Letter to the Editor

The Hospital Anxiety and Depression Scale (HADS) is dead, but like Elvis, there will still be citings

L’objectif de cette étude était de présenter les propriétés psychométriques de l’Échelle de Distorsions Cognitives pour Adultes (EDC-A) ainsi que de repérer les distorsions cognitives mesurées par cette échelle et associées au niveau d’anxiété et de dépression. Notre étude a été menée auprès de 916 personnes (18–85 ans) issues de la population générale. Les participants ont répondu à l’EDC-A et à la Hospital Anxiety and Depression Scale (HADS). L’EDC-A présente une structure factorielle cohérente et chaque sous-dimension des distorsions obtient des alphas de Cronbach supérieurs à .65. L’anxiété et la dépression sont liées à la présence de distorsions cognitives dans le raisonnement. Les sujets dépressifs ont un répertoire de distorsions cognitives plus large que les anxieux. L’EDC-A a permis de repérer des différences dans le traitement de l’information entre l’anxiété et la dépression. La dépression est liée à un traitement biaisé global des informations négatives mais aussi positives, tandis que l’anxiété est liée à un traitement biaisé uniquement des informations négatives.

Cognitive distortions contribute to the maintenance of inappropriate cognitive schemas and play a role in the emergence of pathologies such as anxiety and depression. We developed the Cognitive Distortion Scale for Adults in order to identify distortions in individuals’ reasoning. The main objectives of this study were: (1) to study the psychometric properties of the Cognitive Distortion Scale for Adults, (2) to identify cognitive distortions associated with anxiety and depression in the general population.

The study involved 916 participants (151 men and 765 women) aged 18 to 85-years. The participants completed the Cognitive Distortion Scale for Adults. The tool presents 42 mini scenarios with a daily life situation and a proposition concerning a cognitive distortion. Participants must give their degree of agreement (0 to 10) with this one. Seven cognitive distortions are operationalized (dichotomous reasoning, disqualification of one of the poles, arbitrary focusing, omission of the neutral, requalification in the other pole, maximization and minimization). They also completed the Hospital Anxiety and Depression Scale. Both scales were available online on the Internet. The total duration of the test was approximately 10 minutes. A group of 35 participants completed the two scale 15 days apart.

The sub-dimensions of EDC-A obtain Cronbach alphas higher than .65 and EDC-A has a coherent factor structure. The scale has good temporal stability. Anxiety is predicted by dichotomous reasoning, disqualification of one of the poles, arbitrary focusing and maximization. Depression is predicted by dichotomous reasoning, arbitrary focusing, omission of the neutral and requalification in the other pole. Anxiety and depression are associated with negative cognitive distortions in reasoning. However, depression is also associated with positive cognitive distortions. Subjects with depression produce more varied cognitive distortions than subjects with anxiety.

The Cognitive Distortion Scale for Adults shows promising psychometric properties. Further studies will need to be conducted to confirm these results. Anxiety would be related to biased information treatment of negative information, whereas depression would be related to more comprehensive biased information treatment, both negative and positive information. Anxiety would be related to suboptimal functioning of reasoning abilities; depression would be more characterized by a structural deficit of reasoning abilities.

To examine if chest pain increases the risk of depression and anxiety, or, on the other hand, depression and anxiety increase the risk of chest pain onset in patients with coronary heart disease (CHD).

Prospective clinical study.

16 general practices in the Greater London Primary Care Research Network.

803 participants with a confirmed diagnosis of CHD at baseline on the Quality and Outcomes Framework (QOF) CHD registers.

Rose Angina Questionnaire, HADS depression and anxiety subscales and PHQ-9 were assessed at seven time points, each 6 months apart. Multi-Level Analysis (MLA) and Structural Equation Modelling (SEM) were applied.

Chest pain predicts both more severe anxiety and depression symptoms at all time points until 30 months after baseline. However, although anxiety predicted chest pain in the short term with a strong association, this association did not last after 18 months. Depression had only a small, negative association with chest pain.

In persons with CHD, chest pain increases the risk of both anxiety and depression to a great extent. However, anxiety and depression have only limited effects on the risk for chest pain. This evidence suggests that anxiety and depression tend to be consequences rather than causes of cardiac chest pain. Intervention studies that support persons with CHD by providing this information should be devised and evaluated, thus deconstructing potentially catastrophic cognitions and strengthening emotional coping.

Recently controversy has surrounded the dimensionality of the Hospital Anxiety and Depression Scale (HADS). We assessed the dimensionality of the HADS in a large international sample of patients with ischaemic heart disease (IHD) using confirmatory factor analysis (CFA). The analysis of an international sample enabled the current study to broaden knowledge gained from existing studies with small, regional samples.

Data from the HeartQoL study of patients with IHD (n = 6241, 22 countries speaking 15 languages) were analyzed using CFA.

CFA indicated a hierarchical bifactor solution, with mostly strong item loadings on a general factor (explaining 73% of the variance), and weak to very weak loadings on orthogonal depression (16%) and anxiety (11%) subscales. The bifactor model fits the data significantly better than both the original bidimensional model and Dunbar's higher-order three-factor model.

These results, from a large international sample of patients with IHD, suggest that the HADS scale is dominated by a single general distress factor. Although the best CFA model fit was a hierarchical bifactor solution, the subscales had weak item loadings, providing little psychometric evidence of the ability of the HADS to differentiate anxiety and depressive symptoms. It is argued that clinicians and researchers working with patients with IHD should abandon the HADS and use alternative measures of depression and anxiety.

To examine the association between Type D personality and illness perceptions among colorectal cancer survivors 1–10 years post-diagnosis.

Data from two population-based surveys on colorectal cancer survivors was used. Patients diagnosed between 1998 and 2009, as registered in the Eindhoven Cancer Registry, received a questionnaire on Type D personality (DS14) and illness perceptions (B-IPQ); 81% (n = 3977) responded.

750 (19%) patients had a Type D personality. They believe their illness has significantly more serious consequences, will last significantly longer, and experience significantly more symptoms that they attribute to their illness. Also, they are more concerned about their illness, and their disease more often influences them emotionally. Differences regarding ‘consequences’, ‘concern’ and ‘emotional response’ were also clinically relevant. The majority of patients stated that the cause of their disease was unknown (23.3%), hereditary (20.3%), lifestyle (15.1%), psychological distress (11.9%) or other (11.6%). Significant differences in perceptions on cause of disease between Type Ds and non-Type Ds were found for psychological distress (16.2 vs. 10.9%; p < 0.01), randomness (1.7 vs. 5.3%; p < 0.01) and unknown (18.8 vs. 24.4%; p < 0.01). Multivariate analyses showed that Type D was negatively associated with ‘coherence’ and positively with ‘consequences’, ‘timeline’, ‘identity’, ‘concern’, and ‘emotional representation’.

These results elucidate the associations between personality and illness perceptions, demonstrating their close interrelatedness. Our study may be helpful in further developing theoretical models regarding giving meaning to illness and the illness perceptions that the illness elicits. Future studies should investigate whether interventions can positively impact illness perceptions of Type D cancer patients.