Hospital Anxiety and Depression Scale (HADS)

Hospital Anxiety and Depression Scale (HADS – Depression only)
StudyIdentification toolComparator/ casenessPopulationResults
Consultation
Hahn 2006

Quality assessed: +
HADSCIDI (DSM-IV/ICD-10)N = 204 chronically ill inpatients; 5.9% cardiovascular diseases, 8.8% orthopaedic diseases, 5.4% cancer, 18.6% endocrinologic disease, 53.4% pneumological disease

Mean age = 49.6; age range 18-80

52% male

13 rehabilitation inpatient clinics in Germany

Prevalence of depression35/204
Affective disorder (single episode or recurrent major depression, dysthymia)

Optimal cut-off ≥ 18 – HADS
AUC – 0.785 (0.722-0.839)
Sensitivity – 71.4%
Specificity – 74.6%
PPV – 36.8%
Harter 2001

Quality assessed: +
HADSM-CIDIN=206

Mean age = 48 years

Neck and back pain (70%),
arthropathies (14%),
rheumatic disorders (6%),
other musculoskeletal disorders (10%)

Prevalence of depression10/206
AUC = 0.79 (0.73, 0.85)

Cut-off ≥ 16:
Sensitivity – 78.3%
Specificity – 70.6%
PPV – 28.6%
Harter 2006

Quality assessed: +
HADSM-CIDIN= 569; 36% musculo-skeletal diseases; 29% CVD and 35% Cancer; 50% male; Mean age 54; Age range 22-83

Prevalence of depression59/130
Any depression

HADS
AUC – 0.82 (0.79, 0.86)

Cut-off ≥ 18– HADS
Sensitivity – 73.7%
Specificity – 79.5%
PPV – 30.7%
Healey 2008

Quality assessed: ++
HADSDSM-IV (SCID)N = 49 stroke patients recruited from inpatient rehabilitation units

Mean age = 78.9 (6.79)

Male = 43%

Prevalence of MDD- 7/49

Prevalence of minor depression6/49

Prevalence of any depression – 13/49
Any depression Cut-off ≥ 8 – HADS
Sensitivity – 62% (36-82)
Specificity – 69% (53-82)
PPV – 42% (23-64)
NPV – 83% (66-93)

MDD
Cut-off ≥8 - HADS
Sensitivity – 86% (49-97)
Specificity – 69% (54-81)
PPV – 32% (15-54)
NPV – 97% (83-99)
Herrero 2003

Quality assessed: +
HADSDSM-IV (SCID)N=385, Mean age = 38 years, gender: 204 males, 181 females

General Hospital – all participants were outpatients with severe medical pathology, from neurosurgery, pulmonary, cardiology, neurology and infectious illness settings, Spain

Prevalence of depression - 87/385
Cut-off 7
Sensitivity = 0.92
Specificity = 0.644
Lam 1995

Quality assessed: +
HADSDSM-III-RN=100, age = 69 years, gender: 44 males, 56 females

Elderly primary care patients, Hong Kong

Prevalence of depression9/100
Sensitivity = 0.78
Specificity = 0.91
Lowe 2004A

Lowe2004B – duplicate report

Quality assessed: +
HADSDSM-IV (SCID)N= 501; 21% musculo-skeletal disease, 16% endocrine, nutritional & metabolic disease, 10% cardiovascular/circulatory disease, 7% gastrointestinal disease, 6% respiratory system disease; mean age = 41.7 y/o (SD = 13.8); 32.9% male

395 outpatients from Heidelberg University Medical Hospital

106 patients from 12 GPs in Heidelberg

Prevalence of depression66/501
Any depression

Cut-off ≥ 7– HADS
Sensitivity – 86% (78, 91)
Specificity – 70% (65, 74)
Cut-off ≥ 8– HADS
Sensitivity – 81% (73, 87)
Specificity – 75% (71, 80)
Cut-off ≥ 10– HADS
Sensitivity – 75% (66, 82)
Specificity – 82% (78, 86)

Major depression

Cut-off ≥ 8– HADS
Sensitivity – 88% (78, 95)
Specificity – 69% (64, 73)
Cut-off ≥ 9– HADS
Sensitivity – 85% (78, 95)
Specificity – 76% (64, 73)
Cut-off ≥ 10– HADS
Sensitivity – 74% (62, 84)
Specificity – 83% (79, 86)
Parker 2002

