Examining the stability of the hospital anxiety and depression scale factor structure in adolescents and young adults with cystic fibrosis: A confirmatory factor analysis

Estefany Saez-Flores, Niza A. Tonarely, David H. Barker, Alexandra Quittner

Research output: Contribution to journalArticle

5 Scopus citations


Objective The Hospital Anxiety and Depression Scale (HADS) is a widely used screening measure of anxiety and depression symptoms. However, prior analyses of the measure have found heterogeneous factor structures and called into question its ability to differentiate between symptoms of anxiety and depression. As part of efforts to implement mental health screening in cystic fibrosis (CF) care, the European Cystic Fibrosis Society (ECFS) and Cystic Fibrosis Foundation (CFF) conducted an international survey of 1,454 CF professionals. The HADS was the most commonly used measure in Europe and third most across all 48 countries surveyed. However, the HADS has not been validated for CF. Thus, the objective of this study was to examine its factor structure in a sample of adolescents and young adults with CF. Methods Three theory-based models were tested in 727 individuals with CF (ages 12-25 years, 54% female) using confirmatory factor analyses, with an additional two models tested to improve model fit. Results Chi-square difference tests and majority of fit indices indicated a three-factor structure based on Clark and Watson's tripartite model best fit the data. Conclusions The original HADS two-factor structure demonstrated problematic fit in this sample, indicating poor discrimination between symptoms of anxiety and depression. A three-factor structure demonstrated best fit, indicating existing scoring guidelines and cutoffs would be inappropriate for use with this patient population. Use of the HADS to screen for anxiety and depression in CF could lead to an underestimation of clinically relevant symptomatology for depression and potential overestimation of anxiety symptoms.

Original languageEnglish (US)
Pages (from-to)625-635
Number of pages11
JournalJournal of Pediatric Psychology
Issue number6
StatePublished - Jan 1 2018



  • Anxiety
  • Cystic fibrosis
  • Depression
  • Mental health
  • Structural equation modeling

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Developmental and Educational Psychology

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