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1.  The Depression Anxiety Stress Scales (DASS): detecting anxiety disorder and depression in employees absent from work because of mental health problems 
Occupational and Environmental Medicine  2003;60(Suppl 1):i77-i82.
Aims: To (1) evaluate the psychometric properties and (2) examine the ability to detect cases with anxiety disorder and depression in a population of employees absent from work because of mental health problems.
Methods: Internal consistency, construct validity, and criterion validity of the Depression Anxiety Stress Scales (DASS) were assessed. Furthermore, the ability to identify anxiety disorders or depression was evaluated by calculating posterior probabilities of these disorders following positive and negative test results for different cut off scores of the DASS-Depression and DASS-Anxiety subscales.
Results: Internal consistency of the DASS subscales was high, with Cronbach's alphas of 0.94, 0.88, and 0.93 for depression, anxiety, and stress respectively. Factor analysis revealed a three factor solution, which corresponded well with the three subscales of the DASS. Construct validity was further supported by moderately high correlations of the DASS with indices of convergent validity (0.65 and 0.75), and lower correlations of the DASS with indices of divergent validity (range -0.22 to 0.07). Support for criterion validity was provided by a statistically significant difference in DASS scores between two diagnostic groups. A cut off score of 5 for anxiety and 12 for depression is recommended. The DASS showed probabilities of anxiety and depression after a negative test result of 0.05 and 0.06 respectively. Probabilities of 0.29 for anxiety disorder and 0.33 for depression after a positive test result reflect relatively low specificity of the DASS.
Conclusion: The psychometric properties of the DASS are suitable for use in an occupational health care setting. The DASS can be helpful in ruling out anxiety disorder and depression in employees with mental health problems.
doi:10.1136/oem.60.suppl_1.i77
PMCID: PMC1765723  PMID: 12782751
2.  Rasch model analysis of the Depression, Anxiety and Stress Scales (DASS) 
BMC Psychiatry  2009;9:21.
Background
There is a growing awareness of the need for easily administered, psychometrically sound screening tools to identify individuals with elevated levels of psychological distress. Although support has been found for the psychometric properties of the Depression, Anxiety and Stress Scales (DASS) using classical test theory approaches it has not been subjected to Rasch analysis. The aim of this study was to use Rasch analysis to assess the psychometric properties of the DASS-21 scales, using two different administration modes.
Methods
The DASS-21 was administered to 420 participants with half the sample responding to a web-based version and the other half completing a traditional pencil-and-paper version. Conformity of DASS-21 scales to a Rasch partial credit model was assessed using the RUMM2020 software.
Results
To achieve adequate model fit it was necessary to remove one item from each of the DASS-21 subscales. The reduced scales showed adequate internal consistency reliability, unidimensionality and freedom from differential item functioning for sex, age and mode of administration. Analysis of all DASS-21 items combined did not support its use as a measure of general psychological distress. A scale combining the anxiety and stress items showed satisfactory fit to the Rasch model after removal of three items.
Conclusion
The results provide support for the measurement properties, internal consistency reliability, and unidimensionality of three slightly modified DASS-21 scales, across two different administration methods. The further use of Rasch analysis on the DASS-21 in larger and broader samples is recommended to confirm the findings of the current study.
doi:10.1186/1471-244X-9-21
PMCID: PMC2689214  PMID: 19426512
3.  Validation of the depression anxiety stress scales (DASS) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern Vietnamese women 
BMC Psychiatry  2013;13:24.
Background
Depression and anxiety are recognised increasingly as serious public health problems among women in low- and lower-middle income countries. The aim of this study was to validate the 21-item Depression Anxiety and Stress Scale (DASS21) for use in screening for these common mental disorders among rural women with young children in the North of Vietnam.
Methods
The DASS-21 was translated from English to Vietnamese, culturally verified, back-translated and administered to women who also completed, separately, a psychiatrist-administered Structured Clinical Interview for DSM IV Axis 1 diagnoses of depressive and anxiety disorders. The sample was a community-based representative cohort of adult women with young children living in Ha Nam Province in northern Viet Nam. Cronbach’s alpha, Exploratory Factor Analyses (EFA) and Receiver Operating Characteristic (ROC) analyses were performed to identify the psychometric properties of the Depression, Anxiety, and Stress subscales and the overall scale.
Results
Complete data were available for 221 women. The internal consistency (Cronbach’s alpha) of each sub-scale and the overall scale were high, ranging from 0.70 for the Stress subscale to 0.88 for the overall scale, but EFA indicated that the 21 items all loaded on one factor. Scores on each of the three sub-scales, and the combinations of two or three of them were able to detect the common mental disorders of depression and anxiety in women with a sensitivity of 79.1% and a specificity of 77.0% at the optimal cut off of >33. However, they did not distinguish between those experiencing only depression or only anxiety.
Conclusions
The total score of the 21 items of the DASS21-Vietnamese validation appears to be comprehensible and sensitive to detecting common mental disorders in women with young children in primary health care in rural northern Vietnam and therefore might also be useful to screen for these conditions in other resource-constrained settings.
doi:10.1186/1471-244X-13-24
PMCID: PMC3566910  PMID: 23311374
Screening; Depression; Anxiety; Validation; Women; Vietnam
4.  Role of Depression, Anxiety and Stress in Patients with Oral Lichen Planus: A Pilot Study 
Indian Journal of Dermatology  2015;60(5):445-449.
Context:
Lichen planus is a psychosomatic disease. Higher frequency of psychiatric symptoms, poor quality of life, higher level of anxiety and neuroendocrine and immune dysregulations, all these factors, will enhance the exacerbation of the disease.
Aims:
The present study was to assess depression, anxiety and stress levels in patients with oral lichen planus.
