Demoralization and Depression in Patients With Advanced Cancer: Validation of the German Version of the Demoralization Scale

Context. The concept of demoralization has been widely used to describe states of existential distress and a self-perceived incapacity to deal effectively with a specific stressful situation. Objectives. To evaluate the psychometric properties of the German adaptation of the Demoralization Scale (DS) in patients with advanced cancer. Methods. Participants with heterogeneous tumor sites were recruited in several treatment and rehabilitation facilities. Concurrent and divergent validity of the DS was analyzed through associations with and group differences between measures of distress, depression, anxiety, and meaning-related life attitudes. Results. From a total sample of 1102 patients, 516 individuals (45%) with advanced cancer were enrolled (male 53%, median age 58 years [range 18-88], breast cancer 21%, prostate cancer 17%). The total mean score of the DS was 29.8 (SD = 10.41). Four factors were extracted by exploratory factor analysis, which accounted for 59% of the variation (Cronbach alpha = 0.84): loss of meaning and purpose (alpha = 0.88), disheartenment (alpha = 0.88), dysphoria (alpha = 0.80), and sense of failure (alpha = 0.76). DS dimensions shared between 12% and 62% of the variance. Demoralization was significantly associated with anxiety (r = 0.71), depression (r = 0.61), and distress (r = 0.42). Fifty-seven percent of patients had high distress, 24% depression, and 11% high anxiety. According to different cutoff values, between 16% and 39% were seriously demoralized and 73% had moderate levels of demoralization. Between 5% and 20% of patients were seriously demoralized but not clinically depressed; 60% of patients with moderate levels of demoralization had no depression. Conclusion. Results provide further evidence that the DS is a valid and reliable instrument of high clinical relevance in patients with advanced cancer. J Pain Symptom Manage 2011;42:768-776. (C) 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.