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The Hospital Anxiety And Depression Scale

The Hospital Anxiety And Depression Scale There is a need to assess the contribution of mood disorder, especially anxiety and depression, in order to understand the experience of suffering in the setting of medical practice. Most physicians are aware of this aspect of the illness of their patients but many feel incompetent to provide the patient with reliable information. The Hospital Anxiety And Depression Scale, or HADS, was designed to provide a simple yet reliable tool for use in medical practice. The term 'hospital' in its title suggests that it is only valid in such a setting but many studies conducted throughout the world have confirmed that it is valid when used in community settings and primary care medical practice. It should be emphasised that self-assessment scales are only valid for screening purposes; definitive diagnosis must rest on the process of clinical examination. nature of anxiety and its possible manifestation as Background Quality of life is a broad term without exact definition. It somatic distress. depends on a number of factors: support from friends and relatives, ability to work and interest in one's occupations, Reasons for neglect to detect emotional disorder include accommodation appropriate to expectations and, of the physician's lack of confidence in procedure for detec- course, health and disabilities whether congenital or tion and sometimes a supposition that if it was discussed recently acquired disorder. In the field of ill health physi- the patient may consider that his complaint was not being cians, by their training, concentrate attention on possible taken seriously. The fact remains that it is a frequent con- somatic disorder; the role of emotional disorder be it a comitant of somatic illness or that it may masquerade as reaction to the somatic illness or an independent factor, is somatic disorder [3–5]. A simple method for recognition often overlooked. of emotional disorder in the clinical setting will therefore be of help to the physician. Such information may be pro- For instance pain from a disorder which was previously vided by a questionnaire which the patient may complete tolerable may become intolerable if a depressive state prior to examination. supervenes [1]; in another study [2] of patients who had undergone treatment for maxillo-facial cancer it was The patients' own views are sometimes discounted yet Fal- found that one in three had clinically significant anxiety lowfield [6] considered that the patient was the best judge and somatic symptoms were reduced by discussing the of his/her own state. There may, of course, be situations in Page 1 of 4 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/29 which the patient deliberately attempts to mislead the cli- vide a clinician with useful information; it was therefore nician by exaggerating the emotional element of his ill- decided to concentrate on the loss of pleasure response ness but this is not common; alternatively the emotional [anhedonia] which is one of the two obligatory states for aspect may be suppressed if it is supposed that this will the official definition of 'major depressive disorder' and lead to a diagnosis of psychiatric illness. Any such ques- which, moreover, was considered by Klein [10] to be the tionnaire must therefore not only be brief and easily best guide to the type of depressive mood disorder which understood but should avoid reference to clearly abnor- may be considered to be based on disturbance of neuro- mal perceptions (hallucinations) and such obvious impli- transmitter mechanisms and therefore likely to improve cation of psychiatric disorder as suicidal inclinations. spontaneously or to be alleviated by antidepressant med- ication; therefore the statements analysed for construction A physician in general hospital practice said that he knew of the depressive component of the Scale were largely, that a large proportion of patients attending his clinic although not entirely, based upon the state of reduced were suffering from emotional disorder or else that such ability to experience pleasure, a typical statement being: "I disorder was an important contributory factor to the dis- no longer get pleasure from things I normally enjoy". tress of the illness. He pointed out that large numbers of patients precluded any attempt by himself to conduct Discussion enquiry into emotional aspects of illness but that he often Construction of the Hospital Anxiety And Depression felt that he was informing the patient inaccurately and Scale (HADS) perhaps, by stressing the role of somatic illness, aggravat- The study was conducted in the setting of a general medi- ing the patient's condition. He asked whether there was a cal hospital outpatient clinic. The result of the study simple method, perhaps a questionnaire which the undertaken for this purpose was published under the title patient could complete whilst waiting to see him, which of The Hospital Anxiety And Depression Scale [11]. Full would