Ingvar Bjelland

The validity of the Hospital Anxiety and Depression Scale - An updated literature review

OBJECTIVE To review the literature of the validity of the Hospital Anxiety and Depression Scale (HADS). METHOD A review of the 747 identified papers that used HADS was performed to address the following questions: (I) How are the factor structure, discriminant validity and the internal consistency of HADS? (II) How does HADS perform as a case finder for anxiety disorders and depression? (III) How does HADS agree with other self-rating instruments used to rate anxiety and depression? RESULTS Most factor analyses demonstrated a two-factor solution in good accordance with the HADS subscales for Anxiety (HADS-A) and Depression (HADS-D), respectively. The correlations between the two subscales varied from.40 to.74 (mean.56). Cronbachs alpha for HADS-A varied from.68 to.93 (mean.83) and for HADS-D from.67 to.90 (mean.82). In most studies an optimal balance between sensitivity and specificity was achieved when caseness was defined by a score of 8 or above on both HADS-A and HADS-D. The sensitivity and specificity for both HADS-A and HADS-D of approximately 0.80 were very similar to the sensitivity and specificity achieved by the General Health Questionnaire (GHQ). Correlations between HADS and other commonly used questionnaires were in the range.49 to.83. CONCLUSIONS HADS was found to perform well in assessing the symptom severity and caseness of anxiety disorders and depression in both somatic, psychiatric and primary care patients and in the general population.

The Hordaland Homocysteine Study: A Community-Based Study of Homocysteine, Its Determinants, and Associations with Disease

The Hordaland Homocysteine Study (HHS) is a population-based study of more than 18,000 men and women in the county of Hordaland in Western Norway. The first investigation (HHS-I) took place in 1992-93, when the subjects were aged 40-67 y. In 1997-99, a follow-up study (HHS-II) of 7,053 subjects was carried out. In this large population, plasma levels of total homocysteine (tHcy) are associated with several physiologic and lifestyle factors and common diseases. Increasing age, male sex, smoking, coffee consumption, high blood pressure, unfavorable lipid profile, high creatinine, and the MTHFR 677C > T polymorphism are among the factors associated with increased tHcy levels; physical activity, moderate alcohol consumption, and a good folate or vitamin B-12 status are associated with lower tHcy levels. Subjects with raised tHcy levels have increased risk of cardiovascular morbidity, cardiovascular and noncardiovascular mortality, and are more likely to suffer from depression and from cognitive deficit (elderly). Among women, raised tHcy levels are associated with decreased bone mineral density and increased risk of osteoporosis. Women with raised tHcy levels also have an increased risk of having suffered from pregnancy complications and an adverse pregnancy outcome. Significant associations between tHcy and clinical outcomes are usually observed for tHcy levels > 15 micromol/L, but for most conditions, there is a continuous concentration-response relation with no apparent threshold concentration. Overall, the findings from HHS indicate that a raised tHcy level is associated with multiple clinical conditions, whereas a low tHcy level is associated with better physical and mental health.

Does a higher educational level protect against anxiety and depression? The HUNT study

The relationship of education to the experience of anxiety and depression throughout adult life is unclear. Our knowledge of this relationship is limited and inconclusive. The aim of this study was to examine (1) whether higher educational level protects against anxiety and/or depression, (2) whether this protection accumulates or attenuates with age or time, and (3) whether such a relationship appears to be mediated by other variables. In a sample from the Nord-Trøndelag Health Study 1995--1997 (HUNT 2) (N=50,918) of adults, the cross-sectional associations between educational level and symptom levels of anxiety and depression were examined, stratified by age. The long-term effects of educational level on anxiety/depression were studied in a cohort followed up from HUNT 1 (1984--1986) to HUNT 2 (N=33,774). Low educational levels were significantly associated with both anxiety and depression. The coefficients decreased with increasing age, except for the age group 65-74 years. In the longitudinal analysis, however, the protective effect of education accumulated somewhat with time. The discrepancy between these two analyses may be due to a cohort effect in the cross-sectional analysis. Among the mediators, somatic health exerted the strongest influence, followed by health behaviors and socio-demographic factors. Higher educational level seems to have a protective effect against anxiety and depression, which accumulates throughout life.

The association between habitual diet quality and the common mental disorders in community-dwelling adults : The Hordaland health study

