Quality of Life Research

, Volume 13, Issue 1, pp 191–206 | Cite as

The value of the Hospital Anxiety and Depression Scale (HADS) for comparing women with early onset breast cancer with population-based reference women

  • R.H. Osborne
  • G.R. Elsworth
  • M.A.G. Sprangers
  • F.J. Oort
  • J.L. Hopper


Background: The Hospital Anxiety and Depression Scale (HADS) is frequently used in cancer studies, yet its utility for comparing people with cancer with people in the community is uncertain. Methods: HADS scores were obtained from population-based samples of women with (n = 731) and without (n = 158) early-onset breast cancer. Psychometric properties were examined using differential item functioning (DIF) which is the presence of systematic group differences in certain response items independent of the trait being measured. Results: Women with breast cancer scored lower than reference women on anxiety (mean (SD) 7.5 (4.3) vs. 8.2 (4.0); p = 0.06) and depression (3.3 (3.2) vs. 4.2 (3.0); p = 0.003). Group differences remained following adjustment for demographics. Time since diagnosis was not related to anxiety or depression scores. DIF was present in two anxiety and five depression items. Adjustment for DIF did not substantially change the anxiety or depression group differences. Conclusion: Specific sampling or DIF effects do not explain the observation that women with breast cancer have lower levels of anxiety and depression than population controls. The psychometric properties of the HADS appear to be acceptable in these groups.

Anxiety Breast cancer Depression Differential item functioning Hospital Anxiety and Depression scale 


