia, Cunningham Centre for Palliative Care Research, St Vincent's Sydney and Szalmuk Family Research Unit at Cabrini Health, Clayton, Victoria, Australia.

PMID: 31812103
DOI: 10.1016/j.jpsychores.2019.109889

Abstract

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.

Keywords: Chronic diseases; Demoralization; Depression; Distress; General hospital; Screening.

MeSH terms

Adult
Aged
Chronic Disease / psychology*
Demoralization*
Female
Humans
Italy
Male
Mass Screening / methods*
Middle Aged
Prevalence
Psychometrics / methods*
Stress, Psychological / psychology