title: Refinement and revalidation of the demoralization scale: The DS-II-external validity.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.|School of Psychological Sciences, Monash University, Clayton, Australia.
authors.forename: Sophie
authors.initials: S
authors.lastname: Robinson
authors.affiliation: Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.|Szalmuk Family Psycho-Oncology Unit, Cabrini Health, Malvern, Australia.|Cabrini Palliative Care Service, Prahran, Australia.|Supportive and Palliative Care Unit, Monash Health, Clayton, Australia.
authors.forename: David W
authors.initials: DW
authors.lastname: Kissane
authors.affiliation: Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.|Szalmuk Family Psycho-Oncology Unit, Cabrini Health, Malvern, Australia.
authors.forename: Joanne
authors.initials: J
authors.lastname: Brooker
authors.affiliation: Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.|Szalmuk Family Psycho-Oncology Unit, Cabrini Health, Malvern, Australia.
authors.forename: Courtney
authors.initials: C
authors.lastname: Hempton
authors.affiliation: Cabrini Palliative Care Service, Prahran, Australia.|Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.
authors.forename: Natasha
authors.initials: N
authors.lastname: Michael
authors.affiliation: Department of Palliative Care, Calvary Health Care Bethlehem, Caulfield, Australia.
authors.forename: Jane
authors.initials: J
authors.lastname: Fischer
authors.affiliation: Supportive and Palliative Care Unit, Monash Health, Clayton, Australia.|Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Franco
authors.affiliation: Cabrini Palliative Care Service, Prahran, Australia.
authors.forename: Merlina
authors.initials: M
authors.lastname: Sulistio
authors.affiliation: Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.
authors.forename: David M
authors.initials: DM
authors.lastname: Clarke
authors.affiliation: Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.|Department of Econometrics, Monash University, Clayton, Australia.
authors.forename: Mehmet
authors.initials: M
authors.lastname: Ozmen
authors.affiliation: School of Psychological Sciences, Monash University, Clayton, Australia.|Szalmuk Family Psycho-Oncology Unit, Cabrini Health, Malvern, Australia.
authors.forename: Susan
authors.initials: S
authors.lastname: Burney
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000523:psychology* / Q000628:therapy; D010166:Palliative Care; D011594:Psychometrics / Q000379:methods; D011788:Quality of Life; D015203:Reproducibility of Results; D012307:Risk Factors; D012959:Socioeconomic Factors; D013315:Stress, Psychological / Q000175:diagnosis; D011795:Surveys and Questionnaires
keywords: cancer; construct validity; convergent validity; demoralization; discriminant validity; external validity; revalidation