Materials and Methods:
The psychometric evaluation using the Depression Anxiety Stress Scale (DASS)-42 questionnaire was carried out, by the same investigator on all members of group 1 (Oral Lichen Planus) and group 2 (Control). DASS-42 questionnaire consists of 42 symptoms divided into three subscales of 14 items: Depression scale, anxiety scale, and stress scale.
Statistical Analysis Used:
The Student t test was used to determine statistical difference for both the groups and to evaluate for significant relationships among variables.
Results:
Psychological assessment using DASS-42 reveals lichen planus patients showed higher frequency of psychiatric co morbidities like depression, anxiety and stress compared to control group.
Conclusions:
This study has provided evidence that the DASS-42 questionnaire is internally consistent and valid measures of depression, anxiety, and stress. Psychiatric evaluation can be considered for patients with oral lichen planus with routine treatment protocols are recommended. DASS-42 Questionnaire can also be used to determine the level of anxiety, stress and depression in diseases of the oral mucosa like recurrent apthous stomatitis, burning mouth syndrome and TMD disorders.
doi:10.4103/0019-5154.159625
PMCID: PMC4601409  PMID: 26538689
Anxiety; DASS-42 questionnaire; depression; stress
5.  The QOL-DASS Model to Estimate Overall Quality of Life and General Subjective Health 
Iranian Journal of Psychiatry  2011;6(1):43-46.
Objective
In Order to find how rating the WHOQOL-BREF and DASS scales are combined to produce an overall measure of quality of life and satisfaction with health rating, a QOL-DASS model was designed; and the strength of this hypothesized model was examined using the structural equation modeling.
Method
Participants included a sample of 103 voluntary males who were divided into two groups of unhealthy (N=55) and healthy (N=48). To assess satisfaction and negative emotions of depression, anxiety and stress among the participants, they were asked to fill out the WHOQOL-BREF and The Depression Anxiety Stress Scale (DASS-42).
Results
Our findings on running the hypothesized model of QOL-DASS indicated that the proposed model of QOL-DASS fitted the data well for the both healthy and unhealthy groups.
Conclusion
Our findings with CFA to evaluate the hypothesized model of QOL-DASS indicated that the different satisfaction domain ratings and the negative emotions of depression, anxiety and stress as the observed variables can represent the underlying constructs of general health and quality of life on both healthy and unhealthy groups.
PMCID: PMC3395935  PMID: 22952520
Anxiety; Depression; Quality of Life; Statistical models; Stress
6.  A new instrument for measuring anticoagulation-related quality of life: development and preliminary validation 
Background
Anticoagulation can reduce quality of life, and different models of anticoagulation management might have different impacts on satisfaction with this component of medical care. Yet, to our knowledge, there are no scales measuring quality of life and satisfaction with anticoagulation that can be generalized across different models of anticoagulation management. We describe the development and preliminary validation of such an instrument – the Duke Anticoagulation Satisfaction Scale (DASS).
Methods
The DASS is a 25-item scale addressing the (a) negative impacts of anticoagulation (limitations, hassles and burdens); and (b) positive impacts of anticoagulation (confidence, reassurance, satisfaction). Each item has 7 possible responses. The DASS was administered to 262 patients currently receiving oral anticoagulation. Scales measuring generic quality of life, satisfaction with medical care, and tendency to provide socially desirable responses were also administered. Statistical analysis included assessment of item variability, internal consistency (Cronbach's alpha), scale structure (factor analysis), and correlations between the DASS and demographic variables, clinical characteristics, and scores on the above scales. A follow-up study of 105 additional patients assessed test-retest reliability.
Results
220 subjects answered all items. Ceiling and floor effects were modest, and 25 of the 27 proposed items grouped into 2 factors (positive impacts, negative impacts, this latter factor being potentially subdivided into limitations versus hassles and burdens). Each factor had a high degree of internal consistency (Cronbach's alpha 0.78–0.91). The limitations and hassles factors consistently correlated with the SF-36 scales measuring generic quality of life, while the positive psychological impact scale correlated with age and time on anticoagulation. The intra-class correlation coefficient for test-retest reliability was 0.80.
Conclusions
The DASS has demonstrated reasonable psychometric properties to date. Further validation is ongoing. To the degree that dissatisfaction with anticoagulation leads to decreased adherence, poorer INR control, and poor clinical outcomes, the DASS has the potential to help identify reasons for dissatisfaction (and positive satisfaction), and thus help to develop interventions to break this cycle. As an instrument designed to be applicable across multiple models of anticoagulation management, the DASS could be crucial in the scientific comparison between those models of care.
doi:10.1186/1477-7525-2-22
PMCID: PMC420491  PMID: 15132746
7.  Perceived Stress Scale: Reliability and Validity Study in Greece 
Objective:
To translate the Perceived Stress Scale (versions PSS-4, −10 and −14) and to assess its psychometric properties in a sample of general Greek population.
Methods:
941 individuals completed anonymously questionnaires comprising of PSS, the Depression Anxiety and Stress scale (DASS-21 version), and a list of stress-related symptoms. Psychometric properties of PSS were investigated by confirmatory factor analysis (construct validity), Cronbach’s alpha (reliability), and by investigating relations with the DASS-21 scores and the number of symptoms, across individuals’ characteristics. The two-factor structure of PSS-10 and PSS-14 was confirmed in our analysis. We found satisfactory Cronbach’s alpha values (0.82 for the full scale) for PSS-14 and PSS-10 and marginal satisfactory values for PSS-4 (0.69). PSS score exhibited high correlation coefficients with DASS-21 subscales scores, meaning stress (r = 0.64), depression (r = 0.61), and anxiety (r = 0.54). Women reported significantly more stress compared to men and divorced or widows compared to married or singled only. A strong significant (p < 0.001) positive correlation between the stress score and the number of self-reported symptoms was also noted.
