CRD summary

This generally well-conducted review concluded that Hospital Anxiety and Depression Scale could be a useful screening tool for use in non-psychiatric patients to identify those with emotional distress. There was no evidence to suggest that it was superior to other scales. These conclusions reflect the available data and are likely to be reliable.

Authors' objectives

To assess the accuracy of the Hospital Anxiety and Depression Scale (HADS) in identifying patients with anxiety and depressive disorders.

Searching

MEDLINE, PsycINFO, EMBASE, CINAHL, British Nursing Index and AMED were searched from January 1983 to June 2006. Search terms were reported. Bibliographies of previously published reviews were screened for additional studies. No language restrictions were applied.

Study selection

Studies that administered both HADS and a standardised psychiatric interview (reference standard) to establish a diagnosis of depression, anxiety or both in the same set of participants were eligible for inclusion. Studies were excluded if the time between HADS and the reference standard interview was greater than one month and if sufficient data to calculate sensitivity and specificity for at least one cut-off point between 8 and 11 were not reported.

Studies were initially screened by one reviewer to exclude those that did not compare HADS data with another instrument or interview; two reviewers then independently evaluated the remaining papers for eligibility. Disagreements were resolved by discussion.

For studies of major depressive disorder, mean participant age ranged from 41 to 70 years and the proportion of male participants ranged from 24% to 70%.

For studies of any depressive disorder, mean participant age ranged from 27 to 75 years and the proportion of male participants ranged from 15% to 100%.

For studies of generalised anxiety disorder, mean participant age ranged from 27 to 75 years and the proportion of male participants ranged from zero to 40%.

Studies were conducted in diverse clinical populations and mostly in secondary healthcare settings. Structured Clinical Interview for DSM Disorders (SCID) was the most frequently used reference standard interview for all diagnoses.

Assessment of study quality

The methodological quality of included studies was assessed based on sample size and whether the reference standard diagnostic interview was conducted blind to the results of HADS.

Data extraction

Data were extracted on numbers of true positive, false negative, false positive and true negative test results. These data were used to calculate sensitivities and specificities, positive and negative likelihood ratios and diagnostic odds ratios (DORs), with 95% confidence intervals (CIs).

Data for one third of the included studies were extracted independently by three reviewers and reliability was estimated separately for each possible pair.

Methods of synthesis

Separate meta-analyses were conducted for patients classified using the reference standard interview as having any depressive disorder, major depressive disorder or generalised anxiety disorder. For each group, bivariate diagnostic meta-analysis was used to construct a summary receiver operating characteristic (SROC) curve and derive pooled estimates of sensitivity and specificity, positive and negative likelihood ratios and diagnostic odds ratios.

Between-study heterogeneity was assessed using the I² statistic. Where sufficient data were available, meta-regression analysis of a logit diagnostic odds ratio model was used to investigate potential sources of heterogeneity (baseline prevalence of the disorder in the screened population, sample size, setting, a dichotomous variable comparing in-patient with either outpatient or mixed samples, use of an original English-language or translated version of HADS and whether the reference standard assessment was made blind to the results of HADS).

Publication and small study bias was assessed using Begg funnel plots Egger's weighted regression test.

Results of the review

Twenty-five studies (total number of participants unclear) were included in the final analysis; 41 studies met review inclusion criteria, but were excluded from the meta-analyses because they did not report appropriate data.

Major depressive disorder (11 studies, 1,735 participants, median 128, range 61 to 501) data were pooled at HADS cut-off values for a positive diagnosis of ≥8, ≥9, ≥10 and ≥11; not all studies provided data for all analyses. Sensitivity and specificity varied with cut-off value. At a cut-off of ≥8 (seven studies) pooled sensitivity was 0.82 (95% CI 0.73 to 0.89) and pooled specificity was 0.74 (95% CI 0.60 to 0.84). Between-study heterogeneity was low (28%).

Any depressive disorder (16 studies, 3,244 participants, median 108, range 69 to 1,078) studies could only be pooled for the cut-off value of ≥8 (16 studies). Pooled sensitivity was 0.72 (95% CI 0.62 to 0.80) and pool specificity was 0.86 (95% CI 0.79 to 0.90). Between-study heterogeneity was high (86%).

Generalised anxiety disorder (seven studies, 2,191 participants, median 132, range 100 to 1,078) studies could only be pooled for the cut-off value ≥8 (seven studies). Pooled sensitivity was 0.78 (95% CI 0.68 to 0.85) and pooled specificity was 0.74 (95% CI 0.60 to 0.82). Between-study heterogeneity was high (92%).

The authors stated that data were insufficient to support regression analyses, but reported results for the any depressive disorder analysis; only sample size was found to significantly affect estimates of test performance.

Authors' conclusions

HADS could be a useful screening tool for use in non-psychiatric patients to identify those with emotional distress. There was no evidence to suggest that the HADS was superior to other

scales in the identification of emotional disorders in physically unwell populations.

CRD commentary

This review provided a clearly stated objective and defined inclusion criteria. Various sources were searched for relevant publications. No language restrictions were applied, which minimised the risk of language bias. Measures were taken throughout the review process to mimimise risks error and bias. Some methodological quality criteria were assessed, but results were not reported and so the validity of included study results could not be assessed adequately. Appropriate meta-analytic methods were used.

The authors' conclusions were appropriately cautious, reflected the available data and are likely to be reliable. It should be noted that the conclusions refered to the performance of HADS in relation to other scales and this study did not include any comparative data.

Implications of the review for practice and research

Practice: The authors did not specify any recommendations for clinical practice.

Research: The authors stated that future studies of diagnostic accuracy of HADS should routinely report ROC curves to maximise the data available for subsequent meta-analyses.

Funding

Not stated.

Bibliographic details

Brennan C, Worrall-Davies A, McMillan D, Gilbody S, House A. The Hospital Anxiety and Depression Scale: a diagnostic meta-analysis of case-finding ability. Journal of Psychosomatic Research 2010; 69(4): 371-378. [PubMed: 20846538]

Original Paper URL

http://dx.doi.org/10.1016/j.jpsychores.2010.04.006

Indexing Status

Subject indexing assigned by NLM

MeSH

Anxiety /diagnosis; Anxiety Disorders /diagnosis; Depression /diagnosis; Depressive Disorder /diagnosis; Humans; Odds Ratio; Predictive Value of Tests; Psychiatric Status Rating Scales; Sensitivity and Specificity

AccessionNumber

12010006967

Database entry date

01/06/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.