East Asian Arch Psychiatry 2013;23:6-12


Usefulness of the Hospital Anxiety and Depression Scale for Screening for Psychiatric Morbidity in Chinese Patients with Graves’ Ophthalmopathy
VTC Wong, DKH Yu

Dr Vanessa Ting-Chi Wong, MBBS, MRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.
Dr Derek Kim-Hun Yu, MBBS, FRCSEd, FHKAM (Ophthalmology), FCOphth, MMed (Oph), Department of Ophthalmology, United Christian Hospital, Hong Kong SAR, China.

Address for correspondence: Dr Vanessa Ting-Chi Wong, 1/F East Block, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong SAR, China.
Tel: (852) 2595 4325; email: vtcwong@gmail.com

Submitted: 23 October 2012; Accepted: 14 February 2013

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Objective: To examine the usefulness of the Hospital Anxiety and Depression Scale (HADS) for screening psychiatric morbidity in Chinese patients with Graves’ ophthalmopathy.

Methods: A cross-sectional study was conducted from 1 January 2010 to 31 December 2010 at the specialist eye outpatient clinic at Pamela Youde Nethersole Eastern Hospital. All euthyroid patients diagnosed with Graves’ ophthalmopathy were recruited. They were interviewed with the Chinese version of the HADS and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I. Demographic data and clinical background information were collected from the patients and their hospital records were reviewed.

Results: In all, 124 patients were recruited into the study. Current prevalence of psychiatric disorders was 32%, of which 19% were current depressive disorders and 19% were current anxiety disorders. The HADS provided the best discriminating power for screening for psychiatric morbidity at a cut-off threshold of 10/11. For screening of depressive and anxiety disorders, the cut-off thresholds were 4/5 and 6/7 respectively.

Conclusion: Depression and anxiety disorders were common in the local population of patients with Graves’ ophthalmopathy. Recognising the predictors for psychiatric morbidity could assist clinicians to identify those patients with a predisposition to developing psychiatric complications, and refer them for appropriate treatment. The HADS can be considered as a screening tool for psychiatric morbidity in patients with Graves’ ophthalmopathy.

Key words: Asian continental ancestry group; Graves ophthalmopathy; Psychiatric status rating scales








Vision loss, or the fear of it, is associated with varying degrees of psychological burden greater than the distress resulting from other forms of sensory impairment. Vision loss impacts greatly on a person’s quality of life, often resulting in loss of employment, self-sufficiency, and self-esteem.

Graves’ ophthalmopathy (GO) is the commonest cause of orbital inflammation and proptosis in adults.1 The peak incidences are in the fourth and fifth decades, and the condition is more frequent in women.2 Graves’ ophthalmopathy mostly occurs in those with a history of hyperthyroidism, however, some patients may be euthyroid (6%), hypothyroid (1%), or have Hashimoto’s thyroiditis (3%) at the time of diagnosis.3 Approximately 25 to 50% of patients with Graves’ disease (GD) develop GO, which is often mild and self-limiting, but sight-threatening disease occurs in 3 to 5% of GO patients due to optic neuropathy or corneal breakdown.4,5

Individuals with GO have a facially disfiguring and potentially sight-threatening disease. This affects their self-confidence as they feel they are judged negatively by others,6 and they have considerable emotional distress and occupational impairment.7 Despite the advances of medical knowledge, patients with GO continue to have long-term sequelae of this disfiguring and progressive disorder. Although some overseas studies have investigated the psychological burden of GO,8-11 to date there are no local data available.

To the authors’ knowledge, no previous study has used stringent diagnostic operational criteria or standardised structured instruments to investigate psychiatric morbidity in patients with GO. This study therefore aimed to offer insight into the nature and prevalence of psychiatric morbidity of GO in the local Chinese population, and to assess the usefulness of a well-validated screening tool. Such information would assist health care providers in identifying those at risk and offering timely and holistic care.