Conclusions:
The Greek versions of the PSS-14 and PSS-10 exhibited satisfactory psychometric properties and their use for research and health care practice is warranted.
doi:10.3390/ijerph8083287
PMCID: PMC3166743  PMID: 21909307
Perceived Stress Scale; translation; psychometric properties; validation; Greece
8.  Effects of short duration stress management training on self-perceived depression, anxiety and stress in male automotive assembly workers: a quasi-experimental study 
To examine the effects of short duration stress management training (SMT) on self-perceived depression, anxiety and stress in male automotive assembly workers, 118 male automotive workers from Pekan, Pahang (n = 60, mean age = 40.0 years, SD = 6.67) and Kota Bharu, Kelantan (n = 58, mean age = 38.1 years, SD = 5.86) were assigned to experimental and control group, respectively. A SMT program consisting of aerobic exercise, stress management manual, video session, lecture, question and answer session, and pamphlet and poster session were conducted in the experimental group. A validated short-form Malay version of the Depression Anxiety Stress Scales (DASS-21) were self-administered before and after the intervention program in the experimental and control group and their time and group interaction effects were examined using the repeated measure ANOVA test. Results indicated that the mean (SD) scores for DASS-Depression (p = 0.036) and DASS-Anxiety (p = 0.011) were significantly decreased, respectively, after the intervention program in the experimental group as compared to the control group (significant time-group interaction effects). No similar effect was observed for the mean (SD) scores for DASS-Stress (p = 0.104). However, the mean (SD) scores for subscales of DASS-Depression (Dysphoria, p = 0.01), DASS-Anxiety (Subjective Anxiety, p = 0.007, Situational Anxiety, p = 0.048), and DASS-Stress (Nervous Arousal, p = 0.018, Easily Upset, p = 0.047) showed significant time and group interaction effects. These findings suggest that short duration SMT is effective in reducing some aspects of self-perceived depression, anxiety and stress in male automotive workers.
doi:10.1186/1745-6673-3-28
PMCID: PMC2600780  PMID: 19021918
9.  The Survivor Unmet Needs Survey (SUNS) for haematological cancer survivors: a cross-sectional study assessing the relevance and psychometric properties 
Background
Relevant and psychometrically sound needs assessment tools are necessary for accurate assessment of haematological cancer survivors unmet needs. No previous study has developed nor psychometrically evaluated a comprehensive needs assessment tool for use with population-based samples of haematological cancer survivors. This study aimed to assess the validity and reliability of the Survivor Unmet Needs Survey (SUNS) with haematological cancer survivors.
Methods
The relevance, content and face validity of the SUNS to haematological cancer survivors was assessed using qualitative interviews. Psychometric evaluation was conducted using data collected from haematological cancer survivors, aged 18–80 years at recruitment and recruited from four Australian cancer registries. Construct, convergent and discriminant validity; internal reliability and floor and ceiling effects were assessed. A second survey was completed by a sub-sample of survivors recruited from two of the four registries to assess test-retest reliability.
Results
Results from 17 qualitative interviews confirmed the relevance, face and content validity of the original items of the SUNS for use with haematological cancer survivors. Overall, 1,957 eligible haematological cancer survivors were contacted by the cancer registries. Of these 1,280 were sent a survey, and 715 returned a survey (37% of eligible survivors contacted and 56% of survivors sent a survey). A total of 529 survivors completed all 89 items of the SUNS and were included in the exploratory factor analysis. Exploratory factor analysis supported the original five-factor structure of the SUNS. Evidence for convergent validity was established, with all five domains of the SUNS illustrating a moderate positive correlation with all three subscales of the Depression Anxiety and Stress Scale (DASS-21). All Cronbach’s alpha values were above 0.9 and all corrected item-total correlations were acceptable (>0.2). Criteria for discriminant validity was not met, with only 10 of the 15 (67%) a-priori hypotheses supported. Test-retest reliability was acceptable for 40 of the 89 items (45%) and for three of the five domains. Significant floor effects were evident for all five domains.
Conclusions
The SUNS demonstrates evidence for multiple features of validity and reliability as a measure of unmet needs for haematological cancer survivors. However, evidence supporting some psychometric properties was limited.
doi:10.1186/1472-6963-14-211
PMCID: PMC4026596  PMID: 24886475
Haematological cancer survivors; Psychometric evaluation; Needs assessment; Psycho-oncology; Unmet needs
10.  Working conditions, self-perceived stress, anxiety, depression and quality of life: A structural equation modelling approach 
BMC Public Health  2008;8:48.
Background
The relationships between working conditions [job demand, job control and social support]; stress, anxiety, and depression; and perceived quality of life factors [physical health, psychological wellbeing, social relationships and environmental conditions] were assessed using a sample of 698 male automotive assembly workers in Malaysia.
Methods
The validated Malay version of the Job Content Questionnaire (JCQ), Depression Anxiety Stress Scales (DASS) and the World Health Organization Quality of Life-Brief (WHOQOL-BREF) were used. A structural equation modelling (SEM) analysis was applied to test the structural relationships of the model using AMOS version 6.0, with the maximum likelihood ratio as the method of estimation.
