Cited by 436Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMultiple Sclerosis Research StudiesCancer survivorship and care

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Validation of the Hospital Anxiety and Depression Scale for use with multiple sclerosis patients

Honarmand, Kimia, Feinstein, Anthony·2009·Multiple Sclerosis Journal

DOI 10.1177/1352458509347150

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Abstract

Detecting clinically significant symptoms of depression and anxiety in medically ill patients using self-report rating scales presents a challenge because of somatic confounders. The Hospital Anxiety and Depression Scale (HADS) was developed with this in mind, but has never been validated for a multiple sclerosis population. Our objective was to validate the HADS for multiple sclerosis patients. Multiple sclerosis patients were interviewed for the presence of major depression (n = 180) and anxiety disorders (n = 140) with the Structured Clinical Interview for DSM-IV disorders. A receiver operating characteristic (ROC) analysis was undertaken to assess which HADS cut-off scores give the best yield with respect to diagnoses of major depression and all anxiety disorders defined by the Structured Clinical Interview for DSM-IV. A threshold score of 8 or greater on the HADS depression subscale provides a sensitivity of 90% and specificity of 87.3% (ROC area under the curve 0.938). The same cut-off score gives a sensitivity of 88.5% and a specificity of 80.7% on the anxiety subscale (ROC area under the curve 0.913), but for generalized anxiety disorder only. The study confirms the usefulness of the HADS as a marker of major depression and generalized anxiety disorder, but not other anxiety disorders, in multiple sclerosis patients.

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Background
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“[5] Questionnaires such as Hospital Anxiety and Depression Scale may be used as a quick screening tool.[6] Further input from a neuropsychologist or psychiatrist may be necessary.”
Method
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Method
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Method
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BackgroundInfluential
Development of the Multiple Sclerosis Resiliency Scale (MSRS).
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“…distress (Black & Dorstyn, 2015; Stewart & Yuen, 2011; Trivedi et al., 2011), the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983), a 14-item questionnaire with separate anxiety and depression subscales that has been validated in MS (Honarmand & Feinstein, 2009), was included.”
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Self-citation
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Self-citation
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Method
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Background
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Method
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Background
Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A) for detecting anxiety disorders in adults
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de Vries, R. M. V. D. V., van den Dorpel, J. J. A., Mescheriakova, J. Y., Runia, T. F., Jafari, N., Siepman, T. A. M., Rizopoulos, D., Steyerberg, E. W., & Hintzen, R. Q. (2017) · Multiple Sclerosis Journal · doi:10.1177/1352458517709348 · Cited by 20
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“It has been proposed that a depression subscore (score D) greater than 8 constitutes a significant depressive trait (Honarmand and Feinstein, 2009).”
Background
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“Exclusion criteria are [1] diagnosis of primary PMS (PPMS), [2] relapse within 3 months before baseline visit, [3] severe comorbidity, objectified as a score ≥ 3 in 1 or more organ systems on the Cumulative Illness Rating Scale (CIRS) [36], [4] initiation of fampridine within 6 months of baseline, [5] severe depressio…”
Method
The emotional disorders associated with multiple sclerosis
Raimo, S., Santangelo, G., & Trojano, L. (2021) · Handbook of clinical neurology · doi:10.1016/b978-0-12-822290-4.00009-8 · Cited by 20
Cognitive Behavioral Therapy for Insomnia (CBT-I) for an Adult With Multiple Sclerosis
Majendie, C. M. A., Dysch, L., & Carrigan, N. (2016) · Clinical Case Studies · doi:10.1177/1534650116674594 · Cited by 22
“…have good validity and consistency (Bjelland, Dahl, Haug, & Neckelmann, 2002), not just for patients from non-psychiatric hospital clinics for whom it was developed, but also when used as a marker for depression and generalized anxiety disorders in the MS population (Honarmand & Feinstein, 2009).”
