The Arabic Hospital Anxiety and Depression Scale

Dear Editor, We read with interest the findings by Phan et al. In particular, we were intrigued by the marked improvement in sensitivity and specificity of the Hospital Anxiety and Depression Scale-depression subscale (HADS-D) sub-scale postmodification. A number of published reports, as well as our experience, have pointed out several problems with the current version of the Arabic (HADS). The four-point response scale has been reversed in four items, namely ‘I can laugh and see the funny side of things’, ‘worrying thoughts go through my mind’, ‘I feel restless as if I have to be on the move’ and ‘I look forward with enjoyment to things’. A cohort of 143 patients was given the current Arabic HADS while waiting in a tertiary neurology outpatient clinic in Saudi Arabia (Alamri, unpublished). After recalculating the scores of the four items above, it was found that 14 (9.8%) patients were misdiagnosed as having either depression or anxiety, whereas 12 (8.4%) patients were dismissed as normal when in fact they scored above the cut-off scores of definite cases. The resultant miscalculation in many patients’ scores has resulted in the misdiagnosis of many patients and misplacement of available medical care. This included wasted time and medical resources on patients less likely to have anxiety or depression and missed opportunities to treat patients more likely to have anxiety or depression. Moreover, the current version uses words that might be too colloquial or too ambiguous for an Arab patient. For example, the word ‘‘tension’’ that is translated to the Arabic word ‘‘dheeg’’ can apply to both depression and anxiety. Also, many Arab patients perceive the phrase ‘‘I get a sort of frightened feeling like ‘butterflies’ in the stomach’’ as if it asks about acute abdominal pain or the literal presence of butterflies. Another difficulty with the current translation is its failure to capture the Arab social context and local traditional expressions into account. For instance, many Arab patients respond negatively to the item ‘‘I can enjoy a good book or radio or television programme’’ simply due to the fact that patient, like many other Arab patients, does not usually engage in such activities (as opposed to enjoying time with family and friends, e.g.).These linguistic and sociocultural barriers inherent to translation, in addition to the relatively high prevalence of illiteracy have led to a use of the scale that is vastly different to that for which it was originally developed. Arab researchers now very often have to read out the questions to the patients, explain the different choices and assist the patients to choose an appropriate answer. Not only is this timeand labour-intense, it also makes patients overthink their answer rather than giving immediate answers, all of which defy the very purpose of the HADS.