Gender as a determinant of responses to a self-screening questionnaire on anxiety and depression by patients with coronary artery disease

Gend Med. 2009 Sep;6(3):479-87. doi: 10.1016/j.genm.2009.09.001.


Background: Because patients with coronary artery disease (CAD) could benefit from interventions to decrease psychological distress, it is important to identify these individuals. Both salivary cortisol level and the Hospital Anxiety and Depression Scale (HADS) are recognized measures of stress/anxiety and depression.

Objectives: This study was designed to determine whether there is an association between anxiety and depression, as measured by the HADS, and salivary cortisol levels among patients with CAD, and whether this association is affected by gender.

Methods: All adult residents of Alberta, Canada, undergoing their first cardiac catheterization for CAD (>or=50% occlusion of >or=2 coronary arteries) were eligible for participation in this study. A 14-question survey (the HADS) and 3 saliva-collection devices (a 1-day supply) were sent to the participants' home within 1 week of their initial cardiac catheterization. Participants were asked to take saliva samples for determination of cortisol levels on waking and at 30 and 60 minutes after waking, and then return the completed questionnaire and saliva samples using a prepaid express mailing envelope.

Results: Seventy-one adults (52 men and 19 women) participated in the study. Mean (SD) ages were 68.4 (4.6) years for men and 69.1 (4.4) years for women. Among the women, significant negative correlations were found between the HADS anxiety score and the wake-up and 30-minute cortisol levels (higher HADS scores were associated with lower cortisol levels) (all, P < 0.05). Also among women, negative correlations were found between the HADS depression score and the salivary cortisol values, but the differences were not statistically significant. Conversely, among the men, nonsignificant positive correlations were found between the HADS anxiety scores and the salivary cortisol levels (higher HADS scores were associated with higher cortisol levels), and statistically significant positive correlations were observed between the HADS depression scores and all 3 salivary cortisol values (all, P < 0.05).

Conclusions: Our findings suggest that the HADS is an appropriate screening instrument for anxiety and depression in patients with CAD. In particular, the scale appears to be sensitive for measuring anxiety in women and depression in men. When the HADS is used clinically as a screening tool, it should be examined through a "gender-based lens.".

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anxiety / complications
  • Anxiety / diagnosis*
  • Brief Psychiatric Rating Scale
  • Cohort Studies
  • Coronary Artery Disease / psychology*
  • Depression / complications
  • Depression / diagnosis*
  • Female
  • Humans
  • Hydrocortisone / analysis*
  • Male
  • Middle Aged
  • Saliva / chemistry
  • Sex Factors
  • Stress, Psychological / complications
  • Stress, Psychological / diagnosis


  • Hydrocortisone