Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis
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The Hospital Anxiety and Depression Scale (HADS) is the most extensively validated scale for screening emotional distress in cancer patients. However, thresholds for clinical decision making vary widely across studies. A meta-analysis was conducted with the aim of identifying optimal, empirically derived cut-offs.
PubMed, Embase, and PsycINFO databases were searched for studies that compared the HADS total and its subscale scores against a semi-structured or structured clinical interview as a reference standard with regard to its screening efficacy for any mental disorders and depressive disorders alone. Separate pooled analyses were conducted for single or two adjacent thresholds. A total of 28 studies (inter-rater agreement, κ = 0.86) were included.
The best thresholds for screening for mental disorders were 10 or 11 on the HADS total (sensitivity 0.80; specificity 0.74), 5 on the HADS depression subscale (sensitivity 0.84; specificity 0.50), and 7 or 8 on the HADS anxiety subscale (sensitivity 0.73; specificity 0.65). Respective thresholds for depression screening were 15 for the HADS total (sensitivity 0.87; specificity 0.88), 7 for the HADS depression subscale (sensitivity 0.86; specificity 0.81), and 10 or 11 for the HADS anxiety subscale (sensitivity 0.63; specificity 0.83).
The HADS anxiety subscale performed worse than the total and the depression subscales for both indicators. Diagnostic accuracy varied widely by threshold but was consistently superior for depression screening than for screening of any mental disorder.
KeywordsDistress Depression Hospital Anxiety and Depression Scale Meta-analysis Screening
Conflict of Interest
Neither of the authors have any conflicts of interest or financial interests associated with this work.
This study was supported by the Canadian Institute for Health Research CIHR Team for Supportive Cancer Care (#AQC83559) (AV) and a Quinn Research Assistantship (RDM).
- 1.Anonymous (1999) NCCN practice guidelines for the management of psychosocial distress. Oncology (Huntington) 13:113–147Google Scholar
- 5.Vodermaier A, Linden W (2008) Emotional distress screening in Canadian cancer care: a pan-national survey of utilization, tool choices and practice patterns. Oncol Exch 7(4):37–40Google Scholar
- 9.van’t Spijker A, Trijsburg RW, Duivenvoorden HJ (1997) Psychological sequelae of cancer diagnosis: a meta-analytical review of 58 studies after 1980. Psychosom Med 59:280–293Google Scholar
- 11.Fletcher RH, Fletcher SW (2005) Clinical epidemiology: the essentials. Lippincott Wilkins & Wilkins, BaltimoreGoogle Scholar
- 40.Grassi L, Sabato S, Rossi E et al (2009) Affective syndromes and their screening in cancer patients with early and stable disease: Italian ICD-10 data and performance of the Distress Thermometer from the Southern European Psycho-Oncology Study (SEPOS). J Affect Disord 114:193–199PubMedCrossRefGoogle Scholar
- 44.Bax L, Yu LM, Ikeda N, et al (2006) Development and validation of MIX: Comprehensive free software for meta-analysis of causal research data. BMC Medical Research Methodology 6Google Scholar
- 45.Bax L, Yu LM, Ikeda N, et al: MIX: Comprehensive free software for meta-analysis of causal research data, version 1.7. http://mix-for-meta-analysis.info, 2008
- 46.First M, Spitzer R, Gibbon M et al (1997) Structured clinical interview for DSM–IV Axis I disorders (SCID-I/P). New York State Psychiatric Institute, Biometrics Research Department, New YorkGoogle Scholar
- 47.Wing J, Cooper J, Sartorius N (1974) The measurement and classification of psychiatric symptoms. The description and manual for the PSE and CATEGO system. Cambridge University Press, LondonGoogle Scholar
- 48.Goldberg D, Cooper B, Eastwood M et al (1970) A standardized psychiatric interview for use in community surveys. Brit J Prev Soc Med 24:18–23Google Scholar
- 52.Spitzer R, Endicott J (1975) Schedule for Affective Disorders and Schizophrenia (SADS), 2nd edn. New York State Psychiatric Institute, Biometrics Research, New YorkGoogle Scholar
- 53.Wing J, Babor T, Brugha T et al (1990) SCAN: Schedules for Clinical Assessment in Neuropsychiatry. Arch Gen Psychiatry 47:586–593Google Scholar
- 54.World Health Organization (1989) The Composite International Diagnostic Interview, Core Version 1.0. WHO, GenevaGoogle Scholar