Results
The results of the SEM supported the hypothesized structural model (χ2 = 22.801, df = 19, p = 0.246). The final model shows that social support (JCQ) was directly related to all 4 factors of the WHOQOL-BREF and inversely related to depression and stress (DASS). Job demand (JCQ) was directly related to stress (DASS) and inversely related to the environmental conditions (WHOQOL-BREF). Job control (JCQ) was directly related to social relationships (WHOQOL-BREF). Stress (DASS) was directly related to anxiety and depression (DASS) and inversely related to physical health, environment conditions and social relationships (WHOQOL-BREF). Anxiety (DASS) was directly related to depression (DASS) and inversely related to physical health (WHOQOL-BREF). Depression (DASS) was inversely related to the psychological wellbeing (WHOQOL-BREF). Finally, stress, anxiety and depression (DASS) mediate the relationships between job demand and social support (JCQ) to the 4 factors of WHOQOL-BREF.
Conclusion
These findings suggest that higher social support increases the self-reported quality of life of these workers. Higher job control increases the social relationships, whilst higher job demand increases the self-perceived stress and decreases the self-perceived quality of life related to environmental factors. The mediating role of depression, anxiety and stress on the relationship between working conditions and perceived quality of life in automotive workers should be taken into account in managing stress amongst these workers.
doi:10.1186/1471-2458-8-48
PMCID: PMC2267182  PMID: 18254966
11.  Depression and anxiety in patients with rheumatoid arthritis: prevalence rates based on a comparison of the Depression, Anxiety and Stress Scale (DASS) and the hospital, Anxiety and Depression Scale (HADS) 
BMC Psychiatry  2012;12:6.
Background
While it is recognised that depression is prevalent in Rheumatoid Arthritis (RA), recent studies have also highlighted significant levels of anxiety in RA patients. This study compared two commonly used scales, the Depression Anxiety and Stress Scale (DASS) and the Hospital Anxiety and Depression Scale (HADS), in relation to their measurement range and cut points to consider the relative prevalence of both constructs, and if prevalence rates may be due to scale-specific case definition.
Methods
Patients meeting the criteria for RA were recruited in Leeds, UK and Sydney, Australia and asked to complete a survey that included both scales. The data was analysed using the Rasch measurement model.
Results
A total of 169 RA patients were assessed, with a repeat subsample, resulting in 323 cases for analysis. Both scales met Rasch model expectations. Using the 'possible+probable' cut point from the HADS, 58.3% had neither anxiety nor depression; 13.5% had anxiety only; 6.4% depression only and 21.8% had both 'possible+probable' anxiety and depression. Cut points for depression were comparable across the two scales while a lower cut point for anxiety in the DASS was required to equate prevalence.
Conclusions
This study provides further support for high prevalence of depression and anxiety in RA. It also shows that while these two scales provide a good indication of possible depression and anxiety, the estimates of prevalence so derived could vary, particularly for anxiety. These findings are discussed in terms of comparisons across studies and selection of scales for clinical use.
doi:10.1186/1471-244X-12-6
PMCID: PMC3285517  PMID: 22269280
12.  Anxiety, stress, depression, and psychosocial functioning of Indian adolescents 
Indian Journal of Psychiatry  2015;57(4):367-374.
Background:
Lifetime prevalence of depression and anxiety increases from 1% of the population under age 12 years to ~17%-25% of the population by the end of adolescence. The greatest increase in new cases occurs between 15-18 years. Indian empirical studies have reported a prevalence of psychiatric morbidity in the range between 14.4% and 31.7%; thus, affecting psychosocial functioning.
Aims:
The objectives of the current study were to (i) examine the psychometric properties of the DASS and SDQ on Indian adolescents, (ii) explore the role of socio- demographic variablesand (iii) examine if there was any difference between school going and school dropouts.
Methodology:
Data from 1812 students, aged 12-19 years was collected with mean age = 15.67 years (SD =1.41 years). The participants were administered a booklet containing demographic questionnaire and psychometric scales such as DASS-21 (Henry & Crawford, 2005; Lovibond & Lovibond, 1999) and Strengths and Difficulties Questionnaire (Goodman, 1997).
Statistical Analysis:
Structure validation, correlational analysis and multivariate analysis.
Results and Conclusions:
The results of validation indicated that English and Hindi version of 3 factor model of DASS and 2 factor model of SDQ was an acceptable model fit. It was noted that early adolescents were high on prosocial behaviour whereas late adolescents were high on difficulties score. Females were higher than males on prosocial behaviour. Adolescents residing in rural areas differed from their urban counterparts on prosocial behaviour and anxiety. Government school going adolescents differed from private school going adolescents on prosocial behaviour, stress and anxiety. Negative perception of relationship with family affected adolescents difficulties score, depression and stress. Similarly, negative perception of self-concept leads to higher difficulties score and lower prosocial behaviour score. The school going adolescents differed from non-school going adolescents on stress, depression and anxiety.
doi:10.4103/0019-5545.171841
PMCID: PMC4711236  PMID: 26813517
Anxiety; depression; psychosocial functioning; stress
13.  Anxiety and stress in the postpartum: Is there more to postnatal distress than depression? 
BMC Psychiatry  2006;6:12.
Background
Postnatal depression has received considerable research and clinical attention, however anxiety and stress in the postpartum has been relatively ignored. Along with the widespread use of the Edinburgh Postnatal Depression Scale (EPDS), depression has become the marker for postnatal maladjustment. Symptoms of anxiety tend to be subsumed within diagnoses of depression, which can result in anxiety being minimized or overlooked in the absence of depression. Some researchers have identified the need to distinguish between postnatal depression and anxiety, and to discern cases where depression and anxiety co-exist. The aim of this study was to assess the prevalence of postnatal distress using the EPDS and the Depression Anxiety Stress Scales (DASS-21).
Method
As part of a larger cross-sectional study, the EPDS and DASS-21 were administered to a convenience sample of 325 primiparous mothers, who ranged in age from 18 to 44 years (M = 32 years). Recruited through mother's groups and health centres in Melbourne Australia, inclusion was limited to mothers whose babies were aged between 6 weeks and 6 months. Analyses included comparisons between the classifications of women according to the EPDS and the DASS-21, and an exploration of the extent to which the EPDS identified anxious-depressed women.
