The minimal important difference of the hospital anxiety and depression scale in patients with chronic obstructive pulmonary disease
Open accessAbstract
BACKGROUND: Interpretation of the Hospital Anxiety and Depression Scale (HADS), commonly used to assess anxiety and depression in COPD patients, is unclear. Since its minimal important difference has never been established, our aim was to determine it using several approaches. METHODS: 88 COPD patients with FEV1 </= 50% predicted completed the HADS and other patient-important outcome measures before and after an inpatient respiratory rehabilitation. For the anchor-based approach we determined the correlation between the HADS and the anchors that have an established minimal important difference (Chronic Respiratory Questionnaire [CRQ] and Feeling Thermometer). If correlations were >/= 0.5 we performed linear regression analyses to predict the minimal important difference from the anchors. As distribution-based approach we used the Effect Size approach. RESULTS: Based on CRQ emotional function and mastery domain as well as on total scores, the minimal important difference was 1.41 (95% CI 1.18-1.63) and 1.57 (1.37-1.76) for the HADS anxiety score and 1.68 (1.48-1.87) and 1.60 (1.38-1.82) for the HADS total score. Correlations of the HADS depression score and CRQ domain and Feeling Thermometer scores were < 0.5. Based on the Effect Size approach the MID of the HADS anxiety and depression score was 1.32 and 1.40, respectively. CONCLUSION: The minimal important difference of the HADS is around 1.5 in COPD patients corresponding to a change from baseline of around 20%. It can be used for the planning and interpretation of trials.
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The effect size in terms of total mean affective symptoms was small, but previous evidence suggests treatment effects are in the range important to patients.
“The effect size in terms of the total mean affective symptoms was small, but previous evidence where researchers set out to calculate what a clinically important difference would be on the hospital anxiety and depression scale, suggests that treatment effects are in the range that is important to patients.35”
From Clinical effectiveness of a manual based coping strategy programme (START, STrAtegies for RelaTives) in promoting the mental health of carers of family members with dementia: pragmatic randomised controlled trial (2013) · cites this paper as [35]
The Results estimate a minimal important difference of about 1.5 HADS points in patients with COPD. The Discussion reports a rehabilitation trial whose depression-score reduction exceeded that threshold, but describes its anxiety-score reduction as only borderline important. The paper does not assess the citing study’s treatment effects, and cautions that its threshold may not generalize beyond COPD. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe minimal clinically important difference of subscale scores for anxiety and depression were 1.32 and 1.40 in pulmonary diseases.
“the MCID of subscale scores for anxiety and depression were 1.32 and 1.40 in pulmonary diseases, respectively52.”
From A randomized clinical trial of mindfulness meditation versus exercise in Parkinson’s disease during social unrest (2023) · cites this paper as [52]
The Abstract Results report effect-size estimates of 1.32 and 1.40 for the HADS anxiety and depression scores, respectively. But the study concerns patients with COPD, not pulmonary diseases generally; the Discussion says the authors do not know whether the minimal important difference generalizes to other diseases. (LLM, conf=0.89)
Experimental — accuracy not yet measuredThe MBSWSC group improvements in anxiety and depression are above the 1.5-point decrease required to be deemed an important clinical difference score.
“The MBSWSC group improvements in both anxiety and depression scores in this study appear to be particularly strong, with participants experiencing a 2.72 decrease in anxiety on HADS-A at T2 and a 2.32 decrease in depression on HADS-D at T2, both of which are above the 1.5-point decrease required to be deemed an important clinical difference score (Puhan et al., 2008).”
From A randomised trial of Mindfulness-based Social Work and Self-Care with social workers (2023) · cites this paper as Puhan et al., 2008
The Discussion and Conclusion estimate a minimal important HADS difference of approximately 1.5 points for anxiety and depression in patients with COPD. The Discussion explicitly says it is unknown whether that threshold generalizes to other diseases, so the source does not establish 1.5 points as a universally required cutoff for the MBSWSC group. The reported 2.72- and 2.32-point decreases are results of the citing study, not findings attributed to Puhan et al. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe minimum clinically important difference (MCID) for the HADS subscales is estimated to be a reduction of 1.5 to 2 points.
“Importantly, the minimum clinically important difference (MCID) for the HADS subscales is estimated to be a reduction of 1.5 to 2 points [227–229].”
From Infraslow closed-loop brain training for anxiety and depression (ISAD): a protocol for a randomized, double-blind, sham-controlled pilot trial in adult females with internalizing disorders (2022) · cites this paper as [229]
The Discussion and Conclusion estimate a HADS minimal important difference of about 1.5 points in patients with COPD. The Results give estimates for the anxiety and depression subscales, but this paper does not establish 2 points as the upper end of a 1.5–2-point range; the Discussion also cautions that its estimate may not generalize beyond COPD. No page numbers are available in our copy. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThe MCID of the HADS is estimated to be 1.32 for the HADS anxiety score, corresponding to a change from baseline of around 20%.
“The MCID of the HADS is estimated to be 1.32 for the HADS anxiety score, corresponding to a change from baseline of around 20%.33”
From EMDR treatment for anxiety in MS patients: A pilot study (2020) · cites this paper as [33]
The reported minimal clinically important difference for HADS-A among patients with chronic obstructive pulmonary disease is 1.5.
“The reported MCID for HADS-A among patients with chronic obstructive pulmonary disease is 1.5.58”
From Association of Mindfulness-Based Interventions With Anxiety Severity in Adults With Cancer: A Systematic Review and Meta-analysis (2020) · cites this paper as [58]
The effect size for total mean affective symptoms was small, but previous evidence suggests that treatment effects are in the range that is important to patients.
“The effect size in terms of the total mean affective symptoms was small, but previous evidence from studies in which researchers set out to calculate what a clinically important difference in the HADS would be suggests that treatment effects are in the range that is important to patients.54”
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- Authors
- Puhan, M. A., Frey, M., Büchi, S., & Schünemann, H. J.
- Affiliations
- University Hospital Zurich (CH)
- Klinik Barmelweid (CH)
- Instituto Nazionale Tumori Regina Elena (IT)
- Corresponding author
- Puhan, Milo A
- Venue
- Health and Quality of Life Outcomes
- Published
- 2008
- Volume
- 6
- Issue
- 1
- Pages
- 46
- ISSN
- 1477-7525 (ISSN-L)
- PMC
- PMC2459149
- OpenAlex
- W2128868698
- Cited by
- 586
- References
- 35
- Citations by year
- 2026: 43 · 2025: 44 · 2024: 41 · 2023: 60 · 2022: 48 · 2021: 68 · 2020: 50 · 2019: 37 · 2018: 34 · 2017: 36 · 2016: 28 · 2015: 22 · 2014: 18 · 2013: 14 · 2012: 9
- FWCI
- 10.40
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Health and Quality of Life Outcomes (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, cc-by)
- Zurich Open Repository and Archive (University of Zurich)
- Funders
- National Science Foundation
- European Commission
- Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (115216, 42192, 3233B0/115216/1)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- minimal important difference, Hospital Anxiety and Depression Scale, chronic obstructive pulmonary disease, anxiety, depression, Chronic Respiratory Questionnaire, feeling thermometers, effect size, pulmonary rehabilitation, anchor-based methods, distribution-based methods, patient-reported outcomes
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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