EMPIRICAL STUDIES
doi: 10.1111/scs.12206
Use of the Hospital Anxiety and Depression Scale in Spanish caregivers nchez-Lo pez PhD (Professor)1,2, Rosa Marıa Limin ~ ana-Gras PhD (Lecturer)2,3, Marıa Pilar Sa llar-Flores PhD (Postdoctoral Lucıa Colodro-Conde PhD (Postdoctoral researcher)2,3 and Isabel Cue researcher)1,2 1
Universidad Complutense de Madrid, Madrid, Spain, 2Red Hygeia (Health y GEnder International Alliance), http://www.redhygeia.com/ and 3Universidad de Murcia, Murcia, Spain
Scand J Caring Sci; 2015 Use of the Hospital Anxiety and Depression Scale in Spanish caregivers
Background: The Hospital Anxiety and Depression Scale (HADS) is widely used in the assessment of anxiety and depression, but there are scarce data about its psychometric properties in caregivers of older relatives. Objective: The goal of this study was to analyse the factor structure of the HADS to verify its suitability to assess emotional symptomatology in family caregivers of old people, its internal consistency and confirming its relation with the General Health Questionnaire (GHQ-12) and an index of disease and physical complaints. Methods: One hundred and seventy-five family caregivers (25 men and 150 women) aged 32–86, who were taking care of at least one older person in a situation of dependence, were recruited for this study. A descriptive, comparative, correlational design was employed. The scientific adequacy of the questionnaire and its structure
Introduction There is sufficient evidence supporting the conclusion that caring for a person in a situation of personal dependence can involve risk for the caregiver’s physical and psychological health, regardless of the concrete problem that originated the dependence and the type of relationship established between the caregiver and care recipient. Personal dependence is the functional disability in the development of activity in daily life (1). Caring can be related to positive aspects (2), but it is usually associated with negative consequences for caregivers’ physical and psychological health, regardless of whether they are caring
Correspondence to: Isabel Cu ellar Flores, Facultad de Psicologıa, Campus de Somosaguas, 28223 Madrid, Spain. E-mail: [email protected] © 2015 Nordic College of Caring Science
were analysed using confirmatory factor analysis. The scores obtained in the GHQ and in an index of disease and physical complaints were used as external criteria to assess the adequacy of the HADS for caregivers. Results: Higher levels of anxiety and depression than in the normal population were obtained. The reliability/ internal validity of the questionnaire was adequate. A bifactor model, with one subscale for anxiety and one for depression, provides the best fit to the data. The subscales were related to GHQ-12 and index of diseases/physical complaints. Conclusions: The HADS was shown to be useful to assess the presence of anxiety and depression in family caregivers, and the original two-dimensional model is the most adequate. Keywords: caregivers, depression, anxiety, Hospital Anxiety and Depression Scale, confirmatory factor analysis. Submitted 1 August 2014, Accepted 11 November 2014
for their own disabled children (2–5), older relatives (6–8) or people with severe mental disorders (9, 10). In general – and there is more evidence in the case of caregivers of disabled children and older people – caregivers seem to have worse health and psychological well-being than the general population (11). Depressive symptomatology, both in its behavioural and cognitive correlates, is usually present in a high percentage of caregivers (12, 13). Caregivers’ stress and emotional problems usually manifest in anxious symptomatology, which, as with depression, is frequently accompanied by low selfesteem and coping strategies focused on relieving emotions (3, 5, 14). Anxiety disorders are usually one of the main reasons for caregivers’ visits to primary care, and these disorders have been directly related to their physical health (15). Likewise, diverse studies are in agreement about the negative consequences for physical health of the care situation, such as worse self-reported physical health, 1
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higher presence of symptomatology and negative physiological indices, more chronic diseases and hospitalisations, and more use of medication (16–18). In addition to diverse chronic diseases, the most frequent complaints and somatic disorders are osteoarticular complaints, headaches, exhaustion, cardiovascular or gastrointestinal pathology, alterations of the immune system and respiratory problems (11, 16, 18). In view of the importance of effective detection of mood and anxiety disorders to prevent the development of psychopathology and of diseases in general (15), and taking into account the high prevalence of emotional disorders found in caregivers of dependent people, it is necessary to have screening tests available. These tests must be sufficiently sensitive to account for the heterogeneity of the emotional symptomatology associated with caregiver stress and can identify caregivers at risk of depression or anxiety who require additional attention. The HADS (19) is a brief assessment instrument in detecting diverse dimensions of anxiety and depression in nonpsychiatric populations (20–22). The HADS has been translated and widely used in more than 25 countries since its original development. It has been extensively used in the general population and in a variety of clinical populations where anxiety and depression can coexist with diverse physical diseases, such as arthrosis, cancer, fibromyalgia or chronic fatigue syndrome, among others (23–25). The HADS is a self-applied scale made up of 14 items grouped in two subscales, one addressing depression and the other anxiety, which assesses the emotional status of the past week. The psychometric properties of this instrument confirm that it provides a reliable measurement of anxiety and depression in Spanish populations (26–28). Although there are currently many questionnaires to assess depression and anxiety, the HADS is considered very useful to employ in caregivers, as it allows assessing the severity of the emotional symptomatology with more sensitivity and specificity towards the psychological components (vs. the physiological components) than other similar screening questionnaires, such as the GHQ-12 (29). This instrument also appraises emotional experiences through relatively independent cognitive and behavioural components, which increases its value and utility as it identifies the cognitive process involved in depressive and anxious symptomatology. At the same time, it guides interventions and, more specifically, treatment orientations (20, 24, 26). The HADS has been extensively used and validated in a healthcare context, both in the general population and in primary care patients (20). It is especially recommended for its use in physical disease (30). To date, some studies have been published about the HADS’ psychometric properties in assessing caregivers of cancer and palliative patients (31, 32). This questionnaire has been
used with caregivers of geriatric patients (13, 33, 34), but its psychometric characteristics have not been evaluated in this population. As in the population of interest – caregivers of geriatric patients in a situation of dependence – the physical, social and emotional symptoms are closely related and even overlap. This instrument could facilitate a more specific detection of emotional disorders related to the consequences of caregiver overload. The goal of this study was to analyse the factor structure of the HADS, to verify its suitability in assessing emotional symptomatology in family caregivers of geriatric patients, to analyse its internal consistency and to confirm its relation with other measures of health. It was examined in relation to the GHQ-12 of Goldberg and Williams (35), which is one of the instruments most frequently used as a single screening tool to assess psychological distress (36), and to an index of disease and physical complaints used in the National Spanish Health Survey (37).
Methods Participants A total of 175 caregivers (25 men and 150 women) of geriatric patients in a situation of dependence participated in this study. An important aspect to consider is that the sample size must be sufficient in order for the results to be stable. The effect of sample variability can increase as the number of variables or items increases. Therefore, some of the recommendation criteria are based on the ratio of persons per variable. A number of observations 10 times higher than the number of items on a scale would reduce the standard error of the correlation coefficients (38) (in our case, this would be 140 people). Other recommendations have focused on the size of the communalities of the variables and the number of variables per factor (39). If the communalities are around 0.5 and the number of variables per factor is adequate (e.g. 6), then samples of 100 or 200 people may be sufficient. Taking into account either of the two recommendations, in our case, the sample size is sufficiently large (N = 175) to allow us to perform confirmatory factor analysis. The demographic characteristics of the subjects are shown in Table 1.