Results
The EPDS identified 80 women (25%) as possibly depressed (using a cut-off of over 9), of which the DASS-21 corroborated 58%. In the total sample, 61 women (19%) were classified by the DASS-21 to be depressed. Using broader criteria for distress, it was revealed by the DASS-21 that a further 33 women (10%) showed symptoms of anxiety and stress without depression. A total of 41 women (13%) had symptoms of anxiety either in isolation or in combination with depression. The DASS-21 identified 7% of the sample as being both anxious and depressed. This at-risk sub-group had higher mean EPDS and DASS-depression scores than their depressed-only counterparts.
Conclusion
The prevalence of anxiety and stress in the present study points to the importance of assessing postnatal women for broader indicators of psychological morbidity than that of depression alone. The DASS-21 appears to be a useful instrument for this purpose.
doi:10.1186/1471-244X-6-12
PMCID: PMC1450275  PMID: 16563155
14.  An Aggravated Trajectory of Depression and Anxiety Co-morbid with Hepatitis C: A Within-groups Study of 61 Australian Outpatients 
Background: This study aimed to explore the course of depression and anxiety in chronic hepatitis C patients. Methods:  Data were combined from two studies: (1) Hospital Anxiety and Depression Scale (HADS) scores in 395 consecutive Australian outpatients from 2006 to 2010 formed the baseline measurement; and (2) Depression Anxiety Stress Scales (DASS) scores in a survey of a sub-sample of these patients in 2011 formed the follow-up measurement. After converting DASS to HADS scores, changes in symptom scores and rates of case-ness (≥8), and predictors of follow-up symptoms were assessed. Results:  Follow-up data were available for 61 patients (70.5% male) whose age ranged from 24.5 to 74.6 years (M=45.6). The time to follow-up ranged from 20.7 to 61.9 months (M=43.8). Baseline rates of depression (32.8%) and anxiety (44.3%) increased to 62.3% and 67.2%, respectively. These findings were confirmed, independent of the conversion, by comparing baseline HADS and follow-up DASS scores with British community norms. Baseline anxiety and younger age predicted depression, while baseline anxiety, high school non-completion, and single relationship status predicted anxiety. Conclusion:  This study demonstrated a worsening trajectory of depression and anxiety. Further controlled and prospective research in a larger sample is required to confirm these findings.
doi:10.2174/1745017901511010174
PMCID: PMC4676046  PMID: 26668585
Anxiety; depression; hepatitis C; prognosis; trajectory.
15.  Psychometric analysis of the Self-Harm Inventory using Rasch modelling 
BMC Psychiatry  2009;9:53.
Background
Deliberate Self-Harm (DSH) is the intentional destruction of healthy body tissue without suicidal intent. DSH behaviours in non-clinical populations vary, and instruments containing a range of behaviours may be more informative than ones with restricted content. The Self-Harm Inventory (SHI) is a widely used measure of DSH in clinical populations (mental and physical health) and covers a broad range of behaviours (self-injury, risk taking and self-defeating acts). The test authors recommend the SHI to screen for Borderline Personality Disorder (BPD) using a cut-off score of five or more. The aim of this study was to investigate the psychometric characteristics of the SHI in non-clinical samples.
Methods
The SHI was administered to a sample of 423 non-clinical participants (university students, age range 17 to 30). External validation was informed by the administration of the Depression Anxiety Stress Scales 21 (DASS-21) to a sub-sample (n = 221). Rasch analysis of the SHI was conducted to provide a stringent test of unidimensionality and to identify the DSH behaviours most likely to be endorsed at each total score.
Results
The SHI showed adequate fit to the Rasch model and no modifications were required following checks of local response dependency, differential item functioning and unidimensionality. The scale identified gender and age differences in scores, with females and older participants reporting higher levels of DSH. SHI scores and DASS-21 scores were related.
Conclusion
The recommended cut-off point of five is likely to comprise mild forms of DSH and may not be indicative of psychopathology in a non-clinical population. Rather it may be more indicative of developmentally related risk taking behaviours while a higher cut-off point may be more suggestive of psychopathology as indicated by higher levels of depression, stress and anxiety.
doi:10.1186/1471-244X-9-53
PMCID: PMC2736947  PMID: 19689823
16.  A Pilot Psychometric Study on the Validation of the Older Women’s Non-Medical Stress Scale (OWN-MSS) on an Ethnically Diverse Sample 
Journal of geriatrics and palliative care  2016;4(1):10.13188/2373-1133.1000014.
Introduction
Older women often experience various types of stressors, including the death of a spouse and associated financial stress (often with a lack of social support), emotional stress due to factors such as caregiving and being single, and the challenges of the aging process. These circumstances could produce or aggravate anxious symptomatology that can in turn compound the negative effects of aging. A brief scale of perceived stress that is not confounded with health status and covers multiple culturally relevant potential stressors is needed for quick use in busy medical settings.
Aim
To assess the reliability and the validity of an original stress scale designed to measure perceptions of stress beyond health status in a non-clinical convenience sample of community-dwelling older women.
Method
In this cross-sectional pilot investigation, via conducting item-total correlations and correlational tests of validity, we studied the psychometric properties of our measure using data from volunteer older subjects (mainly low-income and from non-Caucasian backgrounds). The domains covered by the nine items of the tool were selected based on a literature review of common stressors experienced by older adults, especially by older women. Data were collected face-to-face using a demographic list, a well-established depression measure, a brief posttraumatic stress disorder (PTSD) screener, and our 9-item stress tool. Primary outcomes: reliability and validity of the scale of older women’s non-medical stress. Secondary outcomes: demographic characteristics of the sample and correlations between stress items.
