Commentary and perspectiveA validation study of the hospital anxiety and depression scale (HADS) in a Spanish population
Introduction
The prevalence of psychiatric disorders in nonpsychiatric hospital clinics is certainly high [1]. There are many studies on psychiatric morbidity in primary health care and questions of the internist’s ability to detect these disorders [2], [3], [4], [5], [6]. For example, Derogatis et al. (1983) reported that almost half of the ambulatory cancer patients who had been newly admitted to three cancer centers had either adjustment disorders or major depression [7]. Similarly, depression has been identified as an independent predictor of mortality in patients recovering from an acute myocardial infarction [8], [9]. However, lack of recognition of psychological distress by physicians has been documented [10]. Physicians tend to underestimate the degree of distress experienced by their patients, which results in inadequate treatment of these disorders [11], [12]. Appropriate treatment of psychological distress is not only clinically effective but also cost effective [13].
To overcome this important drawback, reliable screening tests for psychiatric disorder have been developed. The instruments studied most widely in a variety of contexts are the General Health Questionnaire (GHQ) [14] and the Hospital Anxiety and Depression Scale (HADS) [15]. HADS is a 14-item self-report screening scale that was originally developed to indicate the possible presence of anxiety and depression states in the setting of a medical nonpsychiatric outpatient clinic [15]. HADS consists of a 7-item anxiety subscale and a 7-item depression subscale. Each item scores on a 4-point Likert scale (e.g., as much as I always do [0]; not quite so much [1]; definitely not so much [2]; and not at all [3]), giving maximum subscale scores of 21 for depression and anxiety, respectively. The questionnaire assesses symptoms over the preceding week. Unlike the GHQ [16], items referring to symptoms that may have a physical cause (e.g., insomnia and weight loss) are not included in the scale. So, the HADS is considered to be unaffected by coexisting general medical conditions [17].
The present study aims to validate the Spanish version of the HADS, assessing several psychometric properties of the questionnaire, and to determine the optimal cut-off points and respective specificity and sensitivity of this version of the scale. Moreover, it is intended to determine the ability of this tool to screen psychiatric disorder cases, especially, mood and anxiety disorders.
Section snippets
Subjects
The study was conducted at the Hospital Clínic, a university general hospital in Barcelona (Spain). Between March 1999 and December 2000, a total of 385 consecutive adult outpatients with severe medical pathology (from Neurosurgery, Pulmonary, Cardiology, Neurology, and Infectious Illness settings) were assessed for screening for psychiatric morbidity. Patients with very poor general health, psychotic illness or significant cognitive impairment were excluded. Subjects were first seen by the
Subject characteristics
Three hundred and eighty-five patients completed the questionnaire and they agreed to be interviewed (Table 1). There were 181 women (47%) and 204 men (53%). The mean age was 38.39 years (SD 12.35). Of the 385 patients participating in the study, no Axis I diagnoses were found in 162 (42%) patients versus 223 patients (58%) diagnosed as having some disorder (Table 2).
Validity and reliability of the HADS
The internal consistency, as assessed by Cronbach’s alpha, was 0.90 for the full scale, 0.84 for the depression subscale and
Discussion
With the growth of consultation-liaison psychiatry as a specialty in its own right, the need for standardized procedures to detect emotional disturbance in patients with physical illness has become increasingly important [27]. In view of this, the present study establishes the Spanish version of the HADS as a reliable and valid tool for screening for psychiatric disorders in general hospital outpatients. The questionnaire possesses good internal consistency and external validity, with favorable
Acknowledgements
The authors gratefully acknowledge the advice on statistics of Xavier Torras.
References (47)
- et al.
Psychiatric morbidity among frequent attending patients in primary care
Gen Hosp Psychiatry
(1995) - et al.
The validity of the Hospital Anxiety and Depression ScaleAn updated literature review
J Psychosom Res
(2002) International experiences with the Hospital Anxiety and Depression ScaleA review of validation data and clinical results
J Psychosom Res
(1997)- et al.
A validation study of three anxiety and depression self-assessment scales
J Psychosom Res
(1987) - et al.
Construct validation of the hospital anxiety and depression scale with clinical population
J Psychosom Res
(2000) - et al.
Anxiety and depression in cancer patientsrelation between the Hospital Anxiety and Depression Scale and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire
J Psychosom Res
(2000) - et al.
Psychiatric morbidity in general practice in the community
Psychol Med
(1976) - et al.
Recognition, management and course of anxiety and depression in general practice
Arch Gen Psychiatry
(1991) Measurement of depression in patients with cancer
Cancer
(1984)- et al.
Diagnosing depression in the hospitalized medically ill
Psychosomatics
(1983)
Depression and chronic medical illness
J Clin Psychiatry
The prevalence of psychiatric disorders among cancer patients
JAMA
Affective disorders and survival after acute myocardial infarction. Results from the post-infarction late potential study
Eur Heart J
Major depression before and after myocardial infarctionits nature and consequences
Psychosom Med
Depression in patients with cancerdiagnosis, biology and treatment
Arch Gen Psychiatry
Depression and the cancer patient
J Clin Psychiatry
Oncologists’ recognition of depression in their patients with cancer
J Clin Oncology
Cost-effectiveness of treatments for major depression in primary care practice
Arch Gen Psychiatry
A scaled version of General Health Questionnaire
Psychol Med
The Hospital Anxiety and Depression Scale
Acta Psychiatr Scand
Validity of the scaled version of the General Health Questionnaire (QHQ-28) in a Spanish population
Psychol Med
The concepts of mild depression
Br J Psychiatry
Diagnostic and statistical manual of mental disorders
Cited by (604)
Impact of a multicomponent program with nonpharmacological therapies for patients with chronic pain
2024, Journal of Healthcare Quality ResearchExercise-based cardio-oncology rehabilitation for cardiotoxicity prevention during breast cancer chemotherapy: The ONCORE randomized controlled trial
2024, Progress in Cardiovascular Diseases