Elsevier

Journal of Critical Care

Volume 30, Issue 4, August 2015, Pages 793-798
Journal of Critical Care

Delirium
Psychometric evaluation of the Hospital Anxiety and Depression Scale 3 months after acute lung injury

https://doi.org/10.1016/j.jcrc.2015.04.006Get rights and content

Abstract

Purpose

To conduct a psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) and to evaluate associations of 2 measures of psychological distress with the HADS Anxiety (HADS-A) and HADS Depression (HADS-D) subscales in acute lung injury (ALI) survivors.

Materials and Methods

We used 3-month post-ALI follow-up data from 151 participants in a multisite prospective cohort study to evaluate the internal consistency and structure of the HADS subscales and items, respectively. We used Spearman ρ correlations and other statistics to relate the 3-level version of the EuroQol-5D (EQ-5D-3L) anxiety/depression item and Medical Outcomes Study Short Form-36 (SF-36) “mental health”–related domains to the HADS subscales.

Results

Internal consistency was good for each of the HADS subscales (α ≥ .70). Exploratory factor analysis revealed a 2-factor structure (anxiety and depression). The EQ-5D-3L item and the SF-36 mental health–related domain scores were associated with HADS-A (ρ = 0.54 and − 0.48 to − 0.70, respectively) and HADS-D (ρ = 0.41 and − 0.48 to − 0.52, respectively) scores (all P < .01). The relationship between the SF-36 mental health domain score and the HADS-A subscale score was particularly strong (ρ = − 0.70, P < .01).

Conclusions

When evaluated in ALI survivors, the HADS has good internal consistency and a 2-factor structure. The HADS subscales were substantially correlated with the EQ-5D-3L anxiety/depression item and SF-36 mental health–related domain scores, suggesting convergent validity for these measures of psychological distress in ALI survivors.

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

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