Journal of Affective Disorders 95 (2006) 29–34www.elsevier.com/locate/jad

Research report

Student anxiety and depression: Comparison of questionnaireand interview assessments

Bernice Andrews ⁎, Jennie Hejdenberg, John Wilding

Department of Psychology, Royal Holloway University of London, Egham Surrey TW20 OEX, United Kingdom

Received 28 November 2005; received in revised form 3 May 2006; accepted 5 May 2006Available online 9 June 2006

Abstract

Background: Recent reports note a reliance on self-report measures and a lack of information about diagnosable mental disorder inuniversity students. Professional concern about perceived increases in student mental health problems raises questions aboutwhether questionnaire assessments can provide valid approximations of such disorders in this group. The aim of this study was tovalidate the Hospital Anxiety and Depression Scale (HADS) against DSM-IV diagnoses in university students.Methods: Eighty-nine students were administered with the HADS followed by the Structured Interview for DSM-IV.Results: At recommended cut-offs HADS anxiety and depression scales both showed good sensitivity in detecting DSM-IVanxietyand depression disorders, and the depression scale showed good specificity and overall efficiency. The HADS anxiety scale showedpoor specificity and moderate overall efficiency. In the absence of an anxiety diagnosis, high HADS anxiety scores were notsignificantly associated with other measured indicators of serious mental health problems.Limitations: Further research is needed to investigate whether the current findings hold for student populations with higher socialdiversity.Conclusions: The HADS depression scale is likely to be a reasonably accurate indicator of depressive conditions in universitystudents at the recommended cut-off but the HADS anxiety scale overestimates the extent of clinical anxiety. Students' self-reported higher symptom levels in comparison to general population norms cannot be assumed to indicate higher levels of moreserious mental health conditions. However this is not to deny the genuine distress and severe problems that some studentsexperience.© 2006 Elsevier B.V. All rights reserved.

Keywords: Depression; Anxiety; University students

1. Introduction

Increases in the severity of presenting problemsreported by student counselling services in Britain andthe United States (Association of University and CollegeCounselling [AUCC], 2002; Benton et al., 2003) have

⁎ Corresponding author.E-mail address: b.andrews@rhul.ac.uk (B. Andrews).

0165-0327/$ - see front matter © 2006 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2006.05.003

prompted an increase in professional concern aboutstudent mental health. A recent working party report bythe Royal College of Psychiatrists (2003) remarked onthe paucity of evidence but concluded that on balanceBritish university students report more mental healthsymptoms than age-matched controls. This was based onevidence from questionnaire studies and the report noteda lack of information on diagnosable mental disorder instudents both in Britain and internationally. The two

30 B. Andrews et al. / Journal of Affective Disorders 95 (2006) 29–34

studies that support the RCP conclusions used symptommeasures of student distress that did not differentiateanxiety from depression (Roberts et al., 1999; Stewart-Brown et al., 2000). One study (Surtees et al., 2002)which modified the General Health Questionnaire toderive DSM-IVanxiety and depression diagnoses foundcase rates in Cambridge University students to be similarto age-matched norms. However, the high social statusand achievement of Cambridge students suggests thattheir mental health might not be representative of allundergraduates. Two sizeable representative studentsurveys have used the Hospital Anxiety and DepressionScale (HADS: Zigmond and Snaith, 1983) and bothfound similar depression and anxiety levels (Webb et al.,1996; Andrews and Wilding, 2004). Using recom-mended cut-offs, depression rates were relatively lowand similar to reported HADS norms for British adults(Crawford et al., 2001) but rates of ‘probable’ caseanxiety at between 23% and 25% for men and between36% and 42% for women were over two- to threefoldhigher than male and female norms of 8% and 15%. Thisraises the question of whether the HADS and similarquestionnaire assessments can provide valid approxima-tions of mental health conditions in students. To addressthis issue the aims of the current study were:

• To validate the HADS against the Structured ClinicalInterview for DSM-IV (SCID: First et al., 2002) in asample of university students.

• To investigate how far the HADS and the SCID areequivalent or independent ways of assessing studentmental health problems by comparing the concurrentvalidity of the two methods in terms of other mentalhealth indicators including treatment history andsubstance abuse.

