The demoralization scale: a report of its development and preliminary validation
Abstract
The development and elaboration of a conceptualization of existential distress in patients with advanced disease is crucial in order to optimize our clinical response within palliative medicine. Demoralization is one expression of existential distress. Its empirical study will be greatly enhanced by a self-report measure that captures its dimensions and intensity. We report here on the development and testing of the Demoralization Scale in 100 patients with cancer. Factor analysis identified five relatively distinct dimensions: loss of meaning, dysphoria, disheartenment, helplessness, and sense of failure. These factors show high internal reliability, and convergent validity with the McGill Quality of Life Scale, Patient Health Questionnaire, Beck Depression Inventory, Beck Hopelessness Scale, Hunter Opinions and Personal Expectations Scale, and the Schedule of Attitudes toward Hastened Death. Its divergent validity is demonstrated through the differentiation of a subgroup of patients with high demoralization who do not meet DSM-IV categorization for a diagnosis of major depression. Confirmatory validation is needed for the scale to be used as a measure of change in interventions designed to treat demoralization.
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The Demoralization Scale has a Cronbach's alpha of 0.94 in Kissane et al. and 0.82 in Iranian patients with cancer.
“Kissane et al. (13) obtained a Cronbach's alpha of this questionnaire of 0.94. In Iranian society, Sarizadeh et al. (14) Cronbach's alpha of this questionnaire in patients with cancer reported 0.82.”
From Acceptance and commitment therapy for demoralization syndrome and cancer-related trauma: A randomized clinical trial study (2021) · cites this paper as Kissane et al. (13)
The DS is a 24-item Likert scale (score range 0-96).
“The DS is a 24-item Likert scale (score range 0–96).6”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
The DS has five subscales: loss of meaning and purpose, dysphoria, disheartenment, helplessness, and sense of failure.
“It has five subscales: loss of meaning and purpose, dysphoria, disheartenment, helplessness, and sense of failure.6”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
Across two studies (n = 200), demoralization was negatively associated with hopefulness.
“and negatively associated with hopefulness (two studies, n = 200)”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
Across five studies (n = 675), the evidence uniformly indicated a strong negative relationship between demoralization and quality of life.
“Uniformly, the evidence indicated a strong negative relationship between demoralization and quality of life (five studies, n = 675).”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
When the DS was used, rates of demoralization were reported dimensionally, with 13%-18% calculated as having clinically significant demoralization.
“Alternatively, when the DS was used, rates of demoralization were reported dimensionally, with 13%–18% calculated as having clinically significant demoralization.6,22,30,33,35,36,39”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
There were consistent findings across 11 studies (n = 2372) of a strong positive relationship between demoralization and depression.
“There were consistent findings for a strong positive relationship between demoralization and depression (11 studies, n = 2372)”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
There were consistent findings across three studies (n = 442) of a positive relationship between demoralization and a desire for hastened death.
“and a desire for hastened death (three studies, n = 442).”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In four of the five validation studies, divergent validity was reported.
“In four of the five validation studies, divergent validity was reported.6,13,30,39”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
Palliative care has recognized the salience of pointlessness to the will to live.
“yet palliative care has recognized the salience of pointlessness to the will to live.6,22,41”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
Establishing consistency in diagnostic criteria will presume an accepted definition of demoralization, leading to an increased opportunity to empirically validate the syndrome across clinical settings and cultures.
“Establishing consistency in diagnostic criteria will presume an accepted definition of demoralization, leading to an increased opportunity to empirically validate the syndrome across clinical settings and cultures.3,6”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
There was consistent evidence that the DS has convergent validity and internal reliability for the total scale.
“Of the studies examining psychometric properties of demoralization measures, there was consistent evidence to suggest that the DS has convergent validity and internal reliability for the total scale.6,13,22,30,39”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
Cites
The PHQ-9: Validity of a brief depression severity measure
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001) · Journal of General Internal Medicine · doi:10.1046/j.1525-1497.2001.016009606.x · Cited by 44,910 · see citing works
Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation
Beck, A. T., Steer, R. A., & Carbin, M. G. (1988) · Clinical Psychology Review · doi:10.1016/0272-7358(88)90050-5 · Cited by 11,696 · see citing works
Spitzer, R. L. (1999) · JAMA · doi:10.1001/jama.282.18.1737 · Cited by 9,802 · see citing works
The measurement of pessimism: the hopelessness scale
Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974) · Journal of Consulting and Clinical Psychology · doi:10.1037/h0037562 · Cited by 5,494 · see citing works
The PHQ-15: Validity of a New Measure for Evaluating the Severity of Somatic Symptoms
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002) · Psychosomatic Medicine · doi:10.1097/00006842-200203000-00008 · Cited by 3,305 · see citing works
A psychometric evaluation of the Beck Depression Inventory–II.
