Screening for anxiety and depression after stroke: Comparison of the Hospital Anxiety and Depression Scale and the Montgomery and Åsberg Depression Rating Scale

Objective

Anxiety and depression after stroke are frequent, but are often overlooked and not assessed. The aims of the study were to (1) assess the prevalence of anxiety and depression and (2) compare the performance of the Hospital Anxiety and Depression Scale (HADS) and Montgomery and Åsberg Depression Rating Scale (MADRS) as screening instruments for anxiety and depression disorders 4 months after stroke.

Methods

Stroke patients, consecutively admitted to a stroke unit, were assessed with HADS and MADRS 4 months after stroke (n=104). Depression and anxiety disorders were diagnosed using the Structured Clinical Interview for DSM-IV (SCID). Measures were compared in terms of correlations, sensitivity, specificity, positive and negative predictive value, overall agreement, kappa, and ROC curves, using DSM-IV diagnoses of “at least one current significant anxiety disorder” (Anxiety) and “any current depression” (Depression), as the clinical criteria.

Results

Anxiety occurred in 23% of patients and Depression in 19% (13% major depression, 3% minor depression, 4% dysthymia). For Anxiety, the optimal screening cut-off was 4 for HADS-A and 6 for HADS-total; for Depression, optimal cut-offs were 4 for HADS-D, 11 for HADS-total, and 8 for MADRS. At cut-offs commonly used in clinical practice for depression screening (HADS-D: 8, MADRS: 12), the MADRS performed marginally better than the HADS.

Conclusion

Anxiety is as prevalent as depression 4 months after stroke. MADRS and HADS-D perform acceptably as screening instruments for depression, and HADS-A for anxiety after stroke. However, lower HADS cut-offs than recommended for the general population should be considered for stroke patients.     

Prevalence of depressive symptoms in Japanese male patients with chronic obstructive pulmonary disease

Aim: The objective of this study was to utilize commonly applied tools, the Hospital Anxiety and Depression Scale – Depression subscale (HADS‐D) and the Center for Epidemiological Studies Depression Scale (CES‐D), to screen for depressive symptoms in patients with stable chronic obstructive pulmonary disease (COPD). Furthermore, we sought to identify whether differences existed in the prevalence of depressive symptoms as assessed by CES‐D and HADS‐D, and predictors of depressive symptoms. Methods: The presence of depressive symptoms in 80 outpatients and 51 inpatients with stable COPD was assessed using the CES‐D and HADS‐D. Data regarding sex, educational level, body mass index, smoking index and pulmonary function were obtained to evaluate their independent contribution as predictors of depressive symptoms. Results: The prevalence of depressive symptoms was 29.8% based on CES‐D and 40.5% based on HADS‐D. A MacNemar test of COPD severity and analysis of the results of depressive symptoms based on CES‐D and HADS‐D revealed significant differences. Logistic regression analysis suggested that ‘severity’ is a predictor of depressive symptoms as assessed by CES‐D, whereas ‘body mass index’, ‘education level’ and ‘setting’ were predictors of depressive symptoms as assessed by HADS‐D. Conclusions: The prevalence of depressive symptoms differed when assessed with CES‐D and HADS‐D. The reasons behind this difference include the fact that HADS‐D frequently detected depressive symptoms in patients with mild COPD as well as a tendency for HADS‐D to be strongly influenced by education levels. In contrast, the severity of COPD was reflected in CES‐D. It is possible that prevalence of depressive symptoms differs in accordance with the applied screening tool.     

Revisiting the dimensionality of the Hospital Anxiety and Depression Scale in an international sample of patients with ischaemic heart disease

Objective

Recently controversy has surrounded the dimensionality of the Hospital Anxiety and Depression Scale (HADS). We assessed the dimensionality of the HADS in a large international sample of patients with ischaemic heart disease (IHD) using confirmatory factor analysis (CFA). The analysis of an international sample enabled the current study to broaden knowledge gained from existing studies with small, regional samples.

Methods

Data from the HeartQoL study of patients with IHD (n = 6241, 22 countries speaking 15 languages) were analyzed using CFA.

Results

CFA indicated a hierarchical bifactor solution, with mostly strong item loadings on a general factor (explaining 73% of the variance), and weak to very weak loadings on orthogonal depression (16%) and anxiety (11%) subscales. The bifactor model fits the data significantly better than both the original bidimensional model and Dunbar's higher-order three-factor model.

