An Analysis of the Validity of the Hospital Anxiety and Depression Scale as a Screening Tool in Patients with Advanced Metastatic Cancer

Abstract

Depression is difficult to diagnose in the terminally ill patient. As a result, it frequently is not treated. This has can have an adverse effect on quality of life and make the palliation of physical symptoms more difficult. In an effort to improve the detection of depression, many palliative care teams are using the Hospital Anxiety and Depression (HAD) scale as a screening tool. The HAD was devised for use in general medical settings and has not been validated for use in palliative care patients. One hundred patients receiving palliative care with an estimated prognosis of 6 months or less were invited to complete the HAD and a semi-structured psychiatric interview, the Present State Examination. The depression and anxiety subscales of the HAD showed poor efficacy for screening when used alone. The optimum threshold was at a combined cut-off of 19, which had a sensitivity of 68% and specificity of 67%. The major construct of the HAD is anhedonia, which may be present at the end of life due to increasing physical illness and may not be pathognomic of a depressive illness in this population. We recommend, therefore, that if the HAD is used as a screening tool in palliative care, it should be as a combined scale, but low sensitivity and specificity may lead to poor efficacy as a screening tool.

Daily Oral Ketamine for the Treatment of Depression and Anxiety in Patients Receiving Hospice Care: A 28-Day Open-Label Proof-of-Concept Trial

“…The primary outcomes for this trial were symptoms of anxiety and depression as measured by the HADS. 57,58 Secondary outcomes included (1) 60 In addition, clinical assessments were made by trained clinicians on days 14 and 28 of the study. Patient ratings were performed by two research nurses and a physician who were trained to a high level of interrater reliability ( > 0.90), which was checked on a regular basis.…”

Pain and palliative medicine

“…It is important that palliative care specialists, especially mental health professionals, distinguish between the despair indicative of an affective disorder associated with a pain magnitude that is disproportionate with disease state (e.g., symptom magnification) and the dysphoria that stems from diminished functional activity inherent in the disease process. Recent investigations into the etiological pathways of depression and determinants of quality of life in chronic illness are illuminating the interactions between physical and psychological conditions and offer the prospect of more effective pain management [2,[38][39][40][41][42].…”

Measurement of psychological distress in palliative care

“…69 While the HADS may be superior to other general psychological symptom measures (such as the General Health Questionnaire) in palliative care patients, 70,71 concerns regarding its sensitivity and specificity as a screening tool in palliative care have been raised. 69 Other anxiety measures are available, but have not been developed specifically for use in physically ill populations. An example is the State-Trait Anxiety Inventory, a 40-item measure, is widely used in other clinical fields, but has had less application in palliative care settings than the HADS.…”