be helpful. He added that questionnaires with a details of the method of construction of the HADS is given large proportion of their content devoted to somatic dis- in the publication presenting it but, briefly, patients com- tress would not be useful; indeed one study [7] had dem- pleted a questionnaire composed of statements relevant onstrated that any questionnaire purporting to provide to either generalised anxiety or 'depression', the latter information on emotional distress in dialysis patients but being largely (but not entirely) composed of reflections of which contained a large proportion of items relating to the state of anhedonia. Thought was also given to whether somatic disorder provided misleading information. A the wording of the items would be easily translated to review of the major existing scales was undertaken [8,9] other languages. After examination by the physician, the and the extent to which somatic factors, such as loss of researchers conducted an interview but were blind to appetite, would contribute to the score derived from com- knowledge of the patients' responses to the questionnaire. pletion. It was considered that most of the scales were During that interview 'depression' was assessed according either lengthy and required administration by a trained to the questions: " Do you take as much interest in things worker, or if short and designed for completion by the as you used to? Do you laugh as readily? Do you feel patient, did not appear to distinguish one type of emo- cheerful? Do you feel optimistic about the future?" i.e. tional disorder from another. These observations led to there was not concentration on the anhedonic state alone. the decision to design another questionnaire. It was The 'anxiety' level was assessed by the questions: "Do you agreed that, in order to make it short it should focus on feel tense and wound up? Do you worry a lot? Do you the two aspects of emotional disorder which the clinician have panic attacks? Do you feel something awful is about considered had most relevance i.e. anxiety and depres- to happen?". The questionnaire responses were analysed sion, that these two concepts be differentiated and that a in the light of the results of this estimation of the severity scoring device provided which would give the best chance of both anxiety and of depression. This enabled a reduc- of reliable and helpful information of the sort which tion of the number of items in the questionnaire to just could be explained to the patient in the context of the dis- seven reflecting anxiety and seven reflecting depres- order for which he was consulting the clinician. sion.(Of the seven depression items five reflected aspects of reduction in pleasure response). Each item had been Thought had to be given to the term 'depression'. Apart answered by the patient on a four point (0–3) response from the varieties of disorder subsumed under the term in category so the possible scores ranged from 0 to 21 for the psychiatric lexicon it is used in everyday parlance for a anxiety and 0 to 21 for depression. An analysis of scores variety of states of distress: demoralisation from pro- on the two subscales of a further sample, in the same clin- longed suffering, reaction to loss [grief], a tendency to ical setting, enabled provision of information that a score undervalue oneself [loss of self-esteem], a pessimistic out- of 0 to 7 for either subscale could be regarded as being in look and so on. A questionnaire designed to cover all the normal range, a score of 11 or higher indicating prob- these concepts would be diffuse and probably fail to pro- able presence ('caseness') of the mood disorder and a Page 2 of 4 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/29 score of 8 to 10 being just suggestive of the presence of the tions for its use. Translations are available to all major respective state. Further work indicated that the two sub- European languages in addition to Arabic, Hebrew, Chi- scales, anxiety and depression, were independent meas- nese, Japanese and Urdu; translation to other languages ures. Subsequent experience enabled a division of each may be arranged by communication with the publishers. mood state into four ranges: normal, mild, moderate and Other potentially useful scales obtainable from nferNel- severe and it is in this form that the HADS is now issued son include a measure of irritability alongside depression by its publisher In the case of illiteracy, or poor vision, the and anxiety, also a questionnaire to detect specific areas of wording of the items and possible responses may be read anxiety e.g. hypodermic injections. to the respondent. Examples of extracts from translation Administration of the HADS Je me promets beaucoup de plaisir de certaines choses: The HADS only takes 2 to 5 minutes to complete. It has been shown to be acceptable by the population for which autant qu'auparavent [0], un peu moins qu'avant [1] it was designed [12]. However, as with any such question- naire, caution must be observed; this is that the patient is, bien moins qu'avant [2], presque jamais [3] in fact, literate and able to read it. Some illiterate people are ashamed of their defect and will pretend to answer the sono riuscito a ridere e a vedere il lato divertente delle cose: statements by haphazard underlining of response options. It is reasonable practice for whoever administers proprio come ho sempre fatto [0], non proprio come un tempo the HADS to ask the intending respondent to read out [1] aloud one or other of the phrases of the questionnaire. This also provides opportunity to provide explanation of sicuramente non come un tempo [2], per niente [3] the purpose of the questionnaire and assurance that, as with all clinical information, it is a confidential document ich kann lachen und die lustige Seite der Dinge sehen: which will aid their doctor to help them. ja, so viel wie immer [0], nicht mehr ganz so viel [1] Since the instruction at the introduction to the HADS is to complete it in order to best indicate how the respondent inzwischen viel weniger [2], uberhaupt nicht [3] has felt in "the past week" it is reasonable to administer the Scale again but at not less than weekly intervals. The Conclusion record chart provided by the publisher enables a graphic There can be no doubt of the need to assess the role of display of progress rather in the manner of a chart for emotional factors in clinical practice. A brief question- record of body temperature. naire is provided for the purpose. Further validation studies of the English and of foreign Many studies have confirmed the validity of the HADS in language translations of the HADS were undertaken in a the setting for which it was designed. Other studies have variety of settings and centres. The first review of these shown it to be a useful instrument in other areas of clini- [13] was published in 1997; the more recent [14] review cal practice. Patients have no difficulty in understanding of 747 identified studies concluded: " The HADS was the reason for request to answer the questionnaire. It is found to perform well in assessing severity and caseness of available from a reliable publisher of psychometric scales; anxiety disorders and depression in both somatic, and translations into many languages have been made and psychiatric cases and [not only in hospital practice for may be provided at request. which it was first designed] in primary care patients and the general population". Authors' contribution The author is the senior member of the team involved in In addition to frequent validation for use in the elderly the construction of the HAD Scale HADS has been validated for use in adolescents [15] References 1. Bradley JJ: Severe localised pain associated with the depres- Obtaining the HADS sive syndrome Brit J Psychiatr 1963, 109:741-5. The HADS was placed with a publisher of test scales distri- 2. Telfer MR and Shepherd JP: Psychological distress in patients bution of the Scale was placed with a publishing firm, the attending an oncology clinic after definitive treatment for maxillo-facial malignant neoplasia Int J Oral Maxillofacial Surgery National Foundation for Educational Research (nferNel- 1993, 22:347-9. son: http://www.nfer-nelson.co.uk or email: informa- 3. Shepherd M, Davis B and Culpan RH: Psychiatric illness in a gen- eral hospital Acta Psychiatr Scand 1960, 35:518-25. tion@nfer-nelson.co.uk). The firm supplies the scale, the chart for recording of scores and the manual with instruc- Page 3 of 4 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/29 4. Maguire GP, Julier DL, Hawton KE and Bancroft JHJ: Psychiatric morbidity and referral on two general medical wards Brit Med J 1974, 1:268-70. 5. Moffic HS and Paykel ES: Depression in medical in-patients Brit J Psychiatr 1975, 126:346-53. 6. Fallowfield LJ: Quality of life measurement in patients with breast cancer J Royal Soc Med 1993, 86:10-2. 7. Kutner NG, Fair PL and Kutner MH: Assessing depression in chronic dialysis patients J Psychosom Res 1985, 29:23-31. 8. Snaith RP: What do depression scales measure? Brit J Psychiatr 1993, 163:293-8. 9. Keedwell P and Snaith RP: What do anxiety scales measure? Acta Psychiatr Scand 1996, 93:177-80. 10. Klein DF: Endogenomorphic depression Arch Gen Psychiatr 1974, 31:447-54. 11. Zigmond AS and Snaith RP: The Hospital Anxiety And Depres- sion Scale Acta Psychiatr Scand 1983, 67:361-70. 12. Clark A and Fallowfield LJ: Quality of life measurement in patients with malignant disease J Royal Soc Med 1986, 79:165-9. 13. Herrmann C: International experience with the Hospital Anx- iety and Depression Scale A review of validation data and clinical results J Psychosom Res 1997, 42:17-41. 14. Bjelland I, Dahl AA, Haug TT and Neckelmann D: The validity of the Hospital Anxiety and Depression Scale; an updated review J Psychiat Res 2002, 52:69-77. 15. White D, Leach C, Sims R and Cottrell D: Validation of the HADS in adolescents Brit J Psychiatr 1999, 175:452-4. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 4 of 4 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health and Quality of Life Outcomes Springer Journals

