Psychiatric–Medical ComorbidityValidity and reliability of the Hospital Anxiety and Depression Scale in a hypertrophic cardiomyopathy clinic: the HADS in a cardiomyopathy population
Introduction
Anxiety disorder and depression frequently occur in the physically ill. Some studies postulate that depression has a prevalence of between 20% and 50% [1], [2] in the general hospital setting. Alternatively, this may be an artifact of the screening process. Early studies investigating the prevalence of psychiatric disorder in medical patients used scales that include somatic symptoms. These scales, therefore, lose their ability to distinguish depression from malaise in the physically ill.
In 1983, Zigmond and Snaith [3] developed the Hospital Anxiety and Depression Scale (HADS) for use as a screening questionnaire in medical outpatient clinics. The HADS is a 14-item self-report questionnaire incorporating anxiety and depression subscales. Each item is scored 0 to 3, and a score of 8 or greater on one or both of the subscales indicates the presence of a depressive or anxiety disorder. Completion of the questionnaire takes only a few minutes. The developers aimed to discard all ambiguous somatic symptoms such as dizziness and lethargy and instead comprised the depression subscale around the psychopathology of anhedonia and the anxiety subscale based upon the cognitive symptoms of anxiety. The HADS has been found to perform reliably in psychiatric, nonpsychiatric and well populations [4] as a screening tool; however, its use as a diagnostic instrument for research may be inappropriate [5]. A low cutoff point on the depression subscale provides adequate sensitivity, but the corresponding positive predictive value (PPV), the probability that a subject who tests positive is a true positive, is disappointingly low. A satisfactory balance cannot be achieved by modifying the cutoff point on this subscale [6], and so, it has been recommended that “caseness,” the presence of depression, anxiety or both, is better defined by the total HADS score [7].
The tripartite model of depression and anxiety, which divides symptoms into three groups [8], poses a further problem for the HADS. According to this model, low positive affectivity or anhedonia characterizes depression, anxiety states are characterized by physiological hyperarousal (PH) and both are nonspecifically associated with general negative affectivity. Hence, the somatic symptoms of PH that the HADS was designed to exclude are those that differentiate anxiety from depression. Nevertheless, the HADS is a simple, self-rating scale that patients find acceptable [9], its use has been validated across a number of different languages [10], [11] and settings [12], [13], and perhaps, more importantly, its widespread use has made it familiar and acceptable to clinicians and researchers alike.
Patients suffering from hypertrophic cardiomyopathy experience raised levels of anxiety, depression and psychosocial dysfunction compared with population norms. These consequences are particularly common in those with chest pain and dyspnea, but are not associated with a family history of hypertrophic obstructive cardiomyopathy (HOCM) or premature sudden death [14]. This study used the HADS as a diagnostic instrument, though it has not yet been validated in this population. The aim of the current study is to assess the performance of the HADS in a clinical population with hypertrophic cardiomyopathy.
Section snippets
Methods
One hundred fifteen consecutive English-speaking patients from a sample of 134 (86% response rate) at a specialist Hypertrophic Cardiomyopathy clinic at St. George's Hospital and Medical School in London agreed to complete the study. The participants first completed the HADS questionnaire, and then one trained researcher (JM) who was blind to the subjects' HADS score performed the Structured Clinical Interview for DSM-III-R nonpatient version [15] (SCID-np), which was considered to be the gold
Results
The sample was comprised of 68 males and 47 females with a median age of 43 years ranging from 23 to 63 years. The prevalence of depression as defined by the SCID-np in this population was 21%, major depression accounting for 75% of this, and anxiety disorders occurred in 39%. Both conditions coexisted in 12% of the population. The mean score on the depression subscale was 6.2 with an S.D. of 3.15. The mean score on the anxiety scale was 7.89 with an S.D. of 2.84, whereas the respective values
Discussion
This is the first study to validate the use of the HADS questionnaire in an HOCM population, and the results affirm those from other studies across differing populations. As can be seen from the AUC, both subscales, but particularly the depression scale, perform well. It can therefore be concluded that the HADS performs well as a screening instrument. The ROC curves confirm the original design as they demonstrate that a cutoff point of 8 on both subscales offers the best compromise between
References (18)
- et al.
The validity of the Hospital Anxiety and Depression Scale: an updated review
J Psychosom Res
(2002) Poor efficacy of the Hospital Anxiety and Depression Scale in the diagnosis of major depressive disorder in both medical and psychiatric patients
J Psychosom Res
(1994)- et al.
Anxiety and depression in patients with chest pain referred for exercise testing
Lancet
(1985) - et al.
Depression in the medically ill: an overview
Am J Psychiatry
(1986) - et al.
Psychiatric disorder in the general hospital
Br J Psychiatry
(1986) - et al.
The Hospital Anxiety and Depression Scale
Acta Psychiatr Scand
(1983) - et al.
A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects
Psychol Med
(1997) - et al.
Comparison of the General Health Questionnaire and the Hospital Anxiety and Depression Scale
Br J Psychiatry
(1990) - et al.
Tripartite model of anxiety and depression: psychometric evidence and taxonomic implications
J Abnorm Psychol
(1991)
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