Abstract
Purpose
The Depression Anxiety Stress Scales (DASS)-21 measures emotional symptoms of depression, anxiety, and stress, is relatively short, and is freely available in the public domain, which has resulted in it being applied to various clinical and non-clinical populations in many countries. The aim of this study was to systematically review the measurement properties of the DASS-21.
Methods
The MEDLINE, Embase, and CINAHL databases were searched. The methodological quality of each identified study was assessed using the updated COSMIN Risk of Bias checklist. The quality of the measurement properties of the studies was rated using the updated criteria for good measurement properties. The quality of evidence was rated using a modified version of the GRADE approach.
Results
This study included 48 studies in its review. The content validity of the DASS-21 demonstrated sufficient moderate-quality evidence. The instrument exhibited sufficient high-quality evidence for bifactor structural validity and internal consistency. The instrument also showed sufficient high-quality evidence for hypothesis testing of construct validity. Regarding criterion validity, only the DASS-21 Depression subscale demonstrated sufficient high-quality evidence. The measurement invariance across gender demonstrated inconsistent moderate-quality evidence. There was insufficient low-quality evidence for the reliability of each subscale. For responsiveness there was sufficient low-quality evidence for depression and stress subscales, and insufficient very-low-quality evidence for anxiety subscale.
Conclusions
The DASS-21 demonstrated sufficient high-quality evidence for bifactor structural validity, internal consistency (bifactor), criterion validity (Depression subscale), and hypothesis testing for construct validity. Further studies are required to assess the other measurement properties of the DASS-21.
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References
World Health Organization. (2016). Investing in treatment for depression and anxiety leads to fourfold return. Retrieved from October 22, 2018 http://www.who.int/mediacentre/news/releases/2016/depression-anxiety-treatment/en/.
Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the depression anxiety stress scales (2nd ed.). Sydney: Psychology Foundation.
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M., & 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.
Lovibond, S. H., & Lovibond, P. F. (1995). 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.
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 nonclinical sample. British Journal of Clinical Psychology, 44(2), 227–239.
Ng, F., Trauer, T., Dodd, S., Callaly, T., Campbell, S., & Berk, M. (2007). The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure. Acta Neuropsychiatrica, 19(5), 304–310.
Shea, T. L., Tennant, A., & Pallant, J. F. (2009). Rasch model analysis of the Depression, Anxiety and Stress Scales (DASS). BMC Psychiatry, 9, 21.
Sinclair, S. J., Siefert, C. J., Slavin-Mulford, J. M., Stein, M. B., Renna, M., & Blais, M. A. (2012). Psychometric evaluation and normative data for the Depression, Anxiety, and Stress Scales-21 (DASS-21) in a nonclinical sample of U.S. adults. Evaluation & Health Professions, 35(3), 259–279.
Apóstolo, J. L. S., Tanner, B. A., & Arfken, C. L. (2012). Confirmatory factor analysis of the Portuguese Depression Anxiety Stress Scales − 21. Revista Latino-Americana de Enfermagem, 20(3), 590–596.
Nanthakumar, S., Bucks, R. S., Skinner, T. C., Starkstein, S., Hillman, D., James, A., et al. (2017). Assessment of the Depression Anxiety and Stress Scale (DASS-21) in untreated obstructive sleep apnea (OSA). Psychological Assessment, 29(10), 1201–1209.
Mokkink, L. B., de Vet, H. C. W., Prinsen, C. A. C., Patrick, D. L., Alonso, J., Bouter, L. M., et al. (2018). COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome measures. Quality of Life Research, 27(5), 1171–1179.
Prinsen, C. A. C., Mokkink, L. B., Bouter, N. M., Alonso, J., Patric, D. L., de Vet, H. C. W., et al. (2018). COSMIN guideline for systematic reviews of Patient-Reported Outcome measures. Quality of Life Research, 27(5), 1147–1157.
Terwee, C. B., Prinsen, C. A. C., Chiarotto, A., Westerman, M. J., Patrick, D. L., Alonso, J., et al. (2018). COSMIN methodology for evaluating the content validity of Patient-Reported Outcome Measures: a Delphi study. Quality of Life Research, 27(5), 1159–1170.
Terwee, C. B., Jansma, E. P., Riphagen, I. I., & de Vet, H. C. W. (2009). Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Quality of Life Research, 18(8), 1115–1123.
Psychology Foundation of Australia. (2017). DASS FAQ (Frequently Asked Questions) 10. Can the DASS be used with children/adolescents? Retrieved from October 22, 2018 http://www2.psy.unsw.edu.au/dass/DASSFAQ.htm#_10.__Can_the_DASS_be_used_with_chil.
Terwee, C. B., Bot, S. D., de Boer, M. R., van der Windt, D. A., Knol, D. L., Dekker, J., et al. (2007). Quality criteria were proposed for measurement properties of health status questionnaires. Journal of Clinical Epidemiology, 60(1), 34–42.
Beck, A. T., & Steer, R. A. (1990). Manual for the beck anxiety inventory. San Antonio, TX: Psychological Cooperation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory manual. San Antonio, TX: Psychological Cooperation.
