Evaluating the factor structure, item analyses, and internal consistency of hospital anxiety and depression scale in Iranian infertile patients

Assessment of Construct Validity and Reliability of the Hospital Anxiety and Depression Scale in Greek Couples With Infertility Undergoing In Vitro Fertilization Cycles

INTRODUCTION

The Hospital Anxiety and Depression Scale (HADS) is a widely used screening instrument created to assess anxiety and depression symptoms during the experience of various health problems. It has also been increasingly applied to populations facing infertility. The current cross-sectional study aimed to assess the construct validity and reliability of the HADS in a sample of Greek participants undergoing in vitro fertilization (IVF) cycles.

MATERIALS AND METHODS

This study included 90 couples with infertility referred to an assisted reproduction unit in Heraklion, Greece, and an infertility center in Athens, Greece. To validate the scale, confirmatory factor analyses (CFA) were performed. Several goodness-of-fit indices were utilized including the comparative fit index (CFI), the root mean squared error of approximation (RMSEA), the standardized root mean square residual (SRMR), and normed chi-square index with the degree of freedom (c2/df). The reliability analysis was conducted by calculating Cronbach's alpha.

RESULTS

The confirmatory factor analysis revealed that all of the four fitness indexes were good (x2/df=1.489, CFI=0.943, RMSEA=0.052, SRMR=0.055). Based on the item-scale correlation coefficients, reliability was very good for the anxiety factor (alpha = 0.808), good for the depression factor (alpha = 0.707), and very good for the total questionnaire (alpha = 0.858).

CONCLUSION

The results of confirmatory factor analyses and reliability analyses proved that HADS met the criteria of construct validity and reliability, making it suitable for use with couples undergoing an IVF cycle. Examining negative emotions, such as anxiety and depression, during the period of fertility problems and its treatment is important to evaluate the psychological maladjustment of couples with infertility and to create psychological interventions by health professionals that help individuals with infertility manage distress during IVF.

Impact of the COVID-19 Pandemic on the Lifestyles and Quality of Life of Women With Fertility Problems: A Cross-Sectional Study

Background: The COVID-19 pandemic has implied worldwide the imposition of confinement measures and mobility restrictions, to a greater or lesser extent. It has also meant the closure of some public medical services such as reproductive care. This situation may have impacted the health-related behaviour and quality of life of women with fertility problems. Objective: The objective of this study was to analyse the effects of confinement and the suspension of reproductive medical care on the lifestyle (diet, physical exercise, and smoking habits), anxiety and depression, and quality of life of infertile women by comparing their pre- and post-confinement situations. Methods: We carried out a cross-sectional, internet-based study. Information was collected on these women's adherence to the Mediterranean diet (MEDAS questionnaire), physical exercise (IPAQ-SF), anxiety and depression (HADS), and quality of life related to fertility (FertiQol) before, during, and after confinement. The survey was conducted between 1 September and 28 October 2020. Results: A total of 85 women participated. There had been a significant increase in anxiety and depression levels (P < 0.001) and an increase in tobacco consumption among female smokers during confinement vs. pre-confinement (62.5% had increased their consumption). The participants had also increased the mean number of hours they spent sitting (P < 0.001). There had also been an increase in vigorous and moderate exercise levels by 40 and 30%, respectively (P = 0.004). However, no differences were observed in these patients' eating habits as a result of confinement (P = 0.416). When the reproduction service was resumed, the participants showed higher anxiety level scores (P = 0.001) with respect to the pre-confinement situation as well as lower mean FertiQol scale score (P = 0.008). Conclusions: Confinement had increased anxiety and depression levels among these infertile women as well as tobacco use among the participants who were smokers. The prolonged closure of reproductive care units decreased the quality of life of the participants of this study. These results suggest the need to implement online programs to improve healthy habits and quality of life of this population group.

Factor structure and reliability of Persian version of hospital anxiety and depression scale in patients with breast cancer survivors

Introduction

Anxiety and depression are significant concerns in breast cancer patients, and it may remain for a long term after primary treatments. The hospital anxiety and depression scale (HADS) is widely used to measure depressive and anxiety symptoms in clinical practices. The purpose of this study was to assess the psychometric properties of the Persian version of this scale in Iranian breast cancer survivors.

Methods

A total of 305 patients with breast cancer, refered to Cancer Hospital in northen Iran and completed the primary treatments were enrolled in. All patients responded to a 14-item HADS. We performed confirmatory factor analysis (CFA) to examine the factor structure of HADS and the item-scale analysis in order to estimate the item reliability and consider the Cronbach’s alpha as a measure of internal consistency.