Dozois, D. J. A., Dobson, K. S., & Ahnberg, J. L. (1998) · Psychological Assessment · doi:10.1037/1040-3590.10.2.83 · Cited by 1,517 · see citing works
Nonspecific Psychological Distress and Other Dimensions of Psychopathology
Dohrenwend, B. P. (1980) · Archives of General Psychiatry · doi:10.1001/archpsyc.1980.01780240027003 · Cited by 947 · see citing works
Cohen, S. R., Mount, B. M., Strobel, M. G., & Bui, F. (1995) · Palliative Medicine · doi:10.1177/026921639500900306 · Cited by 737 · see citing works
Demoralization Syndrome — a Relevant Psychiatric Diagnosis for Palliative Care
Kissane, D. W., Clarke, D. M., & Street, A. F. (2001) · Journal of Palliative Care · doi:10.1177/082585970101700103 · Cited by 624 · see citing works
Self-citationDemoralization: its phenomenology and importance
Clarke, D. M., & Kissane, D. W. (2002) · Australian & New Zealand Journal of Psychiatry · doi:10.1046/j.1440-1614.2002.01086.x · Cited by 590 · see citing works
Self-citationWill to live in the terminally ill
Chochinov, H. M., Tataryn, D., Clinch, J. J., & Dudgeon, D. (1999) · The Lancet · doi:10.1016/s0140-6736(99)80011-7 · Cited by 310 · see citing works
Henkel, V., Mergl, R., Kohnen, R., Maier, W., Möller, H.-J., & Hegerl, U. (2003) · BMJ · doi:10.1136/bmj.326.7382.200 · Cited by 309 · see citing works
Interest in physician-assisted suicide among ambulatory HIV-infected patients
BREITBART, W. S., Rosenfeld, B. D., & Passik, S. D. (1996) · American Journal of Psychiatry · doi:10.1176/ajp.153.2.238 · Cited by 282 · see citing works
Will to live in the terminally ill
Chochinov, H. M. (1999) · The Lancet · doi:10.1016/s0140-6736(98)11448-4 · Cited by 240 · see citing works
Kissane, D. W., Street, A. F., & Nitschke, P. (1998) · The Lancet · doi:10.1016/s0140-6736(98)05406-3 · Cited by 206 · see citing works
Self-citationA Brief History of the Philosophical Foundations of Exploratory Factor Analysis
Mulaik, S. A. (1987) · Multivariate Behavioral Research · doi:10.1207/s15327906mbr2203_3 · Cited by 187 · see citing works
Subjective incompetence, the clinical hallmark of demoralization
de Figueiredo, J. M., & Frank, J. D. (1982) · Comprehensive Psychiatry · doi:10.1016/0010-440x(82)90085-2 · Cited by 177 · see citing works
The schedule of attitudes toward hastened death
Rosenfeld, B. D., BREITBART, W. S., Galietta, M., Kaim, M., Funesti-Esch, J., Pessin, H., Nelson, C. J., & Brescia, R. J. (2000) · Cancer · doi:10.1002/1097-0142(20000615)88:12 · Cited by 131 · see citing works
Quality of life in HIV disease as measured by the McGill Quality of Life Questionnaire
Cohen, S. R., Hassan, S. A., Lapointe, B. J., & Mount, B. M. (1996) · AIDS · doi:10.1097/00002030-199610000-00016 · Cited by 124 · see citing works
Personal hopefulness: A conceptual review of the relevance of the perceived future to psychiatry
Nunn, K. P. (1996) · British Journal of Medical Psychology · doi:10.1111/j.2044-8341.1996.tb01866.x · Cited by 106 · see citing works
The construction and characteristics of an instrument to measure personal hopefulness
Nunn, K., Lewin, T. J., Walton, J. M., & Carr, V. J. (1996) · Psychological Medicine · doi:10.1017/s0033291700035613 · Cited by 96 · see citing works
The Contribution of Demoralization to End of Life Decisionmaking
Kissane, D. W. (2004) · The Hastings Center Report · doi:10.2307/3528690 · Cited by 87 · see citing works
Self-citationDimensions of Psychopathology in the Medically Ill
Clarke, D. M., Mackinnon, A. J., Smith, G. C., McKenzie, D. P., & Herrman, H. (2000) · Psychosomatics · doi:10.1176/appi.psy.41.5.418 · Cited by 75 · see citing works
Self-citationAn empirically derived taxonomy of common distress syndromes in the medically ill
Clarke, D. M., Smith, G. C., Dowe, D. L., & McKenzie, D. P. (2003) · Journal of Psychosomatic Research · doi:10.1016/s0022-3999(02)00410-5 · Cited by 68 · see citing works
Self-citationKissane, D. W., & Kelly, B. J. (2000) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/j.1440-1614.2000.00692.x · Cited by 64 · see citing works
Self-citationOwen, C. A., Tennant, C., Levi, J. A., & Jones, M. (1994) · Psycho-Oncology · doi:10.1002/pon.2960030103 · Cited by 61 · see citing works
