The structure of the hospital anxiety and depression scale (HAD): An appraisal with normal, psychiatric and medical patient subjects

Four published studies which include factor analyses of the items of the Hospital Anxiety and Depression Scale (HAD) are reviewed and new data on psychiatric out-patients are presented. By contrast with the rest, the two studies in English with British subjects clearly support the interpretation of the HAD as a bidimensional measure. However, one anxiety item appears sex-related and misaligned. The problem of item meaning in other cultures is raised. Overall, despite the HADʹs use internationally, there has been a lack of systematic structural evaluation.