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.     

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.     

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.     

Dimensionality of the hospital anxiety and depression scale (HADS) in cardiac patients: comparison of Mokken scale analysis and factor analysis

The hospital anxiety and depression scale (HADS) measures anxiety and depressive symptoms and is widely used in clinical and nonclinical populations. However, there is some debate about the number of dimensions represented by the HADS. In a sample of 534 Dutch cardiac patients, this study examined (a) the dimensionality of the HADS using Mokken scale analysis and factor analysis and (b) the scale properties of the HADS. Mokken scale analysis and factor analysis suggested that three dimensions adequately capture the structure of the HADS. Of the three corresponding scales, two scales of five items each were found to be structurally sound and reliable. These scales covered the two key attributes of anxiety and (anhedonic) depression. The findings suggest that the HADS may be reduced to a 10-item questionnaire comprising two 5-item scales measuring anxiety and depressive symptoms.     

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.     

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.     

Worry and Pathological Worry in Patients with Psoriasis: Cross Sectional and Longitudinal Analyses of the Penn State Worry Questionnaire (PSWQ) in Four Samples of Patients

The purpose of the present study was to examine the psychometric properties of the Penn state Worry Questionnaire (PSWQ) in patients with psoriasis. A series of cross-sectional and longitudinal studies were undertaken to assess the reliability, stability and validity of the measure. Patients with psoriasis from four samples (consecutive attendees, anxious patients, depressed patients, and 6-month follow-up of consecutive attendees) completed the PSWQ and measures assessing related constructs of anxiety and depression (HADS) and coping (COPE). The clinical severity of patients psoriasis was also assessed by dermatologists using the Psoriasis Area and Severity Index (PASI). Exploratory factor analysis was undertaken and receiver operator characteristic (ROC) analyses were used to examine the clinical utility of the PSWQ cut-off score for normal and pathological worry. Exploratory factor analysis suggested that the PSWQ is essentially unidimensional in patients with psoriasis. Intraclass correlation demonstrated that, over a 6-month period, the reproducibility of the PSWQ total scale was good in patients with anxiety and moderate in patients with depression. ROC analysis suggested that the optimum cutoff differentiating pathological worry was > 60, which is commensurate with findings in adult mental health more generally. The PSWQ cutoff for pathological worry showed a lower specificity for depression than anxiety. The PSWQ is an appropriate measure of pathological worry in patients with psoriasis. The cutoff on the scale for pathological worry demonstrates appropriate conceptual overlap with subordinate distress categories of anxiety and depression.     

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).     

The Personal Disturbance Scale (sAD): normative data and latent structure in a large non-clinical sample

The Personal Disturbance Scale [sAD; Bedford & Foulds (1978) Delusions–Symptoms–States Inventory State of Anxiety and Depression. Windsor: NFER-Nelson] is widely used in diverse settings and yet there are unresolved issues concerning its psychometric properties and normative data for the English speaking version are limited. The sAD was administered to a large sample of the general adult population (N=758). Demographic variables (gender, age, years of education and occupational status) had only very modest influences on sAD scores. Tables are presented for conversion of raw scores on the Anxiety, Depression and Total scales to percentiles. The sAD scales possessed adequate convergent and discriminant validity, as demonstrated by their pattern of correlations with two other measures of depression and anxiety (the DASS and the HADS). Ten competing models of the latent structure of the sAD were derived from theoretical and empirical sources. These models were evaluated using confirmatory factor analysis. The best fitting model (CFI=0.96) had a tripartite structure, and consisted of a general factor of psychological distress/negative affectivity (all items loaded on this factor) plus orthogonal specific factors of anxiety and depression. Correlated errors specified according to previous empirical findings were permitted. The theoretical and practical implications of this latent structure are discussed.     

Factor structure of the Chinese version of the Geriatric Depression Scale

Depression is common in patients following stroke and has been found to be related to the degree of functional disability, recovery and engagement in rehabilitation. Consequently, screening for depression is crucial in this group in order to facilitate the delivery of appropriate psychological support. The current study sought to determine key psychometric properties of the Chinese version of the Geriatric Depression Scale (GDS) in this group. Three versions of the GDS were evaluated, these being the 30-item original measure (GDS-30), the short-form version comprising 15 items (GDS-SF) and a recently developed innovative four-item version (GDS-4). Confirmatory factor analysis revealed the GDS-30 and GDS-SF to offer an acceptable fit to data suggesting utility of these measures for screening. However, the GDS-4 offered a poor fit to the data, suggesting this measure was an inadequate measure of depression in this clinical group. Further, though GDS-30 and GDS-SF measures revealed good internal consistency, the performance of the GDS-4 was marginal. However, all GDS-derived measures demonstrated excellent convergent and divergent validity. It is concluded that the GDS-30 is a useful and appropriate screening instrument in this group. Further, the GDS-SF shows promise in terms of development as a multidimensional measure of depression that may have predictive and outcome monitoring potential. The psychometric shortcomings of the GDS-4 strongly suggest that this measure is unsuitable for screening in this clinical group.     

