Research report
Student anxiety and depression: Comparison of questionnaire and interview assessments

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Abstract

Background

Recent reports note a reliance on self-report measures and a lack of information about diagnosable mental disorder in university students. Professional concern about perceived increases in student mental health problems raises questions about whether questionnaire assessments can provide valid approximations of such disorders in this group. The aim of this study was to validate the Hospital Anxiety and Depression Scale (HADS) against DSM-IV diagnoses in university students.

Methods

Eighty-nine students were administered with the HADS followed by the Structured Interview for DSM-IV.

Results

At recommended cut-offs HADS anxiety and depression scales both showed good sensitivity in detecting DSM-IV anxiety and depression disorders, and the depression scale showed good specificity and overall efficiency. The HADS anxiety scale showed poor specificity and moderate overall efficiency. In the absence of an anxiety diagnosis, high HADS anxiety scores were not significantly associated with other measured indicators of serious mental health problems.

Limitations

Further research is needed to investigate whether the current findings hold for student populations with higher social diversity.

Conclusions

The HADS depression scale is likely to be a reasonably accurate indicator of depressive conditions in university students at the recommended cut-off but the HADS anxiety scale overestimates the extent of clinical anxiety. Students' self-reported higher symptom levels in comparison to general population norms cannot be assumed to indicate higher levels of more serious mental health conditions. However this is not to deny the genuine distress and severe problems that some students experience.

Introduction

Increases in the severity of presenting problems reported by student counselling services in Britain and the United States (AUCC, 2002, Benton et al., 2003) have prompted an increase in professional concern about student mental health. A recent working party report by the Royal College of Psychiatrists (2003) remarked on the paucity of evidence but concluded that on balance British university students report more mental health symptoms than age-matched controls. This was based on evidence from questionnaire studies and the report noted a lack of information on diagnosable mental disorder in students both in Britain and internationally. The two studies that support the RCP conclusions used symptom measures of student distress that did not differentiate anxiety from depression (Roberts et al., 1999, Stewart-Brown et al., 2000). One study (Surtees et al., 2002) which modified the General Health Questionnaire to derive DSM-IV anxiety and depression diagnoses found case rates in Cambridge University students to be similar to age-matched norms. However, the high social status and achievement of Cambridge students suggests that their mental health might not be representative of all undergraduates. Two sizeable representative student surveys have used the Hospital Anxiety and Depression Scale (HADS: Zigmond and Snaith, 1983) and both found similar depression and anxiety levels (Webb et al., 1996, Andrews and Wilding, 2004). Using recommended cut-offs, depression rates were relatively low and similar to reported HADS norms for British adults (Crawford et al., 2001) but rates of ‘probable’ case anxiety at between 23% and 25% for men and between 36% and 42% for women were over two- to threefold higher than male and female norms of 8% and 15%. This raises the question of whether the HADS and similar questionnaire assessments can provide valid approximations of mental health conditions in students. To address this issue the aims of the current study were:

  • To validate the HADS against the Structured Clinical Interview for DSM-IV (SCID: First et al., 2002) in a sample of university students.

  • To investigate how far the HADS and the SCID are equivalent or independent ways of assessing student mental health problems by comparing the concurrent validity of the two methods in terms of other mental health indicators including treatment history and substance abuse.

Section snippets

Participants and procedure

Participants were selected for interview from 585 respondents to a survey of home-domiciled second-year undergraduate students at a college of the University of London. The survey and subsequent interviews were conducted over the course of two terms. As the main focus of the study was on student depression, priority was given to respondents with HADS depression scores of 8 or more (‘possible’ or ‘probable’ depression, Zigmond and Snaith, 1983) in the interview selection process. Students

Clinical diagnosis

For the period under review 27 students met DSM-IV criteria for an anxiety or depressive disorder. Table 1 shows the numbers reaching criteria for the different disorders. Eleven met criteria for major depressive disorder or mixed anxiety–depressive disorder, and a further 16 met criteria for panic disorder or generalised anxiety disorder. One case of social phobia was subsumed under panic disorder.

Comparison of HADS cut-off scores with SCID diagnosis

Table 2 shows the numbers of students at the different cut-off scores for the HADS. Rates of

The utility of the HADS as an indicator of anxiety and depressive disorders in students

To the authors' knowledge this is the first study to validate a questionnaire measure of anxiety and depression against a structured clinical assessment in a university setting. The findings suggest that the HADS depression scale is likely to be a reasonably accurate indicator of depressive conditions in university students using a score just below or at the recommended cut-off for probable case depression. In contrast the HADS anxiety scale at the recommended probable case cut-off and above

Acknowledgement

The research was supported by a grant from the Economic and Social Research Council (RES-000-22-0897).

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