Bifactor analysis and construct validity of the HADS: A cross-sectional and longitudinal study in fibromyalgia patients
Abstract
The dimensionality of the Hospital Anxiety and Depression Scale (HADS) is a current source of controversy among experts. The present study integrates a solid theoretical framework (Clark & Watson's, 1991, tripartite theory) and a fine-grained methodological approach (structural equation modeling; SEM) to examine the dimensionality and construct validity of the HADS in fibromyalgia (FM) patients. Using the HADS data of 269 Spanish patients with FM, we estimated the cross-sectional and, for the first time, longitudinal fit (autoregressive model) of 2 competing models (oblique 2-factor vs. bifactor) via confirmatory factor analysis. The pattern of relationships between the HADS latent dimensions and positive and negative affect (PA and NA) was analyzed using SEM. HADS reliability was assessed by computing the omega and omega hierarchical coefficients. The bifactor model, which accounted for the covariance among HADS items with regard to 1 general factor (psychological distress) and 2 specific factors (depression and anxiety), described the HADS structure better than the original oblique 2-factor model during both study periods. All latent dimensions of the bifactor model were temporally stable. The SEM analysis revealed a significant link between psychological distress and NA as well as between depression and low PA. Only the general factor of psychological distress showed adequate reliability. In conclusion, the HADS shows a clear bifactor structure among FM patients. Our results indicate that it is not recommendable to compute anxiety and depression scores separately because anxiety variance is tapped primarily by the broader construct of psychological distress, and both specific dimensions show low reliability.
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The Spanish version of the HADS presents strong psychometric properties in the general population and in patients with fibromyalgia, with high internal consistency (α = 0.80-0.85).
“The Spanish version of the HADS presents strong psychometric properties in the general population and in patients with fibromyalgia, with high internal consistency (α = 0.80–0.85) [20,21].”
From Attachment-Based Compassion Therapy for Reducing Anxiety and Depression in Fibromyalgia (2022) · cites this paper as [21]
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- Authors
- Luciano, J. V., Barrada, J. R., Aguado, J., Osma, J., & García-Campayo, J.
- Affiliations
- Parc Sanitari Sant Joan de Déu (ES)
- Universidad de Zaragoza (ES)
- Venue
- Psychological Assessment
- Published
- 2014-06
- Volume
- 26
- Issue
- 2
- Pages
- 395-406
- ISSN
- 1040-3590 (ISSN-L)
- 1939-134X
- OpenAlex
- W2001678161
- Cited by
- 62
- References
- 57
- Citations by year
- 2026: 6 · 2025: 6 · 2024: 1 · 2023: 2 · 2022: 5 · 2021: 4 · 2020: 10 · 2019: 11 · 2018: 3 · 2017: 5 · 2016: 3 · 2015: 4 · 2014: 2
- FWCI
- 4.09
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychological Assessment (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Institute of Health Carlos III (PI09/90301)
- Topics
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
- Keywords
- Hospital Anxiety and Depression Scale, bifactor model, construct validity, fibromyalgia, dimensionality, psychological distress, anxiety, depression, positive and negative affect, temporal stability, reliability statistics, omega hierarchical
- MeSH terms
- Adult, Aged, Anxiety Disorders, Cross-Sectional Studies, Depressive Disorder, Factor Analysis, Statistical, Female, Fibromyalgia, Humans, Longitudinal Studies, Male, Middle Aged, Psychiatric Status Rating Scales, Psychometrics, Surveys and Questionnaires, Severity of Illness Index, Spain, Reproducibility of Results
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