The ineffectiveness of the Hospital Anxiety and Depression Scale for diagnosis in an Omani traumatic brain injured population

The Frequency of Neuropsychiatric Sequelae After Traumatic Brain Injury in the Global South: A systematic review and meta-analysis

This study aimed to assess the prevalence of neuropsychiatric sequelae following traumatic brain injury (TBI) among the Western Asian, South Asian and African regions of the global south. All studies on psychiatric disturbances or cognitive impairment following TBI conducted (until August 2021) in the 83 countries that constitute the aforementioned regions were reviewed; 6 databases were selected for the literature search. After evaluating the articles using the Joanna Briggs Institute guidelines, the random effects model was used to estimate the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), TBI-related sleep disturbance (TBI-SD), obsessive-compulsive disorder (OCD) and cognitive impairment. Of 56 non-duplicated studies identified in the initial search, 27 were eligible for systematic review and 23 for meta-analysis. The pooled prevalence of depression in 1,882 samples was 35.35%, that of anxiety in 1,211 samples was 28.64%, that of PTSD in 426 samples was 19.94%, that of OCD in 313 samples was 19.48%, that of TBI-SD in 562 samples was 26.67% and that of cognitive impairment in 941 samples was 49.10%. To date, this is the first critical review to examine the spectrum of post-TBI neuropsychiatric sequelae in the specified regions. Although existing studies lack homogeneous data due to variability in the diagnostic tools and outcome measures utilised, the reported prevalence rates are significant and comparable to statistics from the global north.

A systematic review and meta-analysis of diagnostic test accuracy studies of self-report screening instruments for common mental disorders in Arabic-speaking adults

BACKGROUND

Self-report screening instruments are frequently used as scalable methods to detect common mental disorders (CMDs), but their validity across cultural and linguistic groups is unclear. We summarized the diagnostic accuracy of brief questionnaires on symptoms of depression, anxiety and posttraumatic stress disorder (PTSD) among Arabic-speaking adults.

METHODS

Five databases were searched from inception to 22 January 2021 (PROSPERO: CRD42018070645). Studies were included when diagnostic accuracy of brief (maximally 25 items) psychological questionnaires was assessed in Arabic-speaking populations and the reference standard was a clinical interview. Data on sensitivity/specificity, area under the curve, and data to generate 2 × 2 tables at various thresholds were extracted. Meta-analysis was performed using the diagmeta package in R. Quality of studies was assessed with QUADAS-2.

RESULTS

Thirty-two studies (N participants = 4042) reporting on 17 questionnaires with 5-25 items targeting depression/anxiety (n = 14), general distress (n = 2), and PTSD (n = 1) were included. Seventeen studies (53%) scored high risk on at least two QUADAS-2 domains. The meta-analysis identified an optimal threshold of 11 (sensitivity 76.9%, specificity 85.1%) for the Edinburgh Postnatal Depression Scale (EPDS) (n studies = 7, n participants = 711), 7 (sensitivity 81.9%, specificity 87.6%) for the Hospital Anxiety and Depression Scale (HADS) anxiety subscale and 6 (sensitivity 73.0%, specificity 88.6%) for the depression subscale (n studies = 4, n participants = 492), and 8 (sensitivity 86.0%, specificity 83.9%) for the Self-Reporting Questionnaire (SRQ-20) (n studies = 4, n participants = 459).

CONCLUSION

We present optimal thresholds to screen for perinatal depression with the EPDS, anxiety/depression with the HADS, and CMDs with the SRQ-20. More research on Arabic-language questionnaires, especially those targeting PTSD, is needed.

Post-Stroke Psychiatric and Cognitive Symptoms in West Asia, South Asia and Africa: A Systematic Review and Meta-Analysis