Conclusion

These results, from a large international sample of patients with IHD, suggest that the HADS scale is dominated by a single general distress factor. Although the best CFA model fit was a hierarchical bifactor solution, the subscales had weak item loadings, providing little psychometric evidence of the ability of the HADS to differentiate anxiety and depressive symptoms. It is argued that clinicians and researchers working with patients with IHD should abandon the HADS and use alternative measures of depression and anxiety.     

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.     

文拉法辛对慢性阻塞性肺病合并抑郁焦虑患者的治疗作用

目的：研究文拉法辛对慢性阻塞性肺疾病（COPD）合并抑郁焦虑患者生活质量的影响。方法：采用汉密尔顿焦虑量表（HAMA）及汉密尔顿抑郁量表（HAMD）（17项）测量心理状况,将存在轻中度焦虑、抑郁症状的48例COPD患者随机分为文拉法辛组（26例）及对照组（22例）,治疗4周。治疗前后检测患者COPD的各项肺功能指标并用圣乔治呼吸问卷（SGRQ）评价生活质量,应用治疗中出现的症状量表（TESS）评定不良反应。结果：文拉法辛组治疗4周时有效率100%,HAMA及HAMD评分显著降低（P〈0.05）,肺功能均有明显改善（P〈0.05）。结论：文拉法辛能改善COPD患者的焦虑及抑郁症状,提高生活质量。     

Short Form 36 and Hospital Anxiety and Depression Scale. A comparison based on patients with testicular cancer

BACKGROUND: The aim of this study was to compare the scorings of anxiety and depression assessed by the Hospital Anxiety and Depression Scale (HADS-A [Anxiety] and HADS-D [Depression]) with the scorings on the eight subscales of Short Form 36 (SF-36) and the Physical (PCS) and Mental Component Summary (MCS) assessed by the same patients. METHOD: In a cross-sectional study 736 long-term survivors after treatment for testicular cancer (TC) completed HADS and SF-36. Pearson's correlation coefficients were calculated on item and scale level to assess the associations between the HADS and the SF-36 scales and, in particular, between HADS and PCS and MCS, respectively. Independent predictors for PCS and MCS were identified by linear regression analysis. RESULTS: HADS-A and HADS-D were significantly associated with the SF-36 summary scales. HADS-A explained 5% of the variance of PCS and 49% of the variance of MCS. The comparable figures for HADS-D were 10% and 45%, respectively. In the multivariate analysis the HADS-D scoring independently predicted the level of PCS together with the patients' educational level, long-lasting working disability and age (variance: 30%). Both HADS-D and HADS-A remained independent parameters for MCS (variance: 58%) together with the patient's civil status. HADS-D item D4 ("slowed down") was similarly associated with both PCS and MCS. CONCLUSION: In univariate analyses HADS-D and HADS-A were statistically associated with PCS and MCS. The highest r values were observed for the associations between HADS and MCS, in particular between HADS-A and MCS. In the multivariate analyses HADS-D, but not HADS-A, contributed to PCS, whereas both HADS-A and HADS-D were associated with MCS. This pattern of different predictions of the summary scales of SF-36 supports a clinical practice that anxiety and depression should be assessed separately. Additional use of a self-rating instrument for depression and anxiety, such as HADS, is recommended when SF-36 is used for quality of life (QL) assessment.     

An examination of the psychometric properties of the Hospital Anxiety and Depression Scale in Chinese patients with acute coronary syndrome

The psychometric properties of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument for patients with acute coronary syndrome (ACS) were investigated in a translated Chinese version of the instrument. A confirmatory factor analysis (CFA) was conducted on the HADS to establish its psychometric properties in 138 ACS patients over two observation points (within 1 week and 6 months post-admission for ACS). Internal and test–retest reliability values for the HADS total and HADS anxiety sub-scales were found to be acceptable. The HADS depression sub-scale lacked acceptable internal reliability. The underlying factor structure of the HADS comprised three distinct factors, though inconsistency between the best three-factor model fit was observed between observation points. The HADS was confirmed to be a useful screening instrument to assess symptoms of psychological distress in ACS patients. Further research is required to determine the most appropriate use of HADS sub-scale structures in clinical populations.     