Background
Polish validation of the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS battery): correlation of cognitive impairment with mood disorders and fatigue
Betscher, E., Guenter, W., Langdon, D. W., & Bonek, R. (2020) · Neurologia i Neurochirurgia Polska · doi:10.5603/pjnns.a2020.0080 · Cited by 19
“The HADS has been validated in MS [31].”
Method
Cognitive performance shows domain specific associations with regional cortical thickness in multiple sclerosis
Stellmann, J., Wanke, N., Maarouf, A., Gellißen, S., Heesen, C., Audoin, B., Gold, S. M., Zaaraoui, W., & Poettgen, J. (2021) · NeuroImage Clinical · doi:10.1016/j.nicl.2021.102606 · Cited by 19
The manifestation of affective symptoms in multiple sclerosis and discussion of the currently available diagnostic assessment tools
Filser, M., Buchner, A., Fink, G. R., Gold, S. M., & Penner, I. (2022) · Journal of Neurology · doi:10.1007/s00415-022-11359-6 · Cited by 18
“Therefore, research has already addressed the need for improvement in diagnosing depression [74, 75] and anxiety [70, 72, 75] in MS.”
Background
Psychological symptoms and perceived cognitive impairment in multiple sclerosis: The role of rumination.
Malivoire, B. L., Hare, C. J., & Hart, T. L. (2018) · Rehabilitation Psychology · doi:10.1037/rep0000180 · Cited by 18
Developing a measure to assess identity reconstruction in patients with multiple sclerosis.
Stepleman, L. M., Floyd, R. M., Valvano, A. K., Penwell-Waines, L., Wonn, S., Crethers, D., Rahn, R., & Smith, S. E. (2017) · Rehabilitation Psychology · doi:10.1037/rep0000126 · Cited by 18
“The Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) is a validated self-report instrument assessing current symptoms of anxiety and depression in medical populations, such as multiple sclerosis (Honarmand & Feinstein, 2009).”
BackgroundMethod
Psychological and physical predictors of illness intrusiveness in patients with multiple sclerosis
Snyder, S., Foley, F. W., Farrell, E., Beier, M. L., & Zemon, V. M. (2013) · Journal of the Neurological Sciences · doi:10.1016/j.jns.2013.06.009 · Cited by 18
“The HADS has been validated for use with multiple sclerosis patients [16].”
Method
Depression and Anxiety in Multiple Sclerosis Patients: The Role of Genetic Variability of Interleukin 1β
Ferreira, A. M., Leal, B., Ferreira, I., Brás, S., Moreira, I., Samões, R., Sousa, A. P., Santos, E., Silva, B., Costa, P. P., et al. (2021) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2021.102982 · Cited by 17
The relational impact of multiple sclerosis: an integrative review of the literature using a cognitive analytic framework
Blundell Jones, J., Walsh, S., & Isaac, C. (2017) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-017-9506-y · Cited by 17
“While research has revealed that MS affects emotional wellbeing (Honarmand & Feinstein, 2009) for a variety of reasons, the role that relationships play cannot be overlooked.”
Background
The effects of relaxation training on depression and anxiety in people living with long-term neurological conditions
Hampson, N., King, L., Eriksson, L.-M., & Smee, H. (2019) · Disability and Rehabilitation · doi:10.1080/09638288.2018.1554009 · Cited by 17
The relation between goal adjustment, goal disturbance, and mental well-being among persons with multiple sclerosis
Damme, S. V., Kindt, S., Crombez, G., Goubert, L., & Debruyne, J. (2019) · Psychology and Health · doi:10.1080/08870446.2018.1556272 · Cited by 17
Is there a multiple sclerosis personality? Personality characteristics in newly diagnosed multiple sclerosis and association with mood and cognition
Chu, L., Casserly, C. S., Rosehart, H., & Morrow, S. A. (2022) · Journal of the Neurological Sciences · doi:10.1016/j.jns.2022.120145 · Cited by 17
The association of pathological laughing and crying and cognitive impairment in multiple sclerosis
Hanna, J., Feinstein, A., & Morrow, S. A. (2016) · Journal of the Neurological Sciences · doi:10.1016/j.jns.2016.01.002 · Cited by 17
“The HADS is a sensitive and specific measure of major depression and general anxiety validated in MS, with a score of 8 or above on either the depression scale (HADS-D) or anxiety scale (HADS-A) indication of the presence of that symptom [18].”