Recent research has shown that the prevalence of stroke incidents and the number of survivors in developing countries surpass those from developed countries. This study aimed to enumerate the prevalence of post-stroke psychiatric and cognitive symptoms among stroke survivors from West and South Asia and Africa through a systematic review and meta-analysis. Data from each country was systematically acquired from five major databases (PsycINFO, Web of Science, Scopus, PubMed/Medline, and Google Scholar (for any missing articles and grey literature)). Meta-analytic techniques were then used to estimate the prevalence of various post-stoke psychiatric and cognitive symptoms. A total of 36 articles were accrued from 11 countries, of which 25 were evaluated as part of the meta-analysis. The pooled prevalence of post-stroke depression as per the Hospital Anxiety and Depression Scale (HADS), Hamilton Depression Rating Scale, Patient Health Questionnaire, Schedules for Clinical Assessment in Neuropsychiatry (SCAN), Geriatric Depression Scale, and the Montgomery-Asberg Depression Rating Scale ranged from 28.00 to 50.24%. Pooled prevalence of post-stroke anxiety based on the HADS and SCAN was 44.19% and 10.96%, respectively. The pooled prevalence of post-stroke cognitive impairment as per the Mini-Mental Status Examination was 16.76%. This present review has suggested that both psychiatric and cognitive symptoms are common among stroke survivors. Concerted efforts are needed to institute robust studies using culturally sensitive measures to contemplate mechanisms that address the unmet needs of this vulnerable population.

Neural Markers of Vulnerability to Anxiety Outcomes after Traumatic Brain Injury

Anxiety outcomes after traumatic brain injury (TBI) are complex, and the underlying neural mechanisms are poorly understood. Here, we developed a multi-dimensional behavioral profiling approach to investigate anxiety-like outcomes in mice that takes into account individual variability. Departing from the tradition of comparing outcomes in TBI versus sham groups, we identified a subgroup within the TBI group that is vulnerable to anxiety dysfunction, and present increased exploration of the anxiogenic zone compared to sham controls or resilient injured animals, by applying dimensionality reduction, clustering, and post hoc validation to behavioral data obtained from multiple assays for anxiety at several post-injury time points. These vulnerable animals expressed distinct molecular profiles in the corticolimbic network, with downregulation in gamma-aminobutyric acid and glutamate and upregulation in neuropeptide Y markers. Indeed, among vulnerable animals, not resilient or sham controls, severity of anxiety-related outcomes correlated strongly with expression of molecular markers. Our results establish a foundational approach, with predictive power, for reliably identifying maladaptive anxiety outcomes after TBI and uncovering neural signatures of vulnerability to anxiety.

Methylphenidate improves executive functions in patients with traumatic brain injuries: a feasibility trial via the idiographic approach

BACKGROUND

Road traffic accidents are known to be the main cause of traumatic brain injury (TBI). TBI is also a leading cause of death and disability. This study, by means of the idiographic approach (single-case experimental designs using multiple-baseline designs), has examined whether methylphenidate (MPH - trade name Ritalin) had a differential effect on cognitive measures among patients with TBI with the sequel of acute and chronic post-concussion syndromes. The effect on gender was also explored.

METHODS

In comparison with healthy controls, patients with TBI (acute and chronic) and accompanying mild cognitive impairment (MCI) were screened for their integrity of executive functioning. Twenty-four patients exhibiting executive dysfunction (ED) were then instituted with the pharmacological intervention methylphenidate (MPH). The methylphenidate was administered using an uncontrolled, open label design.

RESULTS

The administration of methylphenidate impacted ED in the TBI group but had no effect on mood. Attenuation of ED was more apparent in the chronic phases of TBI. The effect on gender was not statistically significant with regard to the observed changes.

CONCLUSIONS

To our knowledge, this is the first feasibility trial from the Arabian Gulf to report the performance of a TBI population with mild cognitive impairment according to the IQCODE Arabic version. This investigation confirms anecdotal observations of methylphenidate having the potential to attenuate cognitive impairment; particularly those functions that are critically involved in the integrity of executive functioning. The present feasibility trial should be followed by nomothetic studies such as those that adhere to the protocol of the randomized controlled trial. This evidence-based research is the foundation for intervention and future resource allocation by policy- or public health decision-makers.

Depression, apathy and impaired self-awareness following severe traumatic brain injury: a preliminary investigation

Primary Objective: The primary aim of this study was to determine the frequency of severe impaired self-awareness (ISA) in patients with severe traumatic brain injury (TBI) and the correlates of selected clinical, neuropsychiatric and cognitive variables. The secondary aim of the study was to assess depression and apathy on the basis of their level of self-awareness. Methods: Thirty patients with severe TBI and 30 demographically matched healthy control subjects (HCs) were compared on measures of ISA, depression, anxiety, alexithymia, neuropsychiatric symptoms and cognitive flexibility. Results: Twenty percent of the patients demonstrated severe ISA. Severe post-acute ISA was associated with more severe cognitive inflexibility, despite the absence of differences in TBI severity, as evidenced by a Glasgow Coma Scale (GCS) score lower than 9 in all cases in the acute phase. Patients with severe ISA showed lower levels of depression and anxiety but tended to show more apathy and to have greater difficulty describing their emotional state than patients with severe TBI who showed minimal or no disturbance in self-awareness. Conclusion: These findings support the general hypothesis that severe ISA following severe TBI is typically not associated with depression and anxiety, but rather with apathy and cognitive inflexibility.