Procedure The inclusion criteria to select the participants were a person must be caring for a dependent older relative, must speak Spanish and is able to read and write. Caregivers were contacted through professionals working in health centres (hospitals, primary healthcare centres, mental health centres), in associations of relatives (of people with Parkinson or Alzheimer’s), residences, or day © 2015 Nordic College of Caring Science
Use of the HADS in Spanish caregivers Table 1 Sociodemographic variables of the sample of caregivers Frequency/mean (SD, range) Caregiver age Relative age
5.1 13.1 42.3 36.0 3.4 100.0 14.3 40.0 25.7 19.4 14.3 45.7 40.0
10.7 46.7 29.0 13.6
care centres (of senior citizens) or through direct contact, requesting their participation. The data were collected by several trained evaluators.
Measures Hospital Anxiety and Depression Scale (HADS). Fourteen items of Zigmond and Snaith (19), Spanish version of ~ ez (40). Cronbach’s alpha for the Spanish Caro and Iban version was 0.81, and it had adequate convergent validity with regard to the State-Trait Anxiety Inventory (STAI). In the original version, the same cut-off points are proposed to assess both subscales: 0–7: Normal; 8–10: Doubtful; and 11 or more: Clinical problems. 12-item General Health Questionnaire (GHQ-12). Twelve items of Goldberg and Williams (35), Spanish adaptation of Sanchez-L opez and Dresch (36). This questionnaire assesses psychological health. The Spanish version has a Cronbach’s alpha value of 0.76 (standardised alpha: 0.78). The external validity of Factor I (Successful Coping) with the ‘Inventario de Situaciones y Respuestas de Ansiedad’ [ISRA; in English, the Anxiety Situations and © 2015 Nordic College of Caring Science
Responses Inventory of Miguel-Tobal and Cano-Vindel (41)] was very high (Factor I: 0.82; Factor II, 0.70; Factor III, 0.75) (36).
Percentage
56.57 (13.75, 32–86) 80.64 (11.04, 50–99)
Province C aceres 9 Madrid 23 Murcia 74 Segovia 60 Teruel 6 Total 172 Level of education No formal studies 25 Primary studies 70 Secondary and 42 professional education University degree 34 Type of relationship Caregiver cares for his wife 25 Caregiver cares for her husband 80 Caregiver cares for 70 her/his mother/father Aetiology of the relative situation of dependence Parkinson 18 Dementia 79 Older people 49 Other 23
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Questionnaire of complaints/diseases. Twenty-nine items. Based on the questionnaires used in the Spanish National Health Survey (37), this instrument collects information about the existence of 29 chronic diseases such as diabetes, varicose veins, haemorrhoids and migraine headaches. It employs binary response yes/no.
Statistical analysis To verify the utility of the instrument to assess distress in family caregivers, the psychometric characteristics of the HADS in caregiver population must be analysed. For this purpose, confirmatory factor analysis was carried out to determine whether it is more appropriate to apply the HADS as a unidimensional or a multidimensional instrument. Three models were tested: 1 One-dimensional model: the model of Razavi et al. (42). 2 Two-dimensional model: the original two-factor model proposed by Zigmond and Snaith (19) and that of Moorey et al. (43). 3 Three-dimensional model: the model of Dunbar et al. (44) and of Caci et al. (45). With regard to the goodness-of-fit statistics, the following were taken into account: chi2, the root mean square error of approximation (RMSEA), the root mean square residual (RMR), the non-normed fit index (NNFI), the comparative fit index (CFI), the parsimony goodness-offit index (PGFI) and the adjusted goodness-of-fit index (AGFI). The chi2 index should have a low value with a p-value higher than 0.05. Values higher than 0.90 reflect a good fit for the incremental fit indexes: CFI, AGFI and NNFI (46), whereas the value of the RMSEA should be lower than 0.08 (47). With regard to the RMR, the closer it is to 0, the better, and the PGFI is considered adequate when it presents high values (48). Descriptive data were also analysed, the results in the HADS were classified according to the cut-off points proposed by Zigmond and Snaith (19), and internal consistency (Cronbach’s alpha) was examined. Subsequently, the intercorrelations of the subscales were analysed. Moreover, in order to study the external validity of the HADS scores, we confirmed by means of Pearson’s correlations the relationship between this instrument and other measures of health such as the GHQ-12 and the questionnaire of complaints/diseases. Lastly, in order to appraise validity, the scores obtained in this group were compared with scores from the general population extracted by Quintana et al. (49).
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Ethical considerations All the participants gave their written informed consent after the purpose of the investigation and the procedure to be followed had been explained, and the confidentiality of their data and their freedom to participate or to withdraw at any time were guaranteed.
Results
The model of Razavi et al. (42), which offers a one-factor solution, obtained slightly less optimal results than the others. The two-factor models of Zigmond and Snaith (19) and Moorey et al. (43) obtained satisfactory scores in most of the goodness-of-fit statistics, except for RMSEA and AGFI, and no important differences were found between them. Lastly, of the three-factor models, proposed by Dunbar et al. (44) and Caci et al. (45), only the first one obtained scores that support its utility to explain the results.
Factor structure The results of Bartlett’s sphericity test and the Kaiser– Meyer–Olkin (KMO) sample adequacy test showed values of 793.01 (p < 0.001) and 0.86, respectively, so the suitability of the correlation matrix structure was verified, and consequently, the feasibility of using factor analysis was confirmed. Although the model converges with most of the models, the values of the goodness-of-fit statistics were not optimal (see Table 2).
