Categorical and dimensional perspectives on depression in elderly primary care patients – Results of the AgeMooDe study

An accurate diagnosis is essential for the management of late‐life depression in primary care. This study aims to (1) provide information on the agreement on depression diagnoses between general practitioners (GPs), dimensional tools (Geriatric Depression Scale [GDS], Hospital Anxiety and Depression Scale [HADS]) and a categorical tool (Structured Clinical Interview for DSM‐IV criteria [SCID]) and (2) identify factors associated with different diagnoses. As part of the multicenter study “Late‐life depression in primary care: needs, health care utilization and costs (AgeMooDe)” a sample of 1113 primary care patients aged 75 years and older was assessed. The proportion of depression was 24.3% according to GPs, 21.8% for the GDS, 18.9% for the HADS and 8.2% for the SCID. Taking GDS, HADS and SCID as reference standards, recognition of GPs was 47%, 48% and 63%. Cohen's Kappa values indicate slight to moderate agreement between diagnoses. Multinomial logistic regression models showed that patient related factors of depression were anxiety, intake of antidepressants, female gender, a low state of health, intake of medication for chronic diseases and functional impairment. GPs performed better at ruling out depression than ruling in depression. High levels of disagreement between different perspectives on depression indicate that they may be sensitive to different aspects of depression.     

Screening for mental disorders in cancer patients – discriminant validity of HADS and GHQ‐12 assessed by standardized clinical interview

The detection and classification of comorbid mental disorders has major implications in cancer care. Valid screening instruments for different diagnostic specifications are therefore needed. This study investigated the discriminant validity of the German versions of the Hospital Anxiety and Depression Scale (HADS) and the General Health Questionnaire (GHQ‐12). A total of 188 cancer patients participated in the examination, consisting first of the assessment of psychological distress and, second, of the diagnosis of mental disorders according to DSM‐IV by clinical standardized interview (CIDI). Discriminant validity of the two instruments regarding the diagnosis of any mental disorder, anxiety, depression and multiple mental disorders was compared using ROC analysis. Overall, the total HADS scale shows a better screening performance than the GHQ‐12, especially for the detection of depressive and anxiety disorders. Best results are achieved for depressive disorders with an area under the curve (AUC) of 0.80, a sensitivity of 79% and a specificity of 76% (cut‐off point = 17). For the ability of the instruments to detect patients with mental disorders in general, the GHQ‐12 (AUC: 0.68) shows a similar overall accuracy to the HADS (AUC: 0.70). The screening performance of both scales for comorbid mental disorders is comparable. The HADS is a valid screening instrument for depressive and anxiety disorders in cancer care. The GHQ‐12 can be considered as an alternative to the HADS when diagnostic specifications are less detailed and the goal of screening procedures is to detect patients with single or multiple mental disorders in general. Limitations of conventional screening instruments are given through the differing methodological approaches of screening tests (dimensional approach) and diagnosis according to DSM‐IV (categorical approach). Copyright © 2001 Whurr Publishers Ltd.     

Psychological well‐being,depression, and anxiety in Japanese university students

Background: In order to further investigate the relationship of psychological well‐being with depression and anxiety. Method: Students from five universities were solicited to participate in this study and 545 students with a mean age of 20.1 (SD = 2.2) years were finally accessed to analysis. Result: All six dimensions—autonomy (AU), environment mastery (EM), personal growth (PG), positive relationships with others (PR), purpose in life (PL), and self‐acceptance (SA)—of the Scales of Psychological Well‐being Inventory (SPWB) were moderately negatively correlated with depression and anxiety as measured by the Hospital Anxiety and Depression Scale (HADS). Furthermore, due to a good fit with the present data, the model of SPWB on depression and anxiety was consistent with the theory of psychological well‐being and indicated that HADS depression was predicted by EM, PR, and SA, while HADS anxiety was predicted by AU, EM, PG, PR, and SA. Conclusion: SPWB is a reliable measure of well‐being for Japanese young adults, and the negative affectivity such as depression and anxiety is to some extent determined by the lack of psychological well‐being. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Factor structure of the hospital anxiety and depression scale in older patients with major depression