Does the Neurological Damage from a Traumatic Brain Injury Invalidate Measures of Psychopathology Such as the MMPI-2?

Objective

The Gass correction model removes 14 items from the MMPI-2 which refer to neurological damage when assessing a person suffering a traumatic brain injury (TBI). Previous analysis supported ongoing inclusion of the five correction items from MMPI-2 Hs scale in individuals who suffered a TBI. This study investigates the remaining nine correction model items on the Hy and Sc scales.

Participants

A sample of patients with a TBI (n = 242), and the MMPI-2 normative sample (n = 2,600).

Design Main Measures

This is a cross-sectional study testing measurement invariance of two MMPI-2 scales (Hy and Sc) between the TBI and normative samples.

Results

Factor models for each scale were defined and assessed across multiple samples. The Hy scale generated a four-factor model (CFI range .913-.935, RMSEA range .025-.027). The Sc scale generated a five-factor model (CFI range .911-.962, RMSEA range .013-.018). Both models met the criteria of partial measurement invariance. Sensitivity and specificity analysis supported retaining all correction items when assessing persons with a TBI.

Conclusions

These results suggest continued inclusion of all 14 Gass correction model items when assessing a person with a TBI.

Evaluating the Psychometric Properties of 3 Depression Measures in a Sample of Persons With Traumatic Brain Injury and Major Depressive Disorder

OBJECTIVES

To explore the psychometric properties of 3 widely used measures of depression in a sample of individuals with traumatic brain injury (TBI) and major depressive disorder and refine them to maximize efficiency.

DESIGN

Secondary analysis of data from a randomized controlled trial of cognitive-behavioral therapy for depression after TBI.

SETTING

Nationwide recruitment from community and clinical settings.

PARTICIPANTS

One hundred adults within 10 years of complicated mild to severe TBI.

INTERVENTION

Telephone and in-person cognitive-behavioral therapy.

MAIN MEASURES

Patient Health Questionnaire-9 (PHQ-9), Symptom Checklist-20, and Hamilton Depression Rating Scale.

RESULTS

We used Rasch rating scale analysis and multilevel modeling to investigate the 3 measures. Measurement properties of each of the depression measures were strong. We explored modifications to the rating scales to improve efficiency while retaining strong psychometric characteristics. Correlations among these revised measures were high. Treatment effects of each revised depression measure were compared using a multilevel model, and effect size estimates were comparable among the revised PHQ-9, Symptom Checklist-20, and Hamilton Depression Rating Scale.

CONCLUSIONS

Although each of the 3 measures demonstrated adequate reliability, the efficiency of all 3 instruments was improved with rating scale analysis. The PHQ-9 required the fewest modifications and functions well as a measure of depression among those with TBI.

Prevalence of and Risk Factors for Anxiety and Depressive Disorders after Traumatic Brain Injury: A Systematic Review

This review examined pre- and post-injury prevalence of, and risk factors for, anxiety disorders and depressive disorders after traumatic brain injury (TBI), based on evidence from structured diagnostic interviews. A systematic literature search was conducted in EMBASE, MEDLINE, Cochrane Central, PubMed, PsycINFO, and Google Scholar. We identified studies in civilian adults with TBI reporting on the prevalence of anxiety and depressive disorders using structured diagnostic interviews and assessed their quality. Pooled pre- and post-injury prevalence estimates of anxiety disorders and depressive disorders were computed. A total of 34 studies described in 68 publications were identified, often assessing anxiety disorders (n = 9), depressive disorders (n = 7), or a combination of disorders (n = 6). Prevalence rates of psychiatric disorders varied widely. Pooled prevalence estimates of anxiety and depressive disorders were 19% and 13% before TBI and 21% and 17% in the first year after TBI. Pooled prevalence estimates increased over time and indicated high long-term prevalence of Axis I disorders (54%), including anxiety disorders (36%) or depressive disorders (43%). Females, those without employment, and those with a psychiatric history before TBI were at higher risk for anxiety and depressive disorders after TBI. We conclude that a substantial number of patients encounter anxiety and depressive disorders after TBI, and that these problems persist over time. All health care settings should pay attention to the occurrence of psychiatric symptoms in the aftermath of TBI to enable early identification and treatment of these disorders and to enhance the recovery and quality of life of TBI survivors.

