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      The Hospital Anxiety and Depression Scale (HADS): translation and validation study of the Iranian version

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          The Hospital Anxiety and Depression Scale (HADS) is a widely used instrument to measure psychological morbidity in cancer patients. This study aimed to translate and test the reliability and validity of the Iranian version of the HADS.


          The English language version of the HADS was translated into Persian (Iranian language) and was used in this study. The questionnaire was administered to a consecutive sample of 167 breast cancer patients and statistical analysis was performed to test the reliability and validity of the HADS.


          In general the Iranian version of the HADS was found to be acceptable to almost all patients (99%). Cronbach's alpha coefficient (to test reliability) has been found to be 0.78 for the HADS anxiety sub-scale and 0.86 for the HADS depression sub-scale. Validity as performed using known groups comparison analysis showed satisfactory results. Both anxiety and depression sub-scales discriminated well between sub-groups of patients differing in clinical status as defined by their disease stage.


          This preliminary validation study of the Iranian version of the HADS proved that it is an acceptable, a reliable and valid measure of psychological distress among cancer patients.

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          Most cited references 15

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          International experiences with the Hospital Anxiety and Depression Scale--a review of validation data and clinical results.

          More than 200 published studies from most medical settings worldwide have reported experiences with the Hospital Anxiety and Depression Scale (HADS) which was specifically developed by Zigmond and Snaith for use with physically ill patients. Although introduced in 1983, there is still no comprehensive documentation of its psychometric properties. The present review summarizes available data on reliability and validity and gives an overview of clinical studies conducted with this instrument and their most important findings. The HADS gives clinically meaningful results as a psychological screening tool, in clinical group comparisons and in correlational studies with several aspects of disease and quality of life. It is sensitive to changes both during the course of diseases and in response to psychotherapeutic and psychopharmacological intervention. Finally, HADS scores predict psychosocial and possibly also physical outcome.
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            Hospital Anxiety and Depression Scale (HAD): some psychometric data for a Swedish sample.

            The Hospital Anxiety and Depression Scale (HAD) was evaluated in a Swedish population sample. The purpose of the study was to compare the HAD with the Beck Depression Inventory (BDI) and Spielberger's State Trait Anxiety Inventory (STAI). A secondary aim was to examine the factor structure of the HAD. The results indicated that the factor structure was quite strong, consistently showing two factors in the whole sample as well as in different subsamples. The correlations between the total HAD scale and BDI and STAI, respectively, were stronger than those obtained using the different subscales of the HAD (the anxiety and depression subscales). As expected, there was also a stronger correlation between the HAD and the non-physical items of the BDI. It was somewhat surprising that the factor analyses were consistently extracting two factors, 'depression' and 'anxiety', while on the other hand both BDI and STAI tended to correlate more strongly with the total HAD score than with the specific depression and anxiety HAD subscales. Nevertheless, the HAD appeared to be (as was indeed originally intended) a useful clinical indicator of the possibility of depression and clinical anxiety.
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              Detecting psychological distress in cancer patients: validity of the Italian version of the Hospital Anxiety and Depression Scale.

              The psychometric properties of the Italian version of the Hospital Anxiety and Depression Scale and its utility as a screening instrument for anxiety and depression in a non-psychiatric setting were evaluated. The questionnaire was administered twice to 197 breast cancer patients randomised in a phase III adjuvant clinical trial: before the start of chemotherapy and at the first follow-up visit. The presence of psychiatric disorders was evaluated at the follow-up visit using the Structured Clinical Interview for DSM-III-R in 132 patients. Factor analyses identified two strictly correlated factors. Crohnbach's alpha for the anxiety and depression scales ranged between 0.80 and 0.85. At follow-up, 50 patients (38%) were assigned a current DSM-III-R diagnosis, in most cases adjustment disorders (24%) or major depressive disorder (10%). Receiver operating characteristics (ROC) analysis was used to test the discriminant validity for both anxiety and depressive disorders. The comparison of the areas under the curve (AUC) between the two scales did not show any difference in identifying either anxiety (P = 0.855) or depressive disorders (P = 0.357). The 14-item total scale showed a high internal consistency (alpha = 0.89 and 0.88) and a high discriminating power for all the psychiatric disorders (AUC = 0.89; 95% CI = 0.83-0.94). The cut-off point that maximised sensitivity (84%) and specificity (79%) was 10. These results suggest that the total score is a valid measure of emotional distress, so that the Italian version of HADS can be used as a screening questionnaire for psychiatric disorders. The use of the two subscales as a 'case identifier' or as an outcome measure should be considered with caution.

                Author and article information

                Health Qual Life Outcomes
                Health and Quality of Life Outcomes
                BioMed Central (London )
                28 April 2003
                : 1
                : 14
                [1 ]Iranian Institute for Health Sciences Research
                [2 ]Iranian Centre for Breast Cancer (ICBC)
                Copyright © 2003 Montazeri et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.

                Health & Social care


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