Suicide and euthanasia: Patient attitudes in the context of cancer
Owen, C. A., Tennant, C., Levi, J. A., & Jones, M. (1992) · Psycho-Oncology · doi:10.1002/pon.2960010205 · Cited by 49 · see citing works
Demoralisation: its impact on informed consent and medical care
Kissane, D. W. (2001) · The Medical Journal of Australia · doi:10.5694/j.1326-5377.2001.tb143714.x · Cited by 49 · see citing works
Self-citationDemoralization as a Precursor to Serious Depression
Rickelman, B. L. (2002) · Journal of the American Psychiatric Nurses Association · doi:10.1067/mpn.2002.122629 · Cited by 21 · see citing works
Ethnicity and cure rates of Texas children with acute lymphoid leukemia
Hord, M. H., Smith, T. L., Culbert, S. J., Frankel, L. S., & Pinkel, D. P. (1996) · Cancer · doi:10.1002/(sici)1097-0142(19960201)77:3 · Cited by 14 · see citing works
Ledermann, E. K. (2012) · SpringerReference · doi:10.1007/springerreference_70359 · Cited by 12 · see citing works
Hopelessness and Suicidal Behavior: An Overview
Beck, A. T. (1975) · JAMA · doi:10.1001/jama.1975.03260240050026 · Cited by 11 · see citing works
Medical and Ethical Dilemmas when an Advanced Cancer Patient Discontinues Dialysis
Oneschuk, D., & Fainsinger, R. L. (2002) · Journal of Palliative Care · doi:10.1177/082585970201800208 · Cited by 7 · see citing works
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Sorted by citations
Ross, S., Bossis, A., Guss, J., Agin-Liebes, G., Malone, T., Cohen, B., Mennenga, S. E., Belser, A., Kalliontzi, K., Babb, J., et al. (2016) · Journal of Psychopharmacology · doi:10.1177/0269881116675512 · Cited by 1,698 · see citing works
The Patient Dignity Inventory: A Novel Way of Measuring Dignity-Related Distress in Palliative Care
Chochinov, H. M., Hassard, T. H., McClement, S., Hack, T. F., Kristjanson, L. J., Harlos, M., Sinclair, S., & Murray, A. (2008) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2007.12.018 · Cited by 430 · see citing works
Robinson, S., Kissane, D. W., Brooker, J., & Burney, S. (2015) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2014.07.008 · Cited by 401 · see citing works
Self-citationAgin-Liebes, G. I., Malone, T., Yalch, M. M., Mennenga, S. E., Ponté, K. L., Guss, J., Bossis, A. P., Grigsby, J., Fischer, S., & Ross, S. (2020) · Journal of Psychopharmacology · doi:10.1177/0269881119897615 · Cited by 360 · see citing works
Rodin, G., Lo, C., Rydall, A., Shnall, J., Malfitano, C., Chiu, A., Panday, T., Watt, S., An, E., Nissim, R., et al. (2018) · Journal of Clinical Oncology · doi:10.1200/jco.2017.77.1097 · Cited by 338 · see citing works
Fang, C.-K., Chang, M.-C., Chen, P.-J., Lin, C.-C., Chen, G.-S., Lin, J., Hsieh, R.-K., Chang, Y.-F., Chen, H.-W., Wu, C.-L., et al. (2014) · Supportive Care in Cancer · doi:10.1007/s00520-014-2290-4 · Cited by 211 · see citing works
Caruso, R., Nanni, M. G., Riba, M., Sabato, S., Mitchell, A. J., Croce, E., & Grassi, L. (2017) · Acta Oncologica · doi:10.1080/0284186x.2016.1266090 · Cited by 203 · see citing works
Demoralization: a systematic review on its clinical characterization
Tecuta, L., Tomba, E., Grandi, S., & Fava, G. A. (2014) · Psychological Medicine · doi:10.1017/s0033291714001597 · Cited by 195 · see citing works
A Systematic Review of Measures of End‐of‐Life Care and Its Outcomes
Mularski, R. A., Dy, S. M., Shugarman, L. R., Wilkinson, A., Lynn, J., Shekelle, P., Morton, S. C., Sun, V. C.-Y., Hughes, R. G., Hilton, L. K., et al. (2007) · Health Services Research · doi:10.1111/j.1475-6773.2007.00721.x · Cited by 191 · see citing works
Vehling, S., Kissane, D. W., Lo, C., Glaesmer, H., Hartung, T. J., Rodin, G., & Mehnert, A. (2017) · Cancer · doi:10.1002/cncr.30749 · Cited by 182 · see citing works
Self-citationRodríguez‐Prat, A., Balaguer, A., Booth, A., & Monforte‐Royo, C. (2017) · BMJ Open · doi:10.1136/bmjopen-2017-016659 · Cited by 183 · see citing works
Mehnert, A., Vehling, S., Höcker, A., Lehmann, C., & Koch, U. (2011) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2011.02.013 · Cited by 171 · see citing works