BackgroundMethodInfluentialSelf-citation
The link between depression and performance on the Symbol Digit Modalities Test: Mechanisms and clinical significance
Patel, V. P., & Feinstein, A. (2018) · Multiple Sclerosis Journal · doi:10.1177/1352458518770086 · Cited by 17
Self-citation
EMDR treatment for anxiety in MS patients: A pilot study
Wallis, O. C., & de Vries, J. (2020) · Multiple Sclerosis Journal - Experimental, Translational and Clinical · doi:10.1177/2055217320974388 · Cited by 16
“Previous studies have used different cut-off scores ranging from eight or higher to 11 or higher to classify anxiety.(34) However, patient 5 started with an anxiety score of nine, but did benefit from treatment, thus supporting the cut-off value used here.”
Method
Outcome registry of early intensive neurorehabilitation in patients with disorders of consciousness: study protocol of a prospective cohort study
Driessen, D. M. F., Utens, C. M. A., Ribbers, G. M., van Erp, W. S., & Heijenbrok‐Kal, M. H. (2021) · BMC Neurology · doi:10.1186/s12883-021-02099-7 · Cited by 16
Serum vitamin d inversely correlates with depression scores in people with multiple sclerosis
El‐Salem, K., Khalil, H. W., Al‐Sharman, A., Al-Mistarehi, A.-H. W., Yassin, A., Al‐Hayk, K., Qawasmeh, M. A., Bashayreh, S. Y., Kofahi, R. M., & Obeidat, A. Z. (2021) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2020.102732 · Cited by 16
The Interactive Web-Based Program MSmonitor for Self-Management and Multidisciplinary Care in Persons With Multiple Sclerosis: Quasi-Experimental Study of Short-Term Effects on Patient Empowerment
Jongen, P. J., ter Veen, G., Lemmens, W. A. J. G., Donders, R., van Noort, E., & Zeinstra, E. (2020) · Journal of Medical Internet Research · doi:10.2196/14297 · Cited by 16
“On indication Honarmand and Feinstein [30]; Watson et al [31] 0-21 (lower=better); 021 (lower=better) 7 items (0-3); 7 items (0-3) Anxiety in past week; depression in past week HADSj questionnaire”
BackgroundMethod
A mindfulness group intervention in newly diagnosed persons with multiple sclerosis: A pilot study
Morrow, S. A., Riccio, P. M., Vording, N., Rosehart, H., Casserly, C. S., & MacDougall, A. G. (2021) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2021.103016 · Cited by 16
Effects of Robot-Assisted Gait Training in Patients With Multiple Sclerosis
Özsoy-Ünübol, T., Ata, E., Cavlak, M., Demir, S., Candan, Z., & Yılmaz, F. (2021) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000001913 · Cited by 15
“Each subscale has seven items and each item is rated on a scale of 0 to 3; thus, each subscale score ranges from 0 to 21.(20) The EDSS was performed to evaluate the severity of MS.”
Method
Comparison of the accuracy of the 7-item HADS Depression subscale and 14-item total HADS for screening for major depression: A systematic review and individual participant data meta-analysis.
Wu, Y., Levis, B., Daray, F. M., Ioannidis, J. P. A., Patten, S. B., Cuijpers, P. J., Ziegelstein, R. C., Gilbody, S. M., Fischer, F. H., Fan, S., et al. (2023) · Psychological Assessment · doi:10.1037/pas0001181 · Cited by 17
Self-citation
A survey study comparing young adults with MS and healthy controls on self-esteem, self-efficacy, mood and quality of life
Uccelli, M. M., Traversa, S., & Ponzio, M. (2016) · Journal of the Neurological Sciences · doi:10.1016/j.jns.2016.07.039 · Cited by 15
“A HADS score of ≥8 for anxiety or depression was considered indicative of the probable presence of a mood disorder [23].”
