One study comparing the HADS to diagnoses of anxiety and depression in a cohort of patients with osteoarthritis observed greater concordance among the HADS-A and diagnoses of anxiety compared to the concordance among the HADS depression scale and diagnoses of depressive disorders ( 30). An additional study in the elderly yielded high misclassification rates and suggested that the HADS-A possessed limited sensitivity and specificity to detect anxiety disorders in this population ( 32). In primary care populations, cut scores of ≥9 for the HADS-A yielded moderate sensitivity (0.66) and high specificity (0.93) ( 31). Using a cut score of 8 overall provided sensitivities and specificities at ~80% and reaching 90% in a community cohort for the HADS-A for detecting anxiety disorders ( 31). The majority of psychometric studies observed a 2-factor solution, supporting the use of the anxiety subscale as a “stand alone” measure (11 of 19 studies in a recent review of this measure however a few studies did find more than 2 factors (see review by Bjelland et al ). In some populations (elderly), the STAI has shown poor discriminant validity and did not differentiate persons with and without anxiety disorders ( 16). Similarly, while the STAI has not been formally validated in rheumatic disease, studies in rheumatology have similarly observed very high correlations among the STAI and measures of depression (e.g., r = 0.83) ( 5). Like other measures of anxiety, the STAI is also highly correlated with depression and, in some studies, the STAI did not differentiate anxious from depressed patients ( 17). S-Anxiety validity was originally derived from testing in situations characterized by high state stress including classroom examinations, military training programs, etc. In general, construct validity ( 15) of the STAI was somewhat limited in discriminating anxiety from depression, with some studies observing higher correlations between the T-Anxiety scale and measures of depression, as compared to other measures of anxiety ( 5, 16).
To optimize content validity, most items were selected from other anxiety measures on the basis of strong associations with the Taylor Manifest Anxiety Scale ( 13) and Cattell and Scheier's Anxiety Scale Questionnaire ( 14) overall correlations between the STAI and these 2 measures were 0.73 and 0.85, respectively. Finally, a summary of the strengths and weaknesses specific to rheumatology is presented.ĭuring test development, more than 10,000 adults and adolescents were tested. In addition, information regarding responsiveness of each measure to longitudinal change is presented, including responsiveness to change in rheumatology when available. In this review, the content and structure of each measure is presented (number of items, recall period, response options, presence of translations, and adaptations), the use in rheumatic disease when possible is discussed, and the psychometric properties of each measure, particularly when validated in any of the rheumatic diseases, is detailed. The measures reviewed below include the State Trait Anxiety Index, the Beck Anxiety Inventory, and the anxiety subscale of the Hospital Anxiety and Depression Scale. Importantly, the measures included in this review should not be interpreted as diagnostically significant for an anxiety disorder, even generalized anxiety disorder, but should be used to measure the presence of symptoms and to calibrate the severity of general symptoms of anxiety commonly occurring in rheumatic disease.
However, subscales that have been used frequently in rheumatology as “stand-alone” measures, such as the anxiety scale of the Hospital Anxiety and Depression Scale, are included in this review. In addition, broader measures of psychiatric distress, including the Symptom Checklist-90, the General Health Questionnaire, and the Medical Outcomes Study Short Form 36 are not included in this review since they are included elsewhere in this special issue. Specifically, this author excluded measures typically used to evaluate diagnostic criteria or features of specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and others.
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To maintain brevity, the majority of the measures reviewed here were selected to provide broad coverage of general symptoms of anxiety, and measures were excluded if they are intended to identify or characterize a specific Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorder ( 1). For this review, the author included measures that were 1) measures of general measures of anxiety and severity of anxiety symptoms, 2) administered by self-report, 3) used in rheumatologic populations, and 4) has evidence of adequate psychometric data. This review covers commonly used measures of anxiety.
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