Performance of the Hospital Anxiety and Depression Scale as a screening tool for major depressive disorder in cancer patients

OBJECTIVES: (1) To assess the overall performance of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument to identify cases of major depressive disorder (MDD) in mixed cancer outpatients. (2) To determine the sensitivity and specificity of various HADS cut-off scores. (3) To recommend an optimal HADS cut-off score for use in this population. METHODS: A cross-sectional questionnaire and interview survey of consecutive patients attending outpatient clinics in a regional cancer centre in Edinburgh, Scotland, United Kingdom. RESULTS: Thirty (8.3%) of 361 patients met criteria for MDD at interview. With the use of the total HADS score to identify these cases of MDD, the area under the receiver operating characteristic curve was 0.94 (95% CI, 0.91-0.97). A cut-off of 14/15 gave a sensitivity of 0.87 (95% CI, 0.70-0.95), a specificity of 0.85 (95% CI, 0.81-0.89), and a positive predictive value of 0.35, and was considered optimal. CONCLUSION: The HADS can be used effectively as an initial screening tool for the detection of MDD in outpatients attending mixed cancer clinics.     

Evaluation of anxiety in Parkinson’s disease with some commonly used rating scales

This study assessed the concurrent validity of the State-Trait Anxiety Inventory (STAI), the Hospital Anxiety and Depression Scale (HADS) and the Hamilton Anxiety Scale (Ham-A) for evaluating anxiety in a group of 46 Parkinson’s disease (PD) patients. The magnitude of correlations between the scales was high (all p<0.01), indicating a good concurrent validity. The item-by item analysis indicated that the main characteristics of anxiety in PD patients were ‘inability to relax’, ‘restlessness or inability to feel calm’ and ‘feeling tense’. The association between anxiety, as measured by the HADS-A, with demographic characteristics or clinical features of PD was not significant, supporting existing data suggesting that anxiety in PD is not closely correlated with the severity of motor symptoms or the degree of disability. The HADS-A may be the most appropriate scale for documenting patient-reported anxiety in depression.

---

Sommario Questo studio indaga la validità nel valutare l’ansia in un gruppo di 46 pazienti con malattia di Parkinson dell’Inventario per l’ansia di stato e di tratto (STAI-Y), della Hospital Anxiety and Depression Scale (HADS) e della scala Hamilton per l’ansia (Ham-A). Il livello di correlazione tra le scale è elevato (p<0.01), indicando una buona validità convergente. L’analisi dei singoli items mostra che le principali caratteristiche dell’ansia nei pazienti con malattia di Parkinson sono “l’incapacità a rilassarsi”, “l’irrequietezza o incapacità a stare calmo” e “il sentirsi teso”. L’associazione tra l’ansia, misurata con l’HADS, e le caratteristiche demografiche del campione e/o gli aspetti clinici della malattia di Parkinson non è significativa. Tale risultato sostiene i dati presenti in letteratura che suggeriscono che l’ansia nella malattia di Parkinson non è strettamente correlata con la gravità dei sintomi motori o con il livello di disabilità.

     

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     

The factor structure of the Hospital Anxiety and Depression Scale in older individuals with acquired amputations: a comparison of four models using confirmatory factor analysis

BACKGROUND: There has been little attention to the underlying dimensional structure of the Hospital Anxiety and Depression Scale (HADS) in analyses involving individuals older than 65 years of age despite its routine application in this age group. METHODS: The factor structure of the HADS was investigated using a sample of 680 veterans with limb amputations who were aged at least 66 years (mean 79.0, SD 5.02; range 66-92) Four models were specified and estimated using Lisrel 8.54. Model 1 specified a uni-dimensional structure. Model 2 specified a correlated two-factor model. Model 3 specified a correlated two-factor model but with cross factor loadings for item 7. Model 4 specified a three-factor model after Clark and Watson's (1991) tripartite theory of anxiety and depression. RESULTS: Models 2, 3 and 4 were found to adequately fit the data. However, on balance, model 4 was found to be a better explanation of the data than the alternative specifications. CONCLUSIONS: The results indicate that factor models for the HADS developed in younger samples are replicable with older adults, thus supporting the suggestion that the HADS structure is invariant for age. However, considering the composition of the current sample, i.e. veterans with limb amputations, further research is necessary to determine whether these findings are generalisable to the wider population of older adults.     

