Clinimetric properties of the 21-item Depression, Anxiety and Stress Scales (DASS-21)

Giovanni Mansueto, Danilo Carrozzino, Kaj Sparle Christensen, Chiara Patierno, Fiammetta Cosci

Abstract


Background: The Depression, Anxiety and Stress Scale-21 (DASS-21) is a widely used patient-reported outcome measure. While psychometric properties of the DASS-21 have been studied, insufficient attention has been devoted to the assessment of its clinimetric properties. This study verified the clinimetric properties of the Italian version of the DASS-21 according to Clinimetric Patient-Reported Outcome Measures (CLIPROM) criteria.


Methods: This is a cross-sectional study involving 951 university students from April to September 2020. Participants were asked to fill in the DASS-21 via an online survey. Participation was voluntary. Item Response Theory (IRT) models were used to test dimensionality, scalability, and sensitivity of DASS-21.


Results: IRT analyses showed that the DASS-21 total score was a multidimensional measure of psychological distress. Fit to the Rasch model was achieved after excluding five misfitting items and adjusting the sample size, resulting in a 16-item version of the DASS-21. The 16-item version entailed the clinimetric property of sensitivity but included inter-correlated items. Brief versions of the DASS-21 subscales of depression, anxiety, and stress, which did not include locally dependent items, fitted the Rasch model expectations, and had an acceptable unidimensionality and scalability, were identified.


Conclusion: The 16-item version of the DASS-21 may be used as an overall indicator of dysthymia and should be supplemented with the brief versions of the depression, anxiety, and stress subscales, which were found to be valid clinimetric indices.

Keywords


Anxiety; Assessment; Clinimetrics; Depression; Stress; Validity; Clinical psychology.

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References


Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176-181. https://doi.org/10.1037/1040-3590.10.2.176

Bech, P. (2004). Modern psychometrics in clinimetrics. Psychotherapy and Psychosomatics. 73(3), 134-138. https://doi.org/10.1159/000076448

Bech, P. (2007). Dose-response relationship of pregabalin in patients with generalized anxiety disorder: A pooled analysis of four placebo-controlled trials. Pharmacopsychiatry, 40(4), 163-168. https://doi.org/10.1055/s-2007-984400

Bech, P. (2012). Clinical Psychometrics. Wiley-Blackwell.

Bech, P., Bille, J., Møller, S. B., Hellström, L. C., & Østergaard, S. D. (2014). Psychometric validation of the Hopkins Symptom Checklist (SCL-90) subscales for depression, anxiety, and interpersonal sensitivity. Journal of Affective Disorders, 160, 98-103. https://doi.org/10.1016/j.jad.2013.12.005

Bech, P., Carrozzino, D., Austin, S. F., Møller, S. B., & Vassend, O. (2016a). Measuring euthymia within the Neuroticism Scale from the NEO Personality Inventory: a Mokken analysis of the Norwegian general population study for scalability. Journal of Affective Disorders, 193, 99-102. https://doi.org/10.1016/j.jad.2015.12.039

Bech, P., Kessing, L. V., & Bukh, J. D. (2016b). The validity of dysthymia to predict clinical depressive symptoms as measured by the Hamilton Depression Scale at the 5-year follow-up of patients with first episode depression. Nordic Journal of Psychiatry, 70(8), 563-566. https://doi.org/10.1080/08039488.2016.1180712

Benasi, G., Fava, G. A., & Rafanelli, C. (2020). Kellner’s symptom questionnaire, a highly sensitive patient-reported outcome measure: systematic review of clinimetric properties. Psychotherapy and Psychosomatics, 89(2), 74-89. https://doi.org/10.1159/000506110

Bottesi, G., Ghisi, M., Altoè, G., Conforti, E., Melli, G., & Sica, C. (2015). The Italian version of the Depression Anxiety Stress Scales-21: Factor structure and psychometric properties on community and clinical samples. Comprehensive Psychiatry, 60, 170-181. https://doi.org/10.1016/j.comppsych.2015.04.005

Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D.H. (1997). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behaviour Research and Therapy, 35(1), 79-89. https://doi.org/10.1016/s0005-7967(96)00068-x