Stress, anxiety, and depression among parents of children with autism spectrum disorder in Oman: a case-control study

Previous studies carried out in Euro-American populations have unequivocally indicated that psychological disorders of the CASD (caregivers of children with autism spectrum disorder) are marked with high levels of stress, anxiety, and depression. This finding has been attributed to the reaction of having to care for a child with neurodevelopmental disorders. While there have been reports on autism spectrum disorder in Arab/Islamic countries such as Oman, there is no study from this region, to our knowledge, reporting the performance of indices of stress, anxiety, and depression among CASD. This study aimed to examine whether there is variation in the performance of indices of stress, depression, and anxiety explored via Depression, Anxiety and Stress Scale 21 among CASD, caregivers of children with intellectual disabilities, and caregivers of typically developing children. All indices of stress, depression, and anxiety were higher in CASD compared to other caregivers in the control group. This study corroborates with other studies carried out in other populations that caring for children impacts the mental health status of caregivers. Therefore, there are strong grounds to contemplate the mechanism to help such a vulnerable group of family caregivers.

Characterization of depression among patients at urban primary healthcare centers in Oman

AIM

The aim of this study was to estimate the prevalence and predictors of depression among Oman adult population attending primary healthcare clinics (PHCs) in Muscat Governorate in 2011.

METHODOLOGY

A cross-sectional study was conducted on 2005 participants attending 27 different PHCs in Muscat Governorate during 2011. A Patient Health Questionnaire (PHQ-9), together with a socio-demographic and relevant clinical data questionnaire was administered.

RESULTS

Of the 2005 participants, 61.8% were women and 42.1% were of 25-50 age group. Of the total, 44.4% were employed, of whom 51% were government employees. The prevalence of depression among them was 8.1%. The adjusted odds ratios generated by logistic regression models indicated that depression was significantly associated with age greater than 50 years old (OR = 2.23; 95% CI 1.07, 4.22; P = 0.04), female (OR = 1.34; 95% CI 1.12, 3.82; P = 0.03), married (OR = 1.91; 95% CI 1.11, 3.30; P = 0.02), graduated or attended higher education (OR = 1.40; 95% CI 1.03, 2.66; P = 0.04), working in the private sector if employed (OR = 1.72; 95% CI 1.08, 2.75; P = 0.02), and having chronic illness such as diabetes mellitus, hypertension, asthma, heart, thyroid, and renal diseases (OR = 1.82; 95% CI 1.03, 3.51; P = 0.01).

CONCLUSION

The rate of depression appears to be in the lower range compared to rate reported from elsewhere. Some socio-cultural factors that may contribute to the present findings are discussed.

Magnitude and concurrence of anxiety and depression among attendees with multiple sclerosis at a tertiary care Hospital in Oman

Background

Anxiety, depression and functional impairments are commonly reported by persons with multiple sclerosis (PwMS) but no data, to our knowledge, has emerged from an Arab Islamic population. The study aims to investigate the prevalence of anxiety, depression and related disabilities among PwMS attending tertiary care in Sultan Qaboos University Hospital (SQUH), one of the urban hospitals in Oman.

Methods

Consecutive and consenting PwMS (n = 57) and healthy subjects (n = 53) completed the following measures: Hospital Anxiety and Depression Scale (HADS) which was used to measure anxiety (cut-point >7) and depression (>7); and Expanded Disability Status Scale (EDSS) to measure the level of disability (≥5). Characteristics such as socio-demographic and clinical variables were also explored.

Results

Fifty seven subjects with multiple sclerosis (MS) met the inclusion criteria. The majority of them were females who were 40 years old or younger and the majority were employed and unmarried. Approximately 86 % of the participants were using beta interferon, 96 % scored ≥5 in EDSS. MS of the Relapsing-Remitting type constituted the majority of the cohort (94 %). Approximately 35 % and 51 % endorsed symptoms of anxiety and depression respectively. The MS group scored significantly higher than controls on HADS measurements of depression and anxiety.

