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Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis

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Abstract

Purpose

The Hospital Anxiety and Depression Scale (HADS) is the most extensively validated scale for screening emotional distress in cancer patients. However, thresholds for clinical decision making vary widely across studies. A meta-analysis was conducted with the aim of identifying optimal, empirically derived cut-offs.

Methods

PubMed, Embase, and PsycINFO databases were searched for studies that compared the HADS total and its subscale scores against a semi-structured or structured clinical interview as a reference standard with regard to its screening efficacy for any mental disorders and depressive disorders alone. Separate pooled analyses were conducted for single or two adjacent thresholds. A total of 28 studies (inter-rater agreement, κ = 0.86) were included.

Results

The best thresholds for screening for mental disorders were 10 or 11 on the HADS total (sensitivity 0.80; specificity 0.74), 5 on the HADS depression subscale (sensitivity 0.84; specificity 0.50), and 7 or 8 on the HADS anxiety subscale (sensitivity 0.73; specificity 0.65). Respective thresholds for depression screening were 15 for the HADS total (sensitivity 0.87; specificity 0.88), 7 for the HADS depression subscale (sensitivity 0.86; specificity 0.81), and 10 or 11 for the HADS anxiety subscale (sensitivity 0.63; specificity 0.83).

Conclusions

The HADS anxiety subscale performed worse than the total and the depression subscales for both indicators. Diagnostic accuracy varied widely by threshold but was consistently superior for depression screening than for screening of any mental disorder.

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Conflict of Interest

Neither of the authors have any conflicts of interest or financial interests associated with this work.

Funding

This study was supported by the Canadian Institute for Health Research CIHR Team for Supportive Cancer Care (#AQC83559) (AV) and a Quinn Research Assistantship (RDM).

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Authors and Affiliations

  1. Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC V6T 1Z4, Canada

    Andrea Vodermaier & Roanne D. Millman

  2. Department of Obstetrics and Gynaecology—Grosshadern, University of Munich, Munich, Germany

    Andrea Vodermaier

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  1. Andrea Vodermaier
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Correspondence to Andrea Vodermaier.

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Vodermaier, A., Millman, R.D. Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis. Support Care Cancer 19, 1899–1908 (2011). https://doi.org/10.1007/s00520-011-1251-4

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  • DOI: https://doi.org/10.1007/s00520-011-1251-4

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