Results
Based on our sample of older women (N=40, mean age 71 years), good internal consistency between the items of the stress scale was found (Cronbach’s a=.66). The findings of the data analyses also revealed that our psychometric tool has good convergent validity with the PTSD screener (r=.53). Moreover, in contrast with most other stress tools, it has strong discriminant validity (r=.11) with a well-validated depression scale.
Conclusion
Our results suggest that this new measure is psychometrically strong. Future research directions encompass using larger samples, ideally including older men with the modification of the scale’s name, as well as validating this tool against more measures. Clinical implications of our findings are briefly discussed.
PMCID: PMC4933309  PMID: 27390770
Older adults; Stress; Assessment; Psychometrics; Allostatic load; Depression; PTSD
17.  THE UTILITY OF THE GENERALIZED ANXIETY DISORDER SEVERITY SCALE (GADSS) WITH OLDER ADULTS IN PRIMARY CARE 
Depression and anxiety  2009;26(1):E10-E15.
Background
The Generalized Anxiety Disorder Severity Scale (GADSS) is an interview rating scale designed specifically for assessing symptom severity of generalized anxiety disorder (GAD), which has demonstrated positive psychometric data in a sample of adult primary care patients with GAD and panic disorder. However, the psychometric properties of the GADSS have not been evaluated for older adults.
Methods
This study evaluated the psychometric properties of the GADSS, administered via telephone, with a sample of older primary care patients (n = 223) referred for treatment of worry and/or anxiety.
Results
The GADSS demonstrated adequate internal consistency, strong inter-rater reliability, adequate convergent validity, poor diagnostic accuracy, and mixed discriminant validity.
Conclusions
Results provide mixed preliminary support for use of the GADSS with older adults. Depression and Anxiety 26:E10–E15, 2009.
doi:10.1002/da.20520
PMCID: PMC2709998  PMID: 18839400
Generalized Anxiety Disorder Severity Scale; generalized anxiety disorder; elderly; primary care; measurement; psychometrics
18.  The Persian Checklist of Pleasant Events (PCPE): Development, Validity and Reliability 
Iranian Journal of Psychiatry  2015;10(4):246-264.
Objective: Experiencing ‎pleasant events during daily life ‎has a significant positive role in ‎the personal mental health and ‎acts as a keystone for “behavioral ‎activation” (BA) interventions. ‎There are serious differences in ‎the pleasant event schedules in ‎different cultures and countries. ‎We aimed to develop a Persian ‎checklist of pleasant events ‎‎(PCPE) to provide and validate a ‎culturally compatible checklist for ‎Iranians.‎
Methods: To develop a checklist ‎of pleasant events, inspired by ‎Pleasant Events Schedule (PES) ‎‎(MacPhillamy & Lewinsohn, ‎‎1982), we held three focused ‎group discussions with 24 normal ‎healthy participants from both ‎genders (female = 12) and asked ‎them to mention as much ‎pleasant events as possible. ‎When the list reached saturation ‎level, the inappropriate items with ‎respect to legal, cultural and ‎religious concerns were omitted. ‎The final checklist of PCPE ‎consists of two subscales: ‎Frequency (frequency of events ‎during last month) and ‎pleasantness (perceived ‎pleasantness of events). The total ‎score consists of frequency ‎multiplied by pleasantness. To ‎test the reliability and validity of ‎the checklist, the PCPE, ‎Depression, Anxiety and Stress ‎Scale (DASS), the Persian ‎version of WHO Quality of Life ‎and the Demographic ‎Questionnaire were administered ‎in a sample of 104 participants ‎‎(50 male and 54 female).‎
Results: Frequency, ‎pleasantness and the total scores ‎of PCPE showed high levels of ‎internal consistency (Cronbach’s ‎alpha, .976, .976 & .974, ‎respectively). Further support for ‎the convergent validity of the ‎PCPE was obtained via ‎moderate negative correlations ‎with depression, anxiety, stress ‎scores in DASS and positive ‎correlation with quality of life as ‎well as respondent’s perceived ‎happiness. There were negative ‎correlations between frequency, ‎pleasantness and total scores ‎and age of the participants ‎‎(Pearson correlation coefficient, r ‎‎= -.194, p<0.05; r = -.270, p<0.01 ‎& r = -.234, p<0.05, respectively).‎
Conclusion ‏:‏ ‎ PCPE as an ‎assessment tool has shown to ‎have good reliability and validity ‎among Iranians. Further steps ‎should be taken to validate this ‎instrument in different ‎psychopathologies such as ‎depression, addiction and ‎obesity. ‎
PMCID: PMC4801495  PMID: 27006670
Behavioral Activation; Iran; Pleasant Events; Pleasant Events Schedule; Reliability; Validity
19.  A systematic review of depression and anxiety measures with individuals with spinal cord injury 
Spinal cord  2009;47(12):841-851.
Study design
A systematic review.
Objectives
To review and assess the psychometric properties of depression and anxiety instruments used with spinal cord injury (SCI) populations.
Setting
Vancouver, Canada
Methods
Electronic databases were searched for papers reporting psychometric properties of depression and anxiety instruments. Pre-established criteria were used to assess the psychometric properties.
Results
Thirteen papers reporting on the psychometric properties of 13 depression and anxiety instruments are in this review, and include: BDI, BSI, CESD-20, CESD-10, DASS-21, GHQ-28, HADS, Ilfeld-PSI, MEDS, PHQ-9, PHQ-9-Short, SCL-90-R, and the Zung SRS. Reliability data is available for 10 instruments, and validity results are available for 12. Evidence spanned the spectrum of evaluation criteria varying from poor to excellent. Responsiveness data is generally lacking.
