Demoralization's link to depression and anxiety symptoms: A network analysis

Abstract

Demoralization represents a clinical syndrome conceptualized as maladaptive coping to a stressor associated with discouragement, feelings of hopelessness, helplessness, and a loss of meaning in life. It is a prevalent comorbidity in individuals with severe physical illnesses and affects a substantial proportion of the general population when facing global stressors like the COVID-19 pandemic. The main aim of the study was to test whether demoralization and features of depression and anxiety might reflect distinct entities within the general population, specifically in older adults, and to explore symptom interconnections, using a network psychometrics approach. The revised demoralization scale (DS-II) and the patient health questionnaire 4 (PHQ-4) were applied to a representative sample (N = 2434) from the German general population. Network structures were analyzed using exploratory graph analysis (EGA) to identify the most distinct symptom groupings and their relationships. Stability of networks and symptom groupings was tested using bootstrap procedures. EGA revealed unidimensionality within younger adulthood and a four-factor solution within older adults, reliably distinguishing PHQ-4 and DS-II items. The most central features of the network were worthlessness, pointlessness, helplessness, feeling trapped and low mood. Suicidal ideation was more closely related to DS-II worthlessness than to PHQ-4 items. The cross-sectional design and using PHQ-4 instead of more comprehensive measures of depression and anxiety were limitations. In conclusion, in general population, demoralization symptoms can be distinguished from lack of interest or pleasure and low mood. It might represent a valid psychological construct beyond clinical populations. Further investigation of diagnostic implications is encouraged.

Keywords: Anxiety; Demoralization; Depression; Exploratory graph analysis; General population; Patient health questionnaire.