Descriptive statistics and internal consistency Table 3 shows the items corresponding to the subscales of each tested model and the descriptive values obtained, as well as the internal consistency of each subscale. Applying the cut-off values proposed by Zigmond and Snaith (19) for the scores of the anxiety subscale, 20% of the patients showed levels that, in clinical terms, can be considered as possible anxiety (scores of 8 or higher) and 49.7% reported levels that can be considered a
Table 2 Factor structure of the HADS determined through goodness-of-fit tests of the models derived from prior factor analysis. Models of 1, 2 and 3 factors v²
Model
df
Razavi et al. (42) Zigmond and Snaith (19) Moorey et al. (43) Dunbar et al. (44) Caci et al. (45)
77 417.42* 76 387.97* 76 331.85* 73 374.98* No convergence
AGFI
RMSEA
RMS
NNFI
CFI
PGFI
0.62 0.63 0.63 0.63
0.17 0.16 0.16 0.16
0.10 0.099 0.098 0.095
0.89 0.90 0.90 0.90
0.91 0.92 0.92 0.92
0.53 0.53 0.53 0.51
df, degrees of freedom; AGFI, adjusted goodness-of-fit index; RMSEA, root mean square error of approximation; RMS, root mean square residual; NNFI, non-normed fit index; CFI, comparative fit index; PGFI, parsimony goodness-of-fit index. *p < 0.05. Table 3 Descriptive statistics and reliability indexes of the HADS factors
Razavi et al. (42) Total scale Zigmond and Snaith (19) Anxiety subscale Depression subscale Moorey et al. (43) Anxiety subscale Depression subscale Dunbar et al. (44) Negative affectivity subscale Anhedonic depression Autonomic anxiety Caci et al. (45) Anxiety subscale Depression subscale Restlessness subscale
Items
Mean
SD
Cronbach’s alpha
All
21.2114
10.12087
0.91
1,3,5,7,9,11,13 2,4,6,8,10,12,14
10.7543 10.4571
5.26452 5.63111
0.84 0.87
1,3,5,9,11,13 2,4,6,7,8,10,12,14
9.2629 11.9486
4.93516 5.92896
0.85 0.68
1,5,7,11 2,4,6,7,8,10,12,14 3,9,13
6.1086 11.9486 4.6457
3.02379 5.92896 2.90465
0.77 0.86 0.83
7.7143 8.9771 4.5200
4.08650 4.90947 2.16248
0.80 0.85 0.58
1,3,5,9,13 2,4,6,8,10,12 7,11,14
© 2015 Nordic College of Caring Science
Use of the HADS in Spanish caregivers clinical problem of anxiety (scores of 11 or higher). With regard to the depression subscale, using the same cut-off criteria, 21.1% of the patients showed levels of possible depression in clinical terms, and 47.4% presented levels that are considered a clinical problem of depression. With regard to the internal consistency indexes, in the one-factor models and in those of Zigmond and Snaith (19) and Dunbar et al. (44), all the subscales obtained scores Cronbach’s alpha over 0.77, and the highest values corresponded to the subscales proposed by Zigmond and Snaith (19), whereas the remaining models obtained lower scores in some of the subscales. The caregivers who participated in our study (see Table 2) obtained higher scores in anxiety compared with the general population extracted by Quintana et al. (49) [mean anxiety = 6.77, SD = 3.3; t(429) = 9.2382, p < 0.0001]. They also had higher scores in depression [mean depression = 2.44, SD = 2.3; t(429) = 20.4307, p < 0.0001].
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Table 5 Pearson’s correlations between the subscales of each model of the HADS, the GHQ-12 and the number of complaints/diseases Complaints/diseases Razavi et al. (42) Zigmond and Snaith (19) Anxiety subscale Depression subscale Moorey et al. (43) Anxiety subscale Depression subscale Dunbar et al. (44) Negative affectivity subscale Anhedonic depression Autonomic anxiety
GHQ-12
0.190*
0.038
0.224** 0.134
0.005 0.074
0.227** 0.137
0.009 0.058
0.185* 0.137 0.214**
0.029 0.058 0.020
*p < 0.05. **p < 0.01.
presented statistically significant correlations with the GHQ-12 (see Table 5).
Intercorrelation of the subscales and external validity
Discussion
Tables 4 and 5 present the intercorrelations among the subscales of each proposed model and the correlations with the GHQ-12 and the questionnaire of complaints/ diseases, except for the model of Caci et al. (45), as it did not obtain satisfactory results in the confirmatory factor analysis. Pearson’s correlation coefficients between the HADS subscales within each proposed model are reported to be .61-.73 (see Table 4), that is they have a high effect size (50). The correlations among the subscales and the total scale are mostly above 0.90. The anxiety-related subscales of each model showed significant correlations (values between 0.18–0.22), although with a low-moderate effect size (50), with the number of complaints/diseases, but none of them
The present study examined the utility of the HADS as an assessment instrument of psychological distress in family caregivers of senior citizens. Valuable information was obtained about the psychometric properties of the HADS in caregivers and its internal and external validity and reliability. Confirmatory factor analysis showed that the original bifactor model proposed by Zigmond and Snaith (19) provides the best statistical fit for the caregivers of the study, as it presents satisfactory scores in most of the goodness-of-fit statistics, as well as the best reliability indexes. It has been recommended that internal consistency, as measured with Cronbach’s alpha coefficient, should have a value of at least 0.60 for a self-report instrument to be reliable and at least 0.80 when used as
Table 4 Intercorrelations between the subscales
1. Total scale Zigmond and Snaith (19) 2. Anxiety subscale 3. Depression subscale Moorey et al. (43) 4. Anxiety subscale 5. Depression subscale Dunbar et al. (44) 6. Negative affectivity subscale 7. Anhedonic depression subscale 8. Autonomic anxiety subscale All correlations are significant at p < 0.01. © 2015 Nordic College of Caring Science
2
3
4
5
6
7
8
0.924
0.934
0.917
0.943
0.752
0.943
0.891
0.725
0.991 0.722
0.752 0.993
0.893 0.517
0.752 0.993
0.883 0.776
0.733
0.851 0.575
0.733 1
0.910 0.764
0.618
0.631 0.776
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a screening instrument (51). The results indicated that the HADS fulfils these criteria for the Zigmond and Snaith model. In this model, the items of the depression subscale refer mainly to the anhedonic state or inability to feel pleasure, which is considered the central trait of the depressive disorder, whereas the anxiety subscale mainly reports the cognitive aspects of anxiety, although it also reflects some affective aspects more linked to generalised anxiety (19). Although other factor structures have been proposed [the one-factor model of Razavi et al. (42), or the trifactor structures of Dunbar (44), or Caci et al. (45)], the two-factor structure has received extensive empirical support (25, 26, 28, 49, 52). None of the remaining proposals is based on the caregiver population. The results also provide support to the external validity of the HADS, as caregivers obtained higher scores than the general population in depression and anxiety. Almost 50% of the caregivers of our study displayed clinically significant levels of anxiety and depression. This is consistent with other studies that have assessed caregivers (53), showing that most of them present symptoms of anxiety (between 50 and 70%), although the frequency of depressive symptoms is somewhat lower (between 30 and 50%). Caregivers’ higher scores in depression and anxiety could be explained by greater stress in this type of population (11, 12). A tendency towards higher intercorrelations between the HADS subscales is reported in studies of samples with more somatic pathology compared with healthy samples (54). Values obtained in this study show a high intercorrelation between the anxiety and depression subscales that is in accordance with previous findings regarding diminished physical health in caregivers (11, 16–19). Moreover, the intercorrelations achieved confirm both clinical findings and theoretical viewpoints regarding the co-occurrence of such symptoms (55). From the analysis of the relations between the HADS and other health variables, it is concluded that the subscales defined by anxiety in all the factor models studied were positively related to the number of similar complaints/diseases, although with a low-moderate effect size. Other authors have found higher levels of anxiety among caregivers with a higher number of medical complaints and diminished physical health (15). These results support the external validity and utility of the multifactor instrument, as well as its specificity towards the psychological components in contrast to the physiological components of anxiety. With regard to the lack of a relation between the HADS and the GHQ, it can be argued that the latter has some characteristics that may explain the results. The GHQ-12 was designed to screen for nonspecific psychiatric morbidity, while the HADS is designed to screen for anxiety and depression specifically. Furthermore, it has been noted that the GHQ assesses symptoms that can be
affected by diverse physical pathologies (29), which are frequent in the caregiver population (15, 17, 18). In addition, the GHQ items that appraise patients’ social functioning can also lead to false positives in the case of caregivers because their social functioning could be affected by their caring demands. The results of the present study have implications for research and practice. Counting on screening methods to identify family caregivers at maximum risk of distress is required in order for interventions to be targeted. It is expected that the use of psychosocial screening tools like the HADS will increase in this population. Our data provide further evidence for the HADS as a useful test in detecting anxiety and depression in family caregivers of senior citizens. Moreover, the distinction in the HADS between symptoms of anxiety and depression – defended by the original authors of the instrument – is the most appropriate use in family caregivers. This study also has some limitations. The generalisability of the results to the population of family or nonprofessional caregivers is limited due to the fact that it was a convenience sample and to the limited number of males in the sample. Although the sample reflects the distribution of men and women found in some random studies (56, 57) and supports its representativeness, the restricted sample size in relation to men limits the extension of the findings to the population of male caregivers. We recommend conducting additional research that might support our findings with larger samples of males. However, the number of participants was sufficient to analyse the psychometric properties of the instrument, so our study is of sufficient quality to establish the proposed conclusions.