Conclusion

Disability and symptoms of anxiety and depression are common among the PwMS attendees of tertiary care hospital in Oman. Such psychosocial variables have been largely unreported emerging from non-western populations. As these variables are strong indicators of the burden of MS, resolute effort is needed to address such psychosocial dysfunctions in the algorithms of care for PwMS in the Arab Islamic part of the world.

[The prevalence of anxiety and depression in different regions of the Russian Federation and its association with sociodemographic factors (according to the data of the ESSE-RF study)]

AIM

To study the prevalence of anxiety and depression by psychometric methods (the Hospital Anxiety and Depression Scale (HADS) in different regions of the Russian Federation (RF), which are characterized by various climatic, geographic, economic, and demographic indicators.

SUBJECTS AND METHODS

The investigation used the data of the multicenter epidemiological survey of cardiovascular diseases in different regions of the Russian Federation--the ESSE-RF study. The subjects of the study were representative samples from unorganized male and female populations aged 25-64 years from 10 RF regions. The survey included a total 16,877 people (6244 men and 10,623 women). All the examinees were interviewed using a standard questionnaire. An analysis involved their gender, age, education level, place and region of residence, and income and morbidity level. The HADS validated in Russia was used to rate the level of anxiety/depression.

RESULTS

The total prevalence of higher anxiety and depression averaged 46.3 and 25.6%, respectively. Respondents with clinical anxiety/depression constituted more than one third of those who had a higher level of these conditions. In the examined population, the moderate level of anxiety/depression was 7.5 ± 0.06 and 5.1 ± 0.04, respectively. The population of Volgograd, Samara, Saint Petersburg, and Tomsk had the similar values of the moderate level of anxiety/depression (p > 0.05). The lowest level of anxiety/ depression (p < 0.0001) was seen in the dwellers of Tyumen (5.9 ± 0.1 and 3.4 ± 0.1, respectively) and the highest in the Republic of North Ossetia-Alania (NOA) (8.4 ± 0.1 and 6.8 ± 0.1, respectively). These regions showed the lowest and highest prevalence of higher anxiety (22% in Tyumen and 59.8% in the Republic of NOA (p < 0.0001).

CONCLUSION

All the 10 selected RF regions differing in demographic, economic, climatic, and geographical parameters are characterized by a high level of anxiety that remains statistically significant after adjusting for gender and age, so are parameters, such as income and morbidity levels are present in only 4 of the 10 regions.

Heavy Vehicle Crash Characteristics in Oman 2009-2011

In recent years, Oman has seen a shift in the burden of diseases towards road accidents. The main objective of this paper, therefore, is to describe key characteristics of heavy vehicle crashes in Oman and identify the key driving behaviours that influence fatality risks. Crash data from January 2009 to December 2011 were examined and it was found that, of the 22,543 traffic accidents that occurred within this timeframe, 3,114 involved heavy vehicles. While the majority of these crashes were attributed to driver behaviours, a small proportion was attributed to other factors. The results of the study indicate that there is a need for a more thorough crash investigation process in Oman. Future research should explore the reporting processes used by the Royal Oman Police, cultural influences on heavy vehicle operations in Oman and improvements to the current licensing system.

Validity and screening properties of three depression rating scales in a prospective sample of patients with severe traumatic brain injury

OBJECTIVE

To evaluate the validity and utility of the Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI), and Hospital Anxiety and Depression Scale (HADS) as screening tools for depression after severe traumatic brain injury (TBI).

METHODS

Forty-six consecutive survivors of severe TBI were evaluated at a median of 15 months after injury. Receiver operating characteristic (ROC) analysis was performed using HAM-D, BDI, and HADS as predictors, and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) as gold standard.

RESULTS

The area under the curve (AUC) for HAM-D was 0.89, and the optimal cutoff point was 7 (sensitivity 92.9%, specificity 78.1%); for the BDI, the AUC was 0.946 and the optimal cutoff point was 14 (sensitivity 92.3%, specificity 96.7%); for the HADS, the AUC was 0.947 and the optimal cutoff point was 9 (sensitivity 100%, specificity 80.7%); and for the HADS depression subscale, the AUC was 0.937 and the optimal cutoff point was 6 (sensitivity 92.9%, specificity 83.9%). There were no statistically significant differences among the AUCs.