All consecutive patients of Chinese ethnicity aged over 18 years with GO, who attended the eye clinic in a regional hospital in Hong Kong between 1 January 2010 and 31 December 2010, were recruited. Only those who were biochemically euthyroid in the previous 3 months were eligible. Patients with apparent cognitive deficit (e.g. delayed response, inability to follow simple instructions, or disorientation to time, place or person) were screened with the Mini-Mental State Examination by the principal author, and those who scored < 20 were excluded.12 The study was approved by the Ethics Committee of the Hong Kong Eastern Cluster, and written consent was obtained from all patients.


All psychiatric interviews were conducted by the principal author using the locally validated Chinese version of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I (SCID-I), which has been shown to have good inter- rater reliability, with a κ of 0.76 for mood disorder, 0.75 for schizophrenia and other psychotic disorders, and 0.81 for anxiety disorders.13,14 For generalised anxiety disorder (GAD), dysthymic disorder, somatoform disorder, and adjustment disorder, only current diagnoses are produced. The author received training from standardised teaching material, including DVD and the user’s manual, from the Biometrics Research Department, New York State Psychiatric Institute.15

For the Hospital Anxiety and Depression Scale (HADS), patients were asked to rate themselves on 7 depression and 7 anxiety items in the 2 subscales according to their experience in the previous week. Each item has 4 graded options from 0 (absence) to 3 (extreme), giving a maximum of 21 points in each subscale. The optimal balance between sensitivity and specificity for both subscales was suggested by the original authors at a cut-off threshold of 7/8.16 The HADS has been translated and used in the local Chinese setting for other illnesses.17-21 Local studies have reported different cut-off thresholds depending on the population screened, from 8/9 for the HADS Depression (HADS-D) and 5/6 for the HADS Anxiety (HADS-A)17 to a depression score of 6 and an anxiety score of 3.21

Statistical Analyses

Analysis was done using the Statistical Package for the Social Sciences, Windows version 15.0 (SPSS Inc, Chicago [IL], US). A receiver operating characteristic (ROC) curve was used to evaluate the performance of the HADS as a case-screening tool for psychiatric disorders with reference to the SCID.


In all, 160 Chinese patients with GO attended the eye clinic during the 1-year study period. Among these patients, 21 were excluded because they did not meet the inclusion criteria, and 15 refused to participate in the study. A total of 124 patients were recruited and completed the study, giving a response rate of 89%. When comparing the 124 respondents with the 15 non-respondents, there were no statistically significant differences between age, sex, and duration of GD and GO (Table 1).


Of the 124 patients recruited into the study, 80 (65%) were women, and the median age was 54 years. In all, 68 patients (55%) were working, either part-time or full-time, 10 (8%) were unemployed, and only 8 (6%) were receiving social welfare. About half of the patients reported a monthly household income of HK$20,000 or more. A total of 34 patients (27%) were living in public housing, with the rest living in either rented or self-owned accommodation. Most patients (n = 107; 86%) were living with their families (Table 2).

Psychiatric Morbidity

The lifetime prevalence of psychiatric disorders was 46% (34% females and 12% males), with depressive disorders and anxiety disorders at 40% and 22%, respectively (Table 3). The current prevalence of psychiatric disorders in this group was 32% (21% females and 11% males), and that of depressive disorders was found to be 19% (n = 24). Eight patients (6%) had a major depressive disorder and 16 (13%) had dysthymic disorder, adjustment disorder with depressed mood, or minor depressive disorder.

The current prevalence of anxiety disorders was 19% (n = 23). Generalised anxiety disorder, agoraphobia without a history of panic disorder, specific phobia, and anxiety not- otherwise-specified were equally common in this group of patients (all 3%). Of the 40 patients with current psychiatric disorders, only 13 (33%) were receiving psychiatric treatment at the time of the interview.

Hospital Anxiety and Depression Scale

The HADS total scores and subscale scores for all patients with current psychiatric disorders were consistently higher than those without current psychiatric disorders. For all psychiatric disorders, the optimal cut-off point of 10/11 yielded a sensitivity of 75% and specificity of 73% (Fig a). For the HADS-D and HADS-A scores, the optimal cut-off points were 4/5 and 6/7, respectively (Fig b and c).


