Bifactor analysis of the hospital anxiety and depression scale (HADS) in individuals with traumatic brain injury
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Abstract
Anxiety and depression symptoms are commonly experienced after traumatic brain injury (TBI). However, studies validating measures of anxiety and depression for this population are scarce. Using novel indices derived from symmetrical bifactor modeling, we evaluated whether the Hospital Anxiety and Depression Scale (HADS) reliably differentiated anxiety and depression in 874 adults with moderate-severe TBI. The results showed that there was a dominant general distress factor accounting for 84% of the systematic variance in HADS total scores. The specific anxiety and depression factors accounted for little residual variance in the respective subscale scores (12% and 20%, respectively), and overall, minimal bias was found in using the HADS as a unidimensional measure. Further, in a subsample of 184 participants, the HADS subscales did not clearly discriminate between formal anxiety and depressive disorders diagnosed via clinical interview. Results were consistent when accounting for degree of disability, non-English speaking background, and time post-injury. In conclusion, variance in HADS scores after TBI predominately reflects a single underlying latent variable. Clinicians and researchers should exercise caution in interpreting the individual HADS subscales and instead consider using the total score as a more valid, transdiagnostic measure of general distress in individuals with TBI.
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Previous studies have found that a minimal clinically important difference on the HADS subscales should likely fall above 1.7.
“Previous studies have found that a minimal clinically important difference on the HADS sub scales should likely fall above 1.7 [40].”
From Acceptance and commitment therapy for people with depressive and anxiety symptoms following acquired brain injury: Results of the BrainACT randomized controlled trial. (2024) · cites this paper as [40]
In Methods and results (Hypothesis 3), the paper reports that previous studies in patients with cardiovascular or lung disease suggest HADS subscale MCIDs of 1.7–2.5 raw points. This supports the general point, but not a threshold strictly above 1.7; the paper also says MCIDs have not been studied specifically in traumatic brain injury. (LLM, conf=0.83)
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References 99 · Cited by 20
Research works printed but not linked: 3
- [42]First, M. B., Spitzer, R. L., Gibbon, M. & Williams, J. B. W. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition (SCID-I/NP) (2002).
- [62]Stucky BD Edelen MO Reise SP Revicki DA Using hierarchical IRT models to create unidimensional measures from multidimensional data Handbook of Item Response Theory Modeling: Applications to Typical Performance Assessment 2014 Routledge/Taylor & Francis Group 183 206
- [97]Roberts, C., Jäckle, A. & Lynn, P. Causes of mode effects: Separating out interviewer and stimulus effects in comparisons of face-to-face and telephone surveys. In Proc. Survey Research Methods Section 4221–4228. http://www.asasrms.org/Proceedings/y2006f.html (American Statistical Association, 2006).
- Authors
- Carmichael, J., Spitz, G., Gould, K. R., Johnston, L., Samiotis, A., & Ponsford, J.
- Affiliations
- Epworth Hospital (AU)
- Corresponding author
- Carmichael, Jai
- Venue
- Scientific Reports
- Published
- 2023-05-17
- Volume
- 13
- Issue
- 1
- Pages
- 8017-8017
- ISSN
- 2045-2322 (ISSN-L)
- PMC
- PMC10192445
- OpenAlex
- W4377010420
- Cited by
- 20
- References
- 99
- Citations by year
- 2026: 6 · 2025: 7 · 2024: 5 · 2023: 2
- FWCI
- 5.16
- Type
- journal article
- Language
- en
- Update notices
- correction (2023-06-12)
- Open access
- gold
- doi.org
- Locations
- Scientific Reports (publishedVersion, cc-by)
- Research Square (acceptedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Transport Accident Commission (135)
- Australian Government (Research Training Program (RTP) Scholarship)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
- Keywords
- traumatic brain injury, Hospital Anxiety and Depression Scale, anxiety, depression, bifactor analysis, measurement validity, unidimensional measurement
- MeSH terms
- Brain Injuries, Traumatic, Adult, Anxiety, Anxiety Disorders, Depression, Hospitals, Humans, Psychometrics
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