Carrozzino, D., Patierno, C., Guidi, J., Berrocal Montiel, C., Cao, J., Charlson, M. E., Christensen, K. S., Concato, J., De las Cuevas, C., de Leon, J., Eöry, A., Fleck, M. P., Furukawa, T. A., Horwitz, R. I., Nierenberg, A. A., Rafanelli, C., Wang, H., Sonino, N., & Fava, G. A. (2021a). Clinimetric criteria for patient-reported outcome measures. Psychotherapy and Psychosomatics, 90(4), 222-232. https://doi.org/10.1159/000516599

Carrozzino, D., Christensen, K. S., & Cosci, F. (2021b). Construct and criterion validity of patient-reported outcomes (PROs) for depression: a clinimetric comparison. Journal of Affective Disorders, 283, 30-35. https://doi.org/10.1016/j.jad.2021.01.043

Carrozzino, D., Christensen, K. S., Patierno, C., Siri, C., Zecchinelli, A., Pezzoli, G., & Cosci, F. (2022). The Hopkins Symptom Checklist (SCL-90-R): A Patient-Reported Outcome Measure in Parkinson’s Disease. Journal of Geriatric Psychiatry and Neurology, 35(5), 689-697. https://doi.org/10.1177/08919887211060020

Carrozzino, D., Patierno, C., Fava, G. A., & Guidi, J. (2020). The Hamilton rating scales for depression: a critical review of clinimetric properties of different versions. Psychotherapy and Psychosomatics, 89(3), 133-150. https://doi.org/10.1159/000506879

Charlson, M. E., Carrozzino, D., Guidi, J., & Patierno, C. (2022). Charlson Comorbidity Index: A Critical Review of Clinimetric Properties. Psychotherapy and Psychosomatics, 91(1), 8-35. https://doi.org/10.1159/000521288

Christensen, K. S., Oernboel, E., Nielsen, M. G., & Bech, P. (2019). Diagnosing depression in primary care: A Rasch analysis of the major depression inventory. Scandinavian Journal of Primary Health Care, 37(1), 105-112. https://doi.org/10.1080/02813432.2019.1568703

Clara, I., Cox, B., & Enns, M. (2001). Confirmatory factor analysis of the Depression-Anxiety-Stress Scales in depressed and anxious patients. Journal of Psychopathology and Behavioral Assessment, 23(1), 61-67. https://doi.org/10.1023/A:1011095624717

Crawford, J. R., & Henry, J. D. (2003). The Depression Anxiety Stress Scales (DASS): normative data and latent structure in a large non-clinical sample. British Journal of Clinical Psychology, 42(2), 111-131. https://doi.org/10.1348/014466503321903544

Cosci, F. (2021). Clinimetric perspectives in clinical psychology and psychiatry. Psychotherapy and Psychosomatics, 90(4), 217-221. https://doi.org/10.1159/000517028

Cosci, F., & Fava, G. A. (2021). When anxiety and depression coexist: the role of differential diagnosis using clinimetric criteria. Psychotherapy and Psychosomatics, 90(5), 308-317. https://doi.org/10.1159/000517518

Farmer, A., McGuffin, P., & Williams, J. (2002). Measuring Psychopathology. Oxford University Press.

Fava, G. A. (2022). Forty years of clinimetrics. Psychotherapy and Psychosomatics, 91(1), 1-7. https://doi.org/10.1159/000520251

Fava G. A., Carrozzino D., Lindberg L., & Tomba, E. (2018). The clinimetric approach to psychological assessment: A tribute to Per Bech, MD (1942- 2018). Psychotherapy and Psychosomatics, 87(6), 321–326. https://doi.org/10.1159/000493746

Fava, G. A., Ruini, C., & Rafanelli, C. (2004). Psychometric theory is an obstacle to the progress of clinical research. Psychotherapy and Psychosomatics, 73(3), 145-148. https://doi.org/10.1159/000076451

Fava, G. A., Tomba, E., & Sonino, N. (2012). Clinimetrics: the science of clinical measurements. International Journal of Clinical Practice, 66(1), 11-15. https://doi.org/10.1111/j.1742-1241.2011.02825.x

Feinstein, A. R. (1982). T. Duckett Jones memorial lecture. The Jones criteria and the challenges of clinimetrics. Circulation, 66(1), 1-5. https://doi.org/10.1161/01.CIR.66.1.1

Feinstein, A.R. (1983). An additional basic science for clinical medicine: IV. The development of clinimetrics. Annals of Internals Medicine, 99(6), 843-848. https://doi.org/10.7326/0003-4819-99-6-843

Feinstein, A. R. (1987). Clinimetrics. Yale University Press.

