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Apples to apples? Comparison of the measurement properties of hospital anxiety and depression-anxiety subscale (HADS-A), depression, anxiety and stress scale-anxiety subscale (DASS-A), and generalised anxiety disorder (GAD-7) scale in an oncology setting using Rasch analysis and diagnostic accuracy statistics

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A range of anxiety measures is used in oncology but their comparability is unknown. We examined variations in measurement across three commonly used instruments: Hospital Anxiety and Depression-Anxiety subscale (HADS-A); Depression, Anxiety, Stress Scale - Anxiety subscale (DASS-A); and Generalised Anxiety Disorder scale (GAD-7). Participants (n = 164) completed the self-report measures and the Generalised Anxiety Disorder module of the Structured Clinical Interview for DSM-IV (SCID). We performed Rasch analysis and calculated diagnostic accuracy statistics. Instruments measured similar constructs of anxiety, but had different ranges of measurement, with the HADS-A including lower severity symptoms than the other two measures. Anxiety severity was similar for GAD-7 ‘mild’ and HADS-A ‘possible’ categories, but ‘mild’ anxiety on the DASS-A represented more severe symptoms. Conversely, DASS-A ‘severe’ anxiety represented less intense symptoms than GAD-7 ‘severe’ anxiety. Co-calibration indicated a score of eight on the HADS-A was equivalent in anxiety severity to scores of three on the DASS-A and six on the GAD-7. Area under the curve (AUC) was just acceptable for HADS-A and GAD-7 but not DASS-A. The HADS-A, DASS-A and GAD-7 displayed important differences in how they measured anxiety. In particular, categorical classifications of anxiety severity (mild/moderate/severe) were not equivalent across instruments. Thus, prevalence estimates of anxiety symptoms will vary as a consequence of the instrument used. The GAD-7 and HADS-A obtained more similar results and better AUC than the DASS-A. Our co-calibration could be used in future studies and meta-analyses of individual participant data to set cut-off points that provide more consistent classification of anxiety severity.

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The authors would like to thank our Psychologist interviewers and all of the participants who gave so generously of their time. Thanks also to Erin Forbes for assistance with manuscript preparation.


This study was supported by a research grant from the Calvary Mater Newcastle. The funding body had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

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Correspondence to Kerrie Clover.

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All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Kerrie Clover declares that she has no conflict of interest.

Sylvie D. Lambert declares that she has no conflict of interest.

Christopher Oldmeadow declares that he has no conflict of interest.

Benjamin Britton declares that he has no conflict of interest.

Madeleine T. King declares that she has no conflict of interest.

Alex Mitchell declares that he has no conflict of interest.

Gregory Carter reports personal fees from OTSUKA, from null, outside the submitted work.

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Clover, K., Lambert, S.D., Oldmeadow, C. et al. Apples to apples? Comparison of the measurement properties of hospital anxiety and depression-anxiety subscale (HADS-A), depression, anxiety and stress scale-anxiety subscale (DASS-A), and generalised anxiety disorder (GAD-7) scale in an oncology setting using Rasch analysis and diagnostic accuracy statistics. Curr Psychol 41, 4592–4601 (2022).

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