Evaluation of quality-of-life measures for use in palliative care: a systematic review
Albers, G., Echteld, M. A., de Vet, H. C. W., Onwuteaka-Philipsen, B. D., van der Linden, M. H. M., & Deliëns, L. (2009) · Palliative Medicine · doi:10.1177/0269216309346593 · Cited by 150 · see citing works
Refinement and revalidation of the demoralization scale: The DS‐II—internal validity
Robinson, S., Kissane, D. W., Brooker, J., Michael, N. G., Fischer, J., Franco, M. E., Hempton, C., Sulistio, M., Pallant, J., Clarke, D. M., et al. (2016) · Cancer · doi:10.1002/cncr.30015 · Cited by 143 · see citing works
Self-citationA Systematic Review and Meta-Analysis of Demoralization and Depression in Patients With Cancer
Tang, P., Wang, H., & Chou, F. (2015) · Psychosomatics · doi:10.1016/j.psym.2015.06.005 · Cited by 142 · see citing works
Selman, L. E., Harding, R., Gysels, M., Speck, P. W., & Higginson, I. J. (2011) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2010.06.023 · Cited by 141 · see citing works
Ross, S., Agin-Liebes, G., Lo, S., Zeifman, R. J., Ghazal, L., Benville, J., Franco Corso, S., Bjerre Real, C., Guss, J., Bossis, A., et al. (2021) · ACS Pharmacology & Translational Science · doi:10.1021/acsptsci.1c00020 · Cited by 139 · see citing works
Refinement and revalidation of the demoralization scale: The DS‐II—external validity
Robinson, S., Kissane, D. W., Brooker, J., Hempton, C., Michael, N. G., Fischer, J., Franco, M. E., Sulistio, M., Clarke, D. M., Özmen, M., et al. (2016) · Cancer · doi:10.1002/cncr.30012 · Cited by 137 · see citing works
Self-citationSymptom burden, loss of dignity, and demoralization in patients with cancer: a mediation model
Vehling, S., & Mehnert, A. (2013) · Psycho-Oncology · doi:10.1002/pon.3417 · Cited by 135 · see citing works
Demoralization in suicide: A systematic review
Costanza, A., Chytas, V., Ambrosetti, J., Shah, S., Amerio, A., Aguglia, A., Serafini, G., Piguet, V., Luthy, C., Cedraschi, C., et al. (2022) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2022.110788 · Cited by 132 · see citing works
Demoralization, anhedonia and grief in patients with severe physical illness.
Clarke, D. M., Kissane, D. W., Trauer, T., & Smith, G. C. (2005) · PubMed Central · Cited by 118 · see citing works
Self-citationMeasurement of psychological distress in palliative care
Kelly, B. J., McClement, S., & Chochinov, H. M. (2006) · Palliative Medicine · doi:10.1177/0269216306072347 · Cited by 121 · see citing works
Guerrero-Torrelles, M., Monforte‐Royo, C., Rodríguez‐Prat, A., Porta-Sales, J., & Balaguer, A. (2017) · Palliative Medicine · doi:10.1177/0269216316685235 · Cited by 120 · see citing works
Vehling, S., Lehmann, C., Oechsle, K., Bokemeyer, C., Krüll, A., Koch, U., & Mehnert, A. (2010) · Supportive Care in Cancer · doi:10.1007/s00520-010-0845-6 · Cited by 118 · see citing works
Demoralization and death anxiety in advanced cancer
An, E., Lo, C., Hales, S., Zimmermann, C., & Rodin, G. (2018) · Psycho-Oncology · doi:10.1002/pon.4843 · Cited by 115 · see citing works
Kissane, D. W., Patel, S. G., Baser, R. E., Bell, R., Farberov, M., Ostroff, J. S., Li, Y., Singh, B., Kraus, D. H., & Shah, J. P. (2013) · Head & Neck · doi:10.1002/hed.22943 · Cited by 110 · see citing works
Self-citationA Review of the Construct of Demoralization
Robinson, S., Kissane, D. W., Brooker, J., & Burney, S. (2014) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/1049909114553461 · Cited by 107 · see citing works
Self-citationVehling, S., Lehmann, C., Oechsle, K., Bokemeyer, C., Krüll, A., Koch, U., & Mehnert, A. (2012) · Psycho-Oncology · doi:10.1002/pon.1866 · Cited by 97 · see citing works
Validation of the Demoralization Scale in an Irish advanced cancer sample
Mullane, M., Dooley, B., Tiernan, E., & Bates, U. (2009) · Palliative and Supportive Care · doi:10.1017/s1478951509990253 · Cited by 93 · see citing works
Depression and end-of-life care for patients with cancer
Rosenstein, D. L. (2011) · Dialogues in Clinical Neuroscience · doi:10.31887/dcns.2011.13.1/drosenstein · Cited by 92 · see citing works
End-of-life communication in the intensive care unit