OBJECTIVE: Symptomatic anxiety has prognostic significance in major depression. In theory, the Hospital Anxiety and Depression Scale (HADS) should be a useful instrument for measuring the severity of symptomatic anxiety in late-life depression. However, the dimensional structure of the HADS has not been evaluated in elderly depressed patients; it is not known whether the scale actually functions as a bidimensional measure of anxiety and depression in this population. The purpose of this exploratory study, therefore, was to examine the factor structure of the HADS in older patients with major depression. METHOD: The HADS was completed by 213 patients, aged 60 years or older, with DSM-III-R unipolar major depression. Principal components analysis was performed on the full 14-item HADS and on each of its subscales. RESULTS: Two distinct factors, which corresponded to the instrument's depression and anxiety subscales, emerged. The two-factor structure proved reasonably stable when the study group was randomly divided into two halves. Analysis of the subscales resulted in a single factor for each. The subscales had high internal reliability. CONCLUSIONS: These findings confirm that the HADS functions as a bidimensional measure of depression and anxiety in older patients with major depression. The results suggest that the HADS is a valid instrument for measuring severity of anxiety, independent of other depressive symptoms, in this population.     

Rasch analysis of the hospital anxiety and depression scale in Parkinson's disease

The hospital anxiety and depression scale (HADS) is commonly used to assess mood in Parkinson's disease (PD) patients. Very few studies analyze the scale from the standpoint of item response theory. This article sought to analyze how the HADS fits the Rasch model in PD. The HADS was administered to 387 PD patients. Three sets of Rasch analyses were performed for the HADS total score, and anxiety and depression subscales (HADS‐T, ‐A, and ‐D, respectively). Although the HADS‐T and HADS‐A displayed a good fit, with little threshold disordering and no differential item functioning, the HADS‐D failed to fit the model. The person separation index, a reliability measure, was 0.87 (HADS‐T) and 0.80 (HADS‐A). Both HADS‐T and HADS‐A showed unidimensionality. Our results supported the use of HADS‐T as a measure of psychological distress in PD patients. Moreover, the HADS‐A was also an adequate anxiety measure. Further research is required to address the use of HADS‐D in PD. © 2008 Movement Disorder Society     

Using the Hospital Anxiety and Depression Scale to screen for depression in cardiac patients

OBJECTIVE: There is an increasing interest in trying to identify patients with chronic physical illness who would benefit from interventions to decrease psychological distress. The Hospital Anxiety and Depression Scale (HADS) is one measure that can be effectively used to identify patients struggling with anxiety and/or depression in addition to comorbid medical illness such as cardiac disease. The aim of this study is to determine if the HADS correctly identified patients with depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [determined using the Primary Care Evaluation of Mental Disorders (PRIME-MD), a gold-standard diagnostic tool], as depressed and to determine which items on the HADS most strongly predicted the PRIME-MD major depression diagnosis among cardiac patients. METHOD: Patient data were obtained from a randomized controlled trial of treatment for psychological distress in patients surviving recent myocardial infarction or life-threatening ischemic heart disease. The HADS was used to evaluate depression and/or anxiety among patients hospitalized for heart disease, and the PRIME-MD was used to diagnose major depressive disorder (MDD) in these patients. We used receiver-operating characteristic (ROC) curves and logistic regression to analyze patient responses to both of these measures. RESULTS: Among the 79 study patients, the area under the ROC curve (AUC) for the HADS depression subscale was 0.81 with an S.E. of 0.05, and the AUC was 0.70 for the HADS anxiety subscale with an S.E. of 0.06. Using a cutoff of 7 on each HADS subscale to determine PRIME-MD diagnosis of MDD, the sensitivity and specificity were 81% and 54%, respectively, for the depression subscale and 81% and 40%, respectively, for the anxiety subscale. In addition, a few individual HADS items predicted PRIME-MD diagnosis of MDD, namely, concentration and positive anticipation (depression items) and relaxed and worry (anxiety items), each of which were strongly correlated with PRIME-MD diagnosis of MDD. Finally, items positive anticipation and relaxed provided reasonable approximations to the results found from the HADS depression subscale measure, which performed better than the HADS anxiety subscale in predicting PRIME-MD diagnosis of depression. CONCLUSIONS: Using the HADS to detect mental disorders in primary care populations can save valuable physician time, and perhaps ensure that patients are treated for their mental distress as well as medical disease.     

The impact of differing anxiety disorders on outcome following an acute coronary syndrome: time to start worrying?