Quality assessed: +
HADSDSM-IV (CIDI)N= 302 outpatients from cardiology (29.5%),
respiratory (23.2%),
gastroenterology (11.6%).
Nephrology (14.9%),
haematology (7.9%),
rheumatology (5.0%),
radiation oncology (4.6%),
endocrinology (3.3%)

Mean age = 46.5 (SD = 12.9); 63.2% male

111 (36.8%) patients had chronic physical illness; mean duration = 9 years

Australia, Sydney

Prevalence of depression14/160
Depression

Cut-off ≥ 2 – BDI-PC
AUC – 0.892
Sensitivity - 100% (not calculated]
Specificity – 20.5% (5.5, 32.4)
Cut-off ≥ 5 – BDI-PC
AUC – 0.892
Sensitivity - 100% (not calculated]
Specificity – 50.0% (35.2, 64.8)
Cut-off ≥ 6 – BDI-PC
AUC – 0.892
Sensitivity - 100% (not calculated]
Specificity – 65.9% (51.9, 79.9)
Cut-off ≥ 8 – BDI-PC
AUC – 0.892
Sensitivity - 75% (32.6, 100]
Specificity – 70.4% (70.4, 93.2)
Optimal cut-off ≥ 9 – BDI-PC
AUC – 0.892
Sensitivity - 75% (32.6, 100]
Specificity – 70.4% (82.4, 99.4)
Cut-off ≥ 11 – BDI-PC
AUC – 0.892
Sensitivity – 50.0% (1, 99)
Specificity – 93.24% (85.7 100)
Upadhyaya1997

Quality assessed: +
HADSGMS-AGECATN = 72, attendees over 65years old at a medical centre (80 approached to take part in study)

UK, Liverpool

Age = 71.2, 37 males, 35 females

Prevalence of depression20/72
Depression

Optimal cut-off 8/9
Sensitivity 70%
Specificity 87%
Physical health problems
Aben 2002

Quality assessed: +
HADS-DDSM-IVN = 202 (N=176 completed HADS-D); mean age = 68 years; 91 female, 111 male

Stroke patients; Netherlands, Maastricht

Prevalence of major and minor depression51/202
Depression: major depressive and minor disorder (also gives results from major depressive disorder only)

Standard cut-off ≥ 8
Sensitivity – 72.5%
Specificity – 78.9%
PPV – 50.9%
NPV – 90.5%
AUC – 0.83
Akizuki 2003

Quality assessed: +
HADSDSM-IVN = 275; mean age = 52 years; 164 female, 111 male

Cancer patients; Japan, Tokyo and Kashiwa

Prevalence of major depression and adjustment disorder - 168/275
Depression: major depression and adjustment disorder

Standard cut-off ≥ 8
Sensitivity – 96%
Specificity – 45%
PPV – 30%
NPV – 63%
Akizuki 2005

Quality assessed: +
HADSDSM-IVN = 295; mean age = 51; 164 female, 131 male

Cancer patients; Japan

Prevalence of depression53/295
Depression: major depression

Optimal cut-off ≥ 15
Sensitivity – 77%
Specificity 74%
Berard 1998

Quality assessed: +
HADSDSM-IVN=100 Age = 50 years, Gender: 13 males, 87 females

Cancer patients, South Africa

Prevalence of depression :- 21/100
Depression:

Cut-off 8
Sensitivity: 0.71
Specificity 0.95
Golden 2007

Quality assessed: +
HADSDSM-IV (SCID-CV)N = 88 outpatients at a hepatitis C service

Male = 74%

Prevalence of depression28/88
Any depression

HADS-D
AUC – 0.78 (0.68-0.88)

Cut-off ≥ 8 - HADS-D
Sensitivity – 52% (31-72)
Specificity – 83% (71-91)
PPV – 54 (33-74)
NPV – 81% (70-90)

Cut-off ≥ 8 - HADS-A
Sensitivity – 88% (69-97)
Specificity – 68% (55-79)
PPV – 52 (36-68)
NPV – 93% (82-99)
Hall 1999

Quality assessed: +
HADSDSM-IVN=266 age:<75 years, gender: all female

Women with early breast cancer, UK

Prevalence of depression - 99/266
Depression:

