Validity of the Hospital Anxiety and Depression Scale to assess depression and anxiety following traumatic brain injury as compared with the Structured Clinical Interview for DSM-IV

J Affect Disord. 2009 Apr;114(1-3):94-102. doi: 10.1016/j.jad.2008.06.007. Epub 2008 Jul 25.


Background: Rating scales are often used in the assessment of depression and anxiety in traumatic brain injury (TBI), but few have been validated for use with this population. Overlap of symptoms between such disorders and TBI may lead to under- or over-diagnosis of depression or anxiety.

Methods: 100 participants with mild to severe TBI, and 87 informants, were interviewed using the SCID-IV (Axis I). The HADS was administered at the same time.

Results: According to the SCID-IV, 34 participants were diagnosed with major depression and 36 with an anxiety disorder. Higher HADS scores were associated with a greater likelihood of depression and anxiety. However, the "clinical" categories of the HADS did not strongly correspond with the clinical diagnoses of depression and anxiety. Compared with SCID diagnoses, the depression subscale of the HADS had a sensitivity of 62% and a specificity of 92%. The anxiety subscale had a sensitivity of 75% and a specificity of 69%. Positive predictive and negative predictive values were calculated.

Limitations: This study included mostly moderate to severe TBI individuals, recruited from a rehabilitation hospital. Therefore, they may not necessarily be representative of the entire TBI population.

Conclusions: The HADS was a reliable measure of emotional distress in this TBI sample; however the cut-off scores and categories were not useful in predicting caseness of depression and anxiety. Clinicians should be mindful of the sequelae of TBI that may confound the scores yielded in rating scales and should follow up with a psychiatric interview when diagnosis is unclear.

Publication types

  • Comparative Study
  • Evaluation Study

MeSH terms

  • Adult
  • Aged
  • Anxiety Disorders / diagnosis*
  • Anxiety Disorders / epidemiology*
  • Anxiety Disorders / etiology
  • Anxiety Disorders / psychology
  • Brain Injuries / psychology*
  • Depressive Disorder, Major / diagnosis*
  • Depressive Disorder, Major / epidemiology*
  • Depressive Disorder, Major / etiology
  • Depressive Disorder, Major / psychology
  • Diagnostic and Statistical Manual of Mental Disorders
  • Female
  • Glasgow Coma Scale
  • Hospitals
  • Humans
  • Male
  • Middle Aged
  • Neuropsychological Tests
  • Predictive Value of Tests
  • Psychiatric Status Rating Scales
  • ROC Curve
  • Reproducibility of Results
  • Severity of Illness Index
  • Surveys and Questionnaires
  • Young Adult