Validation of the Hospital Anxiety and Depression Scale in Patients with Decompensated Cirrhosis

Background: The Hospital Anxiety and Depression Scale (HADS) demonstrates strong psychometric properties in many populations of patients with serious illness. However, its psychometric performance among patients with decompensated cirrhosis (DC) has not been examined. We investigated the reliability, validity, and responsiveness of the HADS for patients with DC. Methods: This observational study utilized data from patients with DC at enrollment and week 6 follow-up. Two hundred eighteen outpatients with DC were recruited from a liver transplant center, with 145 completing week 6 assessment. We evaluated psychological distress using HADS and Patient Health Questionnaire 9 (PHQ-9). Patients' health-related quality of life (HRQOL) was assessed using the Short-Form Liver Disease Quality of Life questionnaire. We examined reliability, floor/ceiling effects, structural validity, and known-groups validity for anxiety (HADS-Anxiety) and depression (HADS-Depression) subscales. We assessed the convergent validity with the PHQ-9. We predicted the change in HRQOL using the change in depression and anxiety. We also evaluated the internal responsiveness to changes in HRQOL for both HADS-Anxiety and HADS-Depression from baseline to week 6. Results: The HADS-Anxiety and HADS-Depression subscales showed strong internal consistency (Cronbach's alpha>0.8), adequate floor/ceiling effects (<15%), and excellent convergent validity with PHQ-9 (r>0.7). Both domains significantly predicted the changes in HRQOL longitudinally. Both HADS-Anxiety (1.8 [95% confidence interval [CI]: 0.5, 3.2]) and HADS-Depression (2.2 [95%CI: 1, 3.4]) showed responsiveness in patients with decreased HRQOL. Conclusions: The HADS is a reliable, valid, responsive tool for assessing anxiety and depression among patients with DC.