The Hospital Anxiety And Depression Scale

Health and Quality of Life Outcomes , Volume 1 (1) – Aug 1, 2003

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References (29)

Publisher
Springer Journals
Copyright
Copyright © 2003 by Snaith; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Quality of Life Research; Quality of Life Research
eISSN
1477-7525
DOI
10.1186/1477-7525-1-29
pmid
12914662
Publisher site
See Article on Publisher Site

Abstract

There is a need to assess the contribution of mood disorder, especially anxiety and depression, in order to understand the experience of suffering in the setting of medical practice. Most physicians are aware of this aspect of the illness of their patients but many feel incompetent to provide the patient with reliable information. The Hospital Anxiety And Depression Scale, or HADS, was designed to provide a simple yet reliable tool for use in medical practice. The term 'hospital' in its title suggests that it is only valid in such a setting but many studies conducted throughout the world have confirmed that it is valid when used in community settings and primary care medical practice. It should be emphasised that self-assessment scales are only valid for screening purposes; definitive diagnosis must rest on the process of clinical examination. nature of anxiety and its possible manifestation as Background Quality of life is a broad term without exact definition. It somatic distress. depends on a number of factors: support from friends and relatives, ability to work and interest in one's occupations, Reasons for neglect to detect emotional disorder include accommodation appropriate to expectations and, of the physician's lack of confidence in procedure for detec- course, health and disabilities whether congenital or tion and sometimes a supposition that if it was discussed recently acquired disorder. In the field of ill health physi- the patient may consider that his complaint was not being cians, by their training, concentrate attention on possible taken seriously. The fact remains that it is a frequent con- somatic disorder; the role of emotional disorder be it a comitant of somatic illness or that it may masquerade as reaction to the somatic illness or an independent factor, is somatic disorder [3–5]. A simple method for recognition often overlooked. of emotional disorder in the clinical setting will therefore be of help to the physician. Such information may be pro- For instance pain from a disorder which was previously vided by a questionnaire which the patient may complete tolerable may become intolerable if a depressive state prior to examination. supervenes [1]; in another study [2] of patients who had undergone treatment for maxillo-facial cancer it was The patients' own views are sometimes discounted yet Fal- found that one in three had clinically significant anxiety lowfield [6] considered that the patient was the best judge and somatic symptoms were reduced by discussing the of his/her own state. There may, of course, be situations in Page 1 of 4 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/29 which the patient deliberately attempts to mislead the cli- vide a clinician with useful information; it was therefore nician by exaggerating the emotional element of his ill- decided to concentrate on the loss of pleasure response ness but this is not common; alternatively the emotional [anhedonia] which is one of the two obligatory states for aspect may be suppressed if it is supposed that this will the official definition of 'major depressive disorder' and lead to a diagnosis of psychiatric illness. Any such ques- which, moreover, was considered by Klein [10] to be the tionnaire must therefore not only be brief and easily best guide to the type of depressive mood disorder which understood but should avoid reference to clearly abnor- may be considered to be based on disturbance of neuro- mal perceptions (hallucinations) and such obvious impli- transmitter mechanisms and therefore likely to improve cation of psychiatric disorder as suicidal inclinations. spontaneously or to be alleviated by antidepressant med- ication; therefore the statements analysed for construction A physician in general hospital practice said that he knew of the depressive component of the Scale were largely, that a large proportion of patients attending his clinic although not entirely, based upon the state of reduced were suffering from emotional disorder or else that such ability to experience pleasure, a typical statement being: "I disorder was an important contributory factor to the dis- no longer get pleasure from things I normally enjoy". tress of the illness. He pointed out that large numbers of patients precluded any attempt by himself to conduct Discussion enquiry into emotional aspects of illness but that he often Construction of the Hospital Anxiety And Depression felt that he was informing the patient inaccurately and Scale (HADS) perhaps, by stressing the role of somatic illness, aggravat- The study was conducted in the setting of a general medi- ing the patient's condition. He asked whether there was a cal hospital outpatient clinic. The result of the study simple method, perhaps a questionnaire