Guidi, J., & Fava, G. A. (2022). The Clinical Science of Euthymia: A Conceptual Map. Psychotherapy and Psychosomatics, 91(3), 156-167. https://doi.org/10.1159/000524279

Hagell, P., & Westergren, A. (2016). Sample Size and Statistical Conclusions from Tests of Fit to the Rasch Model According to the Rasch Unidimensional Measurement Model (RUMM) Program in Health Outcome Measurement. Journal of Applied Measurement, 17(4), 416-431.

Henry, J. D., & Crawford, J. R. (2005). The short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample. British Journal of Clinical Psychology, 44(2), 227-239. https://doi.org/10.1348/014466505X29657

Hunsley, J., & Meyer, G. J. (2003). The incremental validity of psychological testing and assessment: conceptual, methodological, and statistical issues. Psychological Assessment, 15(4), 446-455. https://doi.org/10.1037/1040-3590.15.4.446

Lee, J., Lee, E. H., & Moon, S. H. (2019). Systematic review of the measurement properties of the Depression Anxiety Stress Scales–21 by applying updated COSMIN methodology. Quality of Life Research, 28(9), 2325-2339. https://doi.org/10.1007/s11136-019-02177-x

Loevinger, J. (1947). A systematic approach to the construction and evaluation of tests of ability. Psychological Monographs, 61(4), i–49. https://doi.org/10.1037/h0093565

Loevinger, J. (1948). The technic of homogeneous tests compared with some aspects of scale analysis and factor analysis. Psychological Bulletin, 45(6), 507–529. https://doi.org/10.1037/h0055827

Loldrup, D., Langemark, M., Hansen, H. J., Olesen, J., & Bech, P. (1989). Clomipramine and mianserin in chronic idiopathic pain syndrome. Psychopharmacology, 99(1), 1-7. https://doi.org/10.1007/BF00634443

Lovibond, P. F., & Lovibond, S. H. (1995a). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335-343. https://doi.org/10.1016/0005-7967(94)00075-U

Lovibond, S. H., & Lovibond, P. F. (1995b). Manual for the Depression Anxiety Stress Scales (2nd ed.). Psychology Foundation Monograph.

Lovibond, S. H., & Lovibond, P. F. (1993). Manual for the Depression Anxiety Stress Scales (DASS) (1st ed.). Psychology Foundation Monograph.

Mahmoud, J., Hall, L. A., & Staten, R. S. (2010). The psychometric properties of the 21-Item Depression Anxiety and Stress Scale (DASS-21) among a sample of young adults. Southern Online Journal of Nursing Research, 10(4), 21-34.

Marais, I., & Andrich, D. (2008). Effects of Varying Magnitude and Patterns of Response Dependence. Journal of Applied Measurement, 9(2), 105-124.

Mboua, P. C., Siakam, C., & Mabo, N. L. (2021). Impact of the resumption of classes on the mental health of students of the Faculty of Letters and Social Sciences of the University of Dschang, in the context of Covid 19. Journal of Affective Disorders Reports, 5:100147. https://doi.org/10.1016/j.jadr.2021.100147

Medvedev, O. N., Krägeloh, C. U., Titkova, E. A., & Siegert, R. J. (2020). Rasch analysis and ordinal-to-interval conversion tables for the Depression, Anxiety and Stress Scale. Journal of Health Psychology, 25(10-11), 1374-1383. https://doi.org/10.1177/1359105318755261

Moya, E., Larson, L. M., Stewart, R. C., Fisher, J., Mwangi, M. N., & Phiri, K. S. (2022). Reliability and validity of depression anxiety stress scale (DASS)-21 in screening for common mental disorders among postpartum women in Malawi. BMC Psychiatry, 22(1), 352. https://doi.org/10.1186/s12888-022-03994-0

Nielsen, M. G., Ørnbøl, E., Vestergaard, M., Bech, P., & Christensen, K. S. (2017). The construct validity of the major depression inventory: a Rasch analysis of a self-rating scale in primary care. Journal of Psychosomatic Research, 97, 70-81. https://doi.org/10.1016/j.jpsychores.2017.04.001