2. Method

2.1. Participants and procedure

Participants were selected for interview from 585respondents to a survey of home-domiciled second-yearundergraduate students at a college of the University ofLondon. The survey and subsequent interviews wereconducted over the course of two terms. As the mainfocus of the study was on student depression, prioritywas given to respondents with HADS depression scoresof 8 or more (‘possible’ or ‘probable’ depression,Zigmond and Snaith, 1983) in the interview selectionprocess. Students indicated on the questionnaire if theywere unwilling to be contacted for interview, and 15%did not wish to be contacted further. In the last month of

the first term and in the 11 weeks of the second term 84%of the willing respondents with HADS depression scoresof 8 or more and 33% with scores of 7 or less wereapproached for interview. Of those approached, 61%(128/210) agreed to be interviewed and 90 were inter-viewed in the time available before the end of the secondterm. All those interviewed gave written informed con-sent. There were no significant differences betweenstudents with and without HADS depression scores of8 or more in rates of willingness to be contacted andagreement to be interviewed, χ2 (1)=1.3 and 0.14 res-pectively. There were also no significant differences onthese factors between students with and without HADSanxiety scores of 8 or more, χ2 (1)=0.38 and 0.16respectively. The final interview sample comprised 70female and 20 male students with a mean age of 20.1(SD=3.1). One female student was later dropped fromthe analysis due to an incomplete section on the clinicalinterview. Excluding this student, 35% had a depressionscore of 8 or more (compared with 18% of all surveyrespondents), and 76% had an anxiety score of 8 or more(compared with 64% of all survey respondents).

2.2. Measures

2.2.1. The Hospital and Anxiety Scale (Zigmond andSnaith, 1983)

The scale consists of 14 items equally dividedbetween anxiety and depression subscales. Each item israted on a scale from 0 to 3 and the respondents rate theresponse which comes closest to how they have beenfeeling in the past week. According to the scale's authorsa score of between 8 and10 identifies possible cases and ascore of 11 or more the probable presence of a clinicallymeaningful anxiety or depressive condition. A recentreview of over 700 studies using the HADS found it tohave good psychometric properties and to perform wellin assessing anxiety and depressive disorders in healthsettings and in the general population (Bjelland et al.,2002). In the current study internal consistency usingCronbach's alpha for the HADS anxiety scale was .82 inboth survey and interview samples and for thedepression scale .74 and .73 for the respective samples.Correlations between the scales were .52 (survey) and.63 (interview). These test values are similar to the meanvalues reported by Bjelland et al.

2.2.2. The Structured Clinical Interview for DSM-IVAxis 1 disorders (SCID)

The relevant sections of the non-patient edition(SCID-1 NP; First et al., 2002) were used to detect thepresence of depressive and anxiety disorders. Sections

Table 1DSM-IV diagnoses of anxiety and depression assessed by the SCIDinterview

Anxiety Depression

Nodepressivedisorder

Majordepressivedisorder

Mixed anxiety–depressivedisorder

No anxietydisorder

62 3 –

Panic disorder a 7 3 –Generalised

anxiety disorder9 3 –

Mixed anxiety–depressivedisorder

– – 2

a Includes 1 social phobia and 2 with co-occurring generalised anxietydisorder.

31B. Andrews et al. / Journal of Affective Disorders 95 (2006) 29–34

covered included major depressive disorder, mixedanxiety and depressive disorder, panic disorder, socialphobia and generalised anxiety disorder. In additionsections on alcohol and drug abuse (but not dependence)were covered. The SCID evaluates current and lifetimediagnosis and the current study covered 12 months priorto the interview. The mean time from receipt ofquestionnaire to interview was 8 weeks (SD=3.6) anddiagnostic status was determined for the period aroundthe date of questionnaire receipt. Diagnosis was basedstrictly on DSM-IV criteria without reference to past orcurrent treatment. Interviews were conducted by trainedpsychologists. All interviews were double rated fromaudiotape with the second rater blind to the initialHADS score. Agreement was good with 97% agreementfor anxiety disorders, 96% for depressive disorders and100% for alcohol and drug abuse. Disagreements wereresolved by discussion at consensus meetings.