CONCLUSION

Our findings support a high validity and utility for the HAM-D, BDI, and HADS as screening tools for depression in patients with severe TBI, without major changes in standard cutoff points.

Grief, Anger, and Relationality: The Impact of a Research-Based Theater Intervention on Emotion Work Practices in Brain Injury Rehabilitation

BACKGROUND

Therapeutic emotion work is performed by health care providers as they manage their own feelings as well as those of colleagues and patients as part of efforts to improve the physical and psychosocial health outcomes of patients. It has yet to be examined within the context of traumatic brain injury rehabilitation.

OBJECTIVE

To evaluate the impact of a research-based theater intervention on emotion work practices of neurorehabilitation staff.

RESEARCH DESIGN

Data were collected at baseline and at 3 and 12 months postintervention in the inpatient neurorehabilitation units of two rehabilitation hospitals in central urban Canada.

SUBJECTS

Participants (N = 33) were recruited from nursing, psychology, allied health, recreational therapy, and chaplaincy.

MEASURES

Naturalistic observations (N = 204.5 hr) of a range of structured and unstructured activities in public and private areas, and semistructured interviews (N = 87) were conducted.

RESULTS

Preintervention analysis indicated emotion work practices were characterized by stringent self-management of empathy, suppression of client grief, adeptness with client anger, and discomfort with reactions of family and spouses. Postintervention analysis indicated significant staff changes in a relationality orientation, specifically improvements in outreach to homosexual and heterosexual family care partners, and support for sexual orientation and intimacy expression. No improvements were demonstrated in grief support.

CONCLUSION

Emotion work has yet to be the focus of initiatives to improve neurorehabilitative care. Our findings suggest the dramatic arts are well positioned to improve therapeutic emotion work and effect cultures of best practice. Recommendations are made for interprofessional educational initiatives to improve responses to client grief and potential intimate partner violence.

Validity of the Depression Anxiety Stress Scales in assessing depression and anxiety following traumatic brain injury

BACKGROUND

Anxiety and depression following traumatic brain injury (TBI) are associated with poorer outcomes. A brief self-report questionnaire would assist in identifying those at risk, however validity of such measures is complicated by confounding symptoms of the injury. This study investigated the validity of the Depression Anxiety Stress Scales (DASS) and Hospital Anxiety and Depression Scale (HADS), in screening for clinical diagnoses of anxiety and mood disorders following TBI.

METHODS

One hundred and twenty-three participants with mild to severe TBI were interviewed using the SCID (Axis I) and completed the DASS and HADS.

RESULTS

The DASS, DASS21 and HADS scales demonstrated validity compared with SCID diagnoses of anxiety and mood disorders as measured by Area Under ROC Curve, sensitivity and specificity. Validity of the DASS depression scale benefited from items reflecting symptoms of devaluation of life, self-deprecation, and hopelessness that are not present on the HADS. Validity of the HADS anxiety scale benefited from items reflecting symptoms of tension and worry that are measured separately for the DASS on the stress scale.

LIMITATIONS

Participants were predominantly drawn from a rehabilitation centre which may limit the extent to which results can be generalized. Scores for the DASS21 were derived from the DASS rather than being administered separately.

CONCLUSIONS

The DASS, DASS21 and HADS demonstrated validity as screening measures of anxiety and mood disorders in this TBI sample. The findings support use of these self-report questionnaires for individuals with TBI to identify those who should be referred for clinical diagnostic follow-up.

Problems in cross-cultural use of the hospital anxiety and depression scale: "no butterflies in the desert"

Objective

The Hospital Anxiety and Depression Scale (HADS) is widely used to screen for anxiety and depression. A large literature is citable in support of its validity, but difficulties are increasingly being identified, such as inexplicably discrepant optimal cutpoints and inconsistent factor-structures. This article examines whether these problems could be due to the construction of the HADS that poses difficulties for translation and cross-cultural use.

Methods

Authors’ awareness of difficulties translating the HADS were identified by examining 20% of studies using the HADS, obtained by a systematic literature search in Pubmed and PsycINFO in May 2012. Reports of use of translations and validation studies were recorded for papers from non-English speaking countries. Narrative and systematic reviews were examined for how authors dealt with different translations.