Contrasting relationship between depression, quantitative gait characteristics and self-report walking difficulties in people with multiple sclerosis
Kalron, A., & Aloni, R. (2017) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2017.10.012 · Cited by 15
“The selected cut-off point was based on Honarmand and Feinstein's (2009) study that validated the HADS with the Structured Clinical Interview for DSM-IV Disorders and its defined scores for depressed and non-depressed (Honarmand and Feinstein, 2009).”
Factors associated with perceived need for mental health care in multiple sclerosis
Orr, J., Bernstein, C. N., Graff, L. A., Patten, S. B., Bolton, J. M., Sareen, J., Marriott, J. J., Fisk, J. D., & Marrie, R. A. (2018) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2018.07.043 · Cited by 15
Sexual Dysfunction in Patients with Multiple Sclerosis from Argentina: What are the Differences Between Women and Men?
Contentti, E. C., Pettinicchi, J. P., Caride, A., & López, P. A. (2019) · Sexuality and Disability · doi:10.1007/s11195-019-09603-5 · Cited by 17
Discontinuing cannabis improves depression in people with multiple sclerosis: A short report
Feinstein, A., Meza, C., Stefan, C., & Staines, R. W. (2020) · Multiple Sclerosis Journal · doi:10.1177/1352458520934070 · Cited by 15
Self-citation
Association between limbic system lesions and anxiety in persons with multiple sclerosis.
Hillyer, A., Sharma, M., Kuurstra, A., Rosehart, H., Menon, R., & Morrow, S. (2023) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2023.105021 · Cited by 12
Don’t be late! Postponing cognitive decline and preventing early unemployment in people with multiple sclerosis: a study protocol
Aarts, J., Saddal, S. R. D., Bosmans, J. E., de Groot, V., de Jong, B. A., Klein, M., Ruitenberg, M. F. L., Schaafsma, F. G., Schippers, E. C. F., Schoonheim, M. M., et al. (2024) · BMC Neurology · doi:10.1186/s12883-023-03513-y · Cited by 15
“Mood and anxiety will be tested using the Hospital Anxiety and Depression Scale (HADS) [80] which has been validated in PwMS [81].”
Method
Mobile Health App (DIGICOG-MS) for Self-Assessment of Cognitive Impairment in People With Multiple Sclerosis: Instrument Validation and Usability Study
Podda, J., Tacchino, A., Ponzio, M., Antonio, F. D., Susini, A., Pedullà, L., Battaglia, M. A., & Brichetto, G. (2024) · JMIR Formative Research · doi:10.2196/56074 · Cited by 14
“Furthermore, patient-reported outcomes (PROs) were assessed for self-reported mood (Hospital Anxiety and Depression Scale [HADS]) [31], upper-limb functionality (Arm Function in Multiple Sclerosis Questionnaire [AMSQ]) [32], and impact of MS (Multiple Sclerosis Impact Scale [MSIS-29]) [33].”
Method
Perceived and objective cognitive impairment in newly diagnosed versus established multiple sclerosis: impact of disease duration
McNicholas, N., Tubridy, N. J., Hutchinson, M., & McGuigan, C. (2020) · Irish Journal of Medical Science (1971 -) · doi:10.1007/s11845-020-02404-2 · Cited by 14
Safety of low-intensity repetitive transcranial magneTic brAin stimUlation foR people living with mUltiple Sclerosis (TAURUS): study protocol for a randomised controlled trial
Makowiecki, K., Stevens, N. J., Cullen, C. L., Zarghami, A., Nguyen, P. T., Johnson, L., Rodger, J., Hinder, M. R., Barnett, M. H., Young, K. M., et al. (2022) · Trials · doi:10.1186/s13063-022-06526-z · Cited by 12
“Hospital Anxiety and Depression Scale: GL Assessment; Available from: https:// www. gl- asses sment. co. uk/ asses sments/ produ cts/? name= HADS.”
