The structure of the Hospital Anxiety and Depression Scale: Theoretical and methodological considerations

The Hospital Anxiety and Depression Scale (HADS; Zigmond - Snaith, 1983) is widely used; however, its factor structure is unclear, with studies reporting differing unidimensional, two-factor and three-factor models. We aimed to address some key theoretical and methodological issues contributing to inconsistencies in HADS structures across samples. We reviewed existing HADS models and compared their fit using confirmatory factor analysis (CFA). We also investigated methodological effects by comparing factor structures derived from Rasch and Principal Components Analysis (PCA) methods, as well as effects of a negative wording factor. An Australian community-dwelling sample consisting of 189 females and 158 males aged 17–86 (M = 35.73, SD = 17.41) completed the 14-item HADS. The Rasch Analysis, PCA and CFA all supported the original two-factor structure. Although some three-factor models had good fit, they had unacceptable reliability. In the CFA, a hierarchical bifactor model with a general distress factor and uncorrelated depression and anxiety subscales produced the best fit, but the general factor was not unidimensional. The addition of a negative wording factor improved model fit. These findings highlight the effects of differing methodologies in producing inconsistent HADS factor structures across studies. Further replication of model fit across samples and refinement of the HADS items is warranted.     

A psychometric evaluation of the Hospital Anxiety and Depression Scale during pregnancy

The utility of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument for anxiety and depression during pregnancy was investigated. A maximum likelihood factor analysis was conducted on the HADS to determine its psychometric properties and utility in 100 women from two culturally diverse populations (UK and Uzbekistan) at 12-weeks and 34-weeks pregnancy. The findings suggest that the HADS lacks the internal reliability requirements of a clinical assessment tool in this population. There was little evidence found to suggest that the HADS measures two dimensions of anxiety and depression consistently and reliably. The findings from this study suggest that the HADS could not be recommended as a clinical screening tool for anxiety and depression in pregnant women. Further research in this area is both desirable and required.     

Rasch analysis of the Hospital Anxiety and Depression Scale in spinal cord injury

Purpose: The purpose of this study was to evaluate the psychometric properties of the Hospital Anxiety and Depression Scale (HADS), applied among persons with spinal cord injury (SCI), using Rasch analysis. Methods: A cross-sectional multicenter study was conducted and the data of 102 people with SCI were analyzed. Rasch analyses were performed to assess dimensionality, overall and individual item fit, response scale structure, targeting, and differential item functioning. Results: The anxiety and depression subscales showed unidimensionality, that is, model and item fit. The two subscales are reliable (r = .72, 0.82) in SCI. No disordered structure of the response scales or differential item functioning in age, gender, education, relationship status, level of spinal lesion were found. Stepwise deletion of the misfitting items did not produce a total score that fulfilled the statistical criteria for unidimensionality. Conclusions: The results of the Rasch analyses support the use of the anxiety and depression subscales among people with SCI. However, further research is needed to confirm these findings and examine sensitivity to change of the HADS in SCI, which would support its use in longitudinal observational and intervention studies. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Validation study of a Portuguese version of the Hospital Anxiety and Depression Scale

The study aims to develop and assess metric proprieties of the Portuguese version of the Hospital Anxiety and Depression Scale. A sequential sample includes 1322 participants diagnosed with cancer, stroke, epilepsy, coronary heart disease, diabetes, myotonic dystrophy, obstructive sleep apnoea, depression and a non-disease group, which completed the HADS. The first step includes translation, retroversion, inspection for lexical equivalence and content validity, and cognitive debriefing. Then we reproduce oblique exploratory factor analysis and use confirmatory factor analysis. We explore the sensibility of the questionnaire. The validation process of the Portuguese HADS version shows metric properties similar to those in international studies, suggesting that it measures the same constructs, in the same way, as the original HADS form.     

Factor structure and measurement invariance of the Women's Health Initiative Insomnia Rating Scale

As part of the Women's Health Initiative Study, the 5-item Women's Health Initiative Insomnia Rating Scale (WHIIRS) was developed. This article summarizes the development of the scale through the use of responses from 66,269 postmenopausal women (mean age = 62.07 years, SD = 7.41 years). All women completed a 10-item questionnaire concerning sleep. A novel resampling technique was introduced as part of the data analysis. Principal-axes factor analysis without iteration and rotation to a varimax solution was conducted for 120,000 random samples of 1,000 women each. Use of this strategy led to the development of a scale with a highly stable factor structure. Structural equation modeling revealed no major differences in factor structure across age and race-ethnic groups. WHIIRS norms for race-ethnicity and age subgroups are detailed.     

