Psychological symptoms, particularly those of anxiety and depression, are highly prevalent in individuals with chronic respiratory disease and associated with increased symptom burden, reduced exercise tolerance, poorer health-related quality of life and suboptimal engagement with pulmonary rehabilitation (PR). Routine assessment of anxiety- and depression-related symptoms within PR, enables identification of clinically significant psychological distress, facilitates appropriate referral or integration of psychological support, and allows evaluation of the impact of PR on mental health outcomes. A range of validated instruments have been used in PR populations, including disease-specific, symptom-focused and generic measures. These tools vary in length, sensitivity to change and conceptual focus (e.g., state vs. trait anxiety; affective vs. somatic symptoms). Importantly, these measures quantify symptom severity or psychological distress and do not, in themselves, yield a diagnosis of an anxiety disorder or depressive disorder. For this reason, most are referred to as “screening” instruments rather than diagnostic tools. Selection of an instrument should consider the clinical or research objective, feasibility within PR programs and the extent to which psychological symptoms overlap with respiratory symptoms such as dyspnea and fatigue.
The following outcome measures on anxiety and depression are described:
- Anxiety Inventory for Respiratory Disease
- Beck Anxiety Inventory
- Breathlessness Belief Questionnaire
- Breathlessness Catastrophizing Scale
- COPD Anxiety Questionnaire-revised
- Depression Anxiety Stress Scale-21
- General Anxiety Disorder Questionnaire
- Hamilton Anxiety Rating Scale/Hamilton Depression Rating Scale
- Hospital Anxiety Depression Scale
- Patient Health Questionnaire-9
- Self-Rating Anxiety Scale
- State Trait Anxiety Inventory
We thank the following who collated this material (ordered alphabetically): Dr Amy Baradell (University of Leicester, Leicester, United Kingdom), Dr Lisa Jane