Levin, T. T., Moreno, B., Silvester, W., & Kissane, D. W. (2010) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2010.04.007 · Cited by 95 · see citing works
Self-citationLethborg, C. E., Aranda, S. K., Cox, S., & Kissane, D. W. (2007) · Palliative & Supportive Care · doi:10.1017/s1478951507000570 · Cited by 90 · see citing works
Self-citationBovero, A., Sedghi, N. A., Opezzo, M., Botto, R., Pinto, M., Ieraci, V., & Torta, R. (2018) · Psycho-Oncology · doi:10.1002/pon.4884 · Cited by 86 · see citing works
Demoralization syndrome among cancer outpatients in Taiwan
Lee, C., Fang, C., Yang, Y., Liu, C., Leu, Y., Wang, T.-E., Chang, Y.-F., Hsieh, R.-K., Chen, Y.-J., Tsai, L., et al. (2011) · Supportive Care in Cancer · doi:10.1007/s00520-011-1332-4 · Cited by 84 · see citing works
Nanni, M. G., Caruso, R., Travado, L., Ventura, C., Palma, A., Berardi, A. M., Meggiolaro, E., Ruffilli, F., Martins, C., Kissane, D., et al. (2018) · Psycho-Oncology · doi:10.1002/pon.4824 · Cited by 78 · see citing works
Self-citationDiagnosis and measurement of subjective incompetence: the clinical hallmark of demoralization
Cockram, C. A., Doros, G., & de Figueiredo, J. M. (2009) · Psychotherapy and Psychosomatics · doi:10.1159/000235737 · Cited by 79 · see citing works
The Use of Palliative Sedation for Existential Distress: A Psychiatric Perspective
Schuman‐Olivier, Z., Brendel, D. H., Forstein, M., & Price, B. H. (2008) · Harvard Review of Psychiatry · doi:10.1080/10673220802576917 · Cited by 79 · see citing works
Boscaglia, N., & M. Clarke, D. (2007) · Psycho-Oncology · doi:10.1002/pon.1044 · Cited by 77 · see citing works
Self-citationDistinguishing symptoms of grief and depression in a cohort of advanced cancer patients
Jacobsen, J. C., Zhang, B., Block, S. D., Maciejewski, P. K., & Prigerson, H. G. (2010) · Death Studies · doi:10.1080/07481180903559303 · Cited by 76 · see citing works
Distress, demoralization and psychopathology: Diagnostic boundaries
de Figueiredo, J. M. (2013) · The European Journal of Psychiatry · doi:10.4321/s0213-61632013000100008 · Cited by 76 · see citing works
Slaaen, M., Ringdal, G. I., Helbostad, J. L., Oldervoll, L. M., Loge, J. H., & Kaasa, S. (2007) · Palliative Medicine · doi:10.1177/0269216307083386 · Cited by 73 · see citing works
Assessment of spiritual suffering in the cancer context: A systematic literature review
Best, M. C., Aldridge, L. J., Butow, P. N., Olver, I., Price, M. A., & Webster, F. (2014) · Palliative & Supportive Care · doi:10.1017/s1478951514001217 · Cited by 67 · see citing works
Murri, M. B., Caruso, R., Ounalli, H., Zerbinati, L., Berretti, E., Costa, S., Recla, E., Folesani, F., Kissane, D. W., Nanni, M. G., et al. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.06.074 · Cited by 68 · see citing works
Self-citationDemoralization: A Life-Preserving Diagnosis to Make for the Severely Medically Ill
Kissane, D. W. (2014) · Journal of Palliative Care · doi:10.1177/082585971403000402 · Cited by 63 · see citing works
Self-citationBovero, A., Botto, R., Adriano, B., Opezzo, M., Tesio, V., & Torta, R. (2019) · Palliative & Supportive Care · doi:10.1017/s1478951519000191 · Cited by 63 · see citing works
Gabel, S. (2013) · Journal of Continuing Education in the Health Professions · doi:10.1002/chp.21175 · Cited by 63 · see citing works
Liu, S. T., Wu, X., Wang, N., Zhao, Q., Xiao, L., Fang, C., Yu, Y., Lin, D., & Zhang, L. L. (2020) · Psycho-Oncology · doi:10.1002/pon.5439 · Cited by 61 · see citing works
Demoralization syndrome: New insights in psychosocial cancer care
Grassi, L. G., & Nanni, M. G. (2016) · Cancer · doi:10.1002/cncr.30022 · Cited by 60 · see citing works
Eggen, A. C., Reyners, A. K. L., Shen, G., Bosma, I., Jalving, M., Leighl, N. B., Liu, G., Richard, N. M., Mah, K., Shultz, D. B., et al. (2020) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2020.02.023 · Cited by 59 · see citing works
Vehling, S., Oechsle, K., Koch, U., & Mehnert, A. (2013) · PLoS ONE · doi:10.1371/journal.pone.0059417 · Cited by 58 · see citing works
Suffering and dying well: on the proper aim of palliative care