Conclusion
Given that the reliability and validity findings range for the most part from adequate to excellent, and the large amount of work to develop cutoff scores specific for SCI populations, there is at present no need to develop SCI specific instruments. Because one measure’s psychometric properties do not clearly stand out, it is difficult to recommend the use of one over another. Overall, more psychometric data is needed, and if the instruments are to be used to evaluate treatment outcomes or change over time, responsiveness data is also required. Administering the instruments in tandem with each other and with clinical diagnostic interviews would provide valuable information, as would comparison of results to normative data specific to persons with SCI.
doi:10.1038/sc.2009.93
PMCID: PMC3176808  PMID: 19621021 CAMSID: cams1951
spinal cord injury; depression; anxiety; reliability; validity; clinical utility
20.  The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic 
BMC Psychiatry  2010;10:21.
Background
Adult separation anxiety disorder (ASAD) has been identified recently, but there is a paucity of data about its prevalence and associated characteristics amongst anxiety patients. This study assessed the prevalence and risk factor profile associated with ASAD in an anxiety clinic.
Methods
Clinical psychologists assigned 520 consecutive patients to DSM-IV adult anxiety subcategories using the SCID. We also measured demographic factors and reports of early separation anxiety (the Separation Anxiety Symptom Inventory and a retrospective diagnosis of childhood separation anxiety disorder). Other self-report measures included the Adult Separation Anxiety Symptom Questionnaire (ASA-27), the Depression, Anxiety, Stress Scales (DASS-21), personality traits measured by the NEO PI-R and the Work and Social Adjustment Scale. These measures were included in three models examining for overall differences and then by gender: Model 1 compared the conventional SCID anxiety subtypes (excluding PTSD and OCD because of insufficient numbers); Model 2 divided the sample into those with and without ASAD; Model 3 compared those with ASAD with the individual anxiety subtypes in the residual group.
Results
Patients with ASAD had elevated early separation anxiety scores but this association was unique in females only. Except for social phobia in relation to some comparisons, those with ASAD recorded more severe symptoms of depression, anxiety and stress, higher neuroticism scores, and greater levels of disability.
Conclusions
Patients with ASAD attending an anxiety clinic are highly symptomatic and disabled. The findings have implications for the classification, clinical identification and treatment of adult anxiety disorders.
doi:10.1186/1471-244X-10-21
PMCID: PMC2846894  PMID: 20219138
21.  The influence of a biopsychosocial-based treatment approach to primary overt hypothyroidism: a protocol for a pilot study 
Trials  2010;11:106.
Background
Hypothyroidism is a prevalent endocrine condition. Individuals with this disease are commonly managed through supplementation with synthetic thyroid hormone, with the aim of alleviating symptoms and restoring normal thyroid stimulating hormone levels. Generally this management strategy is effective and well tolerated. However, there is research to suggest that a significant proportion of hypothyroid sufferers are being inadequately managed. Furthermore, hypothyroid patients are more likely to have a decreased sense of well-being and more commonly experience constitutional and neuropsychiatric complaints, even with pharmacological intervention.
The current management of hypothyroidism follows a biomedical model. Little consideration has been given to a biopsychosocial approach to this condition. Within the chiropractic profession there is growing support for the use of a biopsychosocial-based intervention called Neuro-Emotional Technique (NET) for this population.
Methods/Design
A placebo-controlled, single-blinded, randomised clinical pilot-trial has been designed to assess the influence of Neuro-Emotional Technique on a population with primary overt hypothyroidism. A sample of 102 adults (≥18 years) who meet the inclusion criteria will be randomised to either a treatment group or a placebo group. Each group will receive ten treatments (NET or placebo) over a six week period, and will be monitored for six months. The primary outcome will involve the measurement of depression using the Depression, Anxiety and Stress Scale (DASS). The secondary outcome measures to be used are; serum thyroid stimulating hormone, serum free-thyroxine, serum free-triiodothyronine, serum thyroid peroxidase auto-antibodies, serum thyroglobulin auto-antibodies as well as the measurement of functional health and well-being using the Short-Form-36 Version 2. The emotional states of anxiety and stress will be measured using the DASS. Self-measurement of basal heart rate and basal temperature will also be included among the secondary outcome measures. The primary and secondary measures will be obtained at commencement, six weeks and six months. Measures of basal heart rate and basal temperature will be obtained daily for the six month trial period, with recording to commence one week prior to the intervention.
Discussion
The study will provide information on the influence of NET when added to existing management regimens in individuals with primary overt hypothyroidism.
Trial Registration
ANZCTR Number: 12607000040460
doi:10.1186/1745-6215-11-106
PMCID: PMC2992059  PMID: 21073760
22.  The effects of relaxation on reducing depression, anxiety and stress in women who underwent mastectomy for breast cancer 
Background:
Breast cancer is one of the most frequent malignancies among Iranian women. These patients suffer from a wide range of physical and mental (depression, anxiety and stress) signs and symptoms during the diagnostic and therapeutic processes. Despite the improvement in survival rates due to advances in medical care, different types of psychosocial interventions are still growingly needed considering the increasing number of cancer patients with longer survival times. The objective of this study was to determine the effect of relaxation on depression, anxiety and stress in women who underwent mastectomy for breast cancer.
Materials and Methods:
This clinical trial was conducted during about 4.5 months in a referral chemotherapy clinic of a teaching hospital in Isfahan, Iran. The participants consisted of 48 breast cancer patients who were selected by simple random sampling. They were randomly assigned into two groups of control and case. The control group was treated only by usual medical therapy, whereas the case group was treated by combined medical-relaxation therapy. Data collection tools were the validated Depression, Anxiety and Stress Scale (DASS42) and a demographic questionnaire. Data were analyzed by SPSS using descriptive statistics, repeated measures analysis of variance (ANOVA), chi-square test and paired t-test..
