The DOI matches its Crossref record; 68 of the 69 references it cites were found in a registry or an index.
Diagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: A meta-analysis
Abstract
Objective To examine the validity of the Hospital Anxiety and Depression Scale (HADS) in the identification of psychiatric complications of cancer, as defined by a robust criterion standard.Methods 50 analyses tested the depression subscale (HADS-D), anxiety subscale (HADS-A) or combined scales (HADS-T) against syndromal (clinical) depression (n=22), syndromal anxiety (n=4) or any mental ill health/distress (n=24), all defined by semi-structured psychiatric interview.Results The HADS and its subscales had both strengths and limitations. Overall it appeared to perform marginally better in non-palliative cancer settings. Specific findings for each subscale were as follows. In the identification of depression the HADS-T, HADS-D and HADS-A had a pooled sensitivity and specificity of 82.0%, 77.0%; 71.6%, 82.6% and 80.5%, 77.8%, respectively. All versions performed poorly in case-finding but well in a screening capacity. For anxiety there were no HADS-D studies. The HADS-T and HADS-A had a pooled sensitivity and specificity of 83.9%, 69.9% and 48.7%, 78.7%. They were poor at case-finding but good as screening instruments. For distress (any mental ill health) the HADS-T, HADS-D and HADS-A had a pooled sensitivity and specificity of 72.8%, 80.6%; 75.7%, 66.3% and 65.7%, 71.3%, respectively. When screening for distress and anxiety the HADS-T was the optimal subscale.Conclusion For the identification of depression, anxiety or distress in cancer settings, the HADS (including subscales) is not recommended as a case-finding instrument but it may, subject to concerns about its length, be a suitable addition to screening programme.
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In the citing paper
“The HADS is a 14-item self-report questionnaire that has been widely used to measure psychological distress in cancer patients [21].”
In the citing paper
“The HADS is validated and extensively used in the measurement of distress among cancer survivors (Vodermaier et al., 2009; Mitchell et al., 2010).”
In the citing paper
“Depressive symptoms were measured with the Hospital Anxiety and Depression Scale's (HADS) subscale for depression (HADS-D). 23 Following well-established criteria, the presence of depression was defined as HADS-D ≥ 11, indicating probable moderate or severe depression. 24-26”
From Depressive symptoms predict clinical recurrence of inflammatory bowel disease (2022) · cites this paper as [23]
In the citing paper
“a HADS-D score of ≥ 11 represents a well-established cut off strongly indicating depression, 23-26”
From Depressive symptoms predict clinical recurrence of inflammatory bowel disease (2022) · cites this paper as [23]
Citations
Cites
The Hospital Anxiety and Depression Scale
Zigmond, A. S., & Snaith, R. P. (1983) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.1983.tb09716.x · Cited by 47,139
The validity of the Hospital Anxiety and Depression Scale
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002) · Journal of Psychosomatic Research · doi:10.1016/s0022-3999(01)00296-3 · Cited by 9,779
Moher, D., Cook, D. J., Eastwood, S., Olkin, I., Rennie, D., & Stroup, D. F. (1999) · The Lancet · doi:10.1016/s0140-6736(99)04149-5 · Cited by 4,826
Herrmann, C. (1997) · Journal of Psychosomatic Research · doi:10.1016/s0022-3999(96)00216-4 · Cited by 2,885
The Hospital Anxiety And Depression Scale.
