title: Diagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: a meta-analysis.
abstract: OBJECTIVE
  To examine the validity of the Hospital Anxiety and Depression Scale (HADS) in the identification of psychiatric complications of cancer, as defined by a robust criterion standard.
  
  
  METHODS
  50 analyses tested the depression subscale (HADS-D), anxiety subscale (HADS-A) or combined scales (HADS-T) against syndromal (clinical) depression (n=22), syndromal anxiety (n=4) or any mental ill health/distress (n=24), all defined by semi-structured psychiatric interview.
  
  
  RESULTS
  The HADS and its subscales had both strengths and limitations. Overall it appeared to perform marginally better in non-palliative cancer settings. Specific findings for each subscale were as follows. In the identification of depression the HADS-T, HADS-D and HADS-A had a pooled sensitivity and specificity of 82.0%, 77.0%; 71.6%, 82.6% and 80.5%, 77.8%, respectively. All versions performed poorly in case-finding but well in a screening capacity. For anxiety there were no HADS-D studies. The HADS-T and HADS-A had a pooled sensitivity and specificity of 83.9%, 69.9% and 48.7%, 78.7%. They were poor at case-finding but good as screening instruments. For distress (any mental ill health) the HADS-T, HADS-D and HADS-A had a pooled sensitivity and specificity of 72.8%, 80.6%; 75.7%, 66.3% and 65.7%, 71.3%, respectively. When screening for distress and anxiety the HADS-T was the optimal subscale.
  
  
  CONCLUSIONS
  For the identification of depression, anxiety or distress in cancer settings, the HADS (including subscales) is not recommended as a case-finding instrument but it may, subject to concerns about its length, be a suitable addition to screening programme.
authors.affiliation: Department of Cancer and Molecular Medicine, Leicester Royal Infirmary, University of Leicester LE1 5WW, United Kingdom. alex.mitchell@leicspart.nhs.uk
authors.forename: Alex J
authors.initials: AJ
authors.lastname: Mitchell
authors.forename: Nick
authors.initials: N
authors.lastname: Meader
authors.forename: Paul
authors.initials: P
authors.lastname: Symonds
mesh_terms: D000275:Adjustment Disorders / Q000175:diagnosis* / Q000523:psychology; D001008:Anxiety Disorders / Q000175:diagnosis* / Q000523:psychology; D003866:Depressive Disorder / Q000175:diagnosis* / Q000523:psychology; D006760:Hospitalization; D006801:Humans; D007406:Interview, Psychological; D008403:Mass Screening / Q000706:statistics & numerical data; D009369:Neoplasms / Q000523:psychology*; D010166:Palliative Care / Q000523:psychology*; D011569:Psychiatric Status Rating Scales / Q000706:statistics & numerical data*; D011594:Psychometrics / Q000706:statistics & numerical data; D015203:Reproducibility of Results