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Psychometric Properties of the Persian Version of Death Depression Scale Among Nurses a


Gholam Reza Rajabi , Zahed Begdeli & Zahra Naderi



Department of Counseling, College of Education & Psychology, Shahid Chamran University, Ahvaz, Iran Published online: 07 Apr 2015.

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Death Studies, 0: 1–5, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2014.951495

Psychometric Properties of the Persian Version of Death Depression Scale Among Nurses Gholam Reza Rajabi, Zahed Begdeli, and Zahra Naderi

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Department of Counseling, College of Education & Psychology, Shahid Chamran University, Ahvaz, Iran

This study is an attempt to investigate validity and reliability of the Persian version of Death Depression Scale among male and female nurses at Jundishapur University of Medical Science and 2 private hospitals in Ahvaz, Iran, who were selected by a convenience sampling method after obtaining informed consent. They completed the Death Depression Scale—Revised (DDS-R), Death Anxiety Scale, Death Obsession Scale, as well as Short-Form of Beck Depression Questionnaire (BDI-13). The results of exploratory factor analysis on DDS-R identified 3 factors. Cronbach’s alpha coefficient was 0.93 for the entire measure (19 items), with alphas ranging from .80 to .94 for the individual factors. Indices of concurrent validity for this scale with Death Anxiety, Death Obsession Scales, and BDI-13 were all significant (p < 0.001). Given the validity and reliability of the DDS-R, this scale can be used in clinical settings and research studies.

Interest in the psychological aspect of death and dying has been growing in the last three decades, largely because of the palliative care movement (Bayes, Limonero, Barreto, & Comas, 1997). Among the psychosocial death-related constructs that have been studied, death anxiety has attracted the most interest of researchers, and they have found that it is associated with various demographic and psychological measures (Lonetto & Templer, 1986). However, in addition to death anxiety, different emotions, attitudes, and cognitions surround the end-of-life domain, such as depression (Limonero, 1996). The evidence of depressive components, suffering, hopelessness, loss, and sadness in response to the idea of self-death, the death of significant others, and death in general, has been reported by health professionals who work directly with advanced or dying cancer patients, most notably by Ku¨bler-Ross (1969) in the late 1960s. Ku¨bler-Ross assumed depression as the fourth stage of the dying process. To measure death depression, Templer, Lavoie, Chalgujian, and Thomas-Dobson (1990) introduced and developed the Death Depression Scale. Death Received 26 January 2013; accepted 22 July 2014. Address correspondence to Gholam Reza Rajabi, Department of Counseling, College of Education & Psychology, Shahid Chamran University, Ahvaz, Iran. E-mail: [email protected]

depression is another prominent feature of death distress, characterized by a kind of sadness or conscious reflection related to the individual’s death, other’s death, and=or the concept of death in general (Templer et al., 2001–2002). The Death Depression Scale has generally shown good psychometric properties in its English original form, as well as in the studies in which it has been translated into Arabic (Abdel-Khalek, 1997, 1998) or Spanish (Toma´s-Sa´bado, & Go´mez-Benito, 2003). The empirical research has shown that this scale has adequate internal consistency, good discriminate validity, as well as a meaningful factor structure. This scale’s associations with other instruments in expected directions also provide evidence of strong construct validity. Nevertheless, the discriminate validity of the Death Anxiety and the Death Depression Scale can be debated. Specifically, correlations between the Death Anxiety Scale (Templer, 1970) and the Death Depression Scale have ranged from .55 to .91 across several studies (Alvarado, Templer, Bresler, & Thomas-Dobson, 1992; Hintze, Templer, Cappelletty, & Frederick, 1994; Templer et al., 1990). Previous studies have also supported a four-factor model for the Death Depression Scale, with factors tapping into death sadness, anergia, existential vacuum, and anhedonia (Al-Sabwah & Abdel-Khalek, 2006; Templer



et al., 2001–2002; Tomas-Sabado, Limonero, Temple, & Gomez-Benito, 2004–2005). This study expands upon this previous research and aims to answer the following questions: (a) What is the optimal factor structure for the Persian version of the Death Depression Scale—revised (PDDS-R), as determined by exploratory factor analysis? (b) Does the PDDS-R have a proper concurrent validity and reliability?