(2003) · Health and Quality of Life Outcomes · doi:10.1186/1477-7525-1-29 · Cited by 2,391
SPINHOVEN, P., ORMEL, J., SLOEKERS, P. P. A., KEMPEN, G. I. J. M., SPECKENS, A. E. M., & HEMERT, A. M. V. (1997) · Psychological Medicine · doi:10.1017/s0033291796004382 · Cited by 2,158
Velikova, G., Booth, L., Smith, A. B., Brown, P. M., Lynch, P., Brown, J. M., & Selby, P. J. (2004) · Journal of Clinical Oncology · doi:10.1200/jco.2004.06.078 · Cited by 1,382
Mitchell, A. J. (2008) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2008.04.014 · Cited by 1,192
Self-citationHigh levels of untreated distress and fatigue in cancer patients
Carlson, L. E., Angen, M., Cullum, J., Goodey, E., Koopmans, J., Lamont, L., MacRae, J. H., Martin, M., Pelletier, G., Robinson, J., et al. (2004) · British Journal of Cancer · doi:10.1038/sj.bjc.6601887 · Cited by 939
Psychiatric morbidity and its recognition by doctors in patients with cancer
Fallowfield, L., Ratcliffe, D., Jenkins, V, & Saul, J. (2001) · British Journal of Cancer · doi:10.1054/bjoc.2001.1724 · Cited by 694
Moorey, S., Greer, S., Watson, M., Gorman, C., Rowden, L., Tunmore, R., Robertson, B., & Bliss, J. M. (1991) · The British Journal of Psychiatry · doi:10.1192/bjp.158.2.255 · Cited by 653
Costantini, M., Musso, M., Viterbori, P., Bonci, F., Mastro, L. D., Garrone, O., Venturini, M., & Morasso, G. (1999) · Supportive Care in Cancer · doi:10.1007/s005200050241 · Cited by 542
Screening for emotional distress in cancer patients: a systematic review of assessment instruments
Vodermaier, A., Linden, W., & Siu, C. (2009) · JNCI Journal of the National Cancer Institute · doi:10.1093/jnci/djp336 · Cited by 541 · cited 2×
“Studies that have used structured psychiatric interviews suggest that the prevalence of major depressive disorder is approximately 15% in advanced cancer (Vodermaier et al., 2009).”
BackgroundScreening for Adjustment Disorders and Major Depressive Disorders in Cancer In-Patients
Razavi, D., Delvaux, N., Farvacques, C., & Robaye, E. (1990) · British Journal of Psychiatry · doi:10.1192/bjp.156.1.79 · Cited by 514
Psychological Sequelae of Cancer Diagnosis
Spijker, A. V., Trijsburg, R. W., & Duivenvoorden, H. J. (1997) · Psychosomatic Medicine · doi:10.1097/00006842-199705000-00011 · Cited by 511
Textbook in Psychiatric Epidemiology
(2002) · Wiley eBooks · doi:10.1002/0471234311 · Cited by 510
Söllner, W., DeVries, A., Steixner, E., Lukas, P., Sprinzl, G., Rumpold, G., & Maislinger, S. (2001) · British Journal of Cancer · doi:10.1054/bjoc.2000.1545 · Cited by 442
Screening for anxiety and depression in cancer patients: the effects of disease and treatment
Ibbotson, T., Maguire, P., Selby, P., Priestman, T., & Wallace, L. (1994) · European Journal of Cancer · doi:10.1016/s0959-8049(05)80015-2 · Cited by 421
Construct validation of the hospital anxiety and depression scale with clinical populations
Johnston, M., Pollard, B., & Hennessey, P. (2000) · Journal of Psychosomatic Research · doi:10.1016/s0022-3999(00)00102-1 · Cited by 383