Cut-off 8
Sensitivity: 0.333
Specificity: 0.934
Haworth 2007

Quality assessed: +
HADSDSM-IV (SCID)N=88, Age = 70 years Gender: 73 males, 15 females

Heart failure patients, US

Prevalence of any depression – 22/88
Prevalence of MDD - 13/88
Depression

Cut-off 6
Sensitivity 77.3%
Specificity 89.4%
Ibbotson 1994

Quality assessed: +
HADSDSM-IIIN=513, Median Age = 50-59, Gender: 231 males, 282 females

Cancer patients, UK

Prevalence of depression20/161
Anxiety and Depression

Optimal cut-off >14 – HADS
Sensitivity – 80%
Specificity – 76%
PPV – 41%
Johnson 1995

Quality assessed: +
HADSDSM-III (SCID)N=204 (who received at least one screen and underwent the psychiatric assessment).

GHQ-26: N = 66
HADS N = 93
GDS: N= 120

Mean age (whole sample) = 71 years.

Male : Female = 1.27 : 1

Prevalence of depression (whole sample) – 26/204

Prevalence of major depression (whole sample)- 17/204
Any depression

Threshold 3/4
Sensitivity – 94%
Specificity – 32%
PPV – 25%
NPV – 96%

Threshold 4/5
Sensitivity – 83%
Specificity – 44%
PPV – 26%
NPV – 92%

Threshold 5/6
Sensitivity – 61%
Specificity – 50%
PPV – 23%
NPV – 84%
Love 2004

Quality assessed: +
HADSDSM-IVN= 227 women with stage IV breast cancer involved in RCT; mean age = 52 y/o (SD = 9)

Australia

Prevalence of depression74/227
Any depression (major and minor)

Cut-off ≥ 7– HADS
Sensitivity – 50%
Specificity – 88%
PPV – 67%
NPV – 79%

Cut-off ≥ 8– HADS
Sensitivity – 46%
Specificity – 94%
PPV – 79%
NPV – 78%

Cut-off ≥ 9– HADS
Sensitivity – 35%
Specificity – 95%
PPV – 76%
NPV – 75%

Cut-off ≥ 10– HADS
Sensitivity – 24%
Specificity – 96%
PPV – 75%
NPV – 72%

Cut-off ≥ 11– HADS
Sensitivity – 16%
Specificity – 97%
PPV – 75%
NPV – 71%

Major depression

Cut-off ≥ 7– HADS
Sensitivity – 81%
Specificity – 81%
PPV – 24%
NPV – 98%

Cut-off ≥ 8– HADS
Sensitivity – 75%
Specificity – 85%
PPV – 28%
NPV – 98%

Cut-off ≥ 9– HADS
Sensitivity – 63%
Specificity – 89%
PPV – 29%
NPV – 97%

Cut-off ≥ 10– HADS
Sensitivity – 50%
Specificity – 92%
PPV – 33%
NPV – 96%

Cut-off ≥ 11– HADS
Sensitivity – 38%
Specificity – 95%
PPV – 37%
NPV – 95%
Poole 2006

Quality assessed: +
HADSDSM-III-R (SCID)N = 115 patients from a Hypertrophic Cardiomyopathy clinic

Male = 59.1%

Median age = 43; age range = 23 – 63

England, London

Prevalence of depression18/115
Any depression

HADS-Anxiety subscale
AUC – 0.78

HADS-Depression subscale
AUC – 0.94

Cut-off ≥ 8 - HADS-Anxiety subscale
Sensitivity – 96%
Specificity – 79%
PPV – 74%
NPV – 96%

Cut-off ≥ 8 - HADS-Depression subscale
Sensitivity – 100%
Specificity – 87%
PPV – 67%
NPV – 100%

Cut-off ≥ 10 - HADS-Anxiety subscale
Sensitivity – 27%
Specificity – 86%
PPV – 55%
NPV – 65%

Cut-off ≥ 10 - HADS-Depression subscale
Sensitivity – 46%
Specificity – 95%
PPV – 69%
NPV – 87%

Optimal cut-off ≥ 14 -HADS-total
Sensitivity – 73%
Specificity – 77%
PPV – 74%
NPV – 75%
Reuter 2000

Quality assessed: +
HADSDSM-IVN=188, Mean age = 54 years, gender: 137 males, 51 females

