Tone Tangen Haug

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 Association Between Anxiety, Depression, and Somatic Symptoms in a Large Population: The HUNT-II Study

Objective: Somatic symptoms are prevalent in the community, but at least one third of the symptoms lack organic explanation. Patients with such symptoms have a tendency to overuse the health care system with frequent consultations and have a high degree of disability and sickness compensation. Studies from clinical samples have shown that anxiety and depression are prevalent in such functional conditions. The aim of this study is to examine the connection between anxiety, depression, and functional somatic symptoms in a large community sample. Method: The HUNT-II study invited all inhabitants aged 20 years and above in Nord-Trøndelag County of Norway to have their health examined and sent a questionnaire asking about physical symptoms, demographic factors, lifestyle, and somatic diseases. Anxiety and depression were recorded by the Hospital Anxiety and Depression Scale. Of those invited, 62,651 participants (71.3%) filled in the questionnaire. A total of 10,492 people were excluded due to organic diseases, and 50,377 were taken into the analyses. Results: Women reported more somatic symptoms than men (mean number of symptoms women/men: 3.8/2.9). There was a strong association between anxiety, depression, and functional somatic symptoms. The association was equally strong for anxiety and depression, and a somewhat stronger association was observed for comorbid anxiety and depression. The association of anxiety, depression, and functional somatic symptoms was equally strong in men and women (mean number of somatic symptoms men/women in anxiety: 4.5/5.9, in depression: 4.6/5.9, in comorbid anxiety and depression: 6.1/7.6, and in no anxiety or depression: 2.6/3.6) and in all age groups. The association between number of somatic symptoms and the total score on Hospital Anxiety and Depression Scale was linear. Conclusion: There was a statistically significant relationship between anxiety, depression, and functional somatic symptoms, independent of age and gender. ME = myalgic encephalomyelitis; FSS = functional somatic symptoms; ECA = Epidemiological Catchment Area Study; HADS = Hospital Anxiety and Depression Scale; HADS-A = anxiety subscale of Hospital Anxiety and Depression Scale; HADS-D = depression subscale of Hospital Anxiety and Depression Scale; HADS-AD = comorbid anxiety and depression on Hospital Anxiety and Depression Scale; HADS-T = total score on Hospital Anxiety and Depression Scale; OR = odds ratio.

Psychological factors and somatic symptoms in functional dyspepsia. A comparison with duodenal ulcer and healthy controls.

One hundred patients with functional dyspepsia, 100 patients with duodenal ulcer and 100 healthy controls were assessed on anamnestic factors, somatic symptoms and psychological measures. Patients with functional dyspepsia had significantly higher levels of state-trait anxiety, general psychopathology, depression, a lower general level of functioning and more somatic complaints from different organ systems, especially the musculo-skeletal system, compared to patients with duodenal ulcer and healthy controls. Patients with functional dyspepsia had more frequent dyspepsia symptoms and a longer disease history than duodenal ulcer patients. Discriminant analyses using a model of fifteen psychological and anamnestic variables, classified correctly 71.5% of the subjects due to diagnoses. The test for multiple somatic complaints (Giessener Beschwerdebogen) was the most important discriminating factor (Eigenvalue 0.78). Seventy-five per cent of the patients were correctly classified, 71% by diagnosis with respect to diagnoses of duodenal ulcer and functional dyspepsia using frequency of dyspeptic symptoms as discriminating factor (Eigenvalue 0.40). Functional dyspepsia seems to be a disease entity of its own, distinct from duodenal ulcer and strongly associated with psychological factors.

Low vagal tone and antral dysmotility in patients with functional dyspepsia.

&NA; Effects of acute mental stress on gastric antral motility were investigated in 23 healthy persons and 25 patients with functional dyspepsia (FD). Real‐time ultrasonography of gastric antrum was recorded, after ingestion of 500 ml meat soup, during a 4‐min resting period, 2.5 min of mental stress, and a 4‐min recovery period. Amplitude of antral contractions was scored as a fraction of relaxed area. Motility‐index was calculated as the amplitude multiplied by frequency. Measurement of skin conductance reflected sympathetic tone, and respiratory sinus arrhythmia (RSA) was calculated to index vagal tone. Antral motility was reduced by mental stress in the healthy persons, but not in FD patients. Group differences were significant for amplitude (p < 0.002) and motility‐index scores (p < 0.02). Sympathetic tone increased during stress in both groups. Vagal tone was lower in the FD patients than in the healthy controls (p < 0.001). The lack of stress‐related reduction of motility among patients with FD may, therefore, be a consequence of poor vagal tone.