Latent structure and measurement invariance of the Hospital Anxiety and Depression Scale in cancer outpatients

Background/ObjectiveThe aim of the present study was to compare competing psychometric models and analyze measurement invariance of the Hospital Anxiety and Depression Scale (HADS) in cancer outpatients.MethodThe sample included 3,260 cancer outpatients. Latent structure of the HADS was analyzed using confirmatory factor analysis (CFA) with robust maximum likelihood estimation (MLR). Measurement invariance was tested for age, time of response, gender, and cancer type by comparing nested multigroup CFA models with parameter restrictions.ResultsExcept for the one-factor solutions, all models showed acceptable model fit and measurement invariance. The model with the best fit was the originally proposed two-factor model with exclusion of two items. The one-factor solutions showed inacceptable model fit and were not invariant for age and gender.ConclusionsThe HADS has a robust two-factor structure in cancer outpatients. We recommend excluding item 7 and 10 when screening for anxiety and depression.     

Validity and reliability of electroencephalographic frontal alpha asymmetry and frontal midline theta as biomarkers for depression

Electroencephalographic (EEG) frontal alpha asymmetry (FAA) and frontal midline (FM) theta have been suggested as biomarkers for depression and anxiety, but have mostly been assessed in small and non‐clinical studies. In a clinical sample of 79 adults with depression (ICD‐10: F32), resting EEG and scales of depression (MADRS) and anxiety (HADS‐A) were measured at intake and after 3 months. FAA and FM theta values were referenced to a normative population database. Internal consistency, test‐retest reliability, and correlations with psychiatric tests were examined. Reliability was sufficient. However, FAA and FM theta values were close to the general population, and correlations with psychiatric tests were mostly small and non‐significant, with the exception of FAA on F7–F8 z‐scores and HADS‐A. We conclude that the validity of FAA and FM theta and therefore their potential as biomarkers for depression and anxiety remain unclear.     

Reliability and validity of the Basic Depression Questionnaire

Background/ObjectiveDepressive disorders have a high prevalence around the world. They present a great comorbidity with other disorders like anxiety, thereby making a differential diagnosis very difficult. The Basic Depression Questionnaire was designed to palliate this issue by isolating specific depression symptoms. Our aim is to study the reliability, factorial structure, and differential item functioning of this questionnaire. Method: The sample consisted of 1,397 adults without psychological problems (M_age = 29.76, SD = 11.25, 64.78% women) who completed the CBD. Results: We observed that none of the items presented differential functioning. A monofactorial structure was established. In this model a good fit was obtained by confirmatory factor analysis and a strict invariance by sex. The ordinal alpha was used to check the reliability and it fetched an index of .95. Conclusions: The Basic Depression Questionnaire has adequate psychometric properties. The absence of differential item functioning and the invariance by sex are guarantees of an adequate use to diagnose depression for men and women. So, its clinical use can help to differentiate between the specific diagnoses for depressive disorders and anxiety disorders.     

The Structure of Anxiety and Depression in a Normative Sample of Younger and Older Australian Adolescents

It has been reported that depression and anxiety have overlapping symptoms and are conceptually interrelated. One of the most prominent theoretical developments that explain this association is Clark and Watson’s tripartite model (Journal of Abnormal Psychology, 100:316–336, 1991) that posits these two disorders and negative emotions share a latent component of negative affect (NA). The current study had two aims, (a) to compare a tripartite factor structure against competing models by Confirmatory Factor Analysis (CFA) of the Depression Anxiety and Stress Scales (DASS-21) (Lovibond and Lovibond 1995), and (b) explore the psychometric properties of the DASS-21. The DASS-21 was completed by a representative sample of 4039 young Australians, aged 12–18 years, as part of the South Australian Youth Mental Health Survey (SAYMHS), South Australia, Australia. The best fitting model for the data consisted of anhedonic depression, physiological hyperarousal, and general NA. The psychometric properties of the DASS-21 were excellent with a stable and interpretable factor structure and good internal consistency. The results of the current study suggest that the theoretical tripartite structure of depression and anxiety is robust and applicable among Australian youth. The diagnostic, clinical and theoretical implications of these findings are discussed.     