Findings:
The baseline mean scores of depression, anxiety and stress were not significantly different between the case and control groups. However, the scores in the case group improved significantly after the treatment (p < 0.05). On the contrary, such improvement was not seen in the control group.
Conclusions:
Relaxation therapy can be effective in the improvement of depression, anxiety and stress. Therefore, it can be recommended as an effective care program in patients with malignant disorders.
PMCID: PMC3590692  PMID: 23493112
Relaxation; depression; anxiety; stress; mastectomy; breast cancer
23.  Psychometric properties of the Geriatric Anxiety Inventory (GAI) and its short-form (GAI-SF) in a clinical and non-clinical sample of older adults 
International Psychogeriatrics / Ipa  2014;27(7):1089-1097.
Background:
The Geriatric Anxiety Inventory is a 20-item geriatric-specific measure of anxiety severity. While studies suggest good internal consistency and convergent validity, divergent validity from measures of depression are weak. Clinical cutoffs have been developed that vary across studies due to the small clinical samples used. A six-item short form (GAI-SF) has been developed, and while this scale is promising, the research assessing the psychometrics of this scale is limited.
Methods:
This study examined the psychometric properties of GAI and GAI-SF in a large sample of 197 clinical geriatric participants with a comorbid anxiety and unipolar mood disorder, and a non-clinical control sample (N = 59).
Results:
The internal consistency and convergent validity with other measures of anxiety was adequate for GAI and GAI-SF. Divergent validity from depressive symptoms was good in the clinical sample but weak in the total and non-clinical samples. Divergent validity from cognitive functioning was good in all samples. The one-factor structure was replicated for both measures. Receiver Operating Characteristic analyses indicated that the GAI is more accurate at identifying clinical status than the GAI-SF, although the sensitivity and specificity for the recommended cutoffs was adequate for both measures.
Conclusions:
Both GAI and GAI-SF show good psychometric properties for identifying geriatric anxiety. The GAI-SF may be a useful alternative screening measure for identifying anxiety in older adults.
doi:10.1017/S1041610214001586
PMCID: PMC4501012  PMID: 25111285
anxiety disorders; anxiety; questionnaires; geriatric; Geriatric Anxiety Inventory; older adult
24.  Stress, anxiety, and depression among medical students in a multiethnic setting 
Background
Contemporary literature suggests that medical education might adversely affect students’ mental health. Alfaisal University in Riyadh, Saudi Arabia is a developing institution; hence, there has been a concern regarding the mental well-being of the students.
Objectives
This study was designed to assess the traits of depression, anxiety, and stress among students in relation to potential underlying reasons.
Methods
All 575 medical students across the 5 years of study participated by filling out the Depression, Anxiety, and Stress Scale-21 (DASS-21) questionnaire anonymously twice. Firstly, 2–3 weeks before a major examination (pre-examination), and secondly, during regular classes (post-examination). Correlation was sought regarding sex, year of scholarship, attendance of a premedical university preparatory program (UPP), housing, and smoking. Subjective comments from students were also obtained.
Results
A total of 76.8% and 74.9% of students participated in pre-and post-examination groups, respectively. The majority were the children of expatriate workers in Saudi Arabia, and included Arabs, South Asians, and North Americans. Prevalence of depression, anxiety, and stress was high (43%, 63%, and 41%, respectively) which reduced (to 30%, 47%, and 30%, respectively) to some extent after examinations. Saudis and those who had attended UPP had higher DASS-21 scores. Smoking and female sex predicted higher levels of “baseline” depression, anxiety, or stress. The students perceived the curriculum and schedule to be the primary causes of their high DASS-21 scores.
Conclusion
The students had high “baseline” traits of depression, anxiety, and stress, and these were higher if an examination was near, especially among Saudis and those who had attended UPP. Smoking and female sex predicted higher levels of “baseline” depression, anxiety, or stress. Students suggested that study burden and a busy schedule were the major reasons for their high DASS-21 scores.
doi:10.2147/NDT.S83577
PMCID: PMC4509544  PMID: 26213470
DASS; examination; medical education; smoking; depression; anxiety; stress
25.  Acute mood but not cognitive improvements following administration of a single multivitamin and mineral supplement in healthy women aged 50 and above: a randomised controlled trial 
Age  2015;37(3):38.
A number of randomised controlled trials have indicated that multivitamin/mineral supplementation for a period of 4 weeks or greater can enhance mood and cognition. To date, no studies have investigated whether a single multivitamin dose can benefit mental function in older adults. This study investigated the acute effects of a single multivitamin and mineral and herbal (MVMH) supplement versus placebo on self ratings of mood and the performance of an effortful computerised cognitive battery in a sample of 76 healthy women aged 50–75 years. Mood was assessed using the depression anxiety stress scale (DASS), state trait anxiety inventory–state anxiety scale and visual analogue scales (VAS). Mood was rated at 1 h post supplementation and again after the competition of the cognitive assessments at 2 h post supplementation. It was demonstrated that the MVMH supplement improved overall DASS mood ratings; however, the most prominent effects appeared to be a reduction in ratings of perceived mental stress. These findings were confirmed using visual analogue scales, with these measures also demonstrating MVMH-related increased ratings of calmness. There were no benefits of the MVMH to mood ratings of depression and performance was not enhanced on the cognitive battery. Supplementation with a single multivitamin, mineral and herbal supplement reduces stress several hours after intake in healthy older people.
doi:10.1007/s11357-015-9782-0
PMCID: PMC4408300  PMID: 25903286
Multivitamin; Multivitamin/mineral; Mood; Cognition; Stress; Elderly

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