Effect of desipramine on control of ventilation and depression scores in patients with severe chronic obstructive pulmonary disease

Decreased ventilatory responses to carbon dioxide (CO2) correlate with elevated scores on tests for depression in normal subjects and with episodes of endogenous depression in psychiatric patients. Patients with severe chronic obstructive pulmonary disease (COPD) frequently develop resting hypercapnia due to impaired ventilatory mechanics or drive, and may also have elevated scores on tests for depression. Tricyclic antidepressant drugs can improve ventilatory mechanics and possibly drive. We hypothesized that antidepressant drugs might enhance ventilatory drive and improve arterial blood gases in patients with severe COPD and that these improvements might correlate with improvement in depression scores. Therefore, we studied the effects of desipramine versus placebo on spirometry, resting arterial blood gases, hypercapnic ventilatory and mouth occlusion pressure responses, and scores on the Beck and Zung self-rated depression scales. In our patients the resting arterial CO2 (PaCO2) was found to depend almost equally on ventilatory mechanics and drive. In addition, patients with higher depression scores tended to have a lower PaCO2 when the severity of airways obstruction was taken into consideration. In a 16-week, double-blind, crossover comparison of desipramine with placebo, both treatments led to significant improvement in depression scores. Desipramine had no effects on resting PaCO2, spirometry, or ventilatory control.     

孕晚期综合性医院焦虑抑郁量表评分对产后抑郁症的预测研究

目的 分析孕晚期综合性医院焦虑抑郁量表(Hospital Anxiety and Depression Scale,HAD)评分对产后抑郁症的预测效果,为孕晚期识别产后抑郁症高危孕妇提供依据.方法 采用一般情况调查表及自编相关因素调查表和HAD,在孕晚期对1 230例孕妇进行测评,并于产后4周内采用HAD、爱丁堡产后抑郁量表(Edinburgh Postnatal Depression Scale,EPDS)再次对其进行测评,经受试者工作特征曲线法分析孕晚期HAD分值对产后抑郁症的预测效果.结果 (1)孕晚期焦虑、抑郁症状发生率为5.20％ (64/1 230)、4.07％ (50/1 230);产后抑郁症发生率为9.98％ (121/1 213).(2)根据两步筛查法确诊产后抑郁症患者121例(患者组)和健康对照者1 092名(对照组),2组在年龄、夫妻感情、工作学习压力、分娩育儿及产后抑郁知识的了解程度、产妇对胎儿的性别歧视及入组时HAD评分(A和D评分)以及产后EPDS评分上差异均有统计学意义(x2=6.54、6.92、8.07、23.82、21.88、10.24、9.26、6.63、5.66,均P＜0.05),而婚姻状况、性格、文化程度、职业、不良产史、孕期并发症、丈夫及家人对胎儿性别的歧视方面差异均无统计学意义.(3)经受试者工作特征曲线法分析,孕晚期HAD最佳临界值为9分,预测产后抑郁症的敏感度、特异度分别为86.21％和87.64％、95.43％和94.72％.(4)受试者工作特征曲线下面积分别为0.941和0.914.(5)孕晚期HAD最佳临界值和产后EPDS分值相关(r=0.852、0.846,均P＜0.01).(6)孕晚期HAD≥9分孕妇发生产后抑郁症的相对危险度分别增加15.891、18.264倍.结论 孕晚期可将HAD作为产后抑郁症高危孕妇的常规筛查工具,对HAD分值≥9分的孕妇应同时进行产后抑郁危险因素的综合评估.     

Depression and chronic obstructive pulmonary disease (COPD). Impact on survival

OBJECTIVE: To determine if the presence of depression in patients suffering from chronic obstructive pulmonary disease (COPD) would have an independent impact on mortality. METHOD: Prospective evaluation of the impact of depression according to the ICD-10 criteria for depression. Cox proportional hazards regression was used to evaluate the independent impact of depression after controlling for significant univariate clinical predictors in the data set. Consenting out-patients (n = 49) who meet the criteria for COPD between September 1997 and September 1998. There were no age limits (range: 53-90 years). The sample was 67% female. Survival status at follow-up after a mean of 803 days was measured. RESULTS: At follow-up, 16 patients had died. Depression significantly reduced the mortality risk at follow-up (hazard ratio, 0.30; 95% confidence interval, 0.10-0.93; P = 0.037). The impact of depression remained after control for forced expiratory volume during the first second (FEV1), the only multivariate significant predictor of mortality in the data set (hazard ratio, 0.27; 95% confidence interval, 0.09-0.84; P = 0.024). CONCLUSION: Depression in out-patients suffering from COPD appears to be an independent protector for mortality. Additional studies in larger samples are needed to replicate this finding and to determine possible underlying pathogenetic mechanisms.     