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), 361–370.
Watson, D., Clark, L. A., & Carey, G. (1988). Positive and negative affectivity and their relation to anxiety and depressive disorders. Journal of Abnormal Psychology, 97(3), 346–353.
R Development Core Team. (2010). R: A language and environment for statistical computing. Vienna, Austria: R foundation for Statistical Computing. Retrieved from October 22, 2018 http://www.R-project.org.
Daza, P., Novy, D. M., Stanley, M. A., & Averill, P. (2002). The depression anxiety stress scale-21: Spanish translation and validation with a Hispanic sample. Journal of Psychopathology and Behavioral Assessment, 24(3), 195–205.
Norton, P. J. (2007). Depression Anxiety and Stress Scales (DASS-21): Psychometric analysis across four racial groups. Anxiety Stress and Coping, 20(3), 253–265.
Musa, R., Fadzil, M. A., & Zain, Z. (2007). Translation, validation and psychometric properties of Bahasa Malaysia version of the Depression Anxiety and Stress Scales (DASS). ASEAN Journal of Psychiatry, 8(2), 82–89.
Asghari, A., Saed, F., & Dibajnia, P. (2008). Psychometric properties of the Depression Anxiety Stress Scales-21 (DASS-21) in a non-clinical Iranian sample. International Journal of Psychology, 2(2), 82–102.
Ownsworth, T., Little, T., Turner, B., Hawkes, A., & Shum, D. (2008). Assessing emotional status following acquired brain injury: The clinical potential of the depression, anxiety and stress scales. Brain Injury, 22(11), 858–869.
Gloster, A. T., Rhoades, H. M., Novy, D., Klotsche, J., Senior, A., Kunik, M., et al. (2008). Psychometric properties of the Depression Anxiety and Stress Scale-21 in older primary care patients. Journal of Affective Disorders, 110(3), 248–259.
Ramli, M., Salmiah, M. A., & Nurul Ain, M. (2009). Validation and psychometric properties of Bahasa Malaysia version of the Depression Anxiety and Stress Scales (DASS) among diabetic patients. Malaysian Journal of Psychiatry, 18(2), 1–7.
Wood, B. M., Nicholas, M. K., Blyth, F., Asghari, A., & Gibson, S. (2010). The utility of the short version of the Depression Anxiety Stress Scales (DASS-21) in elderly patients with persistent pain: Does age make a difference? Pain Medicine, 11(12), 1780–1790.
Osman, A., Wong, J. L., Bagge, C. L., Freedenthal, S., Gutierrez, P. M., & Lozano, G. (2012). The Depression Anxiety Stress Scales—21 (DASS-21): further examination of dimensions, scale reliability, and correlates. Journal of Clinical Psychology, 68(12), 1322–1338.
Tran, T. D., Tran, T., & Fisher, J. (2013). 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, 13(1), 24.
Vasconcelos-Raposo, J., Fernandes, H. M., & Teixeira, C. M. (2013). Factor structure and reliability of the depression, anxiety and stress scales in a large Portuguese community sample. The Spanish Journal of Psychology, 16, E10.
Dahm, J., Wong, D., & Ponsford, J. (2013). Validity of the Depression Anxiety Stress Scales in assessing depression and anxiety following traumatic brain injury. Journal of Affective Disorders, 151(1), 392–396.
Oei, T. P., Sawang, S., Goh, Y. W., & Mukhtar, F. (2013). Using the depression anxiety stress scale 21 (DASS-21) across cultures. International Journal of Psychology, 48(6), 1018–1029.
Tonsing, K. N. (2014). Psychometric properties and validation of Nepali version of the Depression Anxiety Stress Scales (DASS-21). Asian Journal of Psychiatry, 8, 63–66.
Musa, R., Ramli, R., Abdullah, K., & Sarkarsi, R. (2011). Concurrent validity of the depression and anxiety components in the Bahasa Malaysia version of the depression and anxiety and stress scale (DASS). ASEAN Journal of Psychiatry, 12(1), 66–70.
Vignola, R. C. B., & Tucci, A. M. (2014). Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. Journal of Affective Disorders, 155, 104–109.
Gomez, R., Summers, M., Summers, A., Wolf, A., & Summers, J. (2014). Depression Anxiety Stress Scales-21: Measurement and structural invariance across ratings of men and women. Assessment, 21(4), 418–426.
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.
Wang, K., Shi, H. S., Geng, F. L., Zou, L. Q., Tan, S. P., Wang, Y., et al. (2016). Cross-cultural validation of the Depression Anxiety Stress Scale–21 in China. Psychological Assessment, 28(5), e88.
Randall, D., Thomas, M., Whiting, D., & McGrath, A. (2017). Depression Anxiety Stress Scales (DASS-21): factor structure in traumatic brain injury rehabilitation. The Journal of Head Trauma Rehabilitation, 32(2), 134–144.
Moore, S. A., Dowdy, E., & Furlong, M. J. (2016). Using the Depression, Anxiety, Stress Scales–21 With US Adolescents: An Alternate Models Analysis. Journal of Psychoeducational Assessment, 35(6), 581–598.