Background: Both depression and anxiety have been implicated as influencing survival following an acute coronary syndrome (ACS). Studies evaluating the contribution of anxiety have produced varying results, perhaps reflecting the use of dimensional self‐report measures of state anxiety and failure to control for co‐morbid depression. We sought to assess the impact of anxiety on outcome in ACS patients using DSM‐IV diagnoses, in addition to self‐report measures, controlling for effects of concurrent depressive diagnosis as well as medical and socio‐demographic variables. Methods: Some 489 patients hospitalized with an ACS were assessed for lifetime and current DSM‐IV anxiety disorders using both Composite International Diagnostic Interview (CIDI) decisions and such decisions complemented by clinical judgments of impairment. Patients were re‐interviewed over the next 12 months to assess cardiac outcome (ACS readmission and cardiac mortality). Results: Univariate analyses revealed a trend for those with a lifetime history of agoraphobia to experience poorer cardiac outcome and for those with a lifetime diagnosis of generalized anxiety disorder (GAD) to experience a superior cardiac outcome. After controlling for post‐ACS depression and key medical and demographic covariates, agoraphobia was a significant predictor of poorer cardiac outcome while the trend for those with a history of GAD to experience a superior cardiac outcome remained. Conclusions: Any impact of “anxiety” on post‐ACS outcome appears to be influenced by the clinical sub‐type. The seemingly paradoxical finding that GAD might improve outcome may reflect “apprehensive worrying” being constructive, by improving self‐management of the individual's cardiac problems. Depression and Anxiety, 2010. © 2009 Wiley‐Liss, Inc.     

The contribution of prenatal and postnatal maternal anxiety and depression to child maladjustment

Background: The adverse effect of both pre‐ and post‐natal maternal anxiety and depression on the development of offspring is shown by a large body of research. No published studies, however, have simultaneously: (i) controlled for co‐occurring prenatal risks that may influence maternal prenatal anxiety and depression; (ii) compared the relative contributions of prenatal and postnatal maternal anxiety and depression on child functioning; and (iii) assessed a full range of child psychopathology and functioning to determine the relative effects of prenatal and postnatal anxiety and depression in the mother. Method: Using 3,298 mother–offspring pairs, the authors examined these factors in a single‐path analytic model. Measurements of maternal anxiety and depression were collected at two time points: 32 weeks prenatal and 1.5 years postnatal. Other prenatal risks were assessed between 8 and 32 weeks of gestation. Child outcomes included (a) ordered‐categorical measures of DSM‐IV externalizing and internalizing disorders, and (b) an assessment of verbal IQ. Results: In both the prenatal and postnatal periods, maternal depression had a wider impact on different types of child maladjustment than maternal anxiety, which appeared more specific to internalizing difficulties in the child. Of note, prenatal risks were prospectively associated with child externalizing difficulties and verbal IQ, beyond the effects of prenatal and postnatal maternal anxiety and depression. Conclusion: The present results suggest that addressing both maternal anxiety and depression, in the prenatal and postnatal periods—as well as associated risk factors—may be the most effective approach to prevent adverse outcomes in the offspring. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

There are no association between IgE levels and symptoms of anxiety and depression in the adult female general population. The Hordaland Health Study (HUSK)

There are multiple reports of increased prevalence of anxiety and depression in patients with asthma, eczema and rhinitis. Suggested biological mechanisms underlying these associations most commonly involve IgE. However, the association between anxiety/depression and IgE has hardly been studied, and the aim of the present study will therefore be to examine the hypothesized association between anxiety/depression and IgE in a general adult female population. A sub-sample of 374 female participants in a population-based general health study in Norway (the Hordaland Health Study) with participation rate 70% was screened for total and allergen-specific IgE. Anxiety and depression were measured employing the Hospital Anxiety and Depression Scale (HADS). This design ensured adequate statistical power, and the population-approach ensured satisfactory variance in both IgE and anxiety/depression. No association between case level or symptom load of anxiety/depression and total or allergen-specific IgE was found. Non-significant tendencies were both positive and negative. This finding was robust across continuous and categorical statistical approaches. Our finding does not question the commonly reported associations between anxiety/depression and asthma, rhinitis and eczema. We do, however, question the relevance of IgE as an aetiological factor in the biological chain underlying these associations.     

