A confirmatory factor analysis of the Hospital Anxiety and Depression scale: Comparing empirically and theoretically derived structures

Abstract

Three factors appear to underlie the HAD scale. Research is needed that examines whether or not using sub-scales based on these factors increases the ability of the HAD scale to detect cases of anxiety and depression.

The Hospital Anxiety and Depression Scale: A meta confirmatory factor analysis

“…A total of eight different factor structures have been suggested in the literature as providing the 'best fit' to the HADS item structure (1 unidimensional distress, 2 bidimensional consisting anxiety and depression, and 5 tridimensional consisting of anxiety depression and restlessness/agitation/negative-affectivity) [1,8,[28][29][30][31][32]. Furthermore, two bifactor structures were considered since this model has been shown to provide the best fit in other studies jointly assessing symptoms of anxiety and depression [17,18].…”

“…Dunbar and colleagues suggested that as well as measuring autonomic anxiety and anhedonic depression, the HADS taps into negative affectivity [8]. Although several items that are closely related to the negative affectivity construct had high loadings on the general factor and low loadings on the anxiety factor (tension: A1; restlessness: A7 and A11; worry: A5), all HADS items had high loadings on the general factor, including those specific to anxiety and depression.…”

“…The Tripartite theory stipulates that the specific component of anxiety is autonomic arousal marked by somatic symptoms, and that the main component of depression is anhedonia characterized by low positive affect-a loss of pleasure and interest in life and inability to feel please even when engaging in pleasurable activities [10]. As was noted by Dunbar and colleagues [8], several of the HADS items fit these constructs well.…”

“…Two alternative hierarchical models -higher-order and bifactor -have been proposed to represent the structure of scales with a general factor. The most widely supported three factor structure in the Cosco et al [5] review of the HADS is a higher-order model, proposed by Dunbar and colleagues [8], based on the tripartite theory of anxiety and depression [9]. The tripartite theory posits that a higher-order general somatopsychic distress trait, negative affectivity (NA), accounts for the observed association between anxiety and depression.…”

Revisiting the dimensionality of the Hospital Anxiety and Depression Scale in an international sample of patients with ischaemic heart disease

“…The higher-order model, proposed by Dunbar et al (16), is based on the Tripartite theory of anxiety and depression (17) and is currently the most-widely supported three factor structure (13). Tripartite theory posits anxiety and depression as lower-level constructs in a tripartite structure (18), with a higherorder general distress factor termed Negative Affectivity (NA) (17).…”