Past and current treatment was covered in the SCIDand additional survey questions covered attendance atthe student counselling service.

2.3. Analysis

To validate the HADS against the SCID its perfor-mance was assessed by reference to two standard criteria:sensitivity (the probability that someone with an anxietyor depressive disorder diagnosis will have testedpositive), and specificity (the probability that someonewithout an anxiety or depressive disorder will have tes-ted negative). These criteria are independent of theprevalence of the disorder in the population and cantherefore be compared across studies. We also calculatedthe positive predictive power of the HADS (theprobability that someone with a positive test, definedby a specified cut-off score, will report a diagnosis). Theperformance of the HADSwas also expressed in terms ofthe percentage of cases correctly classified as having ornot having a diagnosis (overall efficiency). AlthoughDSM-IV precludes a diagnosis of generalised anxietydisorder if it overlaps with major depression, for thepurpose of validating HADS anxiety and depressionscales separately, anxiety diagnoses were made inde-pendently of depressive disorders. In addition mixedanxiety–depressive disorder was included as a depres-sive disorder for validation of HADS depression and asan anxiety disorder for validation of HADS anxiety.

The concurrent validity of the questionnaire andinterview assessments was investigated by simplecomparisons of other mental health indicators betweencases and non-cases with high HADS scores and non-cases with low HADS scores using chi-squared tests.

3. Results

3.1. Clinical diagnosis

For the period under review 27 students met DSM-IVcriteria for an anxiety or depressive disorder. Table 1shows the numbers reaching criteria for the differentdisorders. Eleven met criteria for major depressivedisorder or mixed anxiety–depressive disorder, and afurther 16 met criteria for panic disorder or generalisedanxiety disorder. One case of social phobia wassubsumed under panic disorder.

3.2. Comparison of HADS cut-off scores with SCIDdiagnosis

Table 2 shows the numbers of students at the differentcut-off scores for the HADS. Rates of “possible” and“probable” cases of anxiety (cut-off at 8 and 11 respect-ively) were 76% and 58%. In contrast the rate of DSM-IV anxiety disorders according to the SCID assessmentwas 27%. HADS rates of “possible” and “probable” de-pression were 35% and 11% respectively. ProbableHADS depression was close to the SCID assessment of12% with depressive disorders.

Performance at HADS cut-offs between 8 and 14 areshown in Table 2. The best balance between sensitivityand specificity for HADS anxiety was at a cut-off of 13which gave an overall efficiency of .73. However,sensitivity and specificity were less than .8 and the posi-tive predictive value (PPV) indicated that only half ofthose with a score of 13 or more were SCID anxiety cases.Using a cut-off of 11 resulted in even lower specificity(.52) and PPV dropped to .40. HADS depression per-formed better with an optimal sensitivity/specificity

Table 2Sensitivity, specificity, and positive predictive value of the HADS depression and anxiety scales in detecting students with depression and anxietydisorders

Cut-off points Number at cut-off Sensitivity Specificity Positive predictive value Overall efficiency

HADS anxiety8+ 68 0.96 0.31 0.34 0.489+ 64 0.92 0.36 0.34 0.5110+ 59 0.88 0.42 0.36 0.5411+ 52 0.88 0.52 0.40 0.6212+ 45 0.79 0.60 0.42 0.6513+ 36 0.75 0.72 0.50 0.7314+ 30 0.63 0.77 0.50 0.73

HADS depression8+ 31 1.00 0.76 0.37 0.799+ 23 1.00 0.85 0.48 0.8710+ 17 1.00 0.92 0.65 0.9311+ 10 0.73 0.97 0.80 0.9412+ 5 0.36 0.99 0.80 0.9113+ 3 0.27 1.00 1.00 0.9114+ 3 0.27 1.00 1.00 0.91

Table 3Treatment for mental health problems, alcohol and drug abuse, and12 month prevalence of anxiety or depressive disorders by case anxietyand high and low scores on the HADS anxiety scale

Caseanxiety

No caseanxiety

No caseanxiety

χ2 (df )

HADS11+

HADS11+

HADSb11

n=21 n=28 n=34

Past or currenttreatment

67% (14) 25% (7) 12% (4) 19.12* (2)

Substance abuse 10% (2) 7% (2) 9% (3) 0.09 (2)Case depression/anxiety in year

25% (7) 12% (4) 1.84 (1)

*pb .001.

