title: Demoralization: a systematic review on its clinical characterization.
abstract: BACKGROUND
  Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope.
  
  
  METHODS
  We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word 'demoralization' in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected.
  
  
  RESULTS
  Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes.
  
  
  CONCLUSIONS
  Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.
authors.affiliation: Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy.
authors.forename: L
authors.initials: L
authors.lastname: Tecuta
authors.affiliation: Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy.
authors.forename: E
authors.initials: E
authors.lastname: Tomba
authors.affiliation: Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy.
authors.forename: S
authors.initials: S
authors.lastname: Grandi
authors.affiliation: Laboratory of Psychosomatics and Clinimetrics, Department of Psychology,University of Bologna,Bologna,Italy.
authors.forename: G A
authors.initials: GA
authors.lastname: Fava
mesh_terms: D000223:Adaptation, Psychological; D003865:Major Depressive Disorder / Q000145:classification / Q000175:diagnosis*; D006801:Humans; D009013:Morale
keywords: medical illness