Conclusion It can be concluded that the HADS is a suitable instrument to assess the presence of anxiety and depression in family caregivers of older relatives and that the original bifactorial structure is the most adequate model to detect this symptomatology. Therefore, this study shows the utility of the HADS to assess family caregivers, although it was not specifically designed for them. The HADS, which was validated in general Spanish population and used in caregiver population, is useful to assess mental health of family caregivers of senior citizens. Our results confirm the need to assess the psychological aspects of caregiving in clinical and research contexts.
Acknowledgements Multiannual research project entitled ‘Formal and Relative Caregivers and Health’, subsidised by the Ministry of Health, Social Policy and Equity. Reference number: 18/09. L. Colodro-Conde was supported for a postdoctoral fellowship by Seneca foundation — Regional © 2015 Nordic College of Caring Science
Use of the HADS in Spanish caregivers Agency for Science and Technology, Murcia, Spain (19151/PD/13).
Marıa Pilar Sanchez-L opez was responsible for the study design and drafting of manuscript and the final version of it; Rosa Marıa Limi~ nana-Gras contributed to all versions of the manuscript and was responsible for the data analysis together with Lucıa Colodro-Conde and Isabel Cuellar-Flores. Rosa Marıa Limi~ nana-Gras, Lucıa Colodro-Conde and Isabel Cuellar-Flores were responsible for the data collection and administrative support.
1 Recommendation no 98 (9) Committee of Ministers of the Council of Europe relating to dependence, which was adopted on 18 September 1998. 2 Vermaes I, Janssens J, Bosman A, Guerris J. Parents’ psychological adjustment in families of children with Spina Bifida: a metaanalysis. BMC Pediatr 2005; 5: 1471–2431. 3 Seltzer MM, Greenberg JS, Floyd FJ, Hong J. Accommodative coping and wellbeing of midlife parents of children with mental health problems or developmental disabilities. Am J Orthopsychiatry 2004; 74: 187–95. 4 Wiegner S, Donders J. Predictors of parental distress after congenital disabilities. J Dev Behav Pediatr 2000; 21: 271–4. 5 Limi~ nana RM, Corbalan FJ, SanchezL opez MP. Thinking styles and coping when caring for a child with myelomeningocele. J Dev Phys Disabil 2009; 2: 169–83. 6 Badıa X, Lara N, Roset M. Calidad de vida, tiempo de dedicaci on y carga percibida por el cuidador principal informal del enfermo de Alzheimer [Quality of life, time of dedication and perceived burden by the principal informal caregiver of Alzheimer ill]. Rev Aten Prim 2004; 34: 170–7. 7 Crespo M, L opez J, Zarit S. Depression and anxiety in primary caregivers: a comparative study of caregivers of demented and nondemented older persons. Int J Geriatr Psychiatry 2005; 20: 591–2.
© 2015 Nordic College of Caring Science
Ethical approval This study obtained ethical approval from the institutional review board of the Universidad Complutense of Madrid.
Author contributions
References
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Funding The research leading to this article received funding from the Ministry of Health, Social Policy and Equality (Spain) under grant agreement number 18/09, multiannual research project entitled ‘Formal and Relative Caregivers and Health’. The researchers were independent from the funders.
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23 Axford J, Butt A, Heron C, Hammond J, Morgan J, Alavi A, Bolton J, Bland M. Prevalence of anxiety and depression in osteoarthritis: use of the Hospital Anxiety and Depression Scale as a screening tool. Clin Rheumatol 2010; 29: 1277–83. 24 Garcıa-Campayo J, Pascual A, Alda M, Marzo J, Magall on R, Fortes S. The Spanish version of the fibrofatigue scales: validation of a questionnaire for the observer’s assessment of fibromyalgia and chronic fatigue syndrome. Gen Hosp Psychiatry 2006; 28: 154–60. 25 Smith AB, Selby PJ, Velikova G. Factor analysis of the Hospital Anxiety and Depression Scale from a large cancer population. Psychol Psychother 2002; 75: 165–76. 26 Chivite S, Martınez M, Perez E, Peralta V. HADS: Estudio de criterios de validez interna y externa en una muestra espa~ nola de pacientes hospitalizados. [HADS: Study of external and internal validity in a Spanish simple of hospitalized patients]. Cuad Med Psicosom 2008; 84/85: 9–17. 27 Terol MC, L opez-Roig S, Rodrıguez-Marın J, Martın-Arag on M, Pastor MA. Propiedades psicom etricas de la escala hospitalaria de ansiedad y depresi on (HAD) en poblaci on espa~ nola [Psychometric properties of the HAD in the Spanish population]. Ansiedad y Estres 2007; 13: 163–76. 28 Herrero MJ, Blanch J, Peri JM, De Pablo J, Pintor A, Bulbena A. A validation study of the hospital anxiety and depression scale (HADS) in the Spanish population. Gen Hosp Psychiatry 2003; 25: 277–83. 29 Lewis GH, Wessely SC. Comparison of the general health questionnaire and the Hospital Anxiety and Depression Scale. Br J Psychiatry 1990; 187: 860–4. 30 Goldberg D. The detection and treatment of depression in the physically ill. Mundo Psychiatry 2010; 9: 16–20. 31 Lambert S, Pallant JF, Girgis A. Rasch analysis of the Hospital Anxiety and Depression Scale among caregivers of cancer survivors: implications for its use in psycho-oncology. Psycho-Oncology 2011; 20: 1099–611.