Cancer patients, Germany

Prevalence of depression14/188
HADS
Cut-off 17
Sensitivity = 0.79
Specificity = 0.76
Stafford 2007

Quality assessed: ++
HADS – depression subscaleDSM-IVN = 193 patients hospitalized for percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery

Male = 80.8%

Mean age = 64.14 (S.D. = 10.37); age range 38 – 91

Australia, Geelong

Prevalence of depression54/193
Any depression

HADS-Depression subscale
AUC – 0.85 (S.E. 0.03)

Cut-off ≥ 5 - HADS-Depression subscale
Sensitivity – 77.8%
Specificity – 80.6%
PPV – 60.9%
NPV – 90.3%
Cut-off ≥ 8 - HADS-Depression subscale
Sensitivity – 38.9%
Specificity – 94.2%
PPV – 72.4%
NPV – 79.9%
Strik 2001

Quality assessed: +
HADSDSM-IV (SCID-I)N= 206 post myocardial infraction; 76.1% male

Male – mean age = 59 (SD = 10.6); age range = 34 – 84

Female – mean age = 62.9 (SD = 10.7); age range = 38 – 78

Prevalence of depression39/206
Any depression (major or minor)

Optimal cut-off ≥ 8 - HADS-Depression
AUC – 0.85
Sensitivity 75.0%
Specificity – 77.6%
PPV – 32.1%
NPV – 98.4%
Tang 2004A

Quality assessed: +
HADS –Chinese versionDSM-III-RN = 100 first acute stroke patients, recruited from consecutive admissions to the Stroke Recovery Unit.

Age = 74 years, 55% male

Prevalence of depression – All disorders17/100

Prevalence of MDD8/100
Any depression

Cut-off 5/6
Sensitivity – 0.88
Specificity – 0.51
PPV – 0.27
NPV – 0.96

Cut-off 6/7
Sensitivity – 0.88
Specificity – 0.53
PPV – 0.28
NPV – 0.96

Cut-off 7/8
Sensitivity – 0.82
Specificity – 0.58
PPV – 0.29
NPV – 0.95

Cut-off 5/6
Sensitivity – 0.76
Specificity – 0.63
PPV – 0.30
NPV – 0.93
Tang 2004B

Quality assessed: +
HADS –Chinese versionDSM-III-RN = 60 Chinese patients received rehabilitation after stroke

Prevalence of depression - 14/60
All depressive disorders

Optimal cut-off ≥ 4
AUC – 0.838
Sensitivity - 86%
Specificity – 78%
PPV – 55%
NPV – 93%
Walker 2007

Quality assessed: +
HADS (total; depression subscale; anxiety subscale)SCIDN= 361 cancer patients; 69.3% breast cancer, 12.5% prostate and bladder cancer; 78.9% had no active disease present

33.5% males

Outpatients in clinic in Edinburgh

Prevalence of depression30/361
Major depressive disorder

Optimal cut-off ≥ 7 – HADS-depression subscale
AUC – 0.93 (0.88-0.98)
Sensitivity – 90% (74-97)
Specificity – 88% (84-91)
PPV – 40%

Optimal cut-off ≥ 9 – HADS-anxiety subscale
AUC – 0.90 (0.85-0.95)
Sensitivity – 87% (70-95)
Specificity – 83% (78-86)
PPV – 31%

Cut-off ≥ 13 – HADS-total
Sensitivity – 90% (74-97)
Specificity – 80% (75-84)
PPV – 29%

Cut-off ≥ 14 – HADS-total
Sensitivity – 87% (70-95)
Specificity – 83% (78-86)
PPV – 31%

Cut-off ≥ 15 – HADS-total
Sensitivity – 87% (70-95)
Specificity – 85% (81-89)
PPV – 35%

Cut-off ≥ 16 – HADS-total
Sensitivity – 80% (70-0.95)
Specificity – 90% (86-93)
PPV – 41%

Cut-off ≥ 17 – HADS-total
Sensitivity – 77% (59-88)
Specificity – 92% (89-95)
PPV – 48%

From: Appendix 20, Case identification included and excluded studies

Cover of Depression in Adults with a Chronic Physical Health Problem
Depression in Adults with a Chronic Physical Health Problem: Treatment and Management.
NICE Clinical Guidelines, No. 91.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society; 2010.
Copyright © 2010, The British Psychological Society & The Royal College of Psychiatrists.

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