Co-morbid Psychiatric Disorders

The current prevalence of depressive disorders was 19%, which was comparable to the finding of 23.5% using the HADS,10 but lower than 32.7% from a Korean study using the Becks Depression Inventory.22 The prevalence of major depressive episode and recurrent depressive disorder with current major depressive episode was 6%, while both adjustment disorder with depressed mood and dysthymic disorder was 6%. Community estimates for Hong Kong have reported a 12-month prevalence of 8.4% for major depressive episode.23 The Hong Kong study used telephone interviews,23 which may mask psychiatric stigma that would otherwise be apparent during face-to-face interviews by encouraging disclosure and reducing response bias. The authors did not use the SCID to diagnose major depressive episode, but used clinical judgement based on the DSM-IV symptoms.23

A number of factors may contribute to the development of depression. The commonest and greatest fear of patients with eye disease relates to the risk for blindness and the effect that this would have on their ability to work and to support their families.24 Disfigurement could be experienced as a loss of original personal identity, and frequently causes long-lasting grief, mourning, and depression.25 A changed appearance as a result of GO could further lead to social avoidance and loss of self-esteem. A poorly maintained euthyroid state and the use of steroids in the treatment of GO could also independently lead to depressive symptoms.

Kahaly et al10 found that anxiety was present in 40.2% of GO patients, which was not reflected in this study in which the current prevalence of anxiety disorders was 19%. These patients were recruited from a tertiary-level clinic, whereas in the former study10 it was conducted by a university quaternary-level clinic. The proportion of patients with moderate-to-severe GO in this study was 25%, but it was 69.5% in the study by Kahaly et al.10 The differences in clinical setting and severity of GO might explain why this study group had a lower prevalence of anxiety disorders. The use of the SCID as a more stringent criterion in this study versus the use of HADS as a screening tool in Kahaly et al’s study10 might also have resulted in fewer diagnoses of anxiety disorders.

When comparing these results with those for the local population, Lee et al26 found a community estimate of 4.1% for GAD, which was slightly higher than the 3% prevalence in this study. However, these 2 studies may not be directly comparable as other forms of anxiety disorders were not investigated in the community study.

A local study by Wong27 on psychiatric morbidity of patients with remitted GD showed a prevalence of 17.3% for current depressive disorders, and 6.4% for major depressive episodes. This was comparable to the figures from this study. However, in Wong’s study,27 the prevalence was 50% for current anxiety disorders and 21% for GADs, which were much higher than that in this study. Socio- demographic factors such as age (median age of 54 years in this study vs. 42 years in Wong’s study27), sex (35% vs. 24%27 for men), and social support (74% vs. 58%27 were in a marital relationship) may suggest that the population in this study group had more protective factors against anxiety disorders,28 although more detailed analysis will need to be carried out to determine the significance.

Patients with GO often have a poor self-image.29 These patients are anxious about the negative attitudes of others, or are afraid of appearing confused, arrogant, or uninterested if they do not respond in a socially appropriate manner.30 Subsequently, patients compensate by reducing social exposure, with many taking to concealment or avoidance as a means of coping.24

Screening with Hospital Anxiety and Depression Scale

Under-recognition and under-treatment of GO patients for their psychiatric co-morbidity has been confirmed by this study, where only about 30% of patients with psychiatric disorders were currently receiving mental health support. This may be due to a lack of awareness on the part of both clinicians and patients, the social stigma of being labelled with a mental disorder, denial of such problems, or barriers in the help-seeking pathway. A convenient and simple screening tool would be invaluable in aiding clinicians in a busy outpatient clinic to identify those at risk for developing psychiatric disorders and refer them promptly for appropriate treatment.