32 Gough K, Hudson P. Psychometric properties of the Hospital Anxiety and Depression Scale in family caregivers of palliative care patients. J Pain Symptom Manage 2009; 37: 797–806. 33 Cooper C, Katona C, Orrell M, Livingston G. Coping strategies, anxiety and depression in caregivers of people with Alzheimer’s disease. Int J Geriatr Psychiatry 2008; 23: 929–36. 34 Martinez-Martin P, Arroyo S, RojoAbuin JM, Rodriguez-Blazquez C, Frades B, de Pedro-Cuesta J. Burden, perceived health status, and mood among caregivers of Parkinson’s disease patients. Mov Disord 2008; 23: 1673–80. 35 Goldberg D, Williams P. A User’s Guide to the General Health Questionnaire. 1988, NFER-Nelson, Windsor, UK. 36 Sanchez-L opez MP, Dresch V. The 12-Item General Health Questionnaire (GHQ-12): reliability, external validity and factor structure in the Spanish population. Psicothema 2008; 20: 839–43. 37 Ministerio de Sanidad, Servicios Sociales e Igualdad. Encuesta Nacional de Salud de Espa~ na [Spanish National Health Survey]. 2006, Ministerio de Sanidad, Servicios Sociales e Igualdad, Madrid. 38 Garson DG. Factor Analysis: Statnotes. North Carolina State University Public Administration Program; 2008, http://tx.liberal.ntu.edu.tw/~purplewoo/Literature/!DataAnalysis/Factor %20Analysis-types.htm (last accessed 22 September 2014). 39 MacCallum RC, Widaman KF, Zhang S, Hong S. Sample size in factor analysis. Psychol Methods 1999; 4: 84–99. ~ ez E. La Escala Hospitalar40 Caro I, Iban ia de Ansiedad y Depresi on. Su utilidad practica en Psicologıa de la Salud [The Hospital Anxiety and Depression Scale. Its utility in Health Psychology]. Bol Psicol 1992; 36: 43–69. 41 Miguel-Tobal JJ, Cano-Vindel AR. Inventory of Situations and Response of Anxiety (ISRA): Handbook [Inventario de situaciones de respuestas de ansiedad (ISRA): manual]. 2002, TEA Ediciones, Madrid.
42 Razavi D, Delvaux N, Farvacques C, Robaye E. Screening for adjustment disorders and major depressive disorders in cancer inpatients. Br J Psychiatry 1990; 156: 79–83. 43 Moorey S, Greer S, Watson M, Gorman C, Rowden L, Tunmore R, Robertson B, Bliss J. The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. Br J Psychiatry 1991; 158: 255–9. 44 Dunbar M, Ford G, Hunt K, Der G. A confirmatory factor analysis of the Hospital Anxiety and Depression scale: comparing empirically and theoretically derived structures. Br J Clin Psychol 2000; 39: 79–94. 45 Caci H, Bayle FJ, Mattei V, Dossios C, Robert P, Boyer P. How does the Hospital and Anxiety and Depression Scale measure anxiety and depression in healthy subjects? Psychiatry Res 2003; 118: 89–99. 46 Hoyle RH. Structural Equation Modeling: Concepts, Issues, and Applications. 1995, Sage Publications, Thousand Oaks, CA. 47 Hair F, Anderson R, Tatham R, Black W. Multivariate Data Analysis with Readings, 5th edn. 1995, PrenticeHall, Englewood Cliffs, NJ. 48 Arias B. Desarrollo de un ejemplo de analisis factorial confirmatorio con LISREL, AMOS y SAS. Seminario de Actualizaci on en Investigaci on sobre Discapacidad SAID [Development of an example of confirmatory factor analysis with LISREL, AMOS and SAS. Seminar Update on Disability Research SAID]. Mimeografıa no publicada. 2008. 49 Quintana JM, Padierna A, Esteban C, Arostegui I, Bilbao A, Ruiz I. Evaluation of the psychometric characteristics of the Spanish version of the Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 2003; 107: 216–21. 50 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 1988, Hillsdale, New Jersey: Lawrence Erlbaum Associates, Inc., Publishers. 51 Nunnally JC, Bernstein IH. Psychometric Theory, 3rd edn. 1994, McGrawHill, New York, NY.
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Use of the HADS in Spanish caregivers 52 Singer S, Danker H, Dietz A, Hornemann B, Koscielny S, Oeken J, Matthäus C, Vogel HJ, Krauss O. Screening for mental disorders in laryngeal cancer patients: a comparison of 6 methods. Psycho-Oncology 2008; 17: 280–6. 53 Pochard F, Azoulay E, Chevret S, Lemaire F, Hubert P, Canoui P, Grassin M, Zittoun R, le Gall JR, Dhainaut JF, Schlemmer B; French FAMIREA Group. Symptoms of anxiety and
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depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med 2001; 29: 1893–7. 54 Mykletun A, Stordal E, Dahl AA. Hospital Anxiety and Depression (HAD) Scale: factor structure, item analyses and internal consistency in a large population. Br J Psychiatry 2001; 179: 540–4. 55 Mineka S, Watson D, Clark LA. Comorbidity of anxiety and unipolar
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mood disorders. Annu Rev Psychol 1998; 49: 377–412. 56 IMSERSO. Cuidados a las personas mayores en los hogares espa~ noles: El entorno familiar [Caring for older persons in Spanish homes: The family environment]. 2005, IMSERSO, Madrid. 57 INE. Panoramica de la discapacidad en Espa~ na [Overview of Disabilities in Spain]. Cifras INE. 2009, INE, Madrid.
doi: 10.1111/scs.12206
Use of the Hospital Anxiety and Depression Scale in Spanish caregivers nchez-Lo pez PhD (Professor)1,2, Rosa Marıa Limin ~ ana-Gras PhD (Lecturer)2,3, Marıa Pilar Sa llar-Flores PhD (Postdoctoral Lucıa Colodro-Conde PhD (Postdoctoral researcher)2,3 and Isabel Cue researcher)1,2 1
Universidad Complutense de Madrid, Madrid, Spain, 2Red Hygeia (Health y GEnder International Alliance), http://www.redhygeia.com/ and 3Universidad de Murcia, Murcia, Spain
Scand J Caring Sci; 2015 Use of the Hospital Anxiety and Depression Scale in Spanish caregivers
Background: The Hospital Anxiety and Depression Scale (HADS) is widely used in the assessment of anxiety and depression, but there are scarce data about its psychometric properties in caregivers of older relatives. Objective: The goal of this study was to analyse the factor structure of the HADS to verify its suitability to assess emotional symptomatology in family caregivers of old people, its internal consistency and confirming its relation with the General Health Questionnaire (GHQ-12) and an index of disease and physical complaints. Methods: One hundred and seventy-five family caregivers (25 men and 150 women) aged 32–86, who were taking care of at least one older person in a situation of dependence, were recruited for this study. A descriptive, comparative, correlational design was employed. The scientific adequacy of the questionnaire and its structure
Introduction There is sufficient evidence supporting the conclusion that caring for a person in a situation of personal dependence can involve risk for the caregiver’s physical and psychological health, regardless of the concrete problem that originated the dependence and the type of relationship established between the caregiver and care recipient. Personal dependence is the functional disability in the development of activity in daily life (1). Caring can be related to positive aspects (2), but it is usually associated with negative consequences for caregivers’ physical and psychological health, regardless of whether they are caring
Correspondence to: Isabel Cu ellar Flores, Facultad de Psicologıa, Campus de Somosaguas, 28223 Madrid, Spain. E-mail: [email protected] © 2015 Nordic College of Caring Science
were analysed using confirmatory factor analysis. The scores obtained in the GHQ and in an index of disease and physical complaints were used as external criteria to assess the adequacy of the HADS for caregivers. Results: Higher levels of anxiety and depression than in the normal population were obtained. The reliability/ internal validity of the questionnaire was adequate. A bifactor model, with one subscale for anxiety and one for depression, provides the best fit to the data. The subscales were related to GHQ-12 and index of diseases/physical complaints. Conclusions: The HADS was shown to be useful to assess the presence of anxiety and depression in family caregivers, and the original two-dimensional model is the most adequate. Keywords: caregivers, depression, anxiety, Hospital Anxiety and Depression Scale, confirmatory factor analysis. Submitted 1 August 2014, Accepted 11 November 2014