BackgroundMethodInfluential
Work difficulties in people with multiple sclerosis: The role of anxiety, depression and coping
van Egmond, E. E. A., van der Hiele, K., van Gorp, D., Jongen, P. J., van der Klink, J., Reneman, M., Beenakker, E. A. C., van Eijk, J., Frequin, S. T. F. M., de Gans, K., et al. (2022) · Multiple Sclerosis Journal - Experimental Translational and Clinical · doi:10.1177/20552173221116282 · Cited by 14
“A cut-off score of 8 is regarded as indicative of probable depression and/or probable generalized anxiety in people with MS in the respective subscales.(27)”
Background
Pain-related illness intrusiveness is associated with lower activity engagement among persons with multiple sclerosis
Gromisch, E. S., Kerns, R. D., & Beauvais, J. E. (2019) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2019.101882 · Cited by 14
Measuring the effects of nurse practitioner (NP)-led care on depression and anxiety levels in people with multiple sclerosis: a study protocol for a randomized controlled trial
Smyth, P. S., Watson, K. E., & Tsuyuki, R. T. (2021) · Trials · doi:10.1186/s13063-021-05726-3 · Cited by 13
“Keywords: Multiple sclerosis, Depression, Anxiety, Nurse practitioner, Patient satisfaction, Healthcare delivery, HADS”
BackgroundMethodInfluential
The effect of nurse practitioner (NP-led) care on health-related quality of life in people with multiple sclerosis – a randomized trial
Smyth, P. S., Watson, K. E., Hamarneh, Y. N. A., & Tsuyuki, R. T. (2022) · BMC Neurology · doi:10.1186/s12883-022-02809-9 · Cited by 13
“Using the information from Honarmand and Feinstein [41], [Baseline scores and standard deviation (SD)] and the following assumptions 80% power and a two-sided alpha of 0.025, a total sample size of 200 (100 in each group) was required to detect 1.5 difference [41] between the intervention and the control groups.”
BackgroundMethodInfluential
Perceived illness-related uncertainty among patients with mid-stage relapsing-remitting multiple sclerosis
Sabín, J., Salas, E., Martín-Martínez, J., Candeliere-Merlicco, A., Barrero, F. J., Alonso, A., Sánchez-Menoyo, J. L., Borrega, L., Rodríguez-Rodríguez, M., Gómez-Gutiérrez, M., et al. (2024) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2024.105861 · Cited by 13
The mediating role of processing speed in the relationship between depressive symptoms and cognitive function in multiple sclerosis
Blair, M., Gill, S., Gutmanis, I., Smolewska, K., Warriner, E. M., & Morrow, S. A. (2016) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2016.1164124 · Cited by 13
“…& Snaith, 1983) and the Beck Depression Inventory–Fast Screen (BDIFS; Beck, Steer, & Brown, 2000), both of which are validated measures of depression in MS (Benedict, Fishman, McClellan, Bakshi, & Weinstock-Guttman, 2003; Honarmand & Feinstein, 2009; Watson, Ford, Worthington, & Lincoln, 2014).”
The longitudinal relationship between fatigue, depression, anxiety, disability, and adherence with cognitive status in patients with early multiple sclerosis treated with interferon beta-1a
van Ballegooijen, H., van der Hiele, K., Enzinger, C., de Voer, G., & Visser, L. H. (2022) · eNeurologicalSci · doi:10.1016/j.ensci.2022.100409 · Cited by 13
“HADS scores were analyzed dichotomously to evaluate clinically meaningful changes: patients with a score < 8 were considered not anxious or not depressed, whereas patients with a score ≥ 8 were considered anxious or depressed [17].”