Alfonsson, S., Wallin, E., & Maathz, P. (2017). Factor structure and validity of the Depression, Anxiety and Stress Scale-21 in Swedish translation. Journal of Psychiatric and Mental Health Nursing, 24(2–3), 154–162.
Yusoff, M. S. B. (2013). Psychometric properties of the depression anxiety stress scale in a sample of medical degree applicants. International Medical Journal, 20(3), 295–300.
Apóstolo, J. L. A., Mendes, A. C., & Azeredo, Z. A. (2006). Adaptation to Portuguese of the depression, anxiety and stress scales (DASS). Revista Latino-Americana de Enfermagem, 14(6), 863–871.
Camacho, A., Cordero, E. D., & Perkins, T. (2016). Psychometric Properties of the DASS-21 Among Latina/o College Students by the US-Mexico Border. Journal of Immigrant and Minority Health, 18(5), 1017–1023.
Gomez, R., Summers, M., Summers, A., Wolf, A., & Summers, J. J. (2014). Depression Anxiety Stress Scales-21: factor structure and test-retest invariance, and temporal stability and uniqueness of latent factors in older adults. Journal of Psychopathology and Behavioral Assessment, 36(2), 308–317.
Jafari, P., Nozari, F., Ahrari, F., & Bagheri, Z. (2017). Measurement invariance of the Depression Anxiety Stress Scales-21 across medical student genders. International Journal of Medical Education, 8, 116–122.
Johnson, A. R., Lawrence, B. J., Corti, E. J., Booth, L., Gasson, N., Thomas, M. G., et al. (2016). Suitability of the Depression, Anxiety, and Stress Scale in Parkinson’s disease. Journal of Parkinson’s Disease, 6(3), 609–616.
Johnson, C. E., Bennett, K. S., Newton, J., McTigue, J., Taylor, S., Musiello, T., et al. (2018). A pilot study to assess the validity of the DASS-21 subscales in an outpatient oncology population. Psycho-oncology, 27(2), 695–699.
Mahmoud, J. S. R., Hall, L. A., & Staten, R. (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.
Parkitny, L., McAuley, J. H., Walton, D., Costa, L. O. P., Refshauge, K. M., Wand, B. M., et al. (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.
Wong, D., Dahm, J., & Ponsford, J. (2013). Factor structure of the depression anxiety stress scales in individuals with traumatic brain injury. Brain Injury, 27(12), 1377–1382.
Le, M. T. H., Tran, T. D., Holton, S., Nguyen, H. T., Wolfe, R., & Fisher, J. (2017). Reliability, convergent validity and factor structure of the DASS-21 in a sample of Vietnamese adolescents. PLoS ONE, 12(7), e0180557.
Rusli, B. N., Amrina, K., Trived, S., Loh, K. P., & Shashi, M. (2017). Construct validity and internal consistency reliability of the Malay version of the 21-item depression anxiety stress scale (Malay-DASS-21) among male outpatient clinic attendees in Johor. The Medical Journal of Malaysia, 72(5), 264–270.
Ailliet, L., Knol, D. L., Rubinstein, S. M., de Vet, H. C. W., van Tulder, M. W., & Terwee, C. B. (2013). Definition of the construct to be measured is a prerequisite for the assessment of validity. The Neck Disability Index as an example. Journal of Clinical Epidemiology, 66(7), 775–782.
Reise, S. P., Morizot, J., & Hays, R. D. (2007). The role of the bifactor model in resolving dimensionality issues in health outcomes measures. Quality of Life Research, 16(Suppl 1), 19–31.
Mokkink, L. B., Terwee, C. B., Patrick, D. L., et al. (2010). The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delpi study. Quality of Life Researech, 19(4), 539–549.
de Vet, H. C. W., Terwee, C. B., Mokkink, L. B., & Knol, D. L. (2011). Measurement in medicine: A practical guide (practical guides to biostatistics and epidemiology). London: Cambridge University Press.
Ploit, D. F., & Yang, F. M. (2016). Measurement and the measurement of change. Philadelphia: Wolters Kluwer.
Cassidy, S. A., Bradley, L., Bowen, E., Wigham, S., & Rodgers, J. (2018). Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review. Autism Research, 11(5), 738–754.
van Dijk, S. E. M., Adriaanse, M. C., van der Zwaan, L., Bosmans, J. E., van Marwijk, H. W. J., van Tulder, M. W., et al. (2018). Measurement properties of depression questionnaires in patients with diabetes: a systematic review. Quality of Life Research, 27(6), 1415–1430.
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This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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E.-H.L. conceived the study. J.L. and S.H.M. extracted articles from databases. All authors were involved in the assessment of the methodological quality of each study and the quality of the measurement properties, and evidence-synthesis evaluation. All authors were involved in the writing of this manuscript and approved the final version.
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Lee, J., Lee, EH. & Moon, S.H. Systematic review of the measurement properties of the Depression Anxiety Stress Scales–21 by applying updated COSMIN methodology. Qual Life Res 28, 2325–2339 (2019). https://doi.org/10.1007/s11136-019-02177-x
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DOI: https://doi.org/10.1007/s11136-019-02177-x