ReviewDiagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: A meta-analysis
Introduction
There have been considerable efforts to validate tools that may aid clinicians identify the mental health complications of cancer (Vodermaier et al., 2009, Thekkumpurath et al., 2008). Studies that have used structured psychiatric interviews suggest that the prevalence of major depressive disorder is approximately 15% in advanced cancer (Vodermaier et al., 2009). Studies using self-report methods suggest a prevalence of distress in unselected cancer patients of 30% (Pascoe et al., 2000, Zabora et al., 2001, Fallowfield et al., 2001, Carlson et al., 2004) and those examining broadly defined mental health conditions suggest a rate of 40% or higher (Van't Spijker et al., 1997, Grassi et al., 2005). Clinicians now recognize the importance of treating those with not just major depression, but anxiety disorders and mixed mental disorders. Yet the rate limiting step remains the efficient detection of each disorder (Söllner et al., 2001).
The most extensively studied mood scale in cancer settings (as well as in medical settings in general) is the Hospital Anxiety and Depression Scale (HADS). This is also the most commonly use mood scale in palliative settings (Lawrie et al., 2004). The HADS is actually two conjoint 7-item subscales, one specifically targeted at anxiety (HADS-A) and one focussing on depression (HADS-D) (Zigmond and Snaith, 1983). The HADS was first developed to quantify anxiety and depression in medical patients although it has been widely applied in screening and case-finding studies. It excludes many somatic symptoms for example dizziness and sleep disturbance although does include psychomotor agitation and retardation. The depression scale focuses on anhedonia with no direct question on low mood but several concerning loss of interest/pleasure. There have been several narrative reviews of the HADS in cancer but no quantitative data synthesis and several important questions remain unresolved (Morse et al., 2005). First, it is unclear which version (HADS-D HADS-A or HADS-T) to use for which disorder. Despite the face validity of separate application, these subscales are actually highly inter-related (mean correlation from 21 studies = 0.56) (Bjelland et al., 2002). Similarly, although it is common to look for mental illness (distress) using the combined score from both subscales (HADS-T) (Reuter and Härter, 2001) use of the total score was not recommended by the original authors (Snaith and Zigmond, 1994). That said, some have recommended the HADS-T on theoretical grounds (Flint and Rifat, 1996, Herrmann, 1997, Moorey et al., 1991, Spinhoven et al., 1997) whilst others have not (Martin, 2005, Rodgers et al., 2005, Brandberg et al., 1992, Leung et al., 1993). Second, performance relative to other scales and ability to improve clinicians' diagnosis in implementation studies is not yet resolved. Finally, the diagnostic validity, that is its accuracy against a criterion (gold) standard is still debated, often due to problems comparing studies with different cut-offs and prevalence rates (Bjelland et al., 2002, Johnston et al., 2000, Néron et al., 2007).
The aims of this study were: 1. To examine the diagnostic validity of all versions of the HADS for the detection of mental health complications of cancer and 2. To examine the clinical applicability of the HADS versions using the clinical utility index (defined below) in order to support or refute its use in clinical practice.
Section snippets
Search
A systematic search, appraisal and meta-analysis were conducted. Medline, PsycINFO and Embase abstract databases were searched from inception to October 2009. The keywords (MeSH terms) are available on request. Four full text collections, abstract databases were searched and where necessary, authors were contacted directly for primary data.
Cut-offs and definitions
We used the optimum cut-off (supplied by the primary authors) but also report a restricted analysis with the most common single cut-points. We defined
Search results
From 4451 possible hits involving the HADS scale, 768 involved patients with cancer and 210 examined aspects of scale accuracy. 160 publications were excluded, largely due to inadequate criterion standards although several HADS studies reported inadequate data (Castelli et al., 2009, Miklavcic et al., 2008). Thus there were 50 valid analyses. The data extraction is illustrated in Fig. 1 in accordance with Quality of Reporting of Meta-analyses guidelines (Moher et al., 1999).