Method
Testing the health promotion model for adherence and quality of life in individuals with multiple sclerosis
Penwell-Waines, L., Lewis, K., Valvano, A. K., Smith, S. E., Rahn, R., & Stepleman, L. M. (2016) · Psychology Health & Medicine · doi:10.1080/13548506.2016.1226506 · Cited by 13
“Hospital anxiety and depression scale This 14-item self-report measure of symptoms of depression and anxiety was developed specifically for use in non-psychiatric medical settings (Zigmond & Snaith, 1983), including MS (Honarmand & Feinstein, 2009).”
Method
Anxiety in Argentinian patients with multiple sclerosis: Prevalence and associated factors
Chertcoff, A. S., Curbelo, M. C., Bauer, J. J., Ferrandina, F., Martinez, A., Steinberg, J. D., & Carrá, A. (2020) · Multiple Sclerosis and Related Disorders · doi:10.1016/j.msard.2020.102042 · Cited by 13
Daily hassles reported by Dutch multiple sclerosis patients
van der Hiele, K., Kamminga, N. G. A., Ruimschotel, R. P., Middelkoop, H. A. M., & Visser, L. H. (2012) · Journal of the Neurological Sciences · doi:10.1016/j.jns.2012.06.023 · Cited by 13
“Although they cannot replace a structured clinical interview, self-reports of disability, depression, and anxiety in MS were considered reliable as compared with clinician-derived data [24,31,32].”
BackgroundMethod
Psychological determinants of job retention in multiple sclerosis
Ford, H. L., Wicks, C. R., Stroud, A., & Tennant, A. (2018) · Multiple Sclerosis Journal · doi:10.1177/1352458518754362 · Cited by 12
Interhermispheric inhibition predicts anxiety levels in multiple sclerosis: A corticospinal excitability study
Chalah, M. A., Palm, U., Lefaucheur, J., Créange, A., & Ayache, S. S. (2018) · Brain Research · doi:10.1016/j.brainres.2018.08.029 · Cited by 12
The impact of social capital on patients with multiple sclerosis
Reyes, S., Suárez, S., Allen‐Philbey, K., Thomson, A., & Giovannoni, G. (2020) · Acta Neurologica Scandinavica · doi:10.1111/ane.13244 · Cited by 12

Authors: Honarmand, K., & Feinstein, A.
Affiliations: Sunnybrook Health Science Centre (CA)
ORCID: Honarmand, Kimia
Feinstein, Anthony
Venue: Multiple Sclerosis Journal
Publisher: SAGE Publications
Published: 2009-11-13
Volume: 15
Issue: 12
Pages: 1518-1524
ISSN: 1352-4585 (ISSN-L)
1477-0970
DOI: 10.1177/1352458509347150
OpenAlex: W2114728329
Cited by: 436
References: 43
Citations by year: 2026: 23 · 2025: 32 · 2024: 36 · 2023: 31 · 2022: 34 · 2021: 43 · 2020: 23 · 2019: 27 · 2018: 34 · 2017: 26 · 2016: 32 · 2015: 26 · 2014: 23 · 2013: 12 · 2012: 15
FWCI: 14.36
Type: journal article
Language: en
Open access: closed
Licence: journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations: Multiple Sclerosis Journal (publishedVersion)
PubMed (publishedVersion)
Funders: Multiple Sclerosis Society
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Health Sciences › Medicine › Clinical Neurology › Multiple Sclerosis Research Studies
Health Sciences › Medicine › Oncology › Cancer survivorship and care
Keywords: Hospital Anxiety and Depression Scale, multiple sclerosis, depression, anxiety disorders, generalized anxiety disorder, psychometric validation, cut-off values, sensitivity and specificity, self-report scale
MeSH terms: Adolescent, Adult, Aged, Anxiety Disorders, Major Depressive Disorder, Female, Humans, Male, Middle Aged, Multiple Sclerosis, Predictive Value of Tests, Psychiatric Status Rating Scales, Surveys and Questionnaires, ROC Curve, Sensitivity and Specificity, Severity of Illness Index, Reproducibility of Results, Logistic Models, Young Adult

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Validation of the Hospital Anxiety and Depression Scale for use with multiple sclerosis patients

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