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  1. 1.
    Herrmann C. International experiences with the Hospital Anxiety and Depression Scale — a review of validation data and clinical results. J Psychosom Res 1997; 42: 17-41.Google Scholar
  2. 2.
    Rust J, Golombok S. Modern Psychometrics: The Science of Psychological Assessment. 2nd revised ed. London: Routledge, 2000.Google Scholar
  3. 3.
    Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiat Scand 1983; 67: 361-370.Google Scholar
  4. 4.
    Hopwood P, Howell A, Maguire P. Screening for psychiatric morbidity in patients with advanced breast cancer: Validation of two self-report questionnaires. Br J Cancer 1991b; 64: 353-356.Google Scholar
  5. 5.
    Ibbotson T, Maguire P, Selby P, Priestman T, Wallace L. Screening for anxiety and depression in cancer patients: The effects of disease and treatment. Eur J Cancer 1994; 30a: 37-40.Google Scholar
  6. 6.
    Le Fevre P, Devereux J, Smith S, Lawrie SM, Cornbleet M. Screening for psychiatric illness in the palliative care inpatient setting: A comparison between the Hospital Anxiety and Depression Scale and the General Health Questionnaire-12. Palliative Med 1999; 13: 399-407.Google Scholar
  7. 7.
    Maher EJ, Mackenzie C, Young T, Marks D. The use of the Hospital Anxiety and Depression Scale (HADS) and the EORTC QLQ-C30 questionnaires to screen for treatable unmet needs in patients attending routinely for radiotherapy. Cancer Treat Rev 1996; 22Suppl A: 123-129.Google Scholar
  8. 8.
    Razavi D, Delvaux N, Bredart A, et al. Screening for psychiatric disorders in a lymphoma out-patient population. Eur J Cancer 1992; 28a: 1869-1872.Google Scholar
  9. 9.
    Walker LG, Heys SD, Walker MB, et al. Psychological factors can predict the response to primary chemotherapy in patients with locally advanced breast cancer. Eur J Cancer 1999; 35: 1783-1788.Google Scholar
  10. 10.
    Maguire P, Selby P. Assessing quality of life in cancer patients. Br J Cancer 1989; 60: 437-440.Google Scholar
  11. 11.
    Groenvold M, Fayers PM, Sprangers MA, et al. Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: A valid comparison? J Clin Epidemiol 1999; 52: 523-530.Google Scholar
  12. 12.
    Sprangers MA, Schwartz CE. Integrating response shift into health-related quality of life research: A theoretical model. Soc Sci Med 1999; 48: 1507-1515.Google Scholar
  13. 13.
    Hopper JL, Giles GG, McCredie MRE, Boyle P. Background, rationale and protocol for a case-control-family study of breast cancer. The Breast 1994; 3: 79-86.Google Scholar
  14. 14.
    McCredie MRE, Dite GS, Giles GG, Hopper JL. Breast cancer in Australian women under the age of 40. Cancer Causes Control 1998; 9: 189-198.Google Scholar
  15. 15.
    Bjellanda I, Dahlb AA, Haugc TT, Neckelmannd D. The validity of the Hospital Anxiety and Depression Scale: An updated literature review. J Psychosom Res 2002; 52: 69-77.Google Scholar
  16. 16.
    Carroll BT, Kathol RG, Noyes R, Jr, Wald TG, Clamon GH. Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale. Gen Hosp Psychiat 1993; 15: 69-74.Google Scholar
  17. 17.
    Moorey S, Greer S, Watson M, et al. The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. Br J Psychiat 1991; 158: 255-259.Google Scholar
  18. 18.
    Watson M, Haviland JS, Greer S, Davidson J, Bliss JM. Influence of psychological response on survival in breast cancer: A population-based cohort study. Lancet 1999; 354: 1331-1336.Google Scholar
  19. 19.
    Breslow NE, Day NE. Statistical Methods in Cancer Research. Volume 1: The Analysis of Case-Control Studies. Lyon: International Agency for Research on Cancer, 1980.Google Scholar
  20. 20.
    Oort FJ. Using restricted factor analysis to detect item bias. Methodika 1992; 6: 150-166.Google Scholar
  21. 21.
    Oort FJ. Simulation study of item bias detection with restricted factor analysis. Struct Equation Model 1998; 5: 107-124.Google Scholar
  22. 22.
    Bentler PM, Wu EJC. EQS for Windows Users Guide, Structural Equations Program 5.6. Cino, California: Multivariate Software Inc., 1997.Google Scholar
  23. 23.
    Nunnally JC, Bernstein IH. Psychometric Theory. 3rd ed. New York: McGraw-Hill Higher Education, 1994.Google Scholar
  24. 24.
    Raykov T, Widaman KF. Issues in applied structural equation modeling research. Struct Equation Model 1995; 2: 289-319.Google Scholar
  25. 25.
    Rigdon E. CFI versus RMSEA: A comparison of two fit indices for structural equation modelling. Struct Equation Model 1996; 3: 369-379.Google Scholar
  26. 26.
    Raykov T. Estimation of Composite Reliability for Congeneric Measures. Appl Psychol Meas 1997; 21: 173-184.Google Scholar
  27. 27.
