Comparison of Reliability and Validity of the Breast Cancer depression anxiety stress scales (DASS- 21) with the Beck Depression Inventory-(BDI-II) and Hospital Anxiety and Depression Scale (HADS)

Background: No study has been conducted to determine the reliability and validity of the Depression, Anxiety and Stress Scale (DASS-21), Hospital Anxiety and Depression [HADS] and Beck Depression Inventory (BDI-II) among the Arab Breast Cancer population. Aim: The aim of this study was to compare the reliability and validity of the Depression, Anxiety, and Stress scale (DASS-21), the Beck Depression Inventory-(BDI-II) and Hospital Anxiety and Depression Scale (HADS) among Breast Cancer women in Qatar. Design: This is an observational cohort hospital based study. Subjects: A list of 1,042 eligible breast cancer patients was prepared, from the disease registry from January 2010 to December 2014 who could be contacted. From the available 1,042 list, 730 breast cancer patients information were available (70.0%) and expressed their consent to participate in the study. Methods: Breast cancer women were screened for depression using DSM-IV criteria, followed by data collection based on 21 items Depression Anxiety Stress Scale (DASS-21), Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory (BDI-II) through interviews by trained nurses. Analyses included comparisons between the classifications of women according to the HADS, BDI-II and DASS-21 with classification of breast cancer depression based on DSM IV (Gold standard). Sensitivity, specificity, area under the curve and kappa coefficients was calculated for each scale. Results: The prevalence of postpartum depression was 20% based on DSM-IV criteria while on the other hand the prevalence was 23% based on DASS-21, 21.8% based on BDI-II and 19.7% based on HADS validated tools. Sensitivity was highest for BDI-II (85%) followed by DASS-21 and HADS (78%) based on standard cut off points of ≥17, ≥10 and ≥13 respectively. On the other hand, specificity was highest for DASS-21 (89%) followed by BDI-II (81%) and HADS (80%). The area under the curve (AUC) was 0.86 (95% CI 0.83-0.89) for DASS-21, 0.84 (95% CI 0.80-0.88) for BDI-II and 0.83 (95% CI 0.80- 0.86) for HADS scales. There was highest agreement between DASS-21 and HADS (Kappa =0.80 p value <0.001), followed by DASS-21 and BDI-II (Kappa 0.75, p value <0.001) and BDI-II and EPDS (Kappa 0.60, p <0.001). Conclusions: DASS-21, BDI-II and HADS have excellent sensitivity, and specificity to quickly screen for breast cancer women. Agreement is highest among DASS-21 and HADS. Overall, DASS-21 performed better as compared to the other tools based on sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The Arab version of the DASS-21 exhibited satisfactory psychometric properties and its use for research and health care practice is warranted. Results indicate and support the cross-cultural validity of the DASS-21 in Arab countries.