den Hartogh, G. A. (2017) · Medicine Health Care and Philosophy · doi:10.1007/s11019-017-9764-3 · Cited by 58 · see citing works
Tang, L., Li, Z., & Pang, Y. K. (2019) · Psycho-Oncology · doi:10.1002/pon.5296 · Cited by 57 · see citing works
Gan, L. L., Gong, S., & Kissane, D. W. (2021) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674211060746 · Cited by 57 · see citing works
Self-citationBobevski, I., Kissane, D. W., Vehling, S., McKenzie, D. P., Glaesmer, H., & Mehnert, A. (2018) · Psycho-Oncology · doi:10.1002/pon.4761 · Cited by 53 · see citing works
Self-citationDeveloping Internet interventions to target the individual impact of stigma in health conditions
Thomas, N., McLeod, B., Jones, N., & Abbott, J.-A. (2015) · Internet Interventions · doi:10.1016/j.invent.2015.01.003 · Cited by 55 · see citing works
Cavelti, M., Beck, E., Kvrgic, S., Kossowsky, J., & Vauth, R. (2012) · Journal of Clinical Psychology · doi:10.1002/jclp.20872 · Cited by 55 · see citing works
Demoralization in Parkinson disease
Koo, B. B., Chow, C. A., Shah, D. R., Khan, F. H., Steinberg, B., Derlein, D. L., Nalamada, K., Para, K. S., Kakade, V. M., Patel, A., et al. (2018) · Neurology · doi:10.1212/wnl.0000000000005425 · Cited by 55 · see citing works
Keep calm and carry on (ethically): Durable moral courage in the workplace
Comer, D. R., & Sekerka, L. E. (2017) · Human Resource Management Review · doi:10.1016/j.hrmr.2017.05.011 · Cited by 57 · see citing works
Culture and Demoralization in Psychotherapy
de Figueiredo, J. M., & Gostoli, S. (2013) · Advances in psychosomatic medicine · doi:10.1159/000348735 · Cited by 53 · see citing works
Social Frailty in Late Adulthood: Social Cognitive and Psychological Well-Being Correlates
Henry, J. D., Coundouris, S. P., Mead, J. K., Thompson, B. K., Hubbard, R. E., & Grainger, S. A. (2022) · The Journals of Gerontology Series B · doi:10.1093/geronb/gbac157 · Cited by 53 · see citing works
Grassi, L., Costantini, A., Caruso, R., Brunetti, S., Marchetti, P., Sabato, S., & Nanni, M. G. (2016) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2016.09.009 · Cited by 53 · see citing works
Demoralization and Psychotherapy: A Tribute to Jerome D. Frank, MD, PhD (1909–2005)
de Figueiredo, J. M. (2007) · Psychotherapy and Psychosomatics · doi:10.1159/000099839 · Cited by 53 · see citing works
Costanza, A., Baertschi, M., Richard-Lepouriel, H., Weber, K., Berardelli, I., Pompili, M., & Canuto, A. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17072232 · Cited by 52 · see citing works
Inglehart, R. C., Nash, R. R., Hassan, Q. N., & Schwartzbaum, J. (2021) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2021.01.009 · Cited by 52 · see citing works
Zanicotti, C. G., Perez, D., & Glue, P. (2012) · Journal of Palliative Medicine · doi:10.1089/jpm.2011.0314 · Cited by 52 · see citing works
Scheffold, K., Philipp, R., Engelmann, D., Schulz‐Kindermann, F., Rosenberger, C., Oechsle, K., Härter, M. C., Wegscheider, K., Lordick, F., Lo, C., et al. (2015) · BMC Cancer · doi:10.1186/s12885-015-1589-y · Cited by 52 · see citing works
Bellido‐Pérez, M., Monforte‐Royo, C., Tomás‐Sábado, J., Porta-Sales, J., & Balaguer, A. (2016) · Palliative Medicine · doi:10.1177/0269216316669867 · Cited by 50 · see citing works
Demoralization predicts suicidality in patients with cluster headache
Koo, B. B., Bayoumi, A., Albanna, A. J., Abusuliman, M., Burrone, L., Sico, J. J., & Schindler, E. A. D. (2021) · The Journal of Headache and Pain · doi:10.1186/s10194-021-01241-7 · Cited by 51 · see citing works
Psychological Factors Affecting Oncology Conditions
Grassi, L. G., Biancosino, B., Marmai, L., Rossi, E. G., & Sabato, S. (2007) · KARGER eBooks · doi:10.1159/000106797 · Cited by 49 · see citing works
Attachment security and existential distress among patients with advanced cancer
Vehling, S., Tian, Y., Malfitano, C., Shnall, J., Watt, S., Mehnert, A., Rydall, A. C., Zimmermann, C., Hales, S., Lo, C., et al. (2018) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2018.11.018 · Cited by 48 · see citing works
Characterizing death acceptance among patients with cancer
