Reliability and validity of a Chinese version of the HADS for screening depression and anxiety in psycho-cardiological outpatients
Introduction
Depression and anxiety are considered to be independent risk factors of acute coronary syndrome (ACS), as characterized by unstable angina, non-ST evaluated myocardial infarction and ST evaluated infarction, which are common symptoms in cardiovascular disease (CVD) [1], [2]. Among patients who suffered from myocardial infarction (MI), approximately 20% have been found to have mild to moderate depression, and approximately 14% have been diagnosed with major depressive disorder [3]. Anxiety has likewise been found to be extremely common among patients having coronary artery disease, with in-hospital incidence of anxiety disorders approaching 50% [4], [5]. Depression and anxiety have also been associated with increasing risk of coronary artery disease, increasing risk of death, and reduced quality of life [2], [6], [7], [8]. The instruments used for the screening and diagnosis of depression and anxiety in patients with CVD have been widely researched.
The Hospital Anxiety and Depression Scale (HADS) is a well-recognized, self-reporting scale for screening anxiety and depression. It was developed by Zigmond and Snaith in 1983 to assess anxiety disorders and depression among clinical or hospital patients [9]. The HADS is made up of two parts: an anxiety subscale (HADS-A) and a depression subscale (HADS-D), both of which have seven items. Because of its established validity and reliability, the HADS has been translated into many languages for use around the world. A systematic literature review [10] demonstrated that the HADS performed well in assessing symptom severity and in diagnosing anxiety disorders and depression in various populations, with significant internal consistency and concurrent validity. HADS was a good instrument used for screening anxiety disorders and depression in populations of general hospital patients. However, there has been limited research on the assessment of the HADS in psycho-cardiological outpatients.
The Mini International Neuropsychiatric Interview, Version 5 (MINI) is a short, public domain, diagnostic structured interview that is compatible with ICD-10 and DSM-IV criteria and that captures important subsyndromal variants [11], [12]. The MINI is a validated tool used to diagnose anxiety and depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) [13], which is also similar to the SCID [14] in operation and principle. The MINI has excellent psychometric properties and has been validated against the Structured Clinical Interview for DSM-III-R Diagnoses–Patient Version [15] and the Composite International Diagnostic Interview [11], [12], [16], [17]. There are limited reports on the comparison of the HADS with MINI diagnoses. Because of the potential advantages of using the HADS with new patient populations and because of the lack of research in this area, this study was performed attempting to achieve the follows aims:
- 1.
to examine the relationship between scores of the HADS and the presence or absence of clinical diagnoses of depression and anxiety according to ICD-10 and DSM-IV criteria, as measured by the MINI in psycho-cardiological outpatients;
- 2.
to examine the reliability of the Chinese version HADS among psycho-cardiological outpatients based internal consistency reliability as measured with Cronbach's coefficient alpha;
- 3.
to examine the validity of the Chinese version of the HADS among psycho-cardiological outpatients. Criterion-related validity was assessed using sensitivity, specificity, PPV and NPV of the HADS.
Section snippets
Selection of subjects
Patients attending the psycho-cardiological outpatient center of Peking University People's Hospital were considered to be eligible for this study since the target population included psycho-cardiological outpatients. Eligibility criteria included the ability to understand both written and spoken Chinese, and all participants were required to be at least 18 years of age. Exclusion criteria included a pre-existing diagnosis of depression or anxiety and current use of anti-depressant or
Subject characteristics and prevalence of depression and anxiety in psycho-cardiological outpatients
A total of 100 outpatients (57 male, 43 female) met the inclusion criteria and ultimately participated in the study. The mean age of participating patients was 56.0 years (range 24–84 years, SD: 14.9 years). Most of the patients (78.0%) presented at the psycho-cardiological outpatient center with coronary artery disease (CAD), chest discomfort but no CAD, and/or palpitations. About 7.0% were experiencing recurrent heart failure. More than half (57.0%) of the patients had essential hypertension.
The
Discussion
Increasingly, research has considered depression and anxiety as independent risk factors of coronary artery disease [1], [2]. In fact, screening for depression in coronary artery disease patients has been recommended by the American Heart Association Science Advisory [19], although there is limited evidence to support this recommendation [20]. Whereas some scales, such as the two stages of PHQ2 and PHQ9 have been recommended to screen for depression or anxiety disorders [19], the HADS is a
Conclusions
The cutoff thresholds for the HADS-A and HADS-D have been previously established as 8 for all possible cases of anxiety and depressive disorders. This cutoff, however, does not seem appropriate for psycho-cardiological outpatients. Overall, the HADS was found to be a reliable measuring tool for excluding depression and anxiety in psycho-cardiological outpatients.
Acknowledgment
We were grateful for all of the participants and workers in this study. We also appreciated Laura Skrip for revision of this manuscript.
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The first two authors contributed equally to this study.