It was clear from that review that the best measure for anxiety and depression – the one preferred by clinical staff and patients – was HADS.
Professor Bob Lewin, a clinical psychologist at the Department of Health Sciences, University of York, and the Director of the British Heart Foundation (BHF) Rehabilitation Research Unit

HADS: Helping cardiac patients on the road to recovery (East Riding of Yorkshire PCT)

HADS helps cardiac patients on the road to recovery

The Hospital Anxiety and Depression Scale provides a quick and cost-effective means to assess cardiac patients for anxiety or depression - both of which can undermine patients’ rehabilitation programmes.

Heart and circulatory disease is the UK’s biggest killer, responsible for nearly 200,000 deaths each year. But given timely and appropriate interventions, the prognosis for cardiac patients need not be bleak. Indeed, it’s hard to overstate the importance of cardiac rehabilitation programmes, says Professor Bob Lewin, a clinical psychologist at the Department of Health Sciences, University of York, and the Director of the British Heart Foundation (BHF) Rehabilitation Research Unit.

Patients that take part in such programmes – typically those that have experience of a heart attack or heart surgery – have a 26 per cent relative reduction in cardiac mortality over the following five years, says Professor Lewin. That makes the programmes among the most cost-effective investments that can be made in the management of cardiovascular disease. The structured programmes help reduce the risk factors associated with coronary heart disease.

Cardiac rehabilitation programmes typically involve a mixture of education about risk factors, exercise, relaxation, support and advice to encourage patients to achieve a healthy lifestyle. But in order to increase the likelihood that rehabilitation is successful, it is essential to understand the patients’ emotional reaction to the event, says Professor Lewin.

Those that have suffered a cardiac episode “can be prone to bouts of anxiety and maybe even depression,” he says. “And if the patient is anxious or depressed, the success of the rehabilitation programme can be impaired.” For example, patients that are anxious or even depressed may be less inclined to participate in physical exercise and those that are smokers may find it more difficult to kick the habit.

According to the most recent National Audit of Cardiac Rehabilitation, published in October 2010, more than 17 per cent of patients were borderline clinically depressed and 29 per cent of patients had a similar incidence of anxiety.

The BHF has led the efforts to audit the availability of cardiac rehabilitation in the UK ever since the unveiling of the National Service Framework for Coronary Heart Disease in 2000. That framework proposed that 85 per cent of cardiac patients should be invited to take part in a rehabilitation programme.

At the time, there was no national measurement of the number of cardiac patients being offered rehabilitation programmes, making it impossible to see how well cardiac services performed against those targets, says Professor Lewin. So the BHF, working with Professor Lewin at York University, set out to quantify how many patients were invited to take part and how they benefited.

As part of that initial attempt to audit cardiac rehabilitation programmes, Professor Lewin and his team conducted an exhaustive evaluation of the questionnaires that could be used to evaluate a cardiac rehabilitation programme. They concluded that the best method of evaluating a patient’s mental wellbeing was through using the Hospital Anxiety and Depression Scale (HADS), a self-administered questionnaire published by GL Assessment, the independent specialist in education and psychological assessment.

“It was clear from that review that the best measure for anxiety and depression – the one preferred by clinical staff and patients – was HADS,” says Professor Lewin.

HADS measures depression and anxiety in and outside hospital settings, providing a cost-effective and easy-to-use method for establishing a clinically meaningful assessment of anxiety and depression in patients. It gives cut-off points to indicate whether a patient is within a normal range, or in a mildly, moderately or even severely anxious or depressed state.

The widely-used HADS questionnaire was the obvious choice, as it has a proven track record of being popular with both patients and staff because it is easy to oversee and can be completed quickly.

At East Riding of Yorkshire Primary Care Trust (ERYPT), HADS is used to assess cardiac patients at the very start of their rehabilitation programme, after three months and again after a year. Because HADS is simple and inexpensive, it is the ideal tool for assessing psychological wellbeing during the course of the rehabilitation programme, says Jo Williams, a cardiac rehabilitation specialist nurse at ERYPT.

“After a heart attack some patients really do feel quite down. That can make it harder to motivate them to participate fully in rehabilitation,” says Ms Williams. “So it’s important to understand how they feel psychologically – and that’s not always immediately obvious from just speaking to the patient, so tools like HADS really help.”

HADS provides clinicians with a powerful tool for measuring anxiety and depression, without being disconcerting for the patient, says Ms Williams. “It only takes a few minutes to complete, and it’s not too intrusive,” she says.

Typically, the HADS questionnaire can just be given to patients, without the need for detailed instructions, says Ms Williams. But patients can find the idea of a psychological assessment unsettling, so it really helps when they can see the types of questions being asked and have the reassurance that the assessment isn’t intrusive.

Those few minutes give clinicians hugely valuable insight and the reassurance that the assessments have been shown to produce reliable and accurate results.

HADS is available in over 60 languages, ensuring that clinically meaningful results can be gathered for the vast majority of patients, regardless of their native language. There are other benefits, too.

HADS is used extensively by numerous medical professionals and is so well-known, it provides a convenient tool for communicating a patient’s psychological state to other health professionals, says Ms Williams. “I can simply tell them a patient’s HADS score, and they’ll instantly know what I mean. In that sense, it’s a really useful shorthand tool.”

The HADS score is routinely included in the patient’s rehabilitation records, ensuring that the patient’s GP can follow up as necessary. It also ensures that all clinicians involved at the ERYPT’s rehabilitation programmes can easily check on a patient’s psychological wellbeing.

HADS scores are evaluated as part of the overall national cardiac rehabilitation audit. Unfortunately, not all health providers recognise the value that cardiac rehabilitation programmes provide, says Professor Lewin. So it’s essential that those forward-thinking ones know that they’re getting the best possible value for the money they’ve committed “HADS has proved its value in just the way we hoped it would,” says Professor Lewin.

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