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PSYCHIATRIKI 21 (4), 2010 HOSPITAL ANXIETY AND DEPRESSION SCALE 283depression or anxiety disorder cases. In the presentstudy the mean scores in the anxiety and depressionsubscales of the general population were 5.5±3.6and 4.0±3.1 respectively, compared to 8.7±4.3 and7.3±3.8 in the internal medicine outpatient group.The overall HADS score was 9.6±5.9 and 16.1±7.4 inthe control and internal medicine outpatient grouprespectively.Overall and subscale HADS scores were significantlyhigher in the psychiatric outpatients (HADS-A13.3±4.6, HADS-D 12.6±5.5, HADS-T 25.9±8.9) whencompared to controls (HADS-A 5.5±3.6, HADS-D4.0±3.1, HADS-T 9.6±5.9). Similar results have beenreported in other studies comparing psychiatric patientsand general population controls. 23,25Finally, psychiatric outpatients scored significantlyhigher in the overall and subscale HADS than theinternal medicine outpatients. This statistically significantdifference between the two groups wasalso confirmed by the Beck Depression Inventoryscore and the STAI-S score. Furthermore, a statisticallysignificant positive correlation was observedbetween BDI and HADS-D, STAI-S and HADS-A in thetwo groups supporting the validity of HADS and itssubscales in the internal medicine and psychiatricoutpatients. Similar correlations between the aforementionedscales have also been observed in otherstudies. 26,38,39Statistically significant differences are also notedamong the different diagnostic groups of psychiatricpatients. The overall HADS score, as well as the BDIscore were gradually increasing in patients with adiagnosis of adjustment disorder with mixed anxietyand depressed mood, dysthymic disorder and majordepression. HADS cut-off scores are markedly higherin major depression compared to adjustment disorderwith depressive and anxiety manifestations bothin the psychiatric and the general medical population.21,40–42In the present study given that the anxiety HADSsubscale score is marginally (significantly) differentamong all 3 diagnostic categories of psychiatric patients,the difference observed in the overall HADSscore is attributed to the depression HADS subscalescore, which like the BDI tends to be higher dependingon the severity of the depressive disorder diagnosis.Similarly, in other studies, when a clinical diagnosisof depression is established, HADS appears to be capableof detecting depressive and anxiety disordersand differentiating between anxiety and depressionsymptoms. 43,44It is commonly accepted that HADS is reliable indiscriminating anxiety and depression symptomsand cases of anxiety and depressive disorders in nonpsychiatric hospitalized patients. However, it seemsthat it may also be capable of identifying anxietyand depressive symptoms between psychiatric outpatients,internal medicine outpatients and subjectsin the general population. In addition, the HADS depressionsubscale differentiates the main depressivedisorders like adjustment disorder, dysthymic disorderand major depression.The main factor limiting the generalization of theresults of the present study is the relatively small patientsample.