Review: Use of the Hospital Anxiety and Depression Scale in a Cardiac Emergency Room

The paper reviewed here is a Brazilian study –  ‘Use of the Hospital Anxiety and Depression Scale (HADS) in a Cardiac Emergency Room – Chest Pain Unit’ by Nardi and colleagues and freely available here. In the introduction the authors state that

The objective of the study described herein is to use a self-reporting measure to estimate the prevalence of anxiety and depression in patients admitted to chest pain units


In the methodology section the authors discuss the Hospital Anxiety and Depression Scale. They use the Portuguese version and cite the work that has been done to validate this scale. Characteristics of the sampling were as follows:-

  • Patient included were those with chest pain ‘who were admitted to the Chest Pain Unit of a private hospital in Rio de Janeiro’
  • The study period was May to August 2006
  • Patients were stratified into four groups according to the intensity of the chest pain

Exclusion criteria were

  • ‘severe clinical conditions’
  • ‘severe respiratory failure’
  • ‘hemodynamic instability’
  • ‘neurological conditions with cognitive involvement’
  • Dementia
  • Delirium
  • ‘Any psychiatric disorder that causes changes in awareness or in formal thought processes’

Nursing staff or doctors assessed subjects using the portugues version of the HADS. If the subject scored above 8 on the HADS they were referred to a psychiatrist.


There are a lot of results from the study which can be viewed in the original paper via the link above. There were 167 questionnaires administered and 130 subjects remained after exclusion criteria were applied. The mean age was 61.2 years and 58.5% of the sample were men. In the subjects ‘probable angina’ was the most likely category which the authors had categorised according to the intensity of the chest pain (after the initial stratification further relevant tests were undertaken). 44.6% of the sample scored higher than 8 on the anxiety component which was the threshold used for diagnosing anxiety with 93.7% sensitivity (although this is used as an aid to diagnosis).

After the results of the investigations were available, the researchers were able to divide the groups into those where a physical cause for the chest pain could be determined (PDC) and those where it could not (PIC).

  • Anxiety was recorded (according to the HADS threshold) in 34.8% of the subjects diagnosed with acute coronary syndrome.
  • Anxiety was recorded in 33.9% of the subjects diagnosed with non-acute coronary syndrome PDC
  • Anxiety was recorded in 53.5% of the subjects in the PIC group

The prevalence in the PIC and PDC groups was significantly different using the Chi-squared test (p=0.025) and this is roughly a 20% difference in prevalence rates between the groups.


The authors discuss the significance of their findings and suggest that the HADS could be a useful tool in this setting in both the PDC and PIC groups. I couldn’t see figures for those who were referred to psychiatrists and diagnosed with an anxiety disorder nor could I see a reference to the diagnostic criteria that would be used for case ascertainment under these circumstances. This would be a useful method to examine the meaning of the HADS scores in this population. The large percentage difference between the prevalences in the PIC and PDC groups as well as the  p values for the Chi-Squared test are suggestive of a higher prevalence of anxiety disorders in the former group although case ascertainment would provide convincing evidence. What I found interesting was that the HADS has proved successful enough to be translated into Portuguese and is being used in research in Brazil as well as showing these preliminary benefits of use in the setting in this study. While it could be argued that chest pain in itself could produce anxiety and influence the test scores the lower anxiety scores in people in the PDC group argues against this significantly influencing the HADS anxiety component scores.


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The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.


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