There are no association between IgE levels and symptoms of anxiety and depression in the adult female general population. The Hordaland Health Study (HUSK)

There are multiple reports of increased prevalence of anxiety and depression in patients with asthma, eczema and rhinitis. Suggested biological mechanisms underlying these associations most commonly involve IgE. However, the association between anxiety/depression and IgE has hardly been studied, and the aim of the present study will therefore be to examine the hypothesized association between anxiety/depression and IgE in a general adult female population. A sub-sample of 374 female participants in a population-based general health study in Norway (the Hordaland Health Study) with participation rate 70% was screened for total and allergen-specific IgE. Anxiety and depression were measured employing the Hospital Anxiety and Depression Scale (HADS). This design ensured adequate statistical power, and the population-approach ensured satisfactory variance in both IgE and anxiety/depression. No association between case level or symptom load of anxiety/depression and total or allergen-specific IgE was found. Non-significant tendencies were both positive and negative. This finding was robust across continuous and categorical statistical approaches. Our finding does not question the commonly reported associations between anxiety/depression and asthma, rhinitis and eczema. We do, however, question the relevance of IgE as an aetiological factor in the biological chain underlying these associations.     

Depression and anxiety disorders associated with headache frequency. The Nord‐Trøndelag Health Study

The aim of this large cross‐sectional population‐based study was to examine the association between migraine, non‐migrainous headache and headache frequency with depression, and anxiety disorders. From 1995 to 1997, all 92 566 inhabitants aged 20 years and above in Nord‐Trøndelag County in Norway were invited to participate in the Nord‐Trøndelag Health Study (‘Helseundersøkelsen i Nord‐Trøndelag’ = HUNT‐2). A total of 64 560 participated, whereof 51 383 subjects (80%) completed a headache questionnaire that was included. Of these 51 383 individuals, 47 257 (92%) completed the depression subscale items and 43 478 (85%), the anxiety subscale items of the Hospital Anxiety and Depression Scale (HADS). Associations were assessed in multivariate analyses, estimating prevalence odds ratios (OR) with 95% confidence intervals (CI). Depression and anxiety disorders as measured by HADS, were significantly associated with migraine (OR = 2.7, 95% CI 2.3–3.2; OR = 3.2, 95% CI 2.8–3.6) and non‐migrainous headache (OR = 2.2, 95% CI 2.0–2.5; OR = 2.7, 95% CI 2.4–3.0) when compared with headache‐free individuals. The association was stronger for anxiety disorders than for depression. The ORs for depression and anxiety disorders amongst both migraine and non‐migrainous sufferers increased with increasing headache frequency. Depression and anxiety disorders are associated with both migraine and non‐migrainous headache, and this association seems more dependent on headache frequency than diagnostic category.     

Psychometric attributes of the Hospital Anxiety and Depression Scale in Parkinson's disease

The Hospital Anxiety and Depression Scale (HADS) has been used in Parkinson's disease (PD) but information about its psychometric properties in this context is limited. The aim of this study is to assess the psychometric properties of the HADS in PD. In an observational, cross‐sectional analysis, HADS data quality, acceptability, scaling assumptions, internal consistency, construct validity, and precision were explored. From a sample of 387 PD patients, 22% and 14% scored ≥11 points (definite case) on the HADS anxiety and depression subscales, respectively. Cronbach's alpha was 0.81 and 0.83 for these subscales. Factor analysis revealed two factors (49.8% of the variance) representing anxiety and depression. The HADS closely correlated with health‐related quality of life (HRQL) measures and displayed satisfactory discriminative validity for patients grouped by severity level, disease duration, HRQL status, and treatment. The SEM was 1.84 for HADS‐Anxiety and 1.72 for HADS‐Depression. The HADS is an acceptable, consistent, valid, precise, and potentially responsive scale for use in PD. © 2009 Movement Disorder Society     

Prevalence and correlates of neuropsychiatric symptoms in Parkinson's disease without dementia

A cross‐sectional study of the profile of psychiatric symptoms and their relationships to medications, executive performance, and excessive daytime somnolence (EDS) was conducted on 1351 consecutive Parkinson's disease patients without dementia (PD‐ND). Ratings were: neuropsychiatric inventory (NPI); hospital anxiety and depression scale (HADS); executive performance (semantic, phonemic, and alternating verbal fluencies); and the Epworth sleepiness scale (ESS). Eighty‐seven percent of the subjects reported at least one psychiatric symptom. The most common were depression (70%), anxiety (69%), apathy (48%), and irritability (47%). Fifty percent of the patients had HADS‐depression scores ranging from possible (8–10; 22%) to probable (≥11; 28%) depression. Executive impairment was found in 41% and EDS in 26% of subjects. All considered variables were significantly more common with longer duration and more severe disease. Only depression appeared to be influenced by type of medication, being less prevalent among patients treated with DAs. Five NPI clusters were identified among patients scoring ≥1 on the NPI (87.3%): patients exhibiting predominantly apathy (12.7%), psychosis (3%), depression (13%), anxiety (15.6%), and “low‐total NPI” (43.2%). Neuropsychiatric symptoms are common in nondemented PD patients suggesting that they are an integral part of PD from the beginning of the disease and appears more related to disease progression than to the type of antiparkinsonian medication. Apathy emerged as an independent construct in PD‐ND, indicating the need to address specific therapeutical approaches targeted toward this particular symptom. © 2008 Movement Disorder Society     