which the undertaken for this purpose was published under the title patient could complete whilst waiting to see him, which of The Hospital Anxiety And Depression Scale [11]. Full would be helpful. He added that questionnaires with a details of the method of construction of the HADS is given large proportion of their content devoted to somatic dis- in the publication presenting it but, briefly, patients com- tress would not be useful; indeed one study [7] had dem- pleted a questionnaire composed of statements relevant onstrated that any questionnaire purporting to provide to either generalised anxiety or 'depression', the latter information on emotional distress in dialysis patients but being largely (but not entirely) composed of reflections of which contained a large proportion of items relating to the state of anhedonia. Thought was also given to whether somatic disorder provided misleading information. A the wording of the items would be easily translated to review of the major existing scales was undertaken [8,9] other languages. After examination by the physician, the and the extent to which somatic factors, such as loss of researchers conducted an interview but were blind to appetite, would contribute to the score derived from com- knowledge of the patients' responses to the questionnaire. pletion. It was considered that most of the scales were During that interview 'depression' was assessed according either lengthy and required administration by a trained to the questions: " Do you take as much interest in things worker, or if short and designed for completion by the as you used to? Do you laugh as readily? Do you feel patient, did not appear to distinguish one type of emo- cheerful? Do you feel optimistic about the future?" i.e. tional disorder from another. These observations led to there was not concentration on the anhedonic state alone. the decision to design another questionnaire. It was The 'anxiety' level was assessed by the questions: "Do you agreed that, in order to make it short it should focus on feel tense and wound up? Do you worry a lot? Do you the two aspects of emotional disorder which the clinician have panic attacks? Do you feel something awful is about considered had most relevance i.e. anxiety and depres- to happen?". The questionnaire responses were analysed sion, that these two concepts be differentiated and that a in the light of the results of this estimation of the severity scoring device provided which would give the best chance of both anxiety and of depression. This enabled a reduc- of reliable and helpful information of the sort which tion of the number of items in the questionnaire to just could be explained to the patient in the context of the dis- seven reflecting anxiety and seven reflecting depres- order for which he was consulting the clinician. sion.(Of the seven depression items five reflected aspects of reduction in pleasure response). Each item had been Thought had to be given to the term 'depression'. Apart answered by the patient on a four point (0–3) response from the varieties of disorder subsumed under the term in category so the possible scores ranged from 0 to 21 for the psychiatric lexicon it is used in everyday parlance for a anxiety and 0 to 21 for depression. An analysis of scores variety of states of distress: demoralisation from pro- on the two subscales of a further sample, in the same clin- longed suffering, reaction to loss [grief], a tendency to ical setting, enabled provision of information that a score undervalue oneself [loss of self-esteem], a pessimistic out- of 0 to 7 for either subscale could be regarded as being in look and so on. A questionnaire designed to cover all the normal range, a score of 11 or higher indicating prob- these concepts would be diffuse and probably fail to pro- able presence ('caseness') of the mood disorder and a Page 2 of 4 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/29 score of 8 to 10 being just suggestive of the presence of the tions for its use. Translations are available to all major respective state. Further work indicated that the two sub- European languages in addition to Arabic, Hebrew, Chi- scales, anxiety and depression, were independent meas- nese, Japanese and Urdu; translation to other languages ures. Subsequent experience enabled a division of each may be arranged by communication with the publishers. mood state into four ranges: normal, mild, moderate and Other potentially useful scales obtainable from nferNel- severe and it is in this form that the HADS is now issued son include a measure of irritability alongside depression by its publisher In the case of illiteracy, or poor vision, the and anxiety, also a questionnaire to detect specific areas of wording of the items and possible responses may be read anxiety e.g. hypodermic injections. to the respondent. Examples of extracts from translation Administration of the HADS Je me promets beaucoup de plaisir de certaines choses: The HADS only takes 2 to 5 minutes to complete. It has been shown to be acceptable by the population for which autant qu'auparavent [0], un peu moins qu'avant [1] it was designed [12]. However, as with any such question- naire, caution must be