Objective: Recent evidence suggests a role for diet quality in the common mental disorders depression and anxiety. We aimed to investigate the association between diet quality, dietary patterns, and the common mental disorders in Norwegian adults. Methods: This cross-sectional study included 5731 population-based men and women aged 46 to 49 and 70 to 74 years. Habitual diet was assessed using a validated food frequency questionnaire, and mental health was measured using the Hospital Anxiety and Depression Scale. Results: After adjustments for variables including age, education, income, physical activity, smoking, and alcohol consumption, an a priori healthy diet quality score was inversely related to depression (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.59-0.84) and anxiety (OR = 0.77, 95% CI = 0.68-0.87) in women and to depression (OR = 0.83, 95% CI = 0.70-0.99) in men. Women scoring higher on a healthy dietary pattern were less likely to be depressed (OR = 0.68, 95% CI = 0.57-0.82) or anxious (OR = 0.87, 95% CI = 0.77-0.98), whereas men were more likely to be anxious (OR = 1.19, 95% CI = 1.03-1.38). A traditional Norwegian dietary pattern was also associated with reduced depression in women (OR = 0.77, 95% CI = 0.64-0.92) and anxiety in men (OR = 0.77, 95% CI = 0.61-0.96). A western-type diet was associated with increased anxiety in men (OR = 1.27, 95% CI = 1.14-1.42) and women (OR = 1.29, 95% CI = 1.17-1.43) before final adjustment for energy intake. Conclusions: In this study, those with better quality diets were less likely to be depressed, whereas a higher intake of processed and unhealthy foods was associated with increased anxiety.FFQ = food frequency questionnaire; HADS = Hospital Anxiety and Depression Scale; OR = odds ratio; CI = confidence interval; SD = standard deviation; Kj = kilojoule; PA = physical activity; SES = socioeconomic status; MI = myocardial infarction.

Association of low blood pressure with anxiety and depression: the Nord-Trondelag Health Study.

Background: Low blood pressure has mainly been regarded as ideal, but recent studies have indicated an association with depression in elderly people. Objective: To investigate whether low blood pressure is associated with anxiety and depression in the general population. Design: Cross-sectional study. Setting: Participants in the population-based Nord-Trøndelag Health Study (HUNT-2, 1995–7), Norway. Participants: 60 799 men and women aged 20–89 years filled in the Hospital Anxiety and Depression Scale as part of a general health study. Systolic and diastolic blood pressure was classified in age-stratified and sex-stratified centile groups. Main results: Compared with participants with systolic blood pressure within the 41–60 centile (reference) group, the odds ratio for anxiety was 1.31 (95% confidence intervals (CI) 1.16 to 1.49), for depression 1.22 (95% CI 1.03 to 1.46), and for comorbid anxiety and depression 1.44 (95% CI 1.24 to 1.68) in the group with ⩽5 centile systolic blood pressure. Slightly weaker associations were found of low diastolic blood pressure with anxiety and depression. These associations were similar across sex and age groups. Physical impairment, smoking and angina pectoris influenced the associations only marginally, whereas stroke, myocardial infarction, use of drugs for hypertension, body mass index and several other covariates had no influence. Conclusions: This study represents epidemiological evidence for an association of low blood pressure with anxiety and depression, which is not caused by cardiovascular disease.

Association Between Magnesium Intake and Depression and Anxiety in Community-Dwelling Adults: The Hordaland Health Study:

Objective: Systemic inflammation is associated with both the dietary intake of magnesium, and depression. Limited experimental and clinical data suggest an association between magnesium and depression. Thus, there are reasons to consider dietary magnesium as a variable of interest in depressive disorders. The aim of the present study was to examine the association between magnesium intake and depression and anxiety in a large sample of community-dwelling men and women. This sample consisted of 5708 individuals aged 46–49 or 70–74 years who participated in the Hordaland Health Study in Western Norway. Methods: Symptoms of depression and anxiety were self-reported using the Hospital Anxiety and Depression Scale, and magnesium intake was assessed using a comprehensive food frequency questionnaire. Results: There was an inverse association between standardized energy-adjusted magnesium intake and standardized depression scores that was not confounded by age, gender, body habitus or blood pressure (β=−0.16, 95% confidence interval (CI)=−0.22 to −0.11). The association was attenuated after adjustment for socioeconomic and lifestyle variables, but remained statistically significant (β=−0.11, 95%CI=−0.16 to −0.05). Standardized magnesium intake was also related to case-level depression (odds ratio (OR)=0.70, 95%CI=0.56–0.88), although the association was attenuated when adjusted for socioeconomic and lifestyle factors (OR=0.86, 95%CI=0.69–1.08). The inverse relationship between magnesium intake and score and case-level anxiety was weaker and not statistically significant in the fully adjusted models. Conclusion: The hypothesis that magnesium intake is related to depression in the community is supported by the present findings. These findings may have public health and treatment implications.

Anxiety and depression in individuals with somatic health problems. The Nord-Trøndelag Health Study (HUNT)

There is a high occurrence of depressive symptoms in patients with somatic health problems. About one-third of individuals with somatic health problems have anxiety disorders and/or depression. Comorbid anxiety disorder and depression are found to be more strongly associated with somatic health problems than pure anxiety disorder and pure depression. Objective - To examine the relationship between anxiety disorders and depression and various somatic health problems in the general population. Design - Cross-sectional study with survey methods and clinical examinations. Setting - The Health Study of Nord-Trøndelag, Norway (the HUNT study). Participants - 60 t 869 individuals aged 20-89 years. Main outcome measures - Anxiety disorder, depression and their comorbidity are categorized based on scores on the Hospital Anxiety and Depression Scale. All somatic health variables are self-reported, while blood pressure, height and weight are measured. Multivariate nominal logistic regression analyses are used to investigate the relationship between somatic variables and the anxiety/depression categories. Results - Most somatic health variables show a stronger association with comorbid anxiety disorder/depression than with anxiety disorder or depression alone. About one-third of individuals reporting somatic health problems also have anxiety disorder and/or depression. Conclusion - Somatic health problems carry a high risk of both anxiety disorder and depression. Active identification and treatment of these co-occurring mental disorders are of practical importance.

