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Dass-21 Ansiedad y Estres Biana Vignola BR
Dass-21 Ansiedad y Estres Biana Vignola BR
Research report
art ic l e i nf o a b s t r a c t
Article history: Background: Depression and anxiety have been associated with a range of symptoms that often overlap.
Received 24 September 2013 Depression, Anxiety and Stress Scale‐21 (DASS-21) is a single instrument to assess symptoms of
Accepted 22 October 2013 depression, anxiety and stress. This study aimed to adapt and validate the DASS-21 for use in the
Available online 28 October 2013
Brazilian Portuguese language.
Keywords: Methods: The DASS-21 has been adapted following the translation–back translation methodology from
Depression English to Portuguese. 242 subjects completed the following assessments: the DASS-21, the Beck
Anxiety Depression Index (BDI), Beck Anxiety Index (BAI) and the Inventory of Stress Symptoms of Lipp (ISSL).
Stress Results: The Kaiser–Meyer–Olkin (KMO) result was .949, indicating that the adequacy of the model was
Scales
high. Cronbach's alpha was .92 for the depression, .90 for the stress, and .86 for the anxiety, indicating a
Validity
good internal consistency for each subscale. The correlations between DASS scale and BDI scale, BAI scale
and ISSL inventory were strong. The factorial analysis and distribution of factors among the subscales
indicated that the structure of three distinct factors is adequate.
Limitations: Older subjects over 65 years of age were not largely represented in this sample. A study
specific to this elderly population should be conducted. Another limitation of the study was education
level. The impact of low education in its applicability should be considered.
Conclusions: The findings support the validity of the Brazilian Portuguese version of the DASS-21 and add
to the evidence of the DASS-21 quality and ability to assess emotional states separately, eliminating the
use of different instruments to assess these states.
& 2013 Elsevier B.V. All rights reserved.
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2013.10.031
R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109 105
observation that different types of physical or psychological The instrument's validity was defined by its ability to demonstrate
conditions threatened homeostasis and initiated a cascade of that it measures the indicators it is intended to measure, in this case,
physiological reactions, known as the “general adaptation syn- emotional state disorders.
drome” (Selye, 1936).
The present study examined the four phases of stress that were 2.1. Participants
defined by Lipp (2005) and were expanded from a three phases
model developed by Selye (1936). The stress phases proposed by The study included patients and caregivers in an outpatient
Lipp (2005) include alertness, resistance, exhaustion and near- setting in the city of Santo André/São Paulo, Brazil. Data were
exhaustion. This model defines stress as “a complex reaction and collected from November 2011 to May 2012. Inclusion criteria
overall body components involving physical, psychological, mental included an age between 18 and 75 years and frequent visits to the
and hormonal aspects, which develops in stages or phases”. clinic.
For the DASS, stress is defined as an emotional state that varies
according to an individual evaluation of the situations experienced 2.2. Procedures
as a threat, harm or challenge. The DASS requires an assessment of
demand and a secondary assessment of coping, with the symp- The DASS-21 original English version was sent to a bilingual
toms and emotions serving as the main concept organizer of the teacher (English – Portuguese) for translation to Portuguese
stressful experience as it includes stress and coping strategies (version 1, V1). V1 was given to a teacher of Portuguese language
(Apóstolo et al., 2006). for semantic adjustments and idiosyncratic differences (version 2,
Depression is an emotional and mental disorder that has a very V2). Together with the researcher and other mental health care
complex etiology, despite having well-defined symptoms. The professionals, V2 was compared to the final Portuguese version
etiology of depression includes genetic, biological and environ- tested in Portugal. Analysis of content, meaning and adaptations
mental factors. The environment factors model focuses on “the were made to the Portuguese language used in Brazil to ensure an
emergence of depressive symptoms” (Stroud et al., 2008). understanding of the content (Beaton et al., 2000). The scale was
According to the conception of the DASS, depression is an then translated back to the original language (English). In this
emotional disorder, but has no specific emotion. Depression may sense, the goal was to minimize semantic interpretations and
be associated with a range of emotions, such as anxiety, anger, misunderstandings, to ensure the best possible adaptation to the
guilt and shame. Depression is usually trigged by unfavorable Brazilian culture.
living conditions and may result from the experience of a great A pre-test was conducted with a sample of six subjects during
loss or from feelings of hopeless or that life is not worth living an outpatient medical visit, which revealed no difficulties in
(Apóstolo et al., 2006). understanding the content of the statements. The scale was later
Anxiety is a vague and unpleasant feeling of fear or apprehen- applied to a pilot group (N ¼48) with similar characteristics to the
sion that may be characterized by a tension or discomfort derived final sample. The assessment was answered pertinently, thereby
from the anticipation of danger (Graeff, 2007). Anxiety is asso- demonstrating the subjects had a comprehension and under-
ciated with the perception of certain environmental contexts standing of the propositions.