Results

With a threshold of ≥8, the prevalence of anxiety and depression symptoms (moderate/severe) was 78.9 and 66.9%, respectively. The Cronbach’s alpha coefficients for anxiety and depression were 0.81 and 0.78, respectively. The CFA confirmed the two-factor structure model for HADS, indicating a good fitting summary indexes (χ2/df = 2.83, NFI = 0.88, RFI = 0.82, IFI = 0.92, CFI = 0.92, and RMSEA = 0.078).

Conclusion

The CFA and item reliability analysis have indicated an excellent psychometric property of the Persian version of HADS to measure depressive and anxiety symptoms in breast cancer survivors. Thus, HADS is a useful screening tool to identify post-breast cancer anxiety and depressive disorders.

The prevalence of depression among Iranian infertile couples: an update systematic review and meta-analysis

Background

Depression is a common mental disorder. Infertility can lead to depression. The current systematic review and meta-analysis were conducted to estimate the pooled prevalence of depression among Iranian infertile couples. Seven electronic databases (Google Scholar, MagIran, SID, Science Direct, PubMed, Scopus, Web of Science) were searched, up to August 2019, for relevant published studies. The pooled prevalence of depression also pooled mean of depression score was determined using a random-effects model with a 95% confidence interval (95% CI). All analyses performed using Stata ver11 (Stata Corporation, College Station, TX, USA). The 0.05 was considered a significant level.

The main body

Totally, 230 studies were retrieved and 31 studies included in the meta-analysis. The pooled prevalence of depression among infertile couples was about 35.3% (95 % CI 24.1–46.5), and the prevalence of depression among females and males was 48.7% (95% CI 24.0–73.3) and 9% (95% CI 0% to 23.7%), respectively.

Conclusions

Our findings suggest a high prevalence of depression in infertile couples. The results can highlight an important and growing mental disorder among infertile couples that may be overlooked.

The Persian version of the revised dyadic adjustment scale (RDAS): a validation study in infertile patients

Background

Infertility can have a powerful impact on marital quality. The Revised Dyadic Adjustment Scale (RDAS) is a widely used measure of marital quality. This scale has not been validated in infertile patients. Therefore, this study aimed to evaluate the reliability and validity of the RDAS in a sample of infertile patients.

Methods

The sample of this methodological study consisted of 254 infertile patients referring to a referral infertility clinic in Tehran, Iran. A battery of questionnaires was administered to the participants, including a demographic/fertility questionnaire, the RDAS, the Relationship Assessment Scale (RAS), the Kansas Marital Satisfaction Scale (KMSS), the Couples Satisfaction Index- 4 Item (CSI-4), the Hospital Anxiety and Depression Scale (HADS), and the Perceived Stress Scale-4 Item (PSS-4). Internal consistency of the scale was assessed with Cronbach’s alpha, construct validity was investigated using confirmatory factor analysis (CFA), and convergent validity was examined by correlating the RDAS with RAS, KMSS, CSI-4, HADS, and PSS-4 instruments.

Results

The mean total RDAS score was 49.26 ± 9.34, and 100 patients (39.4%) had marital distress based on the cut-off value of < 48. The second-order three-factor model of the RDAS exhibited an excellent fit to the data, as indicated by χ²/df = 2.26; CFI = 0.96; GFI = 0.91; NFI = 0.93; IFI = 0.96; RMSEA = 0.071 and SRMR = 0.050. The RDAS and its subscales revealed satisfactory internal consistency that ranged from 0.664 to 0.847. Convergent validity was confirmed by strong correlations between RDAS scores and scores on the RAS, KMSS, and CSI-4. These correlations also tended to be larger than correlations with measures of HADS-anxiety, HADS-depression, and PSS-4. Among demographic/fertility variables, only infertility duration was found to be correlated to the RDAS.

Conclusion

The RDAS is a reliable and valid inventory for measuring marital quality in infertile patients. Further validation studies are needed to generalize the underlying structure of the scale in various populations.

The reliability and validity of the Patient Health Questionnaire-9 (PHQ-9) and PHQ-2 in patients with infertility

Background

Depression in patients with infertility often goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) and its ultra-brief version (i.e. PHQ-2) are widely used measures of depressive symptoms. These scales have not been validated in patients with infertility. The aim of the present study was to examine the reliability and validity of the PHQ-9 and PHQ-2 in patients with infertility.

Methods

In this cross-sectional study, a total of 539 patients with infertility from a referral infertility clinic in Tehran, Iran completed the PHQ-9, along with other relevant scales: the WHO-five Well-being Index (WHO-5), the Hospital Anxiety and Depression Scale (HADS), and the Generalized Anxiety Disorder-7 (GAD-7). Factor structure and internal consistency of PHQ-9 were examined via confirmatory factor analysis (CFA) and Cronbach’s alpha, respectively. Convergent validity was evaluated by relationship with WHO-5, HADS and GAD-7.

