ObjectiveThe Hospital Anxiety and Depression Scale (HADS) is widely used to screen for anxiety and depression. A large literature is citable in support of its validity, but difficulties are increasingly being identified, such as inexplicably discrepant optimal cutpoints and inconsistent factor-structures. This article examines whether these problems could be due to the construction of the HADS that poses difficulties for translation and cross-cultural use.MethodsAuthors’ awareness of difficulties translating the HADS were identified by examining 20% of studies using the HADS, obtained by a systematic literature search in Pubmed and PsycINFO in May 2012. Reports of use of translations and validation studies were recorded for papers from non-English speaking countries. Narrative and systematic reviews were examined for how authors dealt with different translations.ResultsOf 417 papers from non-English speaking countries, only 45% indicated whether a translation was used. Studies validating translations were cited in 54%. Seventeen reviews, incorporating data from diverse translated versions, were examined. Only seven mentioned issues of language and culture, and none indicated insurmountable problems in integrating results from different translations.ConclusionInitial decisions concerning item content and response options likely leave the HADS difficult to translate, but we failed to find an acknowledgment of problems in articles involving its translation and cross-cultural use. Investigators’ lack of awareness of these issues can lead to anomalous results and difficulties in interpretation and integration of these results. Reviews tend to overlook these issues and most reviews indiscriminately integrate results from studies performed in different countries. Cross-culturally valid, but literally translated versions of the HADS may not be attainable, and specific cutpoints may not be valid across cultures and language. Claims about rates of anxiety and depression based on integrating cross-cultural data or using the same cutpoint across languages and culture should be subject to critical scrutiny.

The literature on chronic diseases indicates that partner support, as perceived by patients, contributes to well-being of patients in either a positive or a negative way. Previous studies indicated that patients' and partners' perceptions of unsupportive partner behavior are only moderately related. Our aim was (1) to investigate whether discrepancies between patients' and partners' perceptions of two types of unsupportive partner behavior—overprotection and protective buffering—were associated with the level of distress reported by patients with chronic obstructive pulmonary disease (COPD) and (2) to evaluate whether the direction of the differences between patients' and partners' perceptions was associated with distress (i.e., whether patient distress was associated with greater patient or greater partner reports of unsupportive partner behavior). A cross-sectional study was performed using the data of a sample of 68 COPD patients and their spouses. Distress was assessed using the Hopkins Symptom Checklist-25. Patients' and partners' perceptions of unsupportive partner behavior were assessed with a questionnaire measuring overprotection and protective buffering. Distress was independently associated with patients' perceptions of protective buffering and discrepancies in spouses' perceptions of overprotection. Regarding the direction of the discrepancy, we found that greater partner reports of overprotection as compared with patient reports were related to more distress in COPD patients. Our study showed that patients' distress was associated not only with patients' perceptions, but also with discrepancies between patients' and partners' perceptions of unsupportive partner behavior.

Co-morbid conditions are frequently found in patients with COPD. We evaluate the association of co-morbidities with mortality, in stable COPD. 224 patients, mean age 61.2 (± 10.00), 48.2% female, mean FEV1 1.1 (± 0.5) liters, median follow-up time 4.2 years, participated. Medical co-morbidities were scored according to the Charlson Co-morbidity Index (CCI). Depressive symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS) and Symptom Checklist-90 (SCL-90). The Cox proportional hazard model was used for survival analyses. In our sample, 70% of all patients have a co-morbid medical condition or high depressive symptoms. During follow-up 51% of all patients died, and those with heart failure have the highest mortality rate (75%). Age, fat-free mass and exercise capacity were predictive factors, contrary to CCI-scores and high depressive symptoms. An unadjusted association between heart failure and survival was found. Although the presence of co-morbidities, using the CCI-score, is not related to survival, heart failure seems to have a detrimental effect on survival. Higher age and lower exercise capacity or fat-free mass predict mortality.