Elsevier

General Hospital Psychiatry

Volume 25, Issue 4, July–August 2003, Pages 277-283
General Hospital Psychiatry

Commentary and perspective
A validation study of the hospital anxiety and depression scale (HADS) in a Spanish population

https://doi.org/10.1016/S0163-8343(03)00043-4Get rights and content

Abstract

The present study aims to validate the Spanish version of the Hospital Anxiety and Depression Scale (HADS) and to determine the use of this tool for screening mood and anxiety disorders. Psychometric properties of the HADS were assessed in different groups of general medical outpatients attending the Hospital Clínic in Barcelona (N=385), and psychiatric diagnoses were made using DSM-IV criteria. A two-factor solution corresponding to the original two subscales of the HADS was found. The Spanish version of the HADS had good internal consistency and external validity, with favorable sensitivity and specificity in identifying cases of psychiatric disorder as defined by the Structured Clinical Interview for DSM-IV (SCID-I). The psychometric properties of the HADS and its brevity make it useful for screening for psychiatric disorders in the medically ill.

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.

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