Psychometric properties and measurement invariance of Depression,Anxiety and Stress Scales (DASS-21) across cultures

Cross-culturally measurement invariant instruments are useful for the assessment of mental symptoms across cultures. The current study aimed to investigate the psychometric properties and measurement invariance of the Depression, Anxiety and Stress Scales (DASS-21) (DASS) across Pakistan and Germany. German participants were recruited through an online survey (N = 1323), while Pakistani participants were recruited through online survey or paper-and-pencil survey (N = 1841). The DASS-21 showed good reliability, construct and structure validity in both countries. The DASS-21 indicated partial weak (stress subscale) and partial strong measurement invariance (depression and anxiety subscales) between both countries. Latent mean comparison of depression and anxiety symptoms between Pakistani and German students indicated that Pakistani university students experience more symptoms of depression and anxiety. Results suggest that the DASS-21 could be used in Pakistan and Germany, but caution should be taken when making direct comparisons between the two countries.     

Measuring attachment security via the Security Scale: Latent structure,invariance across mothers and fathers and convergent validity

The Security Scale (SS) is a widely used questionnaire measuring attachment towards mother and father in school-aged children. Whilst existing evidence supports concurrent and discriminant validity of the SS, its factorial structure remains largely underexplored. The current study examined the factorial structure of the SS, explored its measurement invariance across mother and father, and evaluated its convergent validity with the Coping Strategies Questionnaire in a sample of 149 Italian children aged 8–10 years. In statistical analyses, we accounted for the ordinal nature of the data and adopted an ad hoc bootstrap procedure for the estimation of measurement invariance. Results supported the factorial validity of the SS and the structural invariance of its underlying construct across parents. Evidence for convergent validity was also found. Overall, the Italian version of the SS is a promising tool to assess attachment in school-aged children.     

An investigation into the psychometric properties of the Hospital Anxiety and Depression Scale in individuals with chronic fatigue syndrome

The study sought to determine the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in individuals with chronic fatigue syndrome (CFS) assessed using a web-based data collection tool. Exploratory and confirmatory factor analyses were conducted on the HADS to determine its psychometric properties in 117 individuals with CFS. Seven models were tested to determine model fit to the data. Internal reliability estimations of the anxiety and depression sub-scales were found to be acceptable, however, a three-factor model was found to provide a significantly better fit to the data when compared to the bi-dimensional two-factor structure previously assumed to underpin the HADS' construct validity. The clinical utility of the HADS in the assessment of anxiety and depression in CFS appears to be fundamentally compromised by the presence of a three-dimensional underlying factor structure. Future revision of the HADS is recommended if the instrument is to be used reliably to screen CFS patients.     

Factor structure, measurement invariance and structural invariance of the MSCEIT V2.0

This study explored factor structure and measurement and structural invariance of the MSCEIT V2.0 across two age groups: 258 young (18-31 years) and 262 older adults (32-79 years). Results supported a three-factor solution reflecting the Experiential Emotional Intelligence area, and Understanding Emotions and Managing Emotions branches. There was evidence of measurement invariance of factor structure and factor loadings, and partial support for invariance of the intercepts. Comparisons of latent factor means suggested that older adults have significantly higher mean scores on two of the three factors: Understanding and Managing Emotions. Implications of the invariance tests and latent means analyses are discussed.     

Relationships between the Beck Depression Inventory and the Hamilton Psychiatric Rating Scale for Depression in depressed outpatients

The Beck Depression Inventory (BDI) and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were used with 300 outpatients diagnosed with DSM-III major depression disorders. A principal-components analysis was performed on the intercorrelations among the 21 BDI and 24 HRSD symptoms. Three orthogonal components were found and interpreted as reflecting differences in self-report and clinical rating methods for measuring the severity of depression. The importance of using both self-reports and clinical ratings for evaluating depression in psychiatric outpatients was discussed.     

Multidimensional structure and measurement invariance of school engagement

This study examined the multidimensional structure and measurement invariance of a school engagement instrument using confirmatory factor analysis (CFA), exploratory structural equation modeling (ESEM), bifactor CFA (BCFA), and bifactor ESEM (BESEM). Participants consisted of 1731 students in Grades 9 - 11 from the 4-H Study of Positive Youth Development in the United States. The use of the CFA, ESEM, BCFA, and BESEM models was expected to provide more insight into the cross-loading and hierarchical structures of school engagement. We found empirical evidence to support the (a) tripartite factor structure of school engagement, (b) existence of cross-loadings and hierarchical structures, (c) measurement invariance across gender (male vs female) and race (European American vs African American), and (d) expected latent means differences by gender.     