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Participants The sample for this study consists of a convenience sample of 201 nurses, 55 male (27.4%) and 146 female (72.6%) recruited from different wards in Emam Khomeini, Golestan, and Shafa government hospitals and Mehr and Arya private hospitals. The mean age of participants was 30.69 (SD ¼ 6.27), with the range of 22 to 52 years. Measures PDDS-R This scale has 21 items and was developed by Templer in 1990 to measure the personal experience of depression symptoms. The items of this scale are arranged either in a 5-point Likert scale ranging from 1 (no) to 5 (very much) or in a binominal format (true ¼ 1, false ¼ 0). The score range (domain) varies from 21 to 105, where a high score indicates high death depression. Items of the PDDS-R were separately translated into Persian by the first and the second authors. The translated versions were then compared to the original text by a psychologist, fluent in English, and the words were modified and confirmed as adequately representing the original items. The primary Persian version was again translated from Persian into English and compared to the original form, which showed high similarity between the two forms.

The Beck Depression Inventory-Short Form (BDI-13) This is a 13-item self-report measure of depression that assesses various cognitive, behavioral, and physiological symptoms associated with depression. The individual is asked to choose an item from a group of choices that best reflects his or her experiences over the past 2 weeks (Rajabi, 2005). The BDI-13 has been shown in a previous study to be a valid and reliable instrument for identifying individuals with moderate and severe depression as established by clinical interviews (Furlanetto, Mendlowicz, & Romildo Bueno, 2005).

Death Obsession Scale (DOS) The DOS (Abdel-Khalek, 1998; Rajabi, 2009) contains 15 items rated on a 5-point Likert-type scale, anchored by 1 (no) and 5 (very much). For the present study, this measure was translated into Persian. Total scores on the DOS range from 15 to 75, with higher scores denoting higher death obsession. High internal reliability has been found for this measure, with alpha coefficients for Iranian men and women of 0.91 and 0.92, respectively (Rajabi, 2009). Further evidence of internal consistency of the DOS has come from studies with Kuwaiti and American participants, which have yielded alpha coefficients of 0.96 and 0.91, respectively (Abdel-Khalek & Lester, 2003). The DOS has shown good concurrent validity with the Obsessive-Compulsion Inventory (Rajabi, 2009). Death Anxiety Scale (DAS) The Death Anxiety Scale (Rajabi & Bahrain, 2002) is a 14-item scale (e.g., ‘‘I am very much afraid to die’’) with a true–false format. A 5-point Likert format was used in the present study. In this study, total scores on this scale can range from 14 to 70, with higher scores denoting higher death anxiety. In its original form, the DAS has been shown to have good test-retest reliability (r ¼ .70), internal consistency (a ¼ .73–.84), and construct validity (Abdel-Khalek, 2002; Rajabi & Bahrain, 2002). Plan of Analysis In this study, using SPSS-16, the following data analyses and methods were applied to study the psychometric characteristics of Death Depression Scale: (a) A Kolmogorov-Smirnov test was run to ensure a normal distribution of the data. (b) Exploratory factor analysis with varimax rotation was performed to identify underlying factors and preliminarily establish factorial validity. (c) Cronbach’s alphas were calculated to test the internal consistency of the measure. (d) Finally, concurrent validity of the scale was assessed by examining correlations between the Death Depression Scale and the 13-item Beck Depression Inventory (Rajabi, 2005), Death Obsession Scale (Rajabi, 2009), and Death Anxiety Scale (Rajabi & Bahrain, 2002). RESULTS To ensure the collected data has a normal distribution, a Kolmogorov-Smirnov test was used. The results (z ¼ 1.30, p ¼ 0.067) showed that the distribution of the collected data is not significantly different from normal. The KMO Index (0.92) and Bartlett test of Sphericity (v2 ¼ 3.08, p < 0.001), showed that the assumed normal

PERSIAN VERSION OF DEATH DEPRESSION SCALE TABLE 1 Factor Loads of Death Depression Scale by Varimax Rotation: Eigenvalues, Percent of Variance Accounted, and Alpha Coefficients Factor Factor Factor Factor 1 2 3 Item 1

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1 .21 .73 .23 2 .23 .73 .37 3 .24 .77 .21 4 .03 .22 .68 5 .20 .60 .46 6 .28 .65 .41 7 .31 .39 .05 8 .48 .48 .22 9 .82 .25 .18 10 .81 .11 .07 11 .85 .27 .13 Eigenvalues 9.62 2.95 1.20 % variance accounted Total of variance Cronbach’s alpha for each factor Cronbach’s alpha

12 13 14 15 16 17 18 19 20 21

Factor 2

.85 .84 .85 .82 .65 .26 .11 .11 .26 .04

.26 .18 .24 .24 .35 .66 .31 .13 .64 .11

.17 .14 .12 .04 .15 .02 .70 .77 .49 .82

45.81% 14.07% 5.79% 65.64% .94 .90 .80 .93 (19 items)

TABLE 2 Concurrent Validity Coefficients of Death Depression Scale—Revised (DDS-R)

DDS-R Factor 1 Factor 2 Factor 3

Factor 1

Factor 2

Factor 3




.41 —

.49 .85 —

.34 .26 .59 —

.52 .41 .49 .34

.70 .57 .65 .47

.75 .52 .69 .64

Note: All of coefficients are significant in P < 0.001.

Obsession Scale, and Death Anxiety Scale. All correlations were positive (in the expected direction) and statistically significant (all ps < 0.001).

Factor 3

distribution have been observed, and the sample size is sufficient for factor analysis. Table 1 shows factors for Death Depression Scale. As shown in Table 1, three extracted factors explain 65.64% of the variance of DDS-R items. The first factor explained 45.81% of the variance, and based on item content, it was labeled Anergia and Vacuum. Items of the second factor accounted for 14.07% variance, and this factor was termed Death Sadness. The third factor accounted for 5.79% of the variance and was labeled Other Death. Thus, the DDS-R was found to be a multi-dimensional scale. It should be noted that 2 items (items 7 and 8) of the 21 items did not have a significant loading on the three extracted factors (in term of factor loadings higher than 0.50), and thus were omitted (see Table 1). The alpha coefficients, after omitting the two items, were 0.93 for the total scale, 0.94 for the Anergia and Vacuum factor (Factor 1, 8 items), .90 for the Death Sadness factor (Factor 2, 7 items), and .80 for the Other Death factor (Factor 3, 4 items). Overall, these results indicate acceptable levels of internal consistency. Table 2 shows the correlation coefficients of DDS-R with the Beck Depression Questionnaire (BI-13), Death



DISCUSSION The purpose of this research was to investigate the validity and reliability the Persian form of the DDS-R and determine its psychometric properties. One noteworthy aspect of the present findings is that the correlations of the Iranian Death Depression Scale—Revised were somewhat higher for measures of Death Anxiety and Obsession, compared with the Beck Depression Inventory–Short Form. Thus, it could be that the DDS-R shares more in common with other death-related constructs (e.g., death anxiety, death obsession) than it does with depression in general. This finding is especially noteworthy because the original English version of the DDS-R correlated more highly with general anxiety than general depression (Templer et al., 1990; Sisco, Reimer, Yanovsky, Thomas-Dobson, & Templer, 1992; Triplett et al., 1995; Abdel-Khalek, 1997, 1998, 2001; Tomas-Sabado & Gomez-Benito, 2002–2003, 2003; Templer et al., 2001–2002). Templer et al. (1990), therefore, inferred that anxiety is the dominant emotion associated with death, and that death depression is more closely associated with general anxiety than with general depression. Results of the exploratory factor analysis suggest that the content and meaning of death depression in other cultures and the Iranian culture are similar to a great extent. The three factors derived from the present study are similar to a four-factor structure identified by Tomas-Sabado et al. (2004–2005) among Spanish students. Specifically, in our study we identified a factor, termed Anergia and Vacuum, which refers to loss of interest in activities of life, loss of energy, and=or becoming discouraged when thinking about death. A second factor, referred to as Death Sadness, was comprised of items reflecting feelings of emptiness and sadness when thinking about death. Finally, a third factor was labeled Other Death, referring to feelings of sadness and dread associated with thoughts about the death of friends and=or family members. It should be noted, however, that Item 7 (death is a lonely matter) and Item 8 (the thought of death makes it difficult to experience pleasure) of the revised form did not load strongly on any of the three factors identified in this study, and thus may not have considerable relevance in Iranian culture. Several limitations of the present work should be mentioned. Notably, the findings of this study cannot be generalized to all nurses or other relevant populations because it is focused on a convenience sample. This study also used a cross-sectional design, which did not allow



for an assessment of test-retest reliability. Furthermore, we were limited to a single sample, and confirmation of the factor structure with a second sample is needed. There is also a need for computation of separate psychometric parameters with male nurses.

ACKNOWLEDGMENTS Our special thanks go to every nurse working in the studied hospitals and those who spent their invaluable time to help the researchers.

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REFERENCES Abdel-Khalek, A. M. (1997). Death, anxiety and depression. Omega, 35, 219–229. Abdel-Khalek, A. M. (1998). Death, anxiety and depression in Lebanese undergraduate. Omega, 37, 289–302. Abdel-Khalek, A. M. (2001). Death, anxiety, and depression in Kuwaiti undergraduates. Omega, 42, 309–319. Abdel-Khalek, A. M. (2002). Death, anxiety, and depression: A comparison between Egyptian, Kuwait, and Lebanese undergraduates. Omega, 45, 277–287. Abdel-Khalek, A. M., & Lester, D. (2003). Death obsession in Kuwaiti and American college students. Death Studies, 27, 541–553. Al-Sabwah, M. N., & Abdel-Khalek, A. M. (2006). Religiosity and death distress in Arabic college students. Death Studies, 30, 365–375. Alvarado, K. A., Templer, D. I., Bresler, C., & Thomas-Dobson, S. (1992). Are anxiety and death depression distinct entities? Omega: Journal of Death and Dying, 26, 113–118. Bayes, R., Liminero, J. T., Barreto, P., & Comas, M. D. (1997). A way to screen for suffering in palliative care. Journal of Palliative Care, 13, 22–26.

Furlanetto, L. M., Mendlowicz, M. V., & Romildo Bueno, J. (2005). The validity of the Beck Depression Inventory-Short Form as a screening and diagnostic instrument for moderate and severe depression in medical inpatients. Journal of Affective Disorders, 86, 87–91. Hintze, J., Templer, D. I., Cappelletty, G. G., & Frederick, W. (1994). Death depression and death anxiety in HIV-infected males. Death Studies, 17, 333–341. Limonero, J. T. (1996). The phenomenon of death as an example of research on emotions [Spanish]. Revista de Psicologı´a General Aplicada, 49, 249–265. Lonetto, R., & Templer, D. I. (1986). Death anxiety. Washington, DC: Hemisphere. Rajabi, G. H. (2005). Psychometric properties of Beck Depression Inventory Short Form Items (BDI-13). Journal of Iranian Psychologists, 1, 291–298. Rajabi, G. H. (2009). The psychometric properties of Death Obsession Scale in freshman undergraduate students. Journal Applied Science, 9, 360–365. Rajabi, G. H., & Bahrain, M. (2002). Items factor analysis of the Death Anxiety Scale. Journal of Psychology, 20, 331–344. Templer, D. I. (1970). The construction and validation of a death anxiety scale. Journal of General Psychology, 82, 165–177. Templer, D. I., Harville, M., Hutton, S., Underwood, R., Tomeo, M., Russell, M., Mitroff, D., & Arikawa, H. (2001–2002). Death Depression Scale–revised. Omega: Journal of Death and Dying, 44, 105–112. Templer, D. I., Lavoie, M., Chalgujian, H., & Thomas-Dobson, S. (1990). The measurement of death depression. Journal of Clinical Psychology, 46, 834–839. Toma´s-Sa´bado, J., & Gomez-Benito, J. (2002–2003). Psychometric properties of the Spanish adaptation of the Death Obsession Scale (DOS). Omega, 46, 259–268. Tomas-Sabado, J., & Gomez-Benito, J. (2003). The Spanish from of the Death Depression Scale. Perceptual and Motor Skills, 96, 49–53. Tomas-Sabado, J., Limonero, J. T., Templer, D. I., & Gomez-Benito, J. (2004–2005). The Death Depression Scale–Revised: Preliminary empirical validation of the Spanish form. Omega, 50, 43–52. Triplett, G., Cohen, D., Reimer, W., Rinaldi, S., Hill, C., Roshdieh, S., . . . Templer, D. I. (1995). Death discomfort differential. Omega, 31, 295–304.



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Items of the Persian Version of the Death Depression Scale


Psychometric properties of the Persian version of Death Depression Scale among nurses.

This study is an attempt to investigate validity and reliability of the Persian version of Death Depression Scale among male and female nurses at Jund...
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