Comorbidity of depression and anxiety in nursing home patients

OBJECTIVES: To assess the occurrence and risk indicators of depression, anxiety, and comorbid anxiety and depression among nursing home patients and to determine whether depression and anxiety are best described in a dimensional or in a categorical classification system. METHODS: DSM and subthreshold anxiety disorders, anxiety symptoms, major and minor depression and depressive symptoms were assessed in 333 nursing home patients of somatic wards of 14 nursing homes in the north west of the Netherlands with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Geriatric Depression Scale (GDS). Comorbidity was studied along a severity gradient. Logistic regression analyses were carried out to identify demographic, health-related, psychosocial and care-related correlates of anxiety and depression. RESULTS: The prevalence of pure depression (PD) was 17.1%, of pure anxiety (PA) 4.8%, and of comorbid anxiety and depression (CAD) 5.1%. Comorbidity increased dependent on severity of both anxiety and depression. Different patterns of risk indicators were demonstrated for PA, PD and CAD for the investigated baseline characteristics. CONCLUSIONS: Comorbidity of anxiety and depression is most prevalent in the more severe depressive and anxious nursing home patients. The gradual increase of comorbidity of anxiety and depression dependent on the levels of severity of depression and anxiety suggests that for nursing home patients a dimensional classification of depression and anxiety is more appropriate than a categorical one. The observed differences in patterns of risk indicators for PA, PD and CAD support a distinguishing of anxiety and depression. Future studies are needed to assess the effect of treatment of PA, PD and CAD in nursing home patients.     

Dimensionality of the Chinese hospital anxiety depression scale in psychiatric outpatients: Mokken scale and factor analyses

Objective: The hospital anxiety and depression scale (HADS) is a widely used scale of anxiety and depression. However, recent studies have challenged the bi-dimensional scoring of the HADS. The present study was to examine the dimensionality of the Chinese HADS.

Methods: We recruited a convenience sample of 214 adult psychiatric outpatients at a medical centre in Taiwan, and they completed the Chinese HADS. We used Mokken scale analysis (MSA), exploratory factor analysis (EFA), exploratory bifactor analysis (EBA) and confirmatory factor analysis (CFA) to examine the dimensionality of the Chinese HADS.

Results: The Chinese HADS was a moderate Mokken scale (H_s?=?0.44), and had a two-factor structure. EBA showed that one general factor, emotional distress, explained 68% of the common variance of the Chinese HADS. CFA confirmed that the bifactor model had the best fit statistics. The items 5 and 7 of the Chinese HADS contributed to structural ambiguity in the Chinese HADS subscales.

Conclusions: The sum scores of the Chinese HADS were a reliable and valid unidimensional measure of emotional distress. The Chinese HADS subscales were incapable of differentiating between anxiety and depression. Clinicians and researchers should choose other scales that are specifically designed for measuring anxiety and depression.     

Depression in relation to age and gender in the general population: the Nord-Trøndelag Health Study (HUNT)

Objective: Previous sample studies of depression have shown a higher prevalence of depression in women, and an inconsistent relation to age has been found for both genders. The aim of the present study was to investigate depression in relation to gender and age in the general adult population. Method: Of the total population of 92 100 individuals aged 20–89 years and living in Nord‐Trøndelag county of Norway, 62 344 (67.7%) filled in valid ratings of depression on the Hospital Anxiety and Depression Scale (HADS). Results: Minimal gender difference was found in dimensional depression scores and in prevalence rates of depression. Both these measures were found to increase continuously with age in both genders. Conclusion: Our results of this population‐based study differ from most sample studies reported, and these discrepancies are discussed with focus on study design, self‐rating, and the concept of depression covered by HADS.     

