The Hospital Anxiety and Depression Scale (HADS) - a discussion

HADS is reported to be problematic by, surprisingly, this paper from Loades, Crawley et al.

"In clinical practice, screening questionnaires which ask about depression and anxiety symptoms, such as the Revised Children’s Anxiety and Depression Scale, RCADS [3], and the Hospital Anxiety and Depression Scale, HADS [4], are often used as part of the assessment process. However, in our paper, we reported our findings of variable discriminative validity of these questionnaires for detecting anxiety and depression separately [2]. Whilst we found sufficiently accurate threshold scores for classifying those with anxiety disorders on both the 47-item and 25-item parent and child versions of the RCADS, we could not identify a sufficiently accurate threshold score for classifying those with depression. We also could not identify sufficiently accurate threshold scores on the HADS for either anxiety or depression."

Mental health screening in adolescents with CFS/ME, Loades, Crawley et al, 2021
 
Another paper that reports issues with HADS.

Michiel Tack said:
They were able to do the KSADS interviews on 164 patients. The results showed that 35.4% met the criteria for at least one mental health diagnosis, 20% met criteria for major depressive disorder and 27% met the criteria for at least one anxiety disorder. These figures are significantly lower than what has been reported previously.

The results also showed that the HADS didn't perform well compared to the KSADS as benchmark. The authors write: "the HADS did not meet the required accuracy criteria for either depression or anxiety; we would therefore recommend that services use other PROMs such as the RCADS for anxiety."
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How common are depression and anxiety in adolescents with CFS and how should we screen for these mental health co-morbidities, 2020, Loades et al
 
This looks relevant to this thread, even though it's about a different questionnaire:

The heading is:
Assessment of body-focussed Beck Anxiety and Beck Depression Inventory items in chronic illness: A preliminary analysis of emotional versus physical causes. by Jill Albertson et al.
 
Thanks for posting those @Andy, good timing. I'm currently in the middle of writing an article on HADS to show how easily it can misinterpret ME/CFS. The basic idea is to use an imaginary ME/CFS patient's answers to the statements and explain his reasoning behind these, with examples from his daily life, so people can see why it is a bad tool. It's even better if I can use Esther Crawley's papers to show that even she agrees. :)

What prompted me to write about HADS was this paper about the very first covid long haulers, the ones after the first SARS outbreak in the 2000s. HADS was one of the scales they used to assess them (but they also used the Fukuda criteria for CFS for example):
Mental Morbidities and Chronic Fatigue in Severe Acute Respiratory Syndrome Survivors - Long-term Follow-up, 2009, Lam et al
 
An investigation into the psychometric properties of the Hospital Anxiety and Depression Scale in individuals with chronic fatigue syndrome

P McCue 1 , Cr Martin, T Buchanan, J Rodgers, Ab Scholey
Affiliations
Abstract

The study sought to determine the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in individuals with chronic fatigue syndrome (CFS) assessed using a web-based data collection tool. Exploratory and confirmatory factor analyses were conducted on the HADS to determine its psychometric properties in 117 individuals with CFS. Seven models were tested to determine model fit to the data. Internal reliability estimations of the anxiety and depression sub-scales were found to be acceptable, however, a three-factor model was found to provide a significantly better fit to the data when compared to the bi-dimensional two-factor structure previously assumed to underpin the HADS' construct validity. The clinical utility of the HADS in the assessment of anxiety and depression in CFS appears to be fundamentally compromised by the presence of a three-dimensional underlying factor structure. Future revision of the HADS is recommended if the instrument is to be used reliably to screen CFS patients.

https://pubmed.ncbi.nlm.nih.gov/21974733/
 
This study of young people is using HADS
Serial Paediatrics Omics Tracking in [ME] (SPOT-ME): protocol paper for a multidisciplinary, observational study..., 2024, Armstrong+

It is justified with the following:
The HADS is a 14-item self-report measure of state-based anxiety and depression, assessed along a 4-point Likert scale. The questionnaire demonstrates good validity and reliability in adolescent populations41 and has been recommended as a mood screening tool in ME/CFS.42
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Reference 41 is
White D, Leach C, Sims R, et al. Validation of the Hospital Anxiety and Depression Scale for use with adolescents. Br J Psychiatry 1999;175:452–4.

And reference 42
Deale A, Husain K, Chalder T, et al. Long-term outcome of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study. Am J Psychiatry 2001;158:2038–42.

It is interesting that a 2001 paper by Chalder in adults, one of the architects of the BPS paradigm for CFS, is used to support the use of HADS, when a recent paper (by Crawley, another BPS proponent) looking at the validity of HADS specifically in young people with 'CFS/ME' clearly found it to be unsuitable.
Andy said:
HADS is reported to be problematic by, surprisingly, this paper from Loades, Crawley et al.