Results

The mean total PHQ-9 and PHQ-2 scores were 8.47 ± 6.17 and 2.42 ± 1.86, respectively, and using a cut-off value of 10 (for PHQ-9) and 3 (for PHQ-2), the prevalence of depressive symptoms was 38.6 and 43.6%, respectively. The Cronbach’s alphas for PHQ-9 and PHQ-2 were, respectively, 0.851 and 0.767, indicating good internal consistency. The CFA results confirmed the one-factor model of the PHQ-9 (χ²/df = 4.29; CFI = 0.98; RMSEA = 0.078 and SRMR = 0.044). Both PHQ-9 and PHQ-2 showed moderate to strong correlation with the measures of WHO-5, HADS-depression, HADS-anxiety, and the GAD-7, confirming convergent validity. In univariate analysis, female sex, long infertility duration, and unsuccessful treatment were significantly associated with depression symptoms.

Conclusion

Both PHQ-9 and PHQ-2 are brief and easy to use measures of depressive symptoms with good psychometric properties that appear suitable for routine use in patients with infertility.

The 'Pleasure&Pregnancy' web-based interactive educational programme versus expectant management in the treatment of unexplained subfertility: protocol for a randomised controlled trial

INTRODUCTION

Many subfertile couples are diagnosed with (relatively) unexplained subfertility and a good prognosis. National professional guidelines (eg, the Netherlands and UK) advise 'expectant management (EM)' for 6-12 months, in which no interaction with healthcare staff is offered. Underpowered studies indicate that face-to-face sex-counselling increases the ongoing pregnancy rates of these couples. In patients with other conditions, web-based interactive educational programmes have the same effect on sexual functioning as face-to-face sex counselling. The 'Pleasure&Pregnancy randomised controlled trial (RCT)' will examine in couples with unexplained subfertility and a good prognosis whether a new web-based interactive educational programme results in a higher chance of naturally conceiving an ongoing pregnancy within 6 months as compared with EM.

METHODS AND ANALYSIS

A multicentre RCT with cost-effectiveness analysis will include heterosexual couples diagnosed with (relatively) unexplained subfertility and a good prognosis in Dutch and Belgian secondary or tertiary fertility clinics. Couples will be randomised between 6 months of EM and 6 months of the Pleasure&Pregnancy-programme. This new web-based interactive educational programme includes eight progressive modules of information (on the biology of conception and pleasurable sex) and sensate focus, couple communication and mindfulness exercises. Couples are offered interaction with their coaches via email and can take part in three moderated chat sessions with peers. The primary outcome of this RCT is the probability of naturally conceiving an ongoing pregnancy within 6 months after randomisation. Secondary outcomes include time-to-pregnancy, live birth rate, costs, sexual functioning and personal and relational well-being. Analysis will be according to intention to treat.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Ethical Committees of the Academic Medical Centre (the Netherlands) and the Leuven University Hospital (Belgium). The findings of this RCT will be disseminated through presentations at international scientific meetings and peer-reviewed publications.

TRAIL REGISTRATION NUMBER

NTR5709; Pre-results.

The effects of depression, anxiety and stress symptoms on the clinical pregnancy rate in women undergoing IVF treatment

OBJECTIVE

Women undergoing assisted reproductive technology treatment, are often anxious and depressed because of their fertility problem and the uncertainties of the treatment with which they have to deal. On the other hand, recent studies have shown that the effects of psychological distress on the IVF treatment outcome is unclear. This study aimed to examine the effects of anxiety, depression, and stress symptoms before IVF treatment on the clinical pregnancy rate, controlling for known confounders.

RESULTS

In total, 142 women undergoing IVF treatment participated in this prospective study. The clinical pregnancy rate was 26.8% in this study. Controlling for age, infertility duration, and cause of infertility, there were no relationship between IVF outcome and anxiety (relative risk (RR) = 1.00; 95% CI 0.91-1.09), depression (RR = 0.96; 95% CI 0.88-1.05), and stress (RR = 1.01; 95% CI 0.96-1.07) symptoms. High woman's age and women with both cause of infertility were independent predictors of IVF clinical pregnancy rate. In sum, we found that anxiety, depression, and stress symptoms were not associated with the IVF clinical pregnancy rate.

Application of the dyadic data analysis in behavioral medicine research: marital satisfaction and anxiety in infertile couples

BACKGROUND

Dyadic data analysis (DDA) is increasingly being used to better understand, analyze and model intra- and inter-personal mechanisms of health in various types of dyads such as husband-wife, caregiver-patient, doctor-patient, and parent-child. A key strength of the DDA is its flexibility to take the nonindependence available in the dyads into account. In this article, we illustrate the value of using DDA to examine how anxiety is associated with marital satisfaction in infertile couples.