Reliability of DSM and empirically derived prototype diagnosis for mood,anxiety and personality disorders

BackgroundProminent psychiatric diagnostic systems such as the DSM-IV and ICD-10 have shown low reliability in clinical practice. An alternative approach to classification of psychiatric disorders is prototype matching. In the current study, we examined reliability of assessing mood, anxiety and personality disorders using a multi-method multi informant approach. More specifically, we examined diagnosis made by treating clinician and independent expert clinical interviewer, using three different diagnostic systems (DSM symptom count, DSM-IV prototype diagnosis and empirically derived prototype diagnosis).MethodsA convenience sample of clinicians (N = 80) and patients (N = 170) from eight community mental health clinics in Israel participated in the study.ResultsOur findings show fair to excellent interrater reliability for prototype dimensional diagnostic systems (ranged from 0.40 to 0.79) for most mood and anxiety disorders examined. Overall, dimensional diagnostic systems, yielded better interrater reliability for mood, anxiety and personality disorders, as compared with categorical diagnosis. There were no significant differences between dimensional systems.ConclusionsOur findings provide further support to the advantages of dimensional over categorical models in increasing reliability.     

Three-dimensional structure of the Hospital Anxiety and Depression Scale in a large French primary care population suffering from major depression.

Few studies have been specifically carried out to characterize the dimensional structure of the Hospital Anxiety and Depression Scale (HADS) and those that have, have yielded contradictory results. We have examined the factor structure and sensitivity to change of the HADS in a large French outpatient primary care population treated with sertraline for major depression (DSM-IV criteria). Factor analysis of the HADS was performed in 2669 outpatients and in subsamples using a principal component procedure with Varimax rotation. Concurrent change sensitivity of the HADS was compared with that for the Hamilton Depression Rating Scale (HDRS) after at least 45 days of sertraline treatment. Three distinct factors emerged from the HADS factor analysis: a "depression" factor and two separate anxiety subscales: "psychic anxiety" and "psychomotor agitation" whose mean reductions in scores from baseline were significantly correlated (0.36-0.45) with the reduction of the HDRS baseline score. These new data provide support for the use of the HADS's three-dimensional structure to measure improvement of selected symptoms of anxiety during antidepressant therapy.     

Normative values for the Hospital Anxiety and Depression Scale (HADS) in the general German population

Objective

The aim of this study was to present normative values for the Hospital Anxiety and Depression Scale (HADS).

Methods

A representative sample of the German general population (N=4410) was tested with the HADS.

Results

Females are more anxious than males, and older subjects are more depressed than younger subjects. The mean scores for anxiety / depression are 4.4 / 4.8 (males) and 5.0 / 4.7 (females). Using the cut-off 8+, the percentages of elevated anxiety and depression in the total sample are 21 % and 23 %, respectively. Regression analyses proved a linear but not a curvilinear age trend of anxiety and depression. Percentile rank norms are given for anxiety, depression, and the HADS total score.

Conclusion

The regression coefficients allow the calculation of expected mean scores for each age and gender distribution of any sample of patients. HADS mean scores are better suited to describe the degree of anxiety and depression in patient samples compared to percentages of subjects with elevated values.     

Depression,anxiety, and functional impairment in children with trichotillomania

Background: Trichotillomania (TTM) remains understudied in children. Adult research suggests that TTM is accompanied by significant depression, anxiety, and functional impairment. The purpose of this study is to examine the occurrence of depression and anxiety in a relatively large sample of youth with TTM and the extent to which these symptoms mediate the relationship between TTM severity and associated impairment. Methods: The study utilized data from the Child and Adolescent Trichotillomania Impact Project (CA‐TIP), an internet‐based sample of 133 youth aged 10–17 (inclusive) with TTM. Results: Over 45% of children with TTM endorsed depressive symptoms and 40% endorsed anxiety symptoms in excess of one standard deviation (SD) above published community norms. More remarkably, 25% of our sample reported depressive and 20% reported anxiety symptoms in excess of 2 SD above these norms. Older participants reported more symptoms of depression and anxiety than younger ones; age of onset (children with later onset), but not duration of illness, was predictive of higher reports of both depressive and anxiety symptoms. Neither depressive nor anxiety symptoms were related to pulling site. Depressive symptoms partially mediated the relationship between TTM severity and functional impairment. Conclusions: Based on an internet sample recruited from the homepage of the Trichotillomania Learning Center, data from this study suggests that symptoms of depression and anxiety may be pervasive among youth with TTM and likely impact functional impairment. Longitudinal studies using directly assessed samples are needed to replicate and extend these findings. Depression and Anxiety, 2009. © 2008 Wiley‐Liss, Inc.