32 B. Andrews et al. / Journal of Affective Disorders 95 (2006) 29–34

balance at a cut-off score of 10, which gave an overallefficiency of .93 with sensitivity and specificity levelsboth over .90. PPV at .65 for this cut-off was better thanthat shown for the optimal anxiety cut-off. Increasing thecut-off to 11 gave a superior PPVof .80, but at the expenseof sensitivity.

3.3. Comparison of HADS and SCID assessments onother mental health indicators

Given the inefficiency of HADS anxiety to distin-guish cases from non-cases, relative to the superiorperformance of HADS depression at all cut-offs,concurrent validity of the SCID and HADS wasinvestigated for anxiety only. Cases of anxiety identifiedby the SCID who also had HADS scores of 11or more(HADS ‘probable’ cases) were compared with HADS‘probable’ cases with no SCID case anxiety diagnosisand low scoring non-cases on other signs of psychopa-thology. This was to determine whether high scoringnon-cases were exhibiting other signs of mental healthproblems not detected by the SCID for the relevant timeperiod that might support the validity of the question-naire assessment. The three groups were compared onthe frequency of past or current treatment for mentalhealth problems, and alcohol and drug abuse. High andlow scoring non-cases were also compared on theprevalence of SCID diagnosed case depression andanxiety episodes for the full 12 month study period. Inthese analyses the three students with case depressionbut without case anxiety were excluded. A cut-off of 11was chosen to distinguish high from low scoring anxietygroups as sensitivity was higher at this cut-off thus

preserving more cases for comparison (three cases werelost with this cut-off). Table 3 shows that the onlysignificant group difference was for past or currenttreatment for mental health problems. The anxiety casesreported the highest treatment rate, with the low scoringnon-cases having the lowest rate. Using the methodrecommended by Seigal and Castellan (1988), theoverall χ2 for this comparison was partitioned intoadditive components, comparing 1) non-cases with andwithout scores of 11 or more, and 2) cases with all non-cases. The first comparison yielded a χ2 of 1.28, ns, andthe second 17.84, pb .001, indicating that the differ-ences were due to clinical interview assessment ratherthan questionnaire score.

For descriptive purposes, the SCID interviewresponses of the 28 non-cases with HADS anxietyscores of 11 or more were examined. Nine of the non-

33B. Andrews et al. / Journal of Affective Disorders 95 (2006) 29–34

cases were positive on Criteria A (excessive worry) andB (difficulty in controlling worry) for generalisedanxiety disorder (GAD). Of these 9, 4 reached at leastone of the other GAD criteria and one of these also hadsub-threshold panic symptoms. For all 4 the anxiety waslimited to a short period not exceeding a month. Of theremaining 19, 3 denied the SCID screening question ofhaving a period of feeling nervous or anxious, 1 reportedsub-threshold panic symptoms with no attendant worryand 15 reported worry that was not present for moredays than not, or the worry could be controlled.

4. Discussion

4.1. The utility of the HADS as an indicator of anxietyand depressive disorders in students

To the authors' knowledge this is the first study tovalidate a questionnaire measure of anxiety anddepression against a structured clinical assessment in auniversity setting. The findings suggest that the HADSdepression scale is likely to be a reasonably accurateindicator of depressive conditions in university studentsusing a score just below or at the recommended cut-offfor probable case depression. In contrast the HADSanxiety scale at the recommended probable case cut-offand above appears to overestimate the extent of clini-cally significant anxiety in this group.