Low vagal activity as mediating mechanism for the relationship between personality factors and gastric symptoms in functional dyspepsia

&NA; Low vagal tone may represent a mediating mechanism for relationships between personality and symptoms of functional dyspepsia (FD) through a mechanism of antral hypomotility. Twenty‐one patients with FD and seventeen healthy controls completed a series of personality tests before vagal and sympathetic activity, antral motility, and abdominal symptoms were assessed in response to a laboratory task. Functional dyspepsia patients had lower scores on vagal tone (p = .054) and motility index (p = .011) in addition to the expected higher scores on epigastric discomfort (p = .002). Psychological factors explained a substantial amount of the variance in vagal activity, antral motility, and reported symptoms. Symptoms were predicted by trait anxiety (STAI‐TR), depression (BDI), and neuroticism (EPQ‐N). Poor vagal tone was related to neuroticism (EPQ‐N). Poor motility was best explained by task‐related state dysphoria (SACL‐STR).

Discriminant analysis of factors distinguishing patients with functional dyspepsia from patients with duodenal ulcer: Significance of somatization

Patients with duodenal ulcer or functional dyspepsia do not differ on dyspeptic symptoms. The aim of the present study was to test the hypothesis that functional dyspepsia and duodenal ulcer are two different diagnostic entities by examining the discriminating power of several anamnestic, biological, and psychosocial variables. Ninety-four patients with duodenal ulcer and 86 patients with functional dyspepsia were included. Anamnestic data, global assessment,Helicobacter pylori status, blood group, Lewisa+ phenotype, and several measures of psychological distress and somatic complaints were registered. Compared to patients with functional dyspepsia, the duodenal ulcer patients were more often infected byHelicobacter pylori and had their stomach discomfort more often relieved by eating. Compared to patients with duodenal ulcer, patients with functional dyspepsia had higher scores of depression, trait anxiety, general psychopathology and different somatic complaints (called somatization). They were also less satisfied with the health care system, their disorder had a greater negative impact on their quality of life, and their global assessment of own health was poorer. Discriminant analysis including age, smoking,Helicobacter pylori status, global assessment, and somatic complaint classified 86.1% of the patients correctly (77.9% of the patients with functional dyspepsia and 93.6% of the patients with duodenal ulcer). It is concluded that duodenal ulcer and functional dyspepsia are two separate diagnostic entities. Patients with duodenal ulcer are older, smoke more often, and almost all are infected withHelicobacter pylori, while patients with functional dyspepsia are characterized by somatization and a negative assessment of their own health.

Subjective Health Complaints and Modern Health Worries in Patients with Subjective Food Hypersensitivity

Perceived food hypersensitivity is much more common than food allergy as medically verified. Unexplained symptoms and wrong attribution are typical in subjective health complaints. We hypothesize that subjective health complaints and worries are abnormally prevalent among patients with subjective food hypersensitivity. Forty-six patients with subjective food hypersensitivity and two control groups, one formed by 50 health care workers and one by 70 sex- and age-matched volunteers from the general population, were included in our study. All filled in two questionnaires: Subjective Health Complaints Inventory and Modern Health Worries Scale. None of the patients had IgE-mediated food allergy. The patients scored significantly higher than the controls on sum scores for four domains of subjective health complaints, including gastrointestinal complaints (P < 0.001), musculoskeletal complaints (P < 0.01), “pseudoneurology” (P < 0.001), and allergy (P < 0.001). Sum scores on modern health worries did not differ significantly between groups. The results support our hypothesis of an association between subjective food hypersensitivity and subjective health complaints, corroborating the view that, in the absence of food allergy, the conditions are sharing pathogenetic mechanisms.