observed; this is that the patient is, bien moins qu'avant [2], presque jamais [3] in fact, literate and able to read it. Some illiterate people are ashamed of their defect and will pretend to answer the sono riuscito a ridere e a vedere il lato divertente delle cose: statements by haphazard underlining of response options. It is reasonable practice for whoever administers proprio come ho sempre fatto [0], non proprio come un tempo the HADS to ask the intending respondent to read out [1] aloud one or other of the phrases of the questionnaire. This also provides opportunity to provide explanation of sicuramente non come un tempo [2], per niente [3] the purpose of the questionnaire and assurance that, as with all clinical information, it is a confidential document ich kann lachen und die lustige Seite der Dinge sehen: which will aid their doctor to help them. ja, so viel wie immer [0], nicht mehr ganz so viel [1] Since the instruction at the introduction to the HADS is to complete it in order to best indicate how the respondent inzwischen viel weniger [2], uberhaupt nicht [3] has felt in "the past week" it is reasonable to administer the Scale again but at not less than weekly intervals. The Conclusion record chart provided by the publisher enables a graphic There can be no doubt of the need to assess the role of display of progress rather in the manner of a chart for emotional factors in clinical practice. A brief question- record of body temperature. naire is provided for the purpose. Further validation studies of the English and of foreign Many studies have confirmed the validity of the HADS in language translations of the HADS were undertaken in a the setting for which it was designed. Other studies have variety of settings and centres. The first review of these shown it to be a useful instrument in other areas of clini- [13] was published in 1997; the more recent [14] review cal practice. Patients have no difficulty in understanding of 747 identified studies concluded: " The HADS was the reason for request to answer the questionnaire. It is found to perform well in assessing severity and caseness of available from a reliable publisher of psychometric scales; anxiety disorders and depression in both somatic, and translations into many languages have been made and psychiatric cases and [not only in hospital practice for may be provided at request. which it was first designed] in primary care patients and the general population". Authors' contribution The author is the senior member of the team involved in In addition to frequent validation for use in the elderly the construction of the HAD Scale HADS has been validated for use in adolescents [15] References 1. Bradley JJ: Severe localised pain associated with the depres- Obtaining the HADS sive syndrome Brit J Psychiatr 1963, 109:741-5. The HADS was placed with a publisher of test scales distri- 2. Telfer MR and Shepherd JP: Psychological distress in patients bution of the Scale was placed with a publishing firm, the attending an oncology clinic after definitive treatment for maxillo-facial malignant neoplasia Int J Oral Maxillofacial Surgery National Foundation for Educational Research (nferNel- 1993, 22:347-9. son: http://www.nfer-nelson.co.uk or email: informa- 3. Shepherd M, Davis B and Culpan RH: Psychiatric illness in a gen- eral hospital Acta Psychiatr Scand 1960, 35:518-25. tion@nfer-nelson.co.uk). The firm supplies the scale, the chart for recording of scores and the manual with instruc- Page 3 of 4 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/29 4. Maguire GP, Julier DL, Hawton KE and Bancroft JHJ: Psychiatric morbidity and referral on two general medical wards Brit Med J 1974, 1:268-70. 5. Moffic HS and Paykel ES: Depression in medical in-patients Brit J Psychiatr 1975, 126:346-53. 6. Fallowfield LJ: Quality of life measurement in patients with breast cancer J Royal Soc Med 1993, 86:10-2. 7. Kutner NG, Fair PL and Kutner MH: Assessing depression in chronic dialysis patients J Psychosom Res 1985, 29:23-31. 8. Snaith RP: What do depression scales measure? Brit J Psychiatr 1993, 163:293-8. 9. Keedwell P and Snaith RP: What do anxiety scales measure? Acta Psychiatr Scand 1996, 93:177-80. 10. Klein DF: Endogenomorphic depression Arch Gen Psychiatr 1974, 31:447-54. 11. Zigmond AS and Snaith RP: The Hospital Anxiety And Depres- sion Scale Acta Psychiatr Scand 1983, 67:361-70. 12. Clark A and Fallowfield LJ: Quality of life measurement in patients with malignant disease J Royal Soc Med 1986, 79:165-9. 13. Herrmann C: International experience with the Hospital Anx- iety and Depression Scale A review of validation data and clinical results J Psychosom Res 1997, 42:17-41. 14. Bjelland I, Dahl AA, Haug TT and Neckelmann D: The validity of the Hospital Anxiety and Depression Scale; an updated review J Psychiat Res 2002, 52:69-77. 15. White D, Leach C, Sims R and Cottrell D: Validation of the HADS in adolescents Brit J Psychiatr 1999, 175:452-4. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 4 of 4 (page number not for citation purposes)

Journal

Health and Quality of Life OutcomesSpringer Journals

Published: Aug 1, 2003

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