for their own disabled children (2–5), older relatives (6–8) or people with severe mental disorders (9, 10). In general – and there is more evidence in the case of caregivers of disabled children and older people – caregivers seem to have worse health and psychological well-being than the general population (11). Depressive symptomatology, both in its behavioural and cognitive correlates, is usually present in a high percentage of caregivers (12, 13). Caregivers’ stress and emotional problems usually manifest in anxious symptomatology, which, as with depression, is frequently accompanied by low selfesteem and coping strategies focused on relieving emotions (3, 5, 14). Anxiety disorders are usually one of the main reasons for caregivers’ visits to primary care, and these disorders have been directly related to their physical health (15). Likewise, diverse studies are in agreement about the negative consequences for physical health of the care situation, such as worse self-reported physical health, 1
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higher presence of symptomatology and negative physiological indices, more chronic diseases and hospitalisations, and more use of medication (16–18). In addition to diverse chronic diseases, the most frequent complaints and somatic disorders are osteoarticular complaints, headaches, exhaustion, cardiovascular or gastrointestinal pathology, alterations of the immune system and respiratory problems (11, 16, 18). In view of the importance of effective detection of mood and anxiety disorders to prevent the development of psychopathology and of diseases in general (15), and taking into account the high prevalence of emotional disorders found in caregivers of dependent people, it is necessary to have screening tests available. These tests must be sufficiently sensitive to account for the heterogeneity of the emotional symptomatology associated with caregiver stress and can identify caregivers at risk of depression or anxiety who require additional attention. The HADS (19) is a brief assessment instrument in detecting diverse dimensions of anxiety and depression in nonpsychiatric populations (20–22). The HADS has been translated and widely used in more than 25 countries since its original development. It has been extensively used in the general population and in a variety of clinical populations where anxiety and depression can coexist with diverse physical diseases, such as arthrosis, cancer, fibromyalgia or chronic fatigue syndrome, among others (23–25). The HADS is a self-applied scale made up of 14 items grouped in two subscales, one addressing depression and the other anxiety, which assesses the emotional status of the past week. The psychometric properties of this instrument confirm that it provides a reliable measurement of anxiety and depression in Spanish populations (26–28). Although there are currently many questionnaires to assess depression and anxiety, the HADS is considered very useful to employ in caregivers, as it allows assessing the severity of the emotional symptomatology with more sensitivity and specificity towards the psychological components (vs. the physiological components) than other similar screening questionnaires, such as the GHQ-12 (29). This instrument also appraises emotional experiences through relatively independent cognitive and behavioural components, which increases its value and utility as it identifies the cognitive process involved in depressive and anxious symptomatology. At the same time, it guides interventions and, more specifically, treatment orientations (20, 24, 26). The HADS has been extensively used and validated in a healthcare context, both in the general population and in primary care patients (20). It is especially recommended for its use in physical disease (30). To date, some studies have been published about the HADS’ psychometric properties in assessing caregivers of cancer and palliative patients (31, 32). This questionnaire has been
used with caregivers of geriatric patients (13, 33, 34), but its psychometric characteristics have not been evaluated in this population. As in the population of interest – caregivers of geriatric patients in a situation of dependence – the physical, social and emotional symptoms are closely related and even overlap. This instrument could facilitate a more specific detection of emotional disorders related to the consequences of caregiver overload. The goal of this study was to analyse the factor structure of the HADS, to verify its suitability in assessing emotional symptomatology in family caregivers of geriatric patients, to analyse its internal consistency and to confirm its relation with other measures of health. It was examined in relation to the GHQ-12 of Goldberg and Williams (35), which is one of the instruments most frequently used as a single screening tool to assess psychological distress (36), and to an index of disease and physical complaints used in the National Spanish Health Survey (37).
Methods Participants A total of 175 caregivers (25 men and 150 women) of geriatric patients in a situation of dependence participated in this study. An important aspect to consider is that the sample size must be sufficient in order for the results to be stable. The effect of sample variability can increase as the number of variables or items increases. Therefore, some of the recommendation criteria are based on the ratio of persons per variable. A number of observations 10 times higher than the number of items on a scale would reduce the standard error of the correlation coefficients (38) (in our case, this would be 140 people). Other recommendations have focused on the size of the communalities of the variables and the number of variables per factor (39). If the communalities are around 0.5 and the number of variables per factor is adequate (e.g. 6), then samples of 100 or 200 people may be sufficient. Taking into account either of the two recommendations, in our case, the sample size is sufficiently large (N = 175) to allow us to perform confirmatory factor analysis. The demographic characteristics of the subjects are shown in Table 1.
Procedure The inclusion criteria to select the participants were a person must be caring for a dependent older relative, must speak Spanish and is able to read and write. Caregivers were contacted through professionals working in health centres (hospitals, primary healthcare centres, mental health centres), in associations of relatives (of people with Parkinson or Alzheimer’s), residences, or day © 2015 Nordic College of Caring Science
Use of the HADS in Spanish caregivers Table 1 Sociodemographic variables of the sample of caregivers Frequency/mean (SD, range) Caregiver age Relative age
5.1 13.1 42.3 36.0 3.4 100.0 14.3 40.0 25.7 19.4 14.3 45.7 40.0
10.7 46.7 29.0 13.6
care centres (of senior citizens) or through direct contact, requesting their participation. The data were collected by several trained evaluators.
Measures Hospital Anxiety and Depression Scale (HADS). Fourteen items of Zigmond and Snaith (19), Spanish version of ~ ez (40). Cronbach’s alpha for the Spanish Caro and Iban version was 0.81, and it had adequate convergent validity with regard to the State-Trait Anxiety Inventory (STAI). In the original version, the same cut-off points are proposed to assess both subscales: 0–7: Normal; 8–10: Doubtful; and 11 or more: Clinical problems. 12-item General Health Questionnaire (GHQ-12). Twelve items of Goldberg and Williams (35), Spanish adaptation of Sanchez-L opez and Dresch (36). This questionnaire assesses psychological health. The Spanish version has a Cronbach’s alpha value of 0.76 (standardised alpha: 0.78). The external validity of Factor I (Successful Coping) with the ‘Inventario de Situaciones y Respuestas de Ansiedad’ [ISRA; in English, the Anxiety Situations and © 2015 Nordic College of Caring Science
Responses Inventory of Miguel-Tobal and Cano-Vindel (41)] was very high (Factor I: 0.82; Factor II, 0.70; Factor III, 0.75) (36).
Percentage
56.57 (13.75, 32–86) 80.64 (11.04, 50–99)
Province C aceres 9 Madrid 23 Murcia 74 Segovia 60 Teruel 6 Total 172 Level of education No formal studies 25 Primary studies 70 Secondary and 42 professional education University degree 34 Type of relationship Caregiver cares for his wife 25 Caregiver cares for her husband 80 Caregiver cares for 70 her/his mother/father Aetiology of the relative situation of dependence Parkinson 18 Dementia 79 Older people 49 Other 23
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Questionnaire of complaints/diseases. Twenty-nine items. Based on the questionnaires used in the Spanish National Health Survey (37), this instrument collects information about the existence of 29 chronic diseases such as diabetes, varicose veins, haemorrhoids and migraine headaches. It employs binary response yes/no.