The prevalence of nausea in the community: psychological, social and somatic factors

Nausea is a commonly reported symptom with a point prevalence of about 12% in the community. Nausea is a prominent symptom in functional gastrointestinal disorders and patients with anxiety and depression frequently present gastrointestinal symptoms such as nausea and abdominal discomfort as their main problem when they consult a doctor. Functional gastrointestinal disorders are strongly related to anxiety and depressive disorders with a lifetime prevalence of 80--90% in samples from clinics of gastroenterology. This study examines the relationship between anxiety disorders, depressions and nausea in a large community sample. A questionnaire on physical and mental health and demographic and life-style factors was sent to all adults 20 years and above in Nord Trøndelag county in Norway. A total of 94,197 questionnaires were sent, with 62,651 persons returning the questionnaire, a response rate of 66.5%. The presence of nausea, heartburn, diarrhea and constipation during the last year was recorded. Anxiety disorders and depressions were based on self-rating of the Hospital Anxiety and Depression Scale (HADS). Forty-eight per cent reported one or several gastrointestinal complaints during the last year. 12.5% complained of nausea. 15.3% had an anxiety disorder and 10.4% a depression based on HADS ratings. Presence of anxiety disorders carried the highest risk for nausea (OR 3.42). Presence of depression also increased the risk, but less than anxiety disorders (OR 1.47). Demographic factors, life-style factors and extra-gastrointestinal conditions did not reduce the OR of anxiety disorders and depressions to any significant extent. We found that the presence of anxiety disorders was the strongest risk factor for nausea. Depression also carried a certain risk while demographic factors, life-style factors and other somatic conditions did not carry any substantial risk for nausea. Differential diagnoses of nausea should therefore include both anxiety and depressive conditions.

EFFECT OF SHORT-TERM COGNITIVE PSYCHOTHERAPY ON RECURRENCE OF DUODENAL ULCER : A PROSPECTIVE RANDOMIZED TRIAL

&NA; The aim of this prospective, randomized trial was to assess whether short‐term cognitive psychotherapy (10 sessions during 4 months) could reduce the 1‐year recurrence rate of duodenal ulcer. One group received psychotherapy; one group was a control group. One hundred patients, aged 17 to 64 years, with duodenal ulcer were selected from March 1989 to May 1991. The main outcome measure was relapse of duodenal ulcer, which was verified by endoscopy. When psychotherapy started after cessation of antiulcer medication, the relapse‐free time was significantly shorter in the therapy group than in the controls. When the protocol was modified so that psychotherapy and antiulcer medication were given concomitantly, there was no significant difference in recurrence rate between the groups at 1‐year follow‐up (84% in the therapy group and 92% in the control group). Symptoms of upper abdominal discomfort/pain, measured every second month, decreased significantly in the therapy group compared to the control group. Psychotherapy led to less neuroticism (Eysenck Personality Questionnaire) and less trait anxiety (Spielberger Trait Anxiety Scale) compared to controls at 4 months. At the 12‐month follow‐up, most of this gain was lost, but the psychotherapy group had lower scores on “concern about disapproval” on the Sociotropy‐Autonomy Scale than the control group. There is no beneficial effect of short‐term cognitive psychotherapy on the 1‐year recurrence rate of duodenal ulcer.

Cognitive therapy in functional dyspepsia

Abstract There is a strong relationship between functional dyspepsia (FD) and psychiatric symptoms like anxiety and depression, and this indicates that psychological therapy could be beneficial for these patients. In cognitive therapy, the goal is to help the patients develop better coping strategies. Cognitive therapy attempts to change dysfunctional thoughts and behavior by cognitive restructuring, behavioral monitoring and role-playing. Method : In this study, patients with FD were randomized to cognitive therapy (10 sessions of 45–50 min) or to a control group. Results : The therapy group had a greater reduction than the controls in dyspeptic symptoms at the end of therapy and at 1 year follow-up. The therapy focused on “target complaints” defined by the patients themselves before the start of therapy, and there was a greater reduction in scores on “target complaints” in the therapy group than in the control group at the end of treatment and at follow-up. Conclusion : Cognitive therapy seems to be effective in reducing symptoms in patients with FD.