Results

Of 417 papers from non-English speaking countries, only 45% indicated whether a translation was used. Studies validating translations were cited in 54%. Seventeen reviews, incorporating data from diverse translated versions, were examined. Only seven mentioned issues of language and culture, and none indicated insurmountable problems in integrating results from different translations.

Conclusion

Initial decisions concerning item content and response options likely leave the HADS difficult to translate, but we failed to find an acknowledgment of problems in articles involving its translation and cross-cultural use. Investigators’ lack of awareness of these issues can lead to anomalous results and difficulties in interpretation and integration of these results. Reviews tend to overlook these issues and most reviews indiscriminately integrate results from studies performed in different countries. Cross-culturally valid, but literally translated versions of the HADS may not be attainable, and specific cutpoints may not be valid across cultures and language. Claims about rates of anxiety and depression based on integrating cross-cultural data or using the same cutpoint across languages and culture should be subject to critical scrutiny.

Improving client-centered brain injury rehabilitation through research-based theater

Traumatic brain injury often results in physical, behavioral, and cognitive impairments perceived by health care practitioners to limit or exclude clients' full participation in treatment decision making. We used qualitative methods to evaluate the short- and long-term impact of "After the Crash: A Play About Brain Injury," a research-based drama designed to teach client-centered care principles to brain injury rehabilitation staff. We conducted interviews and observations with staff of two inpatient neurorehabilitation units in Ontario, Canada. Findings demonstrate the effectiveness of the play in influencing practice through the avoidance of medical jargon to improve clients' understanding and participation in treatment; newfound appreciation for clients' needs for emotional expression and sexual intimacy; increased involvement of family caregivers; and avoidance of staff discussions as if clients were unaware. These findings suggest that research-based drama can effect reflexivity, empathy, and practice change to facilitate a client-centered culture of practice in brain injury rehabilitation.

Anxiety and depression levels of inpatients in the city centre of Kirşehir in Turkey

The aim of this study was to determine the anxiety and depression levels of inpatients. A cross-sectional study was conducted in Kırşehir in the middle part of Turkey with a sample of 433 inpatients. As the data-gathering tools, a questionnaire form and Hospital Anxiety and Depression Scale (HADS) were used. Statistical analyses were performed using Kruskal-Wallis Variance analysis and Mann-Whitney U-test. The mean HADS-depression scores of patients were compared according to the clinics they were in, and the difference was found to be significant for HADS-depression (P < 0.01) scores. The mean HADS-anxiety score of participants was 9.07, and the mean HADS-depression scores was 8.88. Among the participants in this study, 44.3% had an anxiety disorder (HADS-anxiety score of ≥ 10) whereas the 73.7% showed depression (HADS-depression score of ≥ 7). Results indicate that support, counselling, and routine screening for anxiety and depression should be provided to inpatients.

Validity of the Hospital Anxiety and Depression Scale to assess depression and anxiety following traumatic brain injury as compared with the Structured Clinical Interview for DSM-IV

BACKGROUND

Rating scales are often used in the assessment of depression and anxiety in traumatic brain injury (TBI), but few have been validated for use with this population. Overlap of symptoms between such disorders and TBI may lead to under- or over-diagnosis of depression or anxiety.

METHODS

100 participants with mild to severe TBI, and 87 informants, were interviewed using the SCID-IV (Axis I). The HADS was administered at the same time.

RESULTS

According to the SCID-IV, 34 participants were diagnosed with major depression and 36 with an anxiety disorder. Higher HADS scores were associated with a greater likelihood of depression and anxiety. However, the "clinical" categories of the HADS did not strongly correspond with the clinical diagnoses of depression and anxiety. Compared with SCID diagnoses, the depression subscale of the HADS had a sensitivity of 62% and a specificity of 92%. The anxiety subscale had a sensitivity of 75% and a specificity of 69%. Positive predictive and negative predictive values were calculated.

LIMITATIONS

This study included mostly moderate to severe TBI individuals, recruited from a rehabilitation hospital. Therefore, they may not necessarily be representative of the entire TBI population.

CONCLUSIONS

The HADS was a reliable measure of emotional distress in this TBI sample; however the cut-off scores and categories were not useful in predicting caseness of depression and anxiety. Clinicians should be mindful of the sequelae of TBI that may confound the scores yielded in rating scales and should follow up with a psychiatric interview when diagnosis is unclear.