Both HADS scales showed good sensitivity indetecting cases of anxiety and depression in students.Optimal cut-off scores for the two scales respectivelywere 10 for depression and 11 for anxiety. However, theresults indicated that the HADS depression scale was farmore accurate than HADS anxiety in correctly classi-fying non-cases at all specified cut-off scores (Table 2).The lack of specificity of the HADS anxiety scale wassupported by the finding that, in the absence of ananxiety diagnosis, high anxiety scores were notsignificantly associated with other measured indicatorsof serious mental health problems. As in previousclinical research (Andrews and Brown, 1993) theconcurrent validity of the questionnaire assessmentwas poor compared with the interview assessment. Thepoor specificity of the anxiety scale in the current studyis at odds with the review of Bjelland et al. (2002) ofHADS validation studies in predominantly health caresettings which showed both subscales to perform wellwith no particular superiority of one subscale over theother. In the 23 relevant validity studies in this reviewthe optimal balance between sensitivity and specificitywas achieved when ‘caseness’ was defined by a score of8 or more, with sensitivity and specificity in most cases

in the region of .80 for both scales. Taken together withthe much higher levels of HADS anxiety reported in pastBritish student studies compared both to their depres-sion levels (Webb et al., 1996; Andrews and Wilding,2004) and to adult anxiety norms, this suggests thatstudents' self-reports of anxiety symptoms might have adifferent significance or meaning to that of other groupsin the population. The descriptive data suggests thatmuch of the high anxiety that students endorse onquestionnaires may reflect transient feelings andresponses to transient situations. Examples of suchsituations are likely to include coursework deadlines,and relatively short-lived relationship problems (seeAndrews and Wilding, 2004). Another possibilitywarranting further investigation is that individualswith higher educational achievement are more likelyto note and report anxious feelings, however fleeting,particularly within the confines of relatively impersonalhigher educational settings. However, this is not to denythe real distress that may be felt in such situations or thesevere problems that some students experience.

4.2. Limitations

Our study is limited by our recruitment methods.Students scoring high on the HADS depression scale areless common than high scorers on HADS anxiety (Webbet al., 1996, Andrews and Wilding, 2004). To obtain asufficient number of depression cases it was necessaryto over-sample for depression high scorers. The reportedpositive predictive power of the HADS scales cannot begeneralised beyond this sample as PPV is sensitive topopulation prevalence. However this does not affect thefindings on the two standard criteria of sensitivity andspecificity that are independent of population preva-lence. It should also be borne in mind that this study wascarried out with students from an ‘old’ university.Further research is needed to investigate whether thecurrent findings hold for students from new universitieswith higher social diversity. The clinical interviews alsotook place on average some weeks after receipt of thequestionnaire. However the SCID is designed to detectlifetime episodes and onsets and offsets of symptomswere carefully documented.

4.3. Implications for the assessment of student mentalhealth

Bearing in mind these limitations, the findings haveimplications for the interpretation of existing studentstudies and for future research. They support observationsoutlined in the Royal College of Psychiatrists (2003) report

34 B. Andrews et al. / Journal of Affective Disorders 95 (2006) 29–34

that students' self-reported higher symptom levels incomparison to age-matched controls or norms cannot beassumed to indicate higher levels of more serious diag-nosable mental health conditions. The existing studentquestionnaire studies that have reported age-matched groupdifferences (Roberts et al., 1999; Stewart-Brown et al.,2000) have not distinguished anxiety from depression andhigh scores are likely to reflect general emotional distress.

The true prevalence of diagnosable mental healthconditions in student populations is unknown. This isnot surprising since large-scale clinical interviewassessments of representative samples of students areunlikely to be a practical option given the resourcesrequired and problems of recruitment in universitysettings. The question therefore is whether standardisedquestionnaire measures can be used as approximateindicators of mood and anxiety disorders in students.Given the current findings it is possible that depressivedisorders might be easier to detect with questionnairesthan anxiety disorders. Further research is needed toinvestigate this possibility. For example, it will benecessary to validate other standardised questionnairesagainst clinical assessments to determine whetheranxiety scales in general are poor at distinguishingcases from non-cases. It seems likely, however, thatquestionnaires modified to detect DSM-IV conditions ofthe type used by Surtees and colleagues with Cambridgestudents may be a better way forward in the assessmentof student mental health.

Acknowledgement

The research was supported by a grant from theEconomic and Social Research Council (RES-000-22-0897).

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