Screening for adjustment disorders and major depression in otolaryngology patients using the Hospital Anxiety and Depression Scale

The authors conducted a study to demonstrate the prevalence of psychiatric symptoms among 100 otolaryngology inpatients (50 with non-malignant conditions; 50 with malignancies), and to investigate the efficacy of the Hospital Anxiety and Depression Scale (HADS) as a screening test for psychiatric disorders in otolaryngology. A structured interview was conducted according to the Adjustment Disorders and Major Depressive Episodes section of DSM-N, which demonstrated that 30% of the inpatients with benign diseases met the criteria for some psychiatric disorders (one patient for major depression and 14 for adjustment disorders) and that 46% of the inpatients with malignancies met the criteria (nine patients for major depression and 14 for adjustment disorders). There were highly significant differences between the HADS scores of the patients with psychiatric disorders and those without. Comparing the sensitivity and the specificity using the HADS as a screening test, the optimal cut-off point was 12, which produced 92% sensitivity, 90% specificity and 85% positive predictive value (PPV) among not only non-malignant and malignant cases taken together but also among malignant cases only.     

Prevalence of depression and anxiety in hospitalized chronic obstructive pulmonary disease patients and their quality of life: a pilot study

Introduction: There is a high prevalence of psychiatric comorbidities in patients with Chronic Obstructive Pulmonary Disease (COPD). It has been reported that if left untreated, the psychiatric comobidities can lead to poorer quality of life. The present study was initiated to investigate the prevalence of major depressive disorder, generalized anxiety disorder and panic disorder in hospitalized COPD patients and their quality of life. Methods: The Patient Health Questionnaire (PHQ) of the Primary Care Evaluation of Mental Disorders (PRIME‐MD) was administered to screen an opportunistic sample of COPD patients admitted to a general hospital for the abovementioned psychiatric disorders. The Medical Outcomes Study (MOS) 36‐Item Short Form Health Survey (SF‐36) was utilized to assess quality of life. Results: Fifty‐one patients were analyzed. The prevalence of major depressive disorder in this sample on screening was 7.8% (95% CI 2.2–18.9) and that of anxiety disorders (generalized anxiety disorder and panic disorder) was 5.9% (95% CI 1.2–16.2). The quality of life of COPD patients with psychiatric comorbidities in the present study was severely impaired in seven of the eight domains measured by the SF‐36. Discussion: Despite the small sample size of COPD patients, the prevalence of psychiatric comorbidities was not insignificant. The present study showed that the quality of life of hospitalized COPD patients with psychiatric illnesses was significantly lowered. Treatment of COPD should include addressing psychosocial issues.     

Internet administration of the Hospital Anxiety and Depression Scale in a sample of tinnitus patients

OBJECTIVE: To administer and validate the Hospital Anxiety and Depression Scale (HADS) via the Internet to a sample of persons with tinnitus. METHOD: The HADS was converted into a Web page and administered via the Internet to a sample of 157 persons with tinnitus who were recruited for participation in a treatment trial. Also included were the Tinnitus Reaction Questionnaire (TRQ) and the Anxiety Sensitivity Index (ASI). A clinical comparison sample (n=86) was also recruited who completed the same tests in a paper-and-pencil format. RESULTS: Both the Internet and the paper-and-pencil version yielded comparable results in terms of psychometric properties. When using the cut-off of 11 points suggested by Zigmond and Snaith [Acta Psychiatr. Scand. 67 (1983) 361] a 25% (n=40) prevalence of probable anxiety and a 17% (n=27) prevalence of probable depression were found in the Internet group. In the clinic sample, the prevalence was only 15% for both anxiety and depression, suggesting that Internet administration might result in higher percentages. The HADS correlated with both tinnitus distress and anxiety sensitivity. CONCLUSIONS: Internet administration of the HADS results in meaningful and valid data. Consistent with previous research anxiety and depression are common comorbid conditions in individuals with tinnitus, but norms should be developed for Internet based screening.