(places, people, activities, etc.) that are compared to previous A back or reverse translation of the scale from Brazilian
experiences (memory) and that activate specific brain systems Portuguese to the original form written in Australian English was
with adaptive functions (Gray, 1987). In this sense, anxiety may be performed. This back translation was performed by a native
considered as an emotion that is related to a “behavior risk teacher of the English language without prior knowledge of the
evaluation” (Graeff, 2007). original scale.
Lovibond and Lovibond (2004) developed the DASS as a single
instrument to assess symptoms of depression and anxiety in an 2.3. Subjects
interactive and empirically oriented process. The authors also
identified a third factor defined as stress. Their research is based Participants were invited to participate in the study during the
on the tripartite model of anxiety and depression. The DASS was period in which they visited an outpatient clinic for consultations
conceptualized in the form of a 42 items assessment consisting of and examinations. The subjects completed the following assess-
three subscales with 14-items each. The items refer to symptoms ments: the DASS 21, the Beck Depression Inventory (BDI), the Beck
experienced by the subject in the previous week and use a Likert Anxiety Inventory (BAI) and the Inventory of Stress Symptoms of
scale ranging from 0 (“does not apply to me at all”) to 4 (“most of Lipp (ISSL). The completion of all four instruments lasted 30 min
the time applies to me”). Although the full version (DASS-42) on average.
provides data on specific symptoms of each emotional state
assessed, the authors claim that the reduced version of the 2.4. Instruments
instrument (DASS-21) has the same structure as the full version
but only requires half the time to complete the investigation of To validate the DASS, other previously validated instruments were
symptoms (Lovibond and Lovibond, 2004). included in the assessment: the BDI for depression (Beck et al., 1961;
DASS-21 has already been translated to Portuguese from Gomes-Oliveira et al., 2012; Gorenstein and Andrade, 1996;
Portugal (Apóstolo et al., 2006). However, Brazilian Portuguese is Gorenstein et al., 1999;), the BAI for anxiety (Beck et al., 1988;
slightly different from that spoken in Portugal. Furthermore, the Gorenstein and Andrade, 1996) and ISSL for stress (Lipp, 2005). Beck
sociocultural context of Brazil is quite different from that present instruments were used in the construction of the full version DASS
in Portugal. This study aimed to adapt and validate the DASS-21 for that consists of 42 items. There is no instrument in the literature that
use in the Portuguese language spoken in Brazil. is comparable to the DASS stress subscale. This subscale has affinities
with measures of negative affect and was originally compared to
scales that measure risk for coronary heart disease (Lovibond and
2. Method Lovibond, 2004). The emphasis in these previous studies was to
evaluate certain traits or symptoms, not the emotional state itself
The present study aimed to measure the properties and psycho- (Lovibond and Lovibond, 2004). The stress subscale was compared to
metric equivalence of the DASS-21 in a Brazilian sociocultural context. a developed and validated Brazilian instrument known as the
106 R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109
Table 1
DASS subscales and assessed symptoms.
This study was approved by the Ethics in Research Committee The relationship between anxiety and depression has been
of the Federal University of São Paulo, Brazil (1749/11) and written complex despite several decades of research aimed at under-
informed consent was obtained. Participants were guaranteed standing this interaction. They might be different points on the
R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109 107
Table 3
Main component matrix with varimax rotation forced to three factors (depression, stress and anxiety) and correlation matrix of DASS-21 items (n¼ 242).
n
Kaiser–Meyer–Olkin measure of sampling adequacy: 949.
Bartlett's test of sphericity (Approx. χ2): p ¼.000 3542.253.
a
Depression items.
b
Stress items.
c
Anxiety items.
same “continuum” mood/affective disorders or distinct disorders. its short version (DASS-21), which had values ranging from .91 to .97
On the other hand, stress is closely related to both depression and for depression, .81 to .92 for anxiety and .88 to .95 for stress.
anxiety and may lead to the onset of either or both disorders Considering the three factors proposed by the original scale, as
(Kehne, 2007; Kehne and Cain, 2010). The DASS-21 scale was mentioned above, the structure of the current construct had a very
based on the tripartite model of anxiety and depression, which similar distribution of the subscales compared to the original model.
indicates a continuum between depression, anxiety and stress However, item 18 which stated “I felt I was emotional/too sensitive”
(Clark and Watson, 1991). was characterized as a depressive symptom in this study but was
This study aimed to validate the DASS-21 to Brazilian Portu- initially proposed as a stress symptom. Factor loading was used to
guese. The strong correlations (.86, .80 and .74) between instru- indicate how each item (variable) contributed to the formation of the
ments provided evidence for the validity of measuring depression, factor. Thus, this item had a factor loading of .572 in factor 1, which
anxiety and stress as emotional states. grouped the variables that measure depression, and a factor loading
Furthermore, the factor analysis indicated that the most sui- of .497 in factor 2, which grouped the variables that measure stress
table structure included three factors according to the original (the original location of the item). This difference may have occurred
scale (Lovibond and Lovibond, 2004). The factor loadings, which due to cultural differences in Brazil, given that it is possible the
measure the correlation of the item with an individual factor, emotional sensitivity was related to the excessive sadness and
distributed the items in the subscales in a very similar way unpleasant events characteristic of depression.