Screening for Psychological Distress in Japanese Cancer Patients
Kugaya, A., Akechi, T., Okuyama, T., Okamura, H., & Uchitomi, Y. (1998) · Japanese Journal of Clinical Oncology · doi:10.1093/jjco/28.5.333 · Cited by 365
(1993) · PubMed · Cited by 349
Hospital anxiety and depression scale cutoff scores for cancer patients in acute care
Singer, S., Kuhnt, S., Götze, H., Hauss, J., Hinz, A., Liebmann, A., Krauß, O., Lehmann, A., & Schwarz, R. (2009) · British Journal of Cancer · doi:10.1038/sj.bjc.6604952 · Cited by 303
Hopwood, P., Howell, A., & Maguire, P. (1991) · British Journal of Cancer · doi:10.1038/bjc.1991.305 · Cited by 280
Mennella, J. A., & Mennella, J. A. (1997) · Nutrition Today · doi:10.1097/00017285-199707000-00003 · Cited by 266
Screening for depression in head and neck cancer
Katz, M. R., Kopek, N., Waldron, J., Devins, G. M., & Tomlinson, G. (2004) · Psycho-Oncology · doi:10.1002/pon.734 · Cited by 259
Mitchell, A. J. (2008) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.2053 · Cited by 247
Self-citationMoher, D., Cook, D. J., Eastwood, S., Olkin, I., Rennie, D., & Stroup, D. F. (2000) · Oncology Research and Treatment · doi:10.1159/000055014 · Cited by 235
Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach
Keller, M., Sommerfeldt, S., Fischer, C., Knight, L., Riesbeck, M., Löwe, B., Herfarth, C., & Lehnert, T. (2004) · Annals of Oncology · doi:10.1093/annonc/mdh318 · Cited by 235
Mitchell, A. J., Kaar, S. J., Coggan, C., & Herdman, J. (2007) · Psycho-Oncology · doi:10.1002/pon.1228 · Cited by 222
Self-citationSellick, S., & Edwardson, A. D. (2006) · Psycho-Oncology · doi:10.1002/pon.1085 · Cited by 186
Akizuki, N., Akechi, T., Nakanishi, T., Yoshikawa, E., Okamura, M., Nakano, T., Murakami, Y., & Uchitomi, Y. (2003) · Cancer · doi:10.1002/cncr.11358 · Cited by 184
Hall, A., A’Hern, R., & Fallowfield, L. J. (1999) · European Journal of Cancer · doi:10.1016/s0959-8049(98)00308-6 · Cited by 181
Factor analysis of the Hospital Anxiety and Depression Scale from a large cancer population
Smith, A. B., Selby, P. J., Velikova, G., Stark, D., Wright, P., Gould, A., & Cull, A. (2002) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608302169625 · Cited by 162
The Hospital Anxiety and Depression Scale
Snaith, R. P. (1992) · Psychiatric Bulletin · doi:10.1192/pb.16.7.451 · Cited by 156
Pascoe, S., Edelman, S., & KIDMAN, A. D. (2000) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/j.1440-1614.2000.00817.x · Cited by 155
Statistics notes: Bayesians and frequentists
Bland, J. M., & Altman, D. G. (1998) · BMJ · doi:10.1136/bmj.317.7166.1151 · Cited by 152
Fevre, P. L., Devereux, J., Smith, S. W., Lawrie, S. M., & Cornbleet, M. A. (1999) · Palliative Medicine · doi:10.1191/026921699671260095 · Cited by 152
Walker, J., Postma, K., McHugh, G. S., Rush, R., Coyle, B., Strong, V., & Sharpe, M. (2007) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2007.01.009 · Cited by 149
Does routine assessment and real-time feedback improve cancer patients' psychosocial well-being?