"In clinical practice, screening questionnaires which ask about depression and anxiety symptoms, such as the Revised Children’s Anxiety and Depression Scale, RCADS [3], and the Hospital Anxiety and Depression Scale, HADS [4], are often used as part of the assessment process. However, in our paper, we reported our findings of variable discriminative validity of these questionnaires for detecting anxiety and depression separately [2]. Whilst we found sufficiently accurate threshold scores for classifying those with anxiety disorders on both the 47-item and 25-item parent and child versions of the RCADS, we could not identify a sufficiently accurate threshold score for classifying those with depression. We also could not identify sufficiently accurate threshold scores on the HADS for either anxiety or depression."

Mental health screening in adolescents with CFS/ME, Loades, Crawley et al, 2021
Click to expand...
 
From another thread:
Hutan said:
I remember hearing a researcher a few months ago who was associated with the Dunedin prospective study that followed a sample of over 1000 children born in Dunedin, NZ. It's a well respected study, the participants have provided data on so many aspects of their lives. The researcher said that 80% of the participants would have qualified for a mental illness diagnosis at some point in their (so far) 50 years of life.

https://dunedinstudy.otago.ac.nz/files/1610495099121.pdf
I found a study with data on the participants up to the age 45 assessment. 50% of the participants were assessed as meeting the criteria for MDD in one or more of the assessments. 50%.

I think the difficulty in separating that 'biological' depression from despair and misery associated with bad things happening makes any statements about relationships between ME/CFS and depression really questionable.
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So half of the Dunedin study cohort (over 1000 people) would have qualified as having MDD at one of the time points that they were assessed at. Presumably, if the assessments had been annually, rather than 5 yearly, an even bigger percentage of the cohort would have qualified as having MDD.
 
Wyva said:
Thanks for posting those @Andy, good timing. I'm currently in the middle of writing an article on HADS to show how easily it can misinterpret ME/CFS. The basic idea is to use an imaginary ME/CFS patient's answers to the statements and explain his reasoning behind these, with examples from his daily life, so people can see why it is a bad tool. It's even better if I can use Esther Crawley's papers to show that even she agrees. :)

What prompted me to write about HADS was this paper about the very first covid long haulers, the ones after the first SARS outbreak in the 2000s. HADS was one of the scales they used to assess them (but they also used the Fukuda criteria for CFS for example):
Mental Morbidities and Chronic Fatigue in Severe Acute Respiratory Syndrome Survivors - Long-term Follow-up, 2009, Lam et al
Click to expand...
Did you ever do this? If so could you send a link?

I’m trying to find something comprehensive to send my dad to explain his claim that “depression is more common in pwME” isn’t as straightforward as you might think it to be, due to questionnaire bias, and the fact depression isn’t a known illness, but a vague syndrome that seems to catch a lot of illnesses and mental health issues under it’s name.
 
Yann04 said:
Did you ever do this? If so could you send a link?

I’m trying to find something comprehensive to send my dad to explain his claim that “depression is more common in pwME” isn’t as straightforward as you might think it to be, due to questionnaire bias, and the fact depression isn’t a known illness, but a vague syndrome that seems to catch a lot of illnesses and mental health issues under it’s name.
Click to expand...

I didn't do a full detailed article about this in the end but decided to incorporate it into an article about why the BPS model has failed and this is one of the methodological problems I talk about. But it is not very detailed and is in Hungarian, as I intended this article to give insight into the problems with the BPS model that can be understood relatively quickly and easily.

Anyway, here is the google translated version: https://mecfs-hu.translate.goog/202..._sl=hu&_x_tr_tl=en&_x_tr_hl=en&_x_tr_pto=wapp

Unfortunately the translation is not so great, the English version says stress where I said exertion and somehow says that the questionnaires consider depression to be a symptom of ME/CFS, although I said that it confuses the ME/CFS symptoms with depression, etc. It is not the most accurate translation.
 
@Yann04 I remembered this paper by Bateman et al that was published in Mayo Clinic Proceedings. It is not about the HADS scale specifically but a consensus recommendation for ME/CFS in general: https://www.mayoclinicproceedings.org/article/s0025-6196(21)00513-9/fulltext

You might find this part useful, maybe the source will be authoritative enough for your dad:

"Historically, premorbid mood disorders, personality issues, and childhood adversity have been linked to the development of ME/CFS. However, study limitations, such as use of overly broad criteria that included people with depression but not ME/CFS, could confound those findings.1 Mental health after the onset of ME/CFS is similar to that in other medical conditions and better than that seen in depression.24,25 The prevalence of depression and anxiety in ME/CFS is similar to that in other disabling, chronic illnesses.26,27"
 
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