ArticleBMJ open2026
Simplified two-question screening for elevated Hospital Anxiety and Depression Scale (HADS) scores in orthopaedic patients: a retrospective cohort study with prospective validation.
Article in BMJ open, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
objectivesTo assess whether it is possible to reduce the burden of completing the full Hospital Anxiety and Depression Scale (HADS) by identifying patients at risk for elevated HADS ≥11 using fewer questions.
designRetrospective cohort study followed by prospective validation.
settingA large Dutch hospital with orthopaedic patients.
participants13 345 orthopaedic patients with a median age of 53 years (IQR: 37-65) for the retrospective cohort; 100 patients for prospective validation. PRIMARY OUTCOME MEASURE: Incidence of HADS scores ≥11 and performance of a simplified screening model for elevated HADS.
methodsThe full HADS questionnaire consists of 14 items (7 each for anxiety and depression). Logistic regression models were developed retrospectively to predict HADS ≥11 using one or two questions. Models were evaluated based on sensitivity (>90%), negative predictive value (NPV >90%) and reduction of the response burden (>50%). The most effective model was validated prospectively in 100 patients.
resultsThe retrospective cohort included 13 345 patients, with 20% (n=2671) having a HADS score ≥11. The final model, using questions 4 ('I can laugh and see the funny side of things') and 5 ('Worrying thoughts go through my mind'), achieved an area under the curve of 0.934, sensitivity of 95%, NPV of 98% and reduced the questionnaire burden by 57%. Prospective validation confirmed high sensitivity (94%) and NPV (98%) for identifying patients at risk of elevated HADS scores.
conclusionsIn a large Dutch hospital, 20% of orthopaedic patients exhibited elevated HADS scores (≥11). Screening for elevated HADS using only two questions was highly effective, with significant reductions in patient burden. Patients who screen positive should complete the full HADS for accurate diagnosis and management. This approach could reduce the need for full HADS completion in over half of the patients, without sacrificing screening accuracy.
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