Philipp, R., Mehnert, A., Lo, C., Müller, V., Reck, M., & Vehling, S. (2019) · Psycho-Oncology · doi:10.1002/pon.5030 · Cited by 51 · see citing works
Relationship of Suicidal Ideation With Demoralization, Depression, and Anxiety
Xu, K., Hu, D., Liu, Y., Han, Y., Guo, X., Teng, F., & Zhou, Y. (2019) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000974 · Cited by 48 · see citing works
Sun, F., Hung, C., Yao, Y., Fu, C., Tsai, P.-J., & Chiang, C. (2019) · Cancer Nursing · doi:10.1097/ncc.0000000000000740 · Cited by 48 · see citing works
Distress in palliative care patients: Developing patient-centred approaches to clinical management
Lloyd‐Williams, M., Reeve, J. L., & Kissane, D. W. (2008) · European Journal of Cancer · doi:10.1016/j.ejca.2008.02.032 · Cited by 49 · see citing works
Self-citationManaging Cancer And Living Meaningfully: study protocol for a randomized controlled trial
Lo, C., Hales, S., Rydall, A. C., Panday, T., Chiu, A., Malfitano, C., Jung, J., Li, M., Nissim, R. S., Zimmermann, C., et al. (2015) · Trials · doi:10.1186/s13063-015-0811-1 · Cited by 47 · see citing works
Preliminary psychometrics of the Existential Distress Scale in patients with advanced cancer
Lo, C., Panday, T., Zeppieri, J., Rydall, A., Murphy-Kane, P., Zimmermann, C., & Rodin, G. (2017) · European Journal of Cancer Care · doi:10.1111/ecc.12597 · Cited by 44 · see citing works
Clinical utility of demoralization: A systematic review of the literature
Woźniewicz, A., & Cosci, F. (2023) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102227 · Cited by 44 · see citing works
The factor structure and use of the Demoralization Scale ( DS‐IT ) in Italian cancer patients
Grassi, L. G., Costantini, A., Kissane, D. W., Brunetti, S., Caruso, R., Piazza, G. G., Marchetti, P., Sabato, S., & Nanni, M. G. (2017) · Psycho-Oncology · doi:10.1002/pon.4413 · Cited by 46 · see citing works
Self-citationAslakson, R. A., Dy, S. M., Wilson, R. F., Waldfogel, J. M., Zhang, A. W., Isenberg, S. R., Blair, A. B., Sixon, J., Lorenz, K., & Robinson, K. A. (2017) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2017.04.022 · Cited by 46 · see citing works
Demoralization and Quality of Life of Patients with Parkinson Disease
Zhu, B.-H., Kohn, R., Patel, A. S., Koo, B. B., Louis, E., & de Figueiredo, J. (2021) · Psychotherapy and Psychosomatics · doi:10.1159/000514270 · Cited by 41 · see citing works
Belar, A., Arantzamendi, M., Rodríguez-Núñez, A., Santesteban, Y., Martínez, M., López-Saca, J. M., Consigli, S., López–Fidalgo, J., & Centeno, C. (2018) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2018.11.016 · Cited by 43 · see citing works
Ghiggia, A., Pierotti, V., Tesio, V., & Bovero, A. (2021) · Supportive Care in Cancer · doi:10.1007/s00520-021-06363-x · Cited by 45 · see citing works
Schipper, S., Nigam, K. B., Schmid, Y., Piechotta, V., Ljuslin, M., Beaussant, Y., Schwarzer, G., & Boehlke, C. S. (2024) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd015383.pub2 · Cited by 44 · see citing works
Insecure attachment predicts depression and death anxiety in advanced cancer patients
Scheffold, K., Philipp, R., Koranyi, S., Engelmann, D., Schulz‐Kindermann, F., Härter, M. C., & Mehnert, A. (2017) · Palliative & Supportive Care · doi:10.1017/s1478951517000281 · Cited by 42 · see citing works
Nelson, C. J., Saracino, R. M., Roth, A. J., Harvey, E., Martin, A., Moore, M., Marcone, D., Poppito, S. R., & Holland, J. (2019) · Psycho-Oncology · doi:10.1002/pon.4907 · Cited by 41 · see citing works
Hong, Y., Lin, Y., Pan, Y. X., Lin, J. L., Lin, X. J., Zhang, J., & Huang, F. (2022) · Psycho-Oncology · doi:10.1002/pon.6023 · Cited by 41 · see citing works
Baertschi, M., Costanza, A., Richard-Lepouriel, H., Pompili, M., Sarasin, F., Weber, K., & Canuto, A. (2017) · Journal of Affective Disorders · doi:10.1016/j.jad.2016.12.049 · Cited by 41 · see citing works
Relationship between demoralization and quality of life in end‐of‐life cancer patients
Bovero, A., Opezzo, M., & Tesio, V. (2023) · Psycho-Oncology · doi:10.1002/pon.6095 · Cited by 42 · see citing works
Clinical Characterization of Demoralization