Olsen, L. R., Jensen, D. V., Noerholm, V., Martiny, K., & Bech, P. (2003). The internal and external validity of the Major Depression Inventory in measuring severity of depressive states. Psychological Medicine, 33(2), 351-356. https://doi.org/10.1017/s0033291702006724

Page, A. C., Hooke, G. R., & Morrison, D. L. (2007). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in depressed clinical samples. British Journal of Clinical Psychology, 46(3), 283-297. https://doi.org/10.1348/014466506X158996

Pallant, J. F., & Tennant, A. (2007). An introduction to the Rasch measurement model: an example using the Hospital Anxiety and Depression Scale (HADS). British Journal of Clinical Psychology, 46(1), 1-18. https://doi.org/10.1348/014466506X96931

Parkitny, L., McAuley, J. H., Walton, D., Costa, L. O. P., Refshauge, K .M., Wand, B. M., Di Pietro, F., & Moseley, G. L. (2012). Rasch analysis supports the use of the depression, anxiety, and stress scales to measure mood in groups but not in individuals with chronic low back pain. Journal of Clinical Epidemiology, 65(2), 189-198. https://doi.org/10.1016/j.jclinepi.2011.05.010

Rasch, G. (1980). Probabilistic models for some intelligence and attainment tests. The University of Chicago Press.

Sakakibara, B. M., Miller, W. C., Orenczuk, S. G., Wolfe, D. L.; & SCIRE Research Team (2009). A systematic review of depression and anxiety measures used with individuals with spinal cord injury. Spinal Cord, 47(12), 841-51. https://doi.org/10.1038/sc.2009.93

Sechrest, L. (1963). Incremental validity: A recommendation. Educational and Psychological Measurement, 23(1), 153-158. https://doi.org/10.1177/001316446302300113

Sekhar, P., Tee, Q. X., Ashraf, G., Trinh, D., Shachar, J., Jiang, A., Hewitt, J., Green, S., & Turner, T. (2021). Mindfulness-based psychological interventions for improving mental well-being in medical students and junior doctors. Cochrane Database Systematic Reviews, 12(12), CD013740. https://doi.org/10.1002/14651858.CD013740.pub2

Shea, T. L., Tennant, A., & Pallant, J. F. (2009). Rasch model analysis of the Depression, Anxiety and Stress Scales (DASS). BMC Psychiatry. 9(1), 1-10. https://doi.org/10.1186/1471-244X-9-21

Smith, E. L., Garety, P. A., Harding, H., & Hardy, A. (2021). Are there reliable and valid measures of anxiety for people with psychosis? A systematic review of psychometric properties. Psychol Psychother. 94(1), 173-198. https://doi.org/10.1111/papt.12265

Sonino, N., & Fava, G. A. (1998). A simple instrument for assessing stress in clinical practice. Postgradraduate Medical Journal, 74(873), 408-410. https://doi.org/10.1136/pgmj.74.873.408

Tennant, A., & Conaghan, P. G. (2007). The Rasch measurement model in rheumatology: what is it and why use it? When should it be applied, and what should one look for in a Rasch paper? Arthritis Care & Research, 57(8), 1358-1362. https://doi.org/10.1002/art.23108

Timmerby, N., Andersen, J. H., Søndergaard, S., Østergaard, S. D., & Bech, P. (2017). A systematic review of the clinimetric properties of the 6-item version of the Hamilton Depression Rating Scale (HAM-D6). Psychotherapy and Psychosomatics, 86(3), 141-149. https://doi.org/10.1159/000457131

Watson, D., & Clark, L. A. (1984). Negative affectivity: The disposition to experience aversive emotional states. Psychological Bulletin, 96(3), 465–490. https://doi.org/10.1037/0033-2909.96.3.465

Wright, J. G., & Feinstein, A. R. (1992). A comparative contrast of clinimetric and psychometric methods for constructing indexes and rating scales. Journal of Clinical Epidemiology, 45(11), 1201-1218. https://doi.org/10.1016/0895-4356(92)90161-f

Yeung, A. Y., Yuliawati, L., & Cheung, S. H. (2020). A systematic review and meta‐analytic factor analysis of the Depression Anxiety Stress Scales. Clinical Psychology: Science and Practice, 27(4), e12362. https://doi.org/10.1111/cpsp.12362




DOI: https://doi.org/10.13129/2282-1619/mjcp-3795

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