DeliriumPsychometric evaluation of the Hospital Anxiety and Depression Scale 3 months after acute lung injury
Introduction
Survivors of critical illnesses, especially acute lung injury (ALI), frequently have substantial psychological distress, including clinically significant symptoms of anxiety and depression, with associated decrements in functioning and quality of life [1], [2], [3], [4], [5], [6], [7], [8]. Thus, it is important to ensure that reliable and valid measures of psychological distress are available for this population.
One of the most widely used measures of anxiety and depressive symptoms in general medical settings, the Hospital Anxiety and Depression Scale (HADS) [9], [10], [11], [12], is also used commonly in critical illness survivors [2], [5], [6], [7], [12]. The HADS is validated for assessing general anxiety and depressive symptoms in a wide variety of general medical patients [11], [12], [13], [14], [15], [16], [17], [18], [19]; however, there has been limited psychometric evaluation of the HADS in critical illness survivors. In general medical samples, the number of factors supported in analyses of the HADS items has varied from 1 [17] to the more familiar 2 [11], [13], [14], [16], [20], [21] or even 3 [15]. Thus, it is relevant to determine whether the constructs measured using the HADS (ie, anxiety and depressive symptoms) are identifiable (at least partially separable) in ALI survivors. In addition, it is important to understand how the HADS subscales relate to other commonly used measures of psychological distress in this population, to provide information to clinicians and researchers who want to know the extent to which results from different instruments are comparable.
In the current study, we focused on survivors of ALI, an archetypal critical illness [22]. We hypothesized that (1) the HADS items would cohere into 2 related factors (anxiety and depressive symptoms) and (2) that there would be at least moderate associations of the HADS subscales with the 3-level version of the EuroQol-5D (EQ-5D-3L) anxiety/depression item and the Medical Outcomes Study Short Form-36 (SF-36) mental health–related domains.
Section snippets
Study design and patient sample
This psychometric analysis was conducted as part of a multisite prospective cohort study. A total of 520 participants with ALI were recruited from 13 intensive care units (ICUs) at 4 hospitals in Baltimore, MD. Institutional review board approval was obtained at all participating sites, with a waiver of informed consent granted for abstraction of preexisting data from the medical record. Written informed consent was obtained from survivors after they regained decision-making capacity [23] or
Results
Among the 151 participants, the median (interquartile range) age was 49 (40-57) years, with 58% male, 60% white, and 25% with a psychiatric history and 46% with a history of drug/alcohol abuse based on existing medical records (Table 2). In these participants, 38% and 26% endorsed clinically significant anxiety and depressive symptoms, respectively (ie, HADS-A ≥ 8 or HADS-D ≥ 8).
The internal consistency (α) for each of the HADS subscales was good (HADS-A = .79 and HADS-D = .70). The HADS-A and
Discussion
To our knowledge, this is the first psychometric analysis of the HADS in survivors of ALI or other critical illnesses. This analysis demonstrated that the HADS subscales have good internal consistency reliability in ALI survivors. Also, consistent with several other studies in general medical samples, we identified a 2-factor structure of the HADS items, reflecting general anxiety and depressive symptoms. Finally, the EQ-5D-3L anxiety/depression item and SF-36 mental health–related domain
Conclusions
In conclusion, consistent with results of studies in general medical populations, the HADS has good internal consistency and a 2-factor structure (ie, anxiety and depression) in ALI survivors. Each of the HADS subscales was correlated, in the expected directions, with the EQ-5D-3L anxiety/depression item and the 4 mental health–related domains of the SF-36, suggesting convergent validity for these measures of psychological distress.
Acknowledgments
The authors acknowledge the contributions made by Mr Victor Dinglas with data management and Dr Kitty Chan in reviewing a previous version of this manuscript.
This research was supported by the National Institutes of Health (K23 HD074621, P050 HL73994, UL1 TR000424, and R24 HL111895) and by the Johns Hopkins Institute for Clinical and Translational Research. The funding bodies had no role in the study design, manuscript writing, or decision to submit the manuscript for publication. The contents
References (39)
- et al.
General anxiety symptoms after acute lung injury: predictors and correlates
J Psychosom Res
(2013) - et al.
The validity of the Hospital Anxiety and Depression scale: an updated literature review
J Psychosom Res
(2002) - et al.
A confirmatory factor analysis of the Hospital Anxiety and Depression Scale in coronary care patients following acute myocardial infarction
Psychiatry Res
(2003) - et al.
A validation study of the Hospital Anxiety and Depression Scale (HADS) in a Spanish population
Gen Hosp Psychiatry
(2003) - et al.
An analysis of the validity of the Hospital Anxiety and Depression scale as a screening tool in patients with advanced metastatic cancer
J Pain Symptom Manage
(2001) - et al.
Comparison of the Short Form 36 and the Hospital Anxiety and Depression Scale measuring emotional distress in patients admitted for elective coronary angiography
Heart Lung
(2008) - et al.
Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review
Psychosom Med
(2008) - et al.
Depression in general intensive care unit survivors: a systematic review
Intensive Care Med
(2009) - et al.
Health-related quality of life after acute lung injury
Am J Respir Crit Care Med
(1997) - et al.
Quality of life, emotional, and cognitive function following acute respiratory distress syndrome
J Int Neuropsychol Soc
(2004)
Depressive symptoms and impaired physical function after acute lung injury
Am J Respir Crit Care Med
One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial
BMJ
The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury
Am J Respir Crit Care Med
The Hospital Anxiety and Depression Scale
Acta Psychiatr Scand
A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects
Psychol Med
Psychological assessment of ICU survivors: a comparison between the Hospital Anxiety and Depression scale and the Depression, Anxiety and Stress scale
Anaesthesia
The factor structure and factor stability of the Hospital Anxiety and Depression Scale in patients with cancer
Br J Psychiatry
Factor analysis of the Hospital Anxiety and Depression Scale from a large cancer population
Psychol Psychother
The factor structure of the Hospital Anxiety and Depression Scale in acquired brain injury
Brain Inj
Cited by (58)
Depressive symptoms over time among survivors after critical illness: A systematic review and meta-analysis
2024, General Hospital PsychiatryLong-term functional disabilities in intensive care unit survivors: A prospective cohort study
2024, Australian Critical CareAnxiety and depression in intensive care patients six months after admission to an intensive care unit: A cohort study
2023, Intensive and Critical Care NursingAloud real- time reading of intensive care unit diaries: A feasibility study
2023, Intensive and Critical Care Nursing