Fava, G. A., & Guidi, J. (2023) · Psychotherapy and Psychosomatics · doi:10.1159/000530760 · Cited by 40 · see citing works
Murri, M. B., Zerbinati, L., Ounalli, H., Kissane, D. W., Casoni, B., Leoni, M., Rossi, G., Dall'Olio, R., Caruso, R., Nanni, M. G., et al. (2019) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2019.109889 · Cited by 40 · see citing works
Self-citationSuicidal risk and demoralization in Parkinson disease
Elfil, M., Ahmed, N., Alapati, A., Bahekar, R., Kandil, M., Kim, C., Schaefer, S. M., Tinaz, S., Patel, A., de Figueiredo, J. M., et al. (2019) · Journal of Neurology · doi:10.1007/s00415-019-09632-2 · Cited by 40 · see citing works
Chang, T., Huang, P.-C., Hsu, C., & Yen, T. (2022) · Health and Quality of Life Outcomes · doi:10.1186/s12955-022-01962-6 · Cited by 39 · see citing works
Validation of the Death and Dying Distress Scale in patients with advanced cancer
Shapiro, G. K., Mah, K., Li, M., Zimmermann, C., Hales, S., & Rodin, G. (2020) · Psycho-Oncology · doi:10.1002/pon.5620 · Cited by 40 · see citing works
Distinguishing and treating demoralization syndrome in cancer: A review
D, M. F. M., Sorg, E. M., Jacobs, J. M., Leadbetter, R. A., & Guidi, J. (2023) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2023.10.004 · Cited by 38 · see citing works
Depressed patients with incurable cancer: Which depressive symptoms do they experience?
Brenne, E., Loge, J. H., Kaasa, S., Heitzer, E., Knudsen, A. K., & Wasteson, E. (2013) · Palliative & Supportive Care · doi:10.1017/s1478951512000909 · Cited by 38 · see citing works
Frequency of demoralization and depression in cancer patients
Ignatius, J., & De La Garza, R. (2019) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2019.04.013 · Cited by 37 · see citing works
Psycho-Existential Symptom Assessment Scale (PeSAS) Screening in Palliative Care
Kissane, D. W., Appleton, J., Lennon, J., Michael, N., Chye, R., King, T., William, L., Poon, P., Kanathigoda, S., Needham, K., et al. (2022) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2022.08.002 · Cited by 37 · see citing works
Self-citationJulião, M., Nunes, B., & Barbosa, A. (2016) · Palliative and Supportive Care · doi:10.1017/s1478951515001364 · Cited by 36 · see citing works
Wang, Y., Sun, H., Ji, Q., Wu, Q., Wei, J., & Zhu, P. (2023) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/10499091231154887 · Cited by 37 · see citing works
Philipp, R., Kalender, A., Härter, M. C., Bokemeyer, C., Oechsle, K., Koch, U., & Vehling, S. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-046351 · Cited by 37 · see citing works
- Authors
- Kissane, D. W., Wein, S., Love, A., Lee, X. Q., Kee, P. L., & Clarke, D. M.
- Affiliations
- Memorial Sloan Kettering Cancer Center (US)
- The University of Melbourne (AU)
- Monash University (AU)
- Venue
- Journal of Palliative Care
- Publisher
- SAGE Publications
- Published
- 2004-12
- Volume
- 20
- Issue
- 4
- Pages
- 269-276
- ISSN
- 0825-8597 (ISSN-L)
- 2369-5293
- OpenAlex
- W1862997372
- Cited by
- 442
- References
- 33
- Citations by year
- 2026: 36 · 2025: 38 · 2024: 43 · 2023: 30 · 2022: 34 · 2021: 32 · 2020: 22 · 2019: 18 · 2018: 20 · 2017: 25 · 2016: 14 · 2015: 14 · 2014: 13 · 2013: 29 · 2012: 7
- FWCI
- 6.11
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Palliative Care (publishedVersion)
- PubMed (publishedVersion)
- FedUni ResearchOnline (Federation University Australia) (submittedVersion)
- Funders
- McGill University
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Keywords
- demoralization, existential suffering, Demoralization Scale, scale development, cancer patients, palliative care, meaninglessness, helplessness, sense of failure, dysphoria, hopelessness, major depressive disorder, self-report measures, convergent and discriminant validity
- MeSH terms
- Anger, Attitude to Death, Attitude to Health, Depression, Existentialism, Factor Analysis, Statistical, Female, Guilt, Helplessness, Learned, Humans, Male, Middle Aged, Morale, Neoplasms, Psychiatric Status Rating Scales, Psychometrics, Quality of Life, Stress, Psychological, Terminal Care, Victoria, Self Efficacy
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