Anxiety and depression after acute myocardial infarction: an 18-month follow-up study with repeated measures and comparison with a reference population.

Background Recently, there has been substantial improvement in coronary care and a corresponding reduction in mortality after acute myocardial infarction (AMI). Some studies suggest that improved prognosis has led to reduced levels of anxiety and depression after AMI, in both the short and long term. The aims of this study were to assess symptoms of anxiety and depression from the acute event to 18 months following AMI, and to compare results with levels in the Norwegian reference population. Design and methods The progress of 288 patients was monitored using self-reports 3, 6, 12 and 18 months after AMI. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale. Reference population data were obtained from the Nord-Trøndelag Health Study 1995–1997 (the HUNT 2 Study). Results At baseline, 19.7 and 13.6% of AMI patients reported high levels of anxiety and depressive symptoms, respectively. At baseline, AMI patients were more anxious, but not more depressed, when compared with the reference population (P<0.001 and P = 0.092, respectively). After 3–18 months, AMI patients’ levels of anxiety and depression were not higher than levels in the reference population. Anxiety and depression at baseline and after 3 months were the best predictors of anxiety and depression after 18 months, although complications, bed days and lifestyle improvement also significantly predicted depression after 18 months. Conclusion Initially, AMI patients had higher levels of anxiety, but not depressive symptoms. After 3–18 months, these patients were not more anxious or depressed than the Norwegian reference population. Eur J Cardiovasc Prev Rehabil 16:651–659

A dimensional versus a categorical approach to diagnosis: Anxiety and depression in the HUNT 2 study

The aim of this study was to compare a dimensional and a categorical approach to diagnosis, using as an illustration co‐occurring symptoms of anxiety and depression concerning description, associations and predictive power. We analysed data from 60 869 individuals with valid ratings on the Hospital Anxiety and Depression Scale (HADS) and on mental impairment in the age range of 20 to 89 years of the cross‐sectional Nord‐Trøndelag Health Study 1995–1997. There was a wide variation of the dimensional symptom level (subscale scores) within both diagnostic categories (cut‐offs ≥8 on both subscales), as is usually true with categorical and dimensional diagnosis. The dimensional (Spearman) correlation coefficients between anxiety and depression was 0.51 compared to 0.38 for the categorical. The power to predict impairment was weaker with the categorical than with the dimensional approach of the HADS, showing fewer statistically significant coefficients in the logistic regression models and lower area under curve (0.82 versus 0.87). This is an example illustrating the impact use of dimensional diagnoses would have on research and clinical practice. Copyright

A five-year prospective study of fatigue in primary Sjögren’s syndrome

IntroductionFatigue is prevalent in primary Sjögrens syndrome (pSS), and contributes to the considerably reduced health related quality of life in this disease. The symptom is included in proposed disease activity and outcome measures for pSS. Several studies indicate that there is an inflammatory component of fatigue in pSS and other chronic inflammatory rheumatic diseases. The purpose of this study was to investigate fatigue change in pSS in a longitudinal study, and explore whether any clinical or laboratory variables at baseline, including serum cytokines, were associated with a change in fatigue scores over time.MethodsA clinical and laboratory investigation of 141 patients fulfilling the American-European consensus criteria of pSS was undertaken in the period May 2004 to April 2005. Median time since diagnosis was 5.5 years. Examinations included the fatigue questionnaires: fatigue severity scale (FSS), fatigue visual analogue scale (VAS), functional assessment of chronic illness therapy - fatigue (FACIT-F) and medical outcome study short form-36 (SF-36) vitality, which were repeated in a follow-up investigation in January and February 2010.ResultsA total of 122 patients (87%) responded at both time-points. Thirty-five percent of patients experienced a clinically significant FSS increase. On the group level, fatigue measures did not change except that there was a slight deterioration in SF-36 vitality score. High serum anti-Sjögrens syndrome A antigen (anti-SSA) showed weak associations with high baseline fatigue, and patients with increasing fatigue had lower baseline unstimulated whole salivary volume. Weak associations between increasing fatigue and serum immunoglobulin G (IgG), and the pro-inflammatory cytokine interleukin-17 (IL-17), were observed. Baseline sicca symptoms correlated with higher fatigue both at baseline and with increasing fatigue over time. Linear regression analysis did not identify any predictive ability of clinical or laboratory measures on fatigue change over time.ConclusionsFatigue remained mainly unchanged over time. Using multivariate models did not reveal any clinical or laboratory predictors of fatigue change over time.