Statistical analysis To verify the utility of the instrument to assess distress in family caregivers, the psychometric characteristics of the HADS in caregiver population must be analysed. For this purpose, confirmatory factor analysis was carried out to determine whether it is more appropriate to apply the HADS as a unidimensional or a multidimensional instrument. Three models were tested: 1 One-dimensional model: the model of Razavi et al. (42). 2 Two-dimensional model: the original two-factor model proposed by Zigmond and Snaith (19) and that of Moorey et al. (43). 3 Three-dimensional model: the model of Dunbar et al. (44) and of Caci et al. (45). With regard to the goodness-of-fit statistics, the following were taken into account: chi2, the root mean square error of approximation (RMSEA), the root mean square residual (RMR), the non-normed fit index (NNFI), the comparative fit index (CFI), the parsimony goodness-offit index (PGFI) and the adjusted goodness-of-fit index (AGFI). The chi2 index should have a low value with a p-value higher than 0.05. Values higher than 0.90 reflect a good fit for the incremental fit indexes: CFI, AGFI and NNFI (46), whereas the value of the RMSEA should be lower than 0.08 (47). With regard to the RMR, the closer it is to 0, the better, and the PGFI is considered adequate when it presents high values (48). Descriptive data were also analysed, the results in the HADS were classified according to the cut-off points proposed by Zigmond and Snaith (19), and internal consistency (Cronbach’s alpha) was examined. Subsequently, the intercorrelations of the subscales were analysed. Moreover, in order to study the external validity of the HADS scores, we confirmed by means of Pearson’s correlations the relationship between this instrument and other measures of health such as the GHQ-12 and the questionnaire of complaints/diseases. Lastly, in order to appraise validity, the scores obtained in this group were compared with scores from the general population extracted by Quintana et al. (49).
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Ethical considerations All the participants gave their written informed consent after the purpose of the investigation and the procedure to be followed had been explained, and the confidentiality of their data and their freedom to participate or to withdraw at any time were guaranteed.
Results
The model of Razavi et al. (42), which offers a one-factor solution, obtained slightly less optimal results than the others. The two-factor models of Zigmond and Snaith (19) and Moorey et al. (43) obtained satisfactory scores in most of the goodness-of-fit statistics, except for RMSEA and AGFI, and no important differences were found between them. Lastly, of the three-factor models, proposed by Dunbar et al. (44) and Caci et al. (45), only the first one obtained scores that support its utility to explain the results.
Factor structure The results of Bartlett’s sphericity test and the Kaiser– Meyer–Olkin (KMO) sample adequacy test showed values of 793.01 (p < 0.001) and 0.86, respectively, so the suitability of the correlation matrix structure was verified, and consequently, the feasibility of using factor analysis was confirmed. Although the model converges with most of the models, the values of the goodness-of-fit statistics were not optimal (see Table 2).
Descriptive statistics and internal consistency Table 3 shows the items corresponding to the subscales of each tested model and the descriptive values obtained, as well as the internal consistency of each subscale. Applying the cut-off values proposed by Zigmond and Snaith (19) for the scores of the anxiety subscale, 20% of the patients showed levels that, in clinical terms, can be considered as possible anxiety (scores of 8 or higher) and 49.7% reported levels that can be considered a
Table 2 Factor structure of the HADS determined through goodness-of-fit tests of the models derived from prior factor analysis. Models of 1, 2 and 3 factors v²
Model
df
Razavi et al. (42) Zigmond and Snaith (19) Moorey et al. (43) Dunbar et al. (44) Caci et al. (45)
77 417.42* 76 387.97* 76 331.85* 73 374.98* No convergence
AGFI
RMSEA
RMS
NNFI
CFI
PGFI
0.62 0.63 0.63 0.63
0.17 0.16 0.16 0.16
0.10 0.099 0.098 0.095
0.89 0.90 0.90 0.90
0.91 0.92 0.92 0.92
0.53 0.53 0.53 0.51
df, degrees of freedom; AGFI, adjusted goodness-of-fit index; RMSEA, root mean square error of approximation; RMS, root mean square residual; NNFI, non-normed fit index; CFI, comparative fit index; PGFI, parsimony goodness-of-fit index. *p < 0.05. Table 3 Descriptive statistics and reliability indexes of the HADS factors
Razavi et al. (42) Total scale Zigmond and Snaith (19) Anxiety subscale Depression subscale Moorey et al. (43) Anxiety subscale Depression subscale Dunbar et al. (44) Negative affectivity subscale Anhedonic depression Autonomic anxiety Caci et al. (45) Anxiety subscale Depression subscale Restlessness subscale
Items
Mean
SD
Cronbach’s alpha
All
21.2114
10.12087
0.91
1,3,5,7,9,11,13 2,4,6,8,10,12,14
10.7543 10.4571
5.26452 5.63111
0.84 0.87
1,3,5,9,11,13 2,4,6,7,8,10,12,14
9.2629 11.9486
4.93516 5.92896
0.85 0.68
1,5,7,11 2,4,6,7,8,10,12,14 3,9,13
6.1086 11.9486 4.6457
3.02379 5.92896 2.90465
0.77 0.86 0.83
7.7143 8.9771 4.5200
4.08650 4.90947 2.16248
0.80 0.85 0.58
1,3,5,9,13 2,4,6,8,10,12 7,11,14
© 2015 Nordic College of Caring Science
Use of the HADS in Spanish caregivers clinical problem of anxiety (scores of 11 or higher). With regard to the depression subscale, using the same cut-off criteria, 21.1% of the patients showed levels of possible depression in clinical terms, and 47.4% presented levels that are considered a clinical problem of depression. With regard to the internal consistency indexes, in the one-factor models and in those of Zigmond and Snaith (19) and Dunbar et al. (44), all the subscales obtained scores Cronbach’s alpha over 0.77, and the highest values corresponded to the subscales proposed by Zigmond and Snaith (19), whereas the remaining models obtained lower scores in some of the subscales. The caregivers who participated in our study (see Table 2) obtained higher scores in anxiety compared with the general population extracted by Quintana et al. (49) [mean anxiety = 6.77, SD = 3.3; t(429) = 9.2382, p < 0.0001]. They also had higher scores in depression [mean depression = 2.44, SD = 2.3; t(429) = 20.4307, p < 0.0001].
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Table 5 Pearson’s correlations between the subscales of each model of the HADS, the GHQ-12 and the number of complaints/diseases Complaints/diseases Razavi et al. (42) Zigmond and Snaith (19) Anxiety subscale Depression subscale Moorey et al. (43) Anxiety subscale Depression subscale Dunbar et al. (44) Negative affectivity subscale Anhedonic depression Autonomic anxiety
GHQ-12
0.190*
0.038
0.224** 0.134
0.005 0.074
0.227** 0.137
0.009 0.058
0.185* 0.137 0.214**
0.029 0.058 0.020
*p < 0.05. **p < 0.01.
presented statistically significant correlations with the GHQ-12 (see Table 5).