METHODS

This cross-sectional study included 141 infertile couples from a referral infertility clinic in Tehran, Iran between February and May 2017. Anxiety and marital satisfaction were measured by the anxiety subscale of the Hospital Anxiety and Depression Scale and 10-Item ENRICH Marital Satisfaction Scale, respectively. We apply and compare tree different dyadic models to explore the effect of anxiety on marital satisfaction, including the Actor-Partner Interdependence Model (APIM), Mutual Influence Model (MIM), and Common Fate Model (CFM).

RESULTS

This study demonstrated a practical application of the dyadic models. These dyadic models provide results that appear to give different interpretations of the data. The APIM analysis revealed that both men's and women's anxiety excreted an actor effect on their own marital satisfaction. In addition, women's anxiety exerted a significant partner effect on their husbands' marital satisfaction. In MIM analysis, in addition to significant actor effects of anxiety on marital satisfaction, women's reports of marital satisfaction significantly predicted men's marital satisfaction. The CFM analysis revealed that higher couple anxiety scores predicted lower couple marital satisfaction scores.

CONCLUSION

In sum, the study highlights the usefulness of DDA to explore and test the phenomena with inherently dyadic nature. With regard to our empirical data, the findings confirmed that marital satisfaction was influenced by anxiety in infertile couples at both individual and dyadic level; thus, interventions to improve marital satisfaction should include both men and women. In addition, future studies should consider using DDA when dyadic data are available.

Anxiety, depression and probability of live birth in a cohort of women with self-reported infertility in the HUNT 2 Study and Medical Birth Registry of Norway

OBJECTIVE

The 'psychogenic' hypothesis has a long history in the field of infertility. The present study investigated whether anxiety or depressive symptoms are associated with probability of subsequent live birth in a cohort of infertile women from the general population.

METHODS

Using linked data from 12,987 women in the North-Trøndelag Health Study 1995-97 (HUNT 2) and the Medical Birth Registry of Norway (MBRN) a cohort of 467 women with self-reported infertility was followed prospectively in the MBRN for 11 years with regard to live birth. Anxiety and depressive symptoms were measured at baseline in HUNT 2 by the Hospital Anxiety and Depression Scale (HADS), i.e. the Anxiety (HADS-A) and Depression (HADS-D) sub-scales. The relationship between anxiety or depressive symptoms and live birth in the MBRN was analysed using Cox proportional hazards regression analysis.

RESULTS

Anxiety and depressive symptoms were not associated with live birth rates. For anxiety symptoms, the crude hazard ratios (HR) for live birth was 1.004 (95% confidence interval (CI) = 0.96; 1.05); adjusted HR = 0.99 (95% CI = 0.94; 1.04), for depressive symptoms crude HR was 0.98 (95% CI = 0.92; 1.04); adjusted HR = 1.01 (95% CI = 0.94; 1.08). Among the 104 women with HADS-A ≥ 8 and/or HADS-D ≥ 8, 34 (32.7%) were registered with live birth in MBRN during the period of observation. However, 100 (27.6%) of the 363 women with both HADS-A ≤ 7 and HADS-D ≤ 7 were registered with live birth.

CONCLUSION

Anxiety and depressive symptoms are not associated with probability of live birth in women with self-reported infertility in the general population.

The relationship between marital satisfaction and depression in infertile couples: an actor-partner interdependence model approach

BACKGROUND

Much evidence consistent with the Marital Discord Model of Depression (MDMD) suggests that marital discord is associated with depression, but no studies examine the relationship between marital satisfaction and depression at the dyadic level in infertile couples. This study examined the effect of actors' and partners' marital satisfaction on depressive symptoms in husband-wife dyads with infertility using an innovative dyadic analysis approach, the Actor-Partner Interdependence Model (APIM).

METHODS

In this cross-sectional study, the sample comprised of 141 infertile couples in the evaluation phase of treatment. We collected data in a referral infertility center in Tehran, Iran between February and May 2017. Marital satisfaction and depression were measured using ENRICH marital satisfaction scale and Hospital Anxiety and Depression Scale, respectively, before starting the treatment. Dyadic analysis applying the APIM was used. In this study, actor effect is the impact of a person's marital satisfaction on his/her own depression. Partner effect is the impact of a person's marital satisfaction on his/her partner's depression.

RESULTS

The APIM analysis revealed that both men and women's marital satisfaction excreted an actor effect on their own depression (β = - 0.412, P < 0.001; β = - 0.263, P = 0.002, respectively). Furthermore, men's marital satisfaction exerted a significant partner effect on their wives' depression symptoms (β = - 0.170, p = 0.047). However, the wives' marital satisfaction was not related to their husbands' depressive symptoms (β = - 0.028, P = 0.735).

CONCLUSIONS

The findings support that the MDMD is a valid theoretical model for the conceptualization of marital satisfaction and depressive symptoms among infertile couples and suggest that interventions to reduce depressive symptoms should include both men and women.