Ten studies examined
Discussion
This is the first attempt to bring together data from different applications of the HADS across multiple cancer settings in order to test validity in clinical practice. For depression, sensitivity was between 71.6% and 82.0% and specificity was between 77.0% and 82.6%. For anxiety, sensitivity was between 48.7% and 83.9% and specificity was between 69.9% and 78.7%. For distress, sensitivity was between 65.7% and 75.7% and specificity was between 66.3% and 80.6%. We examined the relative merits
Role of funding source
Nothing declared.
Conflict of interest
No conflict declared.
Acknowledgment
Special thanks to the staff of the Postgraduate library, Leicester General Hospital.
References (67)
- et al.
The validity of the Hospital Anxiety and Depression Scale. An updated literature review
J Psychosom Res
(2002) Affective syndromes and their screening in cancer patients with early and stable disease
J. Affect. Disord.
(2009)- et al.
Are we using appropriate self-report questionnaires for detecting anxiety and depression in women with early breast cancer
Eur. J. Cancer
(1999) International experiences with the Hospital Anxiety and Depression Scale: a review of validation data and clinical results
J Psychosom Res
(1997)- et al.
Screening for anxiety and depression in cancer patients: the effects of disease and treatment
Eur. J. Cancer
(1994) - et al.
Construct validation of the hospital anxiety and depression scale with clinical populations
J Psychosom Res
(2000) - et al.
Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach
Ann. Oncol.
(2004) - et al.
An analysis of the validity of the Hospital Anxiety and Depression Scale as a screening tool in patients with advanced metastatic cancer
J Pain Symptom Manage
(2001) A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment
J Psychiatr Res.
(2009)- et al.
Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement
Quality of Reporting of Meta-analyses
(1999)
Predicting mood disorders in breast cancer patients European
J. of Cancer
Screening for depression in people with cancer: the accuracy of the hospital anxiety and depression scale
Clin. Effect Nurs.
Screening for psychiatric disorders in a lymphoma out-patient population
Eur. J. Cancer
Screening for psychological distress in palliative care: a systematic review
J. Pain Symptom Manage.
Performance of the Hospital Anxiety and Depression Scale as a screening tool for major depressive disorder in cancer patients
J. Psychosom. Res.
Development of a brief screening interview for adjustment disorders and major depression in patients with cancer
Cancer
Depressive disorders in an out-patient oncology setting: prevalence, assessment, and management
Psychooncology
Depressive disorders in an out-patient oncology setting: prevalence, assessment, and management
Psychooncology
Bayesians and frequentists
BMJ
Does routine assessment and real-time feedback improve cancer patients' psychosocial well-being?
Eur J Cancer Care
Anxiety and depressive symptoms at different stages of malignant melanoma
Psychooncology
High levels of untreated distress and fatigue in cancer patients
Br. J. Cancer
Depression in lung cancer patients: is the HADS an effective screening tool?
Supportive Care in Cancer Volume Issue Date
Detecting psychological distress in cancer patients: validity of the Italian version of the Hospital Anxiety and Depression Scale
Support. Care Cancer
Psychiatric morbidity and its recognition by doctors in patients with cancer
Br. J. Cancer
Validation of the hospital anxiety and depression scale as a measure of severity of geriatric depression
Int J Geriatr Psychiatry
Use of the Diagnostic Criteria for Psychosomatic Research (DCPR) in oncology
Psychother. Psychosom.
Screening for mental disorders in cancer, cardiovascular and musculoskeletal diseases. Comparison of HADS and GHQ-12
Soc. Psychiatry Psychiatr. Epidemiol.
Screening for psychiatric morbidity in patients with advanced breast cancer: validation of two self-report questionnaires
Br. J. Cancer
Screening for adjustment disorders and major depression in otolaryngology patients using the hospital anxiety and depression scale
International J. of Psychiatry in Clin. Practice
Screening for depression in head and neck cancer
Psycho-oncology
Screening for psychological distress in Japanese cancer patients
Jpn J Clin Oncol
How do palliative medicine physicians assess and manage depression
Palliat. Med.
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