Intercorrelation of the subscales and external validity
Discussion
Tables 4 and 5 present the intercorrelations among the subscales of each proposed model and the correlations with the GHQ-12 and the questionnaire of complaints/ diseases, except for the model of Caci et al. (45), as it did not obtain satisfactory results in the confirmatory factor analysis. Pearson’s correlation coefficients between the HADS subscales within each proposed model are reported to be .61-.73 (see Table 4), that is they have a high effect size (50). The correlations among the subscales and the total scale are mostly above 0.90. The anxiety-related subscales of each model showed significant correlations (values between 0.18–0.22), although with a low-moderate effect size (50), with the number of complaints/diseases, but none of them
The present study examined the utility of the HADS as an assessment instrument of psychological distress in family caregivers of senior citizens. Valuable information was obtained about the psychometric properties of the HADS in caregivers and its internal and external validity and reliability. Confirmatory factor analysis showed that the original bifactor model proposed by Zigmond and Snaith (19) provides the best statistical fit for the caregivers of the study, as it presents satisfactory scores in most of the goodness-of-fit statistics, as well as the best reliability indexes. It has been recommended that internal consistency, as measured with Cronbach’s alpha coefficient, should have a value of at least 0.60 for a self-report instrument to be reliable and at least 0.80 when used as
Table 4 Intercorrelations between the subscales
1. Total scale Zigmond and Snaith (19) 2. Anxiety subscale 3. Depression subscale Moorey et al. (43) 4. Anxiety subscale 5. Depression subscale Dunbar et al. (44) 6. Negative affectivity subscale 7. Anhedonic depression subscale 8. Autonomic anxiety subscale All correlations are significant at p < 0.01. © 2015 Nordic College of Caring Science
2
3
4
5
6
7
8
0.924
0.934
0.917
0.943
0.752
0.943
0.891
0.725
0.991 0.722
0.752 0.993
0.893 0.517
0.752 0.993
0.883 0.776
0.733
0.851 0.575
0.733 1
0.910 0.764
0.618
0.631 0.776
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a screening instrument (51). The results indicated that the HADS fulfils these criteria for the Zigmond and Snaith model. In this model, the items of the depression subscale refer mainly to the anhedonic state or inability to feel pleasure, which is considered the central trait of the depressive disorder, whereas the anxiety subscale mainly reports the cognitive aspects of anxiety, although it also reflects some affective aspects more linked to generalised anxiety (19). Although other factor structures have been proposed [the one-factor model of Razavi et al. (42), or the trifactor structures of Dunbar (44), or Caci et al. (45)], the two-factor structure has received extensive empirical support (25, 26, 28, 49, 52). None of the remaining proposals is based on the caregiver population. The results also provide support to the external validity of the HADS, as caregivers obtained higher scores than the general population in depression and anxiety. Almost 50% of the caregivers of our study displayed clinically significant levels of anxiety and depression. This is consistent with other studies that have assessed caregivers (53), showing that most of them present symptoms of anxiety (between 50 and 70%), although the frequency of depressive symptoms is somewhat lower (between 30 and 50%). Caregivers’ higher scores in depression and anxiety could be explained by greater stress in this type of population (11, 12). A tendency towards higher intercorrelations between the HADS subscales is reported in studies of samples with more somatic pathology compared with healthy samples (54). Values obtained in this study show a high intercorrelation between the anxiety and depression subscales that is in accordance with previous findings regarding diminished physical health in caregivers (11, 16–19). Moreover, the intercorrelations achieved confirm both clinical findings and theoretical viewpoints regarding the co-occurrence of such symptoms (55). From the analysis of the relations between the HADS and other health variables, it is concluded that the subscales defined by anxiety in all the factor models studied were positively related to the number of similar complaints/diseases, although with a low-moderate effect size. Other authors have found higher levels of anxiety among caregivers with a higher number of medical complaints and diminished physical health (15). These results support the external validity and utility of the multifactor instrument, as well as its specificity towards the psychological components in contrast to the physiological components of anxiety. With regard to the lack of a relation between the HADS and the GHQ, it can be argued that the latter has some characteristics that may explain the results. The GHQ-12 was designed to screen for nonspecific psychiatric morbidity, while the HADS is designed to screen for anxiety and depression specifically. Furthermore, it has been noted that the GHQ assesses symptoms that can be
affected by diverse physical pathologies (29), which are frequent in the caregiver population (15, 17, 18). In addition, the GHQ items that appraise patients’ social functioning can also lead to false positives in the case of caregivers because their social functioning could be affected by their caring demands. The results of the present study have implications for research and practice. Counting on screening methods to identify family caregivers at maximum risk of distress is required in order for interventions to be targeted. It is expected that the use of psychosocial screening tools like the HADS will increase in this population. Our data provide further evidence for the HADS as a useful test in detecting anxiety and depression in family caregivers of senior citizens. Moreover, the distinction in the HADS between symptoms of anxiety and depression – defended by the original authors of the instrument – is the most appropriate use in family caregivers. This study also has some limitations. The generalisability of the results to the population of family or nonprofessional caregivers is limited due to the fact that it was a convenience sample and to the limited number of males in the sample. Although the sample reflects the distribution of men and women found in some random studies (56, 57) and supports its representativeness, the restricted sample size in relation to men limits the extension of the findings to the population of male caregivers. We recommend conducting additional research that might support our findings with larger samples of males. However, the number of participants was sufficient to analyse the psychometric properties of the instrument, so our study is of sufficient quality to establish the proposed conclusions.
Conclusion It can be concluded that the HADS is a suitable instrument to assess the presence of anxiety and depression in family caregivers of older relatives and that the original bifactorial structure is the most adequate model to detect this symptomatology. Therefore, this study shows the utility of the HADS to assess family caregivers, although it was not specifically designed for them. The HADS, which was validated in general Spanish population and used in caregiver population, is useful to assess mental health of family caregivers of senior citizens. Our results confirm the need to assess the psychological aspects of caregiving in clinical and research contexts.
Acknowledgements Multiannual research project entitled ‘Formal and Relative Caregivers and Health’, subsidised by the Ministry of Health, Social Policy and Equity. Reference number: 18/09. L. Colodro-Conde was supported for a postdoctoral fellowship by Seneca foundation — Regional © 2015 Nordic College of Caring Science
Use of the HADS in Spanish caregivers Agency for Science and Technology, Murcia, Spain (19151/PD/13).
Marıa Pilar Sanchez-L opez was responsible for the study design and drafting of manuscript and the final version of it; Rosa Marıa Limi~ nana-Gras contributed to all versions of the manuscript and was responsible for the data analysis together with Lucıa Colodro-Conde and Isabel Cuellar-Flores. Rosa Marıa Limi~ nana-Gras, Lucıa Colodro-Conde and Isabel Cuellar-Flores were responsible for the data collection and administrative support.
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© 2015 Nordic College of Caring Science
Ethical approval This study obtained ethical approval from the institutional review board of the Universidad Complutense of Madrid.
Author contributions
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Funding The research leading to this article received funding from the Ministry of Health, Social Policy and Equality (Spain) under grant agreement number 18/09, multiannual research project entitled ‘Formal and Relative Caregivers and Health’. The researchers were independent from the funders.
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