Boyes, A., Newell, S., Girgis, A., McElduff, P., & Sanson‐Fisher, R. (2005) · European Journal of Cancer Care · doi:10.1111/j.1365-2354.2005.00633.x · Cited by 137
Lloyd‐Williams, M., Friedman, T., & Rudd, N. (2001) · Journal of Pain and Symptom Management · doi:10.1016/s0885-3924(01)00358-x · Cited by 135
Schnoll, R. A., Harlow, L. L., Stolbach, L. L., & Brandt, U. (1998) · Psycho-Oncology · doi:10.1002/(sici)1099-1611(199803/04)7:2 · Cited by 133
Mitchell, A. J. (2008) · British Journal of Cancer · doi:10.1038/sj.bjc.6604396 · Cited by 125
Self-citationUse of the diagnostic criteria for psychosomatic research in oncology
Grassi, L., Sabato, S., Rossi, E., Biancosino, B., & Marmai, L. (2005) · Psychotherapy and Psychosomatics · doi:10.1159/000083168 · Cited by 123
Anxiety and depressive symptoms at different stages of malignant melanoma
Brandberg, Y., Bolund, C., Sigurðardóttir, V., Sjödén, P., & Sullivan, M. (1992) · Psycho-Oncology · doi:10.1002/pon.2960010204 · Cited by 107
Rodgers, J., Martin, C. R., Morse, R., Kendell, K., & Verrill, M. W. (2005) · Health and Quality of Life Outcomes · doi:10.1186/1477-7525-3-41 · Cited by 104
Love, A. W., Grabsch, B. E., Clarke, D. M., Bloch, S., & Kissane, D. W. (2004) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/j.1440-1614.2004.01385.x · Cited by 100
Love, A. W., Kissane, D. W., Bloch, S., & Clarke, D. M. (2002) · Australian & New Zealand Journal of Psychiatry · doi:10.1046/j.1440-1614.2002.01014.x · Cited by 97
Grassi, L. G., Sabato, S., Rossi, E. G., Marmai, L., & Biancosino, B. (2008) · Journal of Affective Disorders · doi:10.1016/j.jad.2008.07.016 · Cited by 91
Screening for Psychological Distress in Palliative Care: A Systematic Review
Thekkumpurath, P., Venkateswaran, C., Kumar, M., & Bennett, M. (2008) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2007.11.010 · Cited by 88
Predicting mood disorders in breast cancer patients
Morasso, G., Costantini, M., Viterbori, P., Bonci, F., Mastro, L. D., Musso, M., Garrone, O., & Venturini, M. (2001) · European Journal of Cancer · doi:10.1016/s0959-8049(00)00390-7 · Cited by 88
Which depression screening tools should be used in palliative care?
Lloyd‐Williams, M., Spiller, J. A., & Ward, J. (2003) · Palliative Medicine · doi:10.1191/0269216303pm664oa · Cited by 87
Martin, C. (2005) · Current Psychiatry Reviews · doi:10.2174/1573400052953510 · Cited by 84 · cited 1×
“, 1997) whilst others have not (Martin, 2005; Rodgers et al., 2005; Brandberg et al., 1992; Leung et al., 1993).”
BackgroundScreening for mental disorders in laryngeal cancer patients: a comparison of 6 methods
Singer, S., Danker, H., Dietz, A., Hornemann, B., Koscielny, S., Oeken, J., Matthäus, C., Vogel, H., & Krauß, O. (2007) · Psycho-Oncology · doi:10.1002/pon.1229 · Cited by 79
How do palliative medicine physicians assess and manage depression
Lawrie, I., Lloyd‐Williams, M., & Taylor, F. (2004) · Palliative Medicine · doi:10.1191/0269216304pm865oa · Cited by 77
Screening for mental disorders in cancer, cardiovascular and musculoskeletal diseases
Härter, M. C., Woll, S., Wunsch, A., Bengel, J., & Reuter, K. (2005) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-005-0992-0 · Cited by 76
Screening for psychiatric disorders in a lymphoma out-patient population
Razavi, D., Delvaux, N., Brédart, A., Paesmans, M., Debusscher, L., Bron, D., & Stryckmans, P. A. (1992) · European Journal of Cancer · doi:10.1016/0959-8049(92)90025-w · Cited by 70
Can mood disorder in women with breast cancer be identified preoperatively?
Ramirez, A., Richards, M., Jarrett, Sr., & Fentiman, I. (1995) · British Journal of Cancer · doi:10.1038/bjc.1995.538 · Cited by 67
Reuter, K., & Härter, M. C. (2001) · International Journal of Methods in Psychiatric Research · doi:10.1002/mpr.103 · Cited by 49
Symptom Scales and Diagnostic Schedules in Adult Psychiatry
Murphy, J. M. (2011) · Wiley eBooks · doi:10.1002/9780470976739.ch13 · Cited by 48
Özalp, E., Soygür, H., Cankurtaran, E. Ş., Turhan, L., Akbıyık, D. İ., & Geyik, P. Ö. (2007) · Psycho-Oncology · doi:10.1002/pon.1286 · Cited by 48
Screening for depressive symptoms in patients with unresectable lung cancer
Néron, S., Correa, J. A., Dajczman, E., Kasymjanova, G., Kreisman, H., & Small, D. I. (2007) · Supportive Care in Cancer · doi:10.1007/s00520-007-0225-z · Cited by 43
Hosaka, T., Awazu, H., Aoki, T., Okuyama, T., & Yamawaki, S. (1999) · International Journal of Psychiatry in Clinical Practice · doi:10.3109/13651509909024758 · Cited by 39
Depression in lung cancer patients: is the HADS an effective screening tool?