Factor structure and measurement invariance of the Brief Symptom Inventory (BSI-18) in cancer patients

Background/Objective: The purpose of this study was to assess psychometric properties of the Brief Symptom Inventory (BSI-18), evaluate the measurement invariance with respect to sex, age, and tumor location, and to analyze associations between social support and sociodemographic and clinical variables among individuals with resected, non-advanced cancer. Method: A confirmatory factor analysis was conducted to explore the dimensionality of the scale and test invariance across sex, age, and tumor localization in a prospective, multicenter cohort of 877 patients who completed the BSI-18 and Multidimensional Scale of Perceived Social Support (MSPSS). Results: The results show that 3-factor and 1-factor measurement models provided a good fit to the data; however, a three-factor, second-order model was deemed more appropriate and parsimonious in this population. Alpha coefficients ranged between .75 and .88. Test of measurement invariance showed strong invariance results for sex, age, and tumor location; strong invariance over time was likewise assumed. Less perceived social support appears to correlate with all BSI factors. Conclusions: The study confirmed the tridimensional structure of the BSI-18 and invariance across age, sex, and tumor localization. We recommend using this instrument to measure anxiety, depression, and somatization in epidemiological research and clinical practice.     

A study of the psychometric properties of the Beck Depression Inventory‐II,the Montgomery and Åsberg Depression Rating Scale,and the Hospital Anxiety and Depression Scale in a sample from a healthy population

The objective of this study is to evaluate internal consistency and psychometric properties of the Hospital Anxiety and Depression Scale (HADS), the Beck Depression inventory‐II (BDI‐II) and the Montgomery and Åsberg Depression Rating Scale (MADRS) for screening for major depressive episode (MDE) in a selected sample from a healthy population. Participants answered the BDI‐II and the HADS questionnaires and were interviewed with MADRS. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)‐IV Axis I Disorders‐Clinician Version (SCID‐CV) was used to diagnose MDE. Current MDE was diagnosed in 20 (6%) of the 357 participants. All three scales including the depression sub‐scale for HADS had high area under the receiver operating characteristics curve (ROC) (AUC) (0.84–0.87), and internal consistency was also high for all scales (0.75–0.89). Optimal cut‐off for MDE was ≥ 12 for BDI‐II, MADRS ≥ 8, HADS total ≥ 9, and HADS‐D ≥ 4, which all resulted in sensitivities = 85% and specificities > 78%. Diagnostic accuracy was low on all depression scales (Cohen's kappa = 0.20–0.40). Reports of the properties of depression scales in a healthy population are limited. We found BDI‐II, HADS and MADRS to be acceptable as screening instruments for MDE in a selected sample from healthy population with recommend cut‐offs as mentioned above.     

Psychometric properties of the Revised Child Anxiety and Depression Scale in a clinical sample

This study examined the psychometric properties of the Revised Child Anxiety and Depression Scale (RCADS) in a clinical sample of 513 youth referred for mental health assessment at a university clinic. Internal consistency and factor analysis provided support for the factorial validity of the RCADS. Convergent and discriminant validity tests against both clinical interview and self-report criteria also suggested favorable properties of the RCADS. In comparative tests with traditional measures of anxiety and depression, the RCADS generally showed greater correspondence to specific diagnostic syndromes. Clinical cutoffs are reported for the purposes of future clinical and research applications.     

Confirmatory factor structure and measurement invariance of the Memory Compensation Questionnaire

Recent research with the Memory Compensation Questionnaire (MCQ) has examined changes, functions, and correlates of compensatory strategy use in older adults. The twofold aim of this study was to test (a) the hypothesized structure of the MCQ and (b) structural equivalence across age, gender, and time. The 7-scale MCQ was designed to measure 5 compensatory mechanisms and 2 general aspects of compensatory awareness. The authors assembled a 3-wave (6-year) sample (N = 521; age = 55-85 years) from the Victoria Longitudinal Study. The results of structural equation modeling supported (a) the a priori structure of the MCQ and (b) the inference of measurement invariance across the 3 dimensions. Accordingly, the MCQ is available for measuring self-reported efforts to compensate for everyday memory losses.     

Validating the Student-Teacher Relationship Scale: testing factor structure and measurement invariance across child gender and age in a Dutch sample

The Student-Teacher Relationship Scale (STRS) is widely used to examine teachers' relationships with young students in terms of closeness, conflict, and dependency. This study aimed to verify the dimensional structure of the STRS with confirmatory factor analysis, test its measurement invariance across child gender and age, improve its measurement of the dependency construct, and extend its age range. Teachers completed a slightly adapted STRS for a Dutch sample of 2335 children aged 3 to 12. Overall, the 3-factor model showed an acceptable fit. Results indicated metric invariance across gender and age up to 8years. Scalar invariance generally did not hold. Lack of metric invariance at ages 8 to 12 primarily involved Conflict items, whereas scale differences across gender and age primarily involved Closeness items. The adapted Dependency scale showed strong invariance and higher internal consistencies than the original scale for this Dutch sample. Importantly, the revealed non-invariance for gender and age did not influence mean group comparisons.     