The authors of the HADS suggested a cut-off threshold of 7/8 for both HADS-D and HADS-A to achieve an optimal balance between sensitivity and specificity.16 Local studies have reported different cut-off thresholds, depending on the population screened, from 8/9 for HADS-D and 5/6 for HADS-A17 to a depression score of 6 and an anxiety score of 3.21 In this study, the ROC curve demonstrated that the best cut-off threshold was 10/11 when using the HADS total score to screen for any current psychiatric morbidity. For HADS-D and HADS-A scores, the cut-off thresholds were 4/5 and 6/7, respectively. These thresholds still fell within the range of 3 to 11 for both HADS sub-scores that offered a sensitivity of 37 to 100% and a specificity of 21 to 97%, as reported in a review of 24 studies with different patient populations and case definitions.31 The large difference in HADS performance may be due to the different illnesses being studied. The cut-off thresholds for this study were chosen with a view to balancing the specificity and sensitivity rates so as to maximise the benefit of a quick screening test without subjecting patients to excessive stress from being referred to a psychiatrist for further assessment.


Recruiting every consecutive GO patient in the eye clinic over a 1-year period eliminated the need for randomisation and reflected the real-world situation by enrolling patients with a broad spectrum of disease severity. However, the cross-sectional design of this study did not enable investigation of causal relationships between GO and psychiatric disorders. Patients in this specialist clinic may not be representative of the entire local GO population, and the results may not be readily generalised to other areas of Hong Kong.

This study did not have a control group of GD patients without GO for comparison. A control group would have allowed for factors such as the economic, social, and political environment at the time to be adjusted accordingly. The local study of patients with remitted GD27 did not find any correlation between severity of GO and current depressive and anxiety disorders. This may be because the patients in this study group had relatively mild GO (i.e. NO SPECS scores of ≤4), whereas patients with corneal involvement and sight loss (i.e. NO SPECS scores of 5 and 6, respectively) might have more pronounced psychopathology.27

Potential confounding factors such as stress- coping mechanisms, help-seeking behaviour, personality characteristics, perceived social support, and visual impairment in the family have been implicated in the past,32 but were not included in this study. For better understanding about the complexity of the interplay between those factors, a prospective study with a larger sample size should be planned in the future.

The HADS and SCID have their own strengths and weaknesses. The bi-dimensionality of the HADS has been questioned in the past,33 and whether item 7 (“I can sit at ease and feel relaxed.”) designed to screen for anxiety, should be placed in the depression subscale or be removed completely.20,34 Despite its shortcomings, the HADS continues to be a valid and reliable tool for screening psychiatric disorders in medically ill people. The SCID, generally regarded as a gold standard, only generates current diagnoses for certain disorders, hence the lifetime prevalence may have been underestimated. The inclusion of a disease-specific instrument may also be helpful, but to the authors’ knowledge, only a disease-specific quality- of-life questionnaire, not a screening tool for psychiatric morbidity, has been validated.35,36

Clinical Implications

This study has shown that patients with GO were at increased risk of developing psychiatric morbidity. The current prevalence of psychiatric disorders was 32%, and depressive and anxiety disorders were the main conditions diagnosed. This wide-scale phenomenon is under- recognised, and many of these affected individuals were not receiving appropriate mental health care.

Inclusion of the HADS rating scale with a cut-off threshold of 10/11 can be a practical way to screen for psychiatric morbidity in similar patient populations. The HADS rating scale could also be used in the future to monitor patients’ progress over time. The outcome of psychiatric intervention or treatment response for GO could then be assessed for efficacy and cost-effectiveness, thus enabling better planning and use of resources.

A holistic approach in the form of a combined thyroid eye clinic involving endocrinologists, ophthalmologists, and psychiatrists can better meet the different needs of patients, such as accurate control of thyroid dysfunction, early diagnosis and treatment of eye disease and associated psychiatric disorders, and providing education on the importance of smoking cessation. Patient support groups can also facilitate effective dissemination of information, promote more efficient use of health care, and empower patients to make effective efforts towards rehabilitation. Ultimately, the goal is to benefit patients by providing appropriate psychiatric intervention to improve quality of life.


We would like to thank Dr LW Dunn, Chief-of-Service, Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.


The authors declared that there is no conflict of interest in this study.


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