Castelli, L., Binaschi, L., Caldera, P., & Torta, R. (2009) · Supportive Care in Cancer · doi:10.1007/s00520-009-0604-8 · Cited by 36
Reeve, J. L., Lloyd‐Williams, M., & Dowrick, C. F. (2008) · Palliative Medicine · doi:10.1177/0269216307087953 · Cited by 36
Morse, R., Kendell, K., & Barton, S. B. (2005) · Clinical Effectiveness in Nursing · doi:10.1016/j.cein.2006.08.012 · Cited by 28
Miklavcic, Snoj, Z., Mlakar, J., & Pregelj, P. (2008) · PubMed · Cited by 18
The prevalence of psychological distress by cancer site
Zabora, J., BrintzenhofeSzoc, K., Curbow, B., Hooker, C., & Piantadosi, S. (2001) · Psycho-Oncology · doi:10.1002/1099-1611(200101/02)10:1
Research works printed but not linked: 1
- Berard, 1998, Depressive disorders in an out-patient oncology setting: prevalence, assessment, and management, Psychooncology, 7, 112, 10.1002/(SICI)1099-1611(199803/04)7:2<112::AID-PON300>3.0.CO;2-W · DOI
Cited by
Sorted by citations
Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., & Meader, N. (2011) · The Lancet Oncology · doi:10.1016/s1470-2045(11)70002-x · Cited by 2,449
Self-citationMitchell, A. J., Ferguson, D. W., Gill, J., Paul, J., & Symonds, P. (2013) · The Lancet Oncology · doi:10.1016/s1470-2045(13)70244-4 · Cited by 749
Self-citationThe Hospital Anxiety and Depression Scale: A meta confirmatory factor analysis
Norton, S., Cosco, T. D., Doyle, F., Done, J., & Sacker, A. (2012) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2012.10.010 · Cited by 426
Anxiety and Depression in Cancer Survivors
Yi, J. C., & Syrjala, K. L. (2017) · Medical Clinics of North America · doi:10.1016/j.mcna.2017.06.005 · Cited by 389
Bocéréan, C., & Dupret, É. (2014) · BMC Psychiatry · doi:10.1186/s12888-014-0354-0 · Cited by 347
Metadata
- Authors
- Mitchell, A. J., Meader, N., & Symonds, P.
- Affiliations
- University of Leicester (GB)
- University College London (GB)
- Corresponding author
- Mitchell, Alex J.
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 2010-11
- Volume
- 126
- Issue
- 3
- Pages
- 335-348
- ISSN
- 0165-0327 (ISSN-L)
- OpenAlex
- W2108265793
- Cited by
- 394
- References
- 69
- Citations by year
- 2026: 25 · 2025: 17 · 2024: 31 · 2023: 23 · 2022: 33 · 2021: 31 · 2020: 26 · 2019: 26 · 2018: 22 · 2017: 29 · 2016: 28 · 2015: 22 · 2014: 23 · 2013: 12 · 2012: 21
- FWCI
- 1.97
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Affective Disorders (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Keywords
- Hospital Anxiety and Depression Scale, diagnostic validity, cancer-related depression, cancer-related anxiety, palliative care, psychiatric distress, screening tool, case finding, sensitivity and specificity, mental health screening
- MeSH terms
- Adjustment Disorders, Anxiety Disorders, Depressive Disorder, Hospitalization, Humans, Interview, Psychological, Mass Screening, Neoplasms, Palliative Care, Psychiatric Status Rating Scales, Psychometrics, Reproducibility of Results
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