The Hospital Anxiety and Depression Scale: a pilot study to examine its latent structure and the link between psychological state and symptom severity in transient ischaemic attack patients

Transient ischaemic attack (TIA) is often associated with anxiety and depression, which may precipitate secondary stroke and interfere with treatment. The Hospital Anxiety and Depression Scale (HADS) is widely used to assess these states and to inform the management of any associated psychological problems, but there is considerable debate about what it actually measures. The HADS scores from a range of different clinical groups have been reviewed in order to assess its psychometric properties, but so far, no research has examined either its latent structure when used with TIA patients, or the association between symptom severity and the test’s validity. The aims of this study, therefore, were to investigate: (a) the underlying structure of the HADS when used with TIA patients; and (b) the impact of symptom severity on the validity of the HADS. The HADS and a functional capacity measure were administered by post to a sample of 542 confirmed TIA patients. Exploratory factor analysis was conducted on the HADS scores to establish its underlying structure for this clinical group, and then, sub-sample correlations were undertaken between the anxiety/depression scores for different levels of functional capacity. Two factors emerged, with 13 of the 14 HADS items loading significantly on both, suggesting there is a common affective state underlying the standard anxiety and depression scales. Further data-exploration indicated that convergence between these affective states increased as functional capacity deteriorated. The results suggest firstly that the HADS measures general subjective distress when used with TIA patients, and secondly that the higher reported symptom severity in this clinical group may be associated with reduced affective differentiation. As the ability to retain clear affective discrimination is associated with health and well-being, this could provide a focus for post-TIA rehabilitation.     

A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury

This study aimed to evaluate the preliminary psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in a community sample of adults living with a spinal cord injury (SCI). A cross-sectional design was used with 963 people living in the community with an SCI. Participants were recruited via three spinal centres in the United Kingdom. They completed the HADS and the Life Satisfaction Questionnaire. Psychometric analyses were conducted for the whole sample, by gender and level of injury. The HADS demonstrated good internal consistency, with promising content validity. Two factors, approximating to anxiety and depression were extracted via factor analysis for the whole sample, by gender and level of injury. In line with existing literature, females scored significantly higher than males on the anxiety subscale. Item 7 ("I can sit at ease and feel relaxed") was found to be a complex item, with a potentially different meaning within this population. This study presents preliminary findings, which support the psychometric integrity of the HADS within an outpatient population with SCI. Items that included potential somatic components revealed a more complex factor loading profile. Recommendations are made to further investigate this measure with amendments to such items, incorporating inpatients and independent measures of anxiety and depression to address validity directly.     

The Career Satisfaction Scale: Longitudinal measurement invariance and latent growth analysis

The present research analyses the adequacy of the widely used Career Satisfaction Scale (CSS; Greenhaus, Parasuraman, & Wormley, 1990 ) for measuring change over time. We used data of a sample of 1,273 professionals over a 5‐year time period. First, we tested longitudinal measurement invariance of the CSS. Second, we analysed changes in career satisfaction by means of multiple indicator latent growth modelling (MLGM). Results revealed that the CSS can be reliably used in mean change analyses. Altogether, career satisfaction was relatively stable over time; however, we found significant variance in intra‐individual growth trajectories and a negative correlation between the initial level of and changes in career satisfaction. Professionals who were initially highly satisfied became less satisfied over time. Theoretical and practical implications with respect to the construct of career satisfaction and its development over time (i.e., alpha, beta, and gamma change) are discussed.     

Revised Child Anxiety and Depression Scale: a Psychometric Examination in Chinese Youth

There remains a need for a disorder-specific inventory of children’s depression and anxiety that can reliably screen anxious and depressive disorder symptomatology in Chinese children. The Revised Child and Anxiety Depression Scale (RCADS) is a self-report questionnaire assessing anxiety and depression in children (Chorpita et al., 2000; Piqueras et al., 2017). This study sought to evaluate its psychometric properties in a Mainland Chinese sample. Students from the 4th to 11th grades (N?=?1001) participated in this study. Each of the RCADS subscales, by age and sex, possessed reliability coefficients ranging between .63 and .81. Means and standard deviations for RCADS subscales calculated for the age and sex sub-samples were reported. Participants reported slightly lower levels on five subscales than for Chorpita et al. (2000) normative sample. The scales were significantly and strongly correlated with the Child Behavior Checklist (CBCL) subscales (somatic, withdrawal, anxiety) as well as CBCL internalizing scores. Fit statistics suggested marginal to adequate fit for the six-factor model for the Chinese youth. The present study provides foundational support for the psychometric properties of the RCADS in a large sample of Chinese youth yet indicates that factor structure might be improved through enhanced sampling of culturally relevant symptom expressions.