The Yale-Brown Obsessive-Compulsive Scale: Confirmatory Factor Analytic Findings

The psychometric properties of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) have recently been heavily examined. Specifically, a number of researchers have been interested in determining the factor structure of this scale to find whether it best forms a one, two, or three factor model. The present study continued this examination by considering different scaling models using confirmatory factor analysis with a sample of individuals diagnosed with Obsessive-Compulsive Disorder (OCD). One hundred and forty-six individuals diagnosed with OCD participated and were administered the Y-BOCS and scales measuring depression (Hamilton Depression Rating Scale) and anxiety (Hamilton Anxiety Rating Scale). It was found that the Y-BOCS forms two different two-factor models. One model consisted of an obsessions and compulsions factor; the other composed of disturbance and symptom severity factors. It was likewise found that depression and anxiety were related to both factors in one model (disturbance and symptom severity). The finding that depression was related to obsessions and anxiety to compulsions was found, as in a previous factor analysis of the Y-BOCS. These findings suggest that OCD may be best characterized as a multidimensional syndrome that may not be adequately examined by a single unitary factor as described in the Y-BOCS.     

Factor structure and psychometric characteristics of the beck depression inventory-II

The present study evaluated the factor structure and psychometric properties of the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) in the nonclinical sample of 230 young adults. The BDI-II is a revised version of the BDI-IA. We evaluated the fit of three alternative models to the sample data, using confirmatory factor analysis. Results provided support for the fit of the oblique three-factor model. The BDI-II and factor scales had satisfactory coefficient alpha indices. We obtained gender differences on the BDI-II item, total, and factor scale scores. We examined the relations of the BDI-II with demographic variables and with other self-report measures of social desirability, anxiety, depression, stress, and self-esteem. We also examined the issue of whether specific self-report measures of anxiety and depression assess separate or different constructs. We discuss the limitations of the present study.     

Factor solutions of the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) in a Swedish population

Culturally validated rating scales for social anxiety disorder (SAD) are of significant importance when screening for the disorder, as well as for evaluating treatment efficacy. This study examined construct validity and additional psychometric properties of two commonly used scales, the Social Phobia Scale and the Social Interaction Anxiety Scale, in a clinical SAD population (n?=?180) and in a normal population (n?=?614) in Sweden. Confirmatory factor analyses of previously reported factor solutions were tested but did not reveal acceptable fit. Exploratory factor analyses (EFA) of the joint structure of the scales in the total population yielded a two-factor model (performance anxiety and social interaction anxiety), whereas EFA in the clinical sample revealed a three-factor solution, a social interaction anxiety factor and two performance anxiety factors. The SPS and SIAS showed good to excellent internal consistency, and discriminated well between patients with SAD and a normal population sample. Both scales showed good convergent validity with an established measure of SAD, whereas the discriminant validity of symptoms of social anxiety and depression could not be confirmed. The optimal cut-off score for SPS and SIAS were 18 and 22 points, respectively. It is concluded that the factor structure and the additional psychometric properties of SPS and SIAS support the use of the scales for assessment in a Swedish population.     

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.     

The Social Phobia Inventory: screening and cross-cultural validation in Spanish adolescents

Availability of brief, self-report measures to be used as screening instruments is crucial to detect correctly youth with social anxiety disorder and therefore, reach those otherwise under-detected and under-treated. A previous study revealed that the Social Phobia Inventory (SPIN) was potentially an appropriate measure for screening social anxiety among US adolescents. However, there is a lack of information concerning its properties as a screening test in other cultures and languages. This is the main objective of this study, although further validity of the scale is provided as well. The sample consisted of 192 adolescents (a sample composed of 114 subjects with a principal diagnosis of social anxiety disorder; and a group consisting of 78 subjects with no diagnosis of social phobia). Results suggest that the Social Phobia Inventory has demonstrated good psychometric properties and indeed may be used as a screening tool in Spanish-speaking adolescents.     

Psychometric evaluation of the Fear of Positive Evaluation Scale in patients with social anxiety disorder

The Fear of Positive Evaluation Scale (FPES; J. W. Weeks, R. G. Heimberg, & T. L. Rodebaugh, 2008) was designed to assess fear of positive evaluation, a proposed cognitive component of social anxiety. Although previous findings on the psychometric properties of the FPES have been highly encouraging, only 1 previous study has examined the psychometric profile of the FPES in a sample of patients with social anxiety disorder (T. A. Fergus et al., 2009). The primary purpose of the present study was to conduct a large multisite examination of the psychometric profile of the FPES among patients with a principal diagnosis of social anxiety disorder (n = 226; generalized subtype = 97.8%). Responses of nonanxious control participants (n = 42) were also examined. The factorial validity, internal consistency, test-retest reliability, construct validity, and treatment sensitivity of the FPES were strongly supported by our findings. Furthermore, an FPES cutoff score was identified for distinguishing levels of fear of positive evaluation characteristic of patients with social anxiety disorder from those characteristic of the control group. Results provide additional support for the psychometric properties of the FPES in clinical samples.