compared to the original scale: .81 for depression, .83 for anxiety Furthermore, the phrase on the original scale written as “I felt I
and .81 for stress (Lovibond and Lovibond, 2004). was rather touchy” was translated to “I felt I was very irritable” in
The results obtained in the current study support a positive the Portugal version (Apóstolo et al., 2006) and “I felt that I was a
evaluation of the quality of the DASS-21 compared to other bit emotional/too sensitive” in this Brazilian version. When the
validation studies of the same scale. In an earlier Spanish study same phrase was written in the back-translated version, the
(Daza et al., 2002), the alpha values were .96 for the total scale, .93 translation “I felt like I was being a little too emotional/sensitive”
for depression, .86 for anxiety and .91 for stress. was quite different from the original meaning. Thus, the original
An evaluation study of the psychometric properties of the DASS- English expression did not have an equivalent term in the
21 applied to 222 older patients in Houston (EUA) had an alpha equal semantics of Portuguese language in either Brazil or Portugal.
to .94 for the total scale and .87, .89 and .69 for the subscales of In the validation study of the DASS-21 for the Spanish language
depression, anxiety and stress, respectively (Gloster et al., 2008). (Daza et al., 2002), the three-factor structure explained the data
Other studies supported favorable psychometric properties of the more clearly. The depression subscale was highly correlated with
DASS when applied to adults with anxiety and/or mood disorders the BDI (.86). The anxiety subscale was highly correlated with the
(Antony et al., 1998; Brown et al., 1997; Clara et al., 2001; Crawford BDI (.82). Comparing the correlation results between the stress
and Henry, 2005); Covic et al., 2012). The studies showed good subscale and the Beck Anxiety and Depression Inventories, the
internal consistency with the DASS in its full version (DASS-42) and correlation index was highest between stress and depression (.74).
108 R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109
The results of this study indicate that the structure of three legitimacy of each subscale as an independent measure. Moreover,
separate factors is closer to that originally proposed by the authors the current findings support the use of the DASS-21 for the initial
of the DASS-21 as a means to evaluate three different but diagnosis and evaluation of therapeutic measures. However, cul-
correlated emotional states. tural and social issues should be considered in understanding
From a phenomenological standpoint, anxiety and depression stress as an emotional state, which may predict or aggravate
are clearly distinct phenomena. However, it has been very difficult depression and anxiety disorders.
to compare and understand both constructs empirically and to This study provides further support for methodology aimed at
understand the relationship between the two emotional states. identifying symptoms of depression, anxiety and stress using a
This study provides further support that depression, anxiety and validated instrument. The DASS-21 enables a more accurate
stress are distinct phenomena. Based on the data obtained, it can diagnosis of these disorders by different professionals outside
be argued that the constructs under consideration may be differ- the field of psychiatry, eliminating the use of different instruments
ent points along the same continuum and may share some to assess these states. This also facilitates seeking earlier treatment
common symptoms as proposed by Clark and Watson (1991) in and referring an individual for specialized treatment when con-
their Tripartite Model of Anxiety and Depression. gruent with the individual's needs.
According to Apóstolo et al. (2011), major depression occurs
through a process very similar to a continuous physiological process
and to chronic stress. The authors argued that the experience of Role of funding source
First author got a scholarship for her master degree from Coordenação de
continuous negative effects may cause general distress in the
Aperfeiçoamento de Pessoal de Nível Superior (CAPES). CAPES had no further role
individual that may result in recurrent disturbances of brain struc- in study design; in the collection, analysis and interpretation of data; in the writing
tures underling some depression disorders (Apóstolo et al., 2011). of the report; or in the decision to submit the paper for publication.
In this context, it is possible to assume that there will inevitably
be a substantial comorbidity between the two disorders and their
symptoms. Conflict of interest
Authors declare that there is no conflict of interest.
Anxiety can be defined as an emotional state associated with
the future, which consists of psychological and physiological
components that are part of the normal spectrum of human Acknowledgments
experience (Bernik and Lopes, 2011). According to these same The authors thank to Souza, A.A.L. for helping in analysis and to the
authors, stress may progress to pathological anxiety and/or Cardiologists Partners-Owners of Clinica Eucor, who supported this research and
depression. In this sense, anxiety or depression may be two allowed data collection.
symptoms of the same disease, thereby increasing the difficulty
of diagnosing the symptoms. References
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