    Benfante R, Reed D, MacLean C, Kagan A. Response bias in the Honolulu Heart Program. Am J Epidemiol 1989; 130: 1088-1100.Google Scholar
  28. 28.
    Lindsted KD, Fraser GE, Steinkohl M, Beeson WL. Healthy volunteer effect in a cohort study: Temporal resolution in the Adventist Health Study. J Clin Epidemiol 1996; 49: 783-790.Google Scholar
  29. 29.
    Lisspers J, Nygren A, Soderman E. Hospital Anxiety and Depression Scale (HAD): Some psychometric data for a Swedish sample. Acta Psychiat Scand 1997; 96: 281-286.Google Scholar
  30. 30.
    Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AM. A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 1997; 27: 363-370.Google Scholar
  31. 31.
    Hall A, A'Hern R, Fallowfield L. Are we using appropriate self-report questionnaires for detecting anxiety and depression in women with early breast cancer? Eur J Cancer 1999; 35: 79-85.Google Scholar
  32. 32.
    Love AW, Kissane DW, Bloch S, Clarke D. Diagnostic efficiency of the Hospital Anxiety and Depression Scale in women with early stage breast cancer. Aust N Z J Psychiatry 2002; 36: 246-250.Google Scholar
  33. 33.
    Bundred N, Maguire P, Reynolds J, et al. Randomised controlled trial of effects of early discharge after surgery for breast cancer. Br Med J 1998; 317: 1275-1279.Google Scholar
  34. 34.
    Dean C. Psychiatric morbidity following mastectomy: Preoperative predictors and types of illness. J Psychosom Res 1987; 31: 385-392.Google Scholar
  35. 35.
    Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. Br Med J 1990; 301: 575-580.Google Scholar
  36. 36.
    Hughson AV, Cooper AF, McArdle CS, Smith DC. Psychosocial consequences of mastectomy: Levels of morbidity and associated factors. J Psychosom Res 1988; 32: 383-391.Google Scholar
  37. 37.
    Maunsell E, Brisson J, Deschenes L. Psychological distress after initial treatment for breast cancer: A comparison of partial and total mastectomy. J Clin Epidemiol 1989; 42: 765-771.Google Scholar
  38. 38.
    Ramirez AJ, Richards MA, Jarrett SR, Fentiman IS. Can mood disorder in women with breast cancer be identified preoperatively? Br J Cancer 1995; 72: 1509-1512.Google Scholar
  39. 39.
    Dorval M, Maunsell E, Deschenes L, Brisson J, Masse B. Long-term quality of life after breast cancer: Comparison of 8-year survivors with population controls. J Clin Oncol 1998; 16: 487-494.Google Scholar
  40. 40.
    Ellman R, Thomas BA. Is psychological wellbeing impaired in long-term survivors of breast cancer? J Med Screen 1995; 2: 5-9.Google Scholar
  41. 41.
    Fulton C. The prevalence and detection of psychiatric morbidity in patients with metastatic breast cancer. Eur J Cancer Care (Engl) 1998; 7: 232-239.Google Scholar
  42. 42.
    Pinder KL, Ramirez AJ, Black ME, Richards MA, Gregory WM, Rubens RD. Psychiatric disorder in patients with advanced breast cancer: Prevalence and associated factors. Eur J Cancer 1993; 29a: 524-527.Google Scholar
  43. 43.
    Hopwood P, Howell A, Maguire P. Psychiatric morbidity in patients with advanced cancer of the breast: Prevalence measured by two self-rating questionnaires. Br J Cancer 1991a; 64: 349-352.Google Scholar
  44. 44.
    Hammerlid E, Ahlner-Elmqvist M, Bjordal K, et al. A prospective multicentre study in Sweden and Norway of mental distress and psychiatric morbidity in head and neck cancer patients. Br J Cancer 1999; 80: 766-774.Google Scholar
  45. 45.
    Al-Ghazal SK, Fallowfield L, Blamey RW. Does cosmetic outcome from treatment of primary breast cancer influence psychosocial morbidity? Euro J Surg Oncol 1999; 25: 571-573.Google Scholar
  46. 46.
    Kissane DW, Clarke DM, Ikin J, et al. Psychological morbidity and quality of life in Australian women with early-stage breast cancer: A cross-sectional survey. Med J Aust 1998; 169: 192-196.Google Scholar
  47. 47.
    Osborne RH, Elsworth GR, Kissane DW, Burke SA, Hopper JL. The Mental Adjustment to Cancer (MAC) scale: Replication and refinement in 632 breast cancer patients. Psychol Med 1999; 29: 1335-1345.Google Scholar

Copyright information

© Kluwer Academic Publishers 2004

Authors and Affiliations

  • R.H. Osborne
    • 1
    • 2
  • G.R. Elsworth
    • 3
  • M.A.G. Sprangers
    • 4
  • F.J. Oort
    • 4
  • J.L. Hopper
    • 1
  1. 1.Centre for Genetic Epidemiology, School of Population HealthThe University of MelbourneAustralia
  2. 2.AFV Centre for Rheumatic Diseases, Department of MedicineThe University of Melbourne, Royal Melbourne HospitalParkvilleAustralia
  3. 3.Collaborative Institute for Research, Consulting and Learning in EvaluationRMIT UniversityAustralia
  4. 4.Department of Medical PsychologyThe University of AmsterdamNetherlands

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