title: Factor analyses of the Hospital Anxiety and Depression Scale: a Bayesian structural equation modeling approach.
abstract: OBJECTIVE
  The latent structure of the Hospital Anxiety and Depression Scale (HADS) has caused inconsistent results in the literature. The HADS is frequently analyzed via maximum likelihood confirmatory factor analysis (ML-CFA). However, the overly restrictive assumption of exact zero cross-loadings and residual correlations in ML-CFA can lead to poor model fits and distorted factor structures. This study applied Bayesian structural equation modeling (BSEM) to evaluate the latent structure of the HADS.
  
  
  METHODS
  Three a priori models, the two-factor, three-factor, and bifactor models, were investigated in a Chinese community sample (N = 312) and clinical sample (N = 198) using ML-CFA and BSEM. BSEM specified approximate zero cross-loadings and residual correlations through the use of zero-mean, small-variance informative priors. The model comparison was based on the Bayesian information criterion (BIC).
  
  
  RESULTS
  Using ML-CFA, none of the three models provided an adequate fit for either sample. The BSEM two-factor model with approximate zero cross-loadings and residual correlations fitted both samples well with the lowest BIC of the three models and displayed a simple and parsimonious factor-loading pattern.
  
  
  CONCLUSIONS
  The study demonstrated that the two-factor structure fitted the HADS well, suggesting its usefulness in assessing the symptoms of anxiety and depression in clinical practice. BSEM is a sophisticated and flexible statistical technique that better reflects substantive theories and locates the source of model misfit. Future use of BSEM is recommended to evaluate the latent structure of other psychological instruments.
authors.affiliation: Centre on Behavioral Health, The University of Hong Kong, 2/F, The Hong Kong Jockey Club Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong, ttaatt@hku.hk.
authors.forename: Ted Chun Tat
authors.initials: TC
authors.lastname: Fong
authors.forename: Rainbow Tin Hung
authors.initials: RT
authors.lastname: Ho
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001007:Anxiety / Q000175:diagnosis* / Q000523:psychology; D001008:Anxiety Disorders / Q000175:diagnosis; D001499:Bayes Theorem; D003863:Depression / Q000175:diagnosis* / Q000523:psychology; D003866:Depressive Disorder / Q000175:diagnosis* / Q000523:psychology; D005163:Factor Analysis, Statistical; D005260:Female; D006723:Hong Kong; D006801:Humans; D007802:Language; D008297:Male; D008875:Middle Aged; D008960:Models, Psychological; D011569:Psychiatric Status Rating Scales; D011594:Psychometrics / Q000295:instrumentation / Q000706:statistics & numerical data; D011788:Quality of Life; D011795:Surveys and Questionnaires