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The Short Demoralization Scale (SDS): A new tool to appraise demoralization in palliative care patients

  • Laura Galiana (a1), David Rudilla (a2), Amparo Oliver (a1) and Pilar Barreto (a3)



The Demoralization Scale (DS) is the most widely used measure for assessing demoralization. Following the recent clamor for brief assessment tools, and taking into account that demoralization has proved to be a symptom that needs to be controlled and treated in the palliative care setting, a shorter scale is needed. The aim of the present research is to introduce and evaluate the Short Demoralization Scale (SDS).


We employed a cross-sectional design that included a survey of 226 Spanish palliative care patients from the Hospital General Universitario de Valencia. We employed the SDS, the DS, and the Hospital Anxiety and Depression Scale (HADS).


The confirmatory factor analysis supported the one-factor structure of the SDS (χ2(5) = 12.915; p = 0.024; CFI = 0.999; RMSEA = 0.084; CI 95% = [0.028, 0.141]). The reliability was found to be appropriate, with a value of Cronbach's alpha (α) equal to 0.920. A cutoff criterion of 10 was established, which favored the interpretability of the instrument.

Significance of results:

The SDS corrects previous limitations, has a simple scoring system, is cost-effective, and is widely and fully available. In addition, our findings demonstrate that the SDS can be employed effectively in the clinical context.


Corresponding author

Address correspondence and reprint requests to: Laura Galiana, Department of Methodology for the Behavioral Sciences, University of Valencia, Avenida Blasco Ibañez 21, 46010 Valencia, Spain. E-mail:


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Akizuki, N., Yamawaki, S., Akechi, T., et al. (2005). Development of an Impact Thermometer for use in combination with the Distress Thermometer as a brief screening tool for adjustment disorders and/or major depression in cancer patients. Journal of Pain and Symptom Management, 29(1), 9199. Available from
Antunes, B., Harding, R., Higginson, I.J., et al. (2014). Implementing patient-reported outcome measures in palliative care clinical practice: A systematic review of facilitators and barriers. Palliative Medicine, 28(2), 158175. Epub ahead of print Jun 25, 2013. Available from
Bausewein, C., Daveson, B., Benalia, H., et al. (2011). Outcome measurement in palliative care: The essentials. London: The PRISMA Project. Available from
Benito, E., Oliver, A., Galiana, L., et al. (2014). Development and validation of a new tool for the assessment and spiritual care of palliative care patients. Journal of Pain and Symptom Management, 47(6), 100810018. Epub ahead of print Oct 5 m 2013. Available from
Bjordal, K., de Graeff, A., Fayers, P.M., et al. (2000). A 12-country field study of the EORTC QLQ–C30 (version 3.0) and the head and neck cancer specific module (EORTC QLQ–H&N35) in head and neck patients. European Journal of Cancer, 36(14), 17961807.
Bossola, M., Murri, R., Onder, G., et al. (2010). Physicians' knowledge of health-related quality of life and perception of its importance in daily clinical practice. Health and Quality of Life Outcomes, 8, 43. Available from https://
Butcher, J.N., Graham, J.R., Williams, C.L., et al. (1990). Development and use of the MMPI–2 content scales. Minneapolis: University of Minnesota Press.
Chochinov, H.M., Wilson, K.G., Enns, M., et al. (1997). “Are you depressed?” Screening for depression in the terminally ill. The American Journal of Psychiatry, 154(5), 674676. Available from
Cicchetti, D.V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6(4), 284290.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences, 2nd ed. Mahwah, NJ: Lawrence Erlbaum.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1), 155159.
Cormier, J. & Askew, R.L. (2011). Assessment of patient-reported outcomes in patients with melanoma. Surgical Oncology Clinics of North America, 20(1), 201213. Available from
Costantini, A., Picardi, A., Brunetti, S., et al. (2013). La versione italiana della Demoralization Scale: Uno studio di validazione [Italian version of the Demoralization Scale: A validation study] [in Italian]. Rivista di Psichiatria, 48(3), 234239. Available from
Dalal, D.K. & Carter, N.T. (2015). Negatively worded items negatively impact survey research. In More statistical and methodological myths and urban legends. Lance, C.E. & Vanderberg, R.J. (eds.), pp. 112132. New York: Routledge.
Daveson, B.A., Simon, S.T., Benalia, H., et al. (2012). Are we heading in the same direction? European and African doctors' and nurses' views and experiences regarding outcome measurement in palliative care. Palliative Medicine, 26(3), 242249. Epub ahead of print Jun 22, 2011.
Dawson, J., Doll, H., Fitzpatrick, R., et al. (2010). Routine use of patient-reported outcome measures in healthcare settings. BMJ, 340, 464467. Available from
De Jong, C.A.J., Kissane, D.W., Geessink, R.J., et al. (2008). Demoralization in opioid-dependent patients: A comparative study with cancer patients and community subjects. The Open Addiction Journal, 1, 79. Available from
Dohrenwend, B.P., Shrout, P.E., Egri, G., et al. (1980). Nonspecific psychological distress and other dimensions of psychopathology: Measures for use in the general population. Archives of General Psychiatry, 37(11), 12291236.
Hadnagy, Z., Csikós, A. & Nagy, L. (2012). Introduction of the demoralization scale in Hungary: A study on demoralization and depression among hospice patients [in Hungarian]. Orvosi Hetilap, 153(19), 737743.
Harding, R., Simon, S.T., Benalia, H., et al. (2011). The PRISMA Symposium 1: Outcome tool use. Disharmony in European outcomes research for palliative and advanced disease care: Too many tools in practice. Journal of Pain and Symptom Management , 42(4), 493500. Available from
Hearn, J. & Higginson, I.J. (1997). Outcome measures in palliative care for advanced cancer patients: A review. Journal of Public Health Medicine, 19(2), 193199. Available from
Higginson, I.J. & Carr, A.J. (2001). Measuring quality of life: Using quality of life measures in the clinical setting. BMJ, 322(7297), 12971300. Available from
Hu, L. & Bentler, P.M. (1999). Cut-off criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 155.
Hung, H.C., Chen, H.W., Chang, Y.F., et al. (2010). Evaluation of the reliability and validity of the Mandarin version of Demoralization Scale for cancer patients. Journal of Internal Medicine of Taiwan, 21(6), 427435.
Julião, M., Nunes, B., Sobral, M.A., et al. (2015). Is it useful to ask “Está deprimido?” (“Are you depressed?”) to terminally ill Portuguese patients? Results from outpatient research. Palliative & Supportive Care, 14(2), 138141. Epub ahead of print May 20.
Julião, M., Nunes, B. & Barbosa, A. (2016). Prevalence and factors associated with demoralization syndrome in patients with advanced disease: Results from a cross-sectional Portuguese study. Palliative & Supportive Care, 14(5), 468473. Epub ahead of print Jan 6.
Kissane, D.W., Wein, S., Love, A., et al. (2004). The Demoralization Scale: A report of its development and preliminary validation. Journal of Palliative Care, 20(4), 269276.
Mehnert, A., Vehling, S., Hocker, A., et al. (2011). Demoralization and depression in patients with advanced cancer: Validation of the German version of the Demoralization Scale. Journal of Pain and Symptom Management, 42(5), 768776. Epub ahead of print May 18. Available from
Mokkink, L.B., Terwee, C.B., Patrick, D.L., et al. (2010). The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An International Delphi study. Quality of Life Research, 19, 539549. Available from
Morita, T., Tsunoda, J., Inoue, S., et al. (2001). Improved accuracy of physicians' survival prediction for terminally ill cancer patients using the Palliative Prognostic Index. Palliative Medicine, 15(5), 419424.
Mularski, R.A., Rosenfeld, K., Coons, S., et al. (2007). Measuring outcomes in randomized prospective trials in palliative. Journal of Pain and Symptom Management, 34(Suppl. 1), S7S19. Epub ahead of print May 25.
Mullane, M., Dooley, B., Tiernan, E., et al. (2009). Validation of the demoralization scale in an Irish advanced cancer sample. Palliative & Supportive Care, 7(3), 323330.
Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23(10), 433441.
Robinson, S., Kissane, D.W., Brooker, J., et al. (2016 a). Refinement and revalidation of the Demoralization Scale: The DS–II. External validity. Cancer, 122(14), 22602267. Epub ahead of print May 12.
Robinson, S., Kissane, D.W., Brooker, J., et al. (2016 b). Refinement and revalidation of the Demoralization Scale: The DS–II, Internal validity. Cancer, 122(14), 22512259. Epub ahead of print May 12.
Rose, M. & Bezjak, A. (2009). Logistics of collecting patient-reported outcomes (PROs) in clinical practice: An overview and practical examples. Quality of Life Research, 18(1), 125136. Epub ahead of print Jan 20.
Rudilla, D., Galiana, L., Oliver, A., et al. (2015). Comparing counseling and dignity therapies in home care patients: A pilot study. Palliative & Supportive Care, 14(4), 321329. Epub ahead of print Oct 14.
Rudilla, D., Oliver, A., Galiana, L., et al. (2016 a). A new measure of home care patients' dignity at the end of life: The Palliative Patients' Dignity Scale (PPDS). Palliative & Supportive Care, 14(2), 99108. Epub ahead of print Jun 11, 2015.
Rudilla, D., Galiana, L., Oliver, A., et al. (2016 b). Demoralization Scale in Spanish-speaking palliative care patients. Journal of Pain and Symptom Management, 51(4), 769775. Epub ahead of print Dec 22, 2015.
Sloan, J.A., Halyard, M.Y., Frost, M.H., et al. (2007). The Mayo Clinic manuscript series relative to the discussion, dissemination, and operationalization of the Food and Drug Administration guidance on patient-reported outcomes. Value in Health, 10(Suppl. 2), S59–S63.
Terwee, C.B., Bot, S.D.M., de Boer, M.R., et al. (2007). Quality criteria were proposed for measurement properties of health status questionnaires. Journal of Clinical Epidemiology, 60(1), 3442. Epub ahead of print Aug 24, 2006.
Zigmond, A.S. & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), 361370.
Zimmermann, C. & Rodin, G. (2004). The denial of death thesis: Sociological critique and implications for palliative care. Palliative Medicine, 18(2), 121128.


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The Short Demoralization Scale (SDS): A new tool to appraise demoralization in palliative care patients

  • Laura Galiana (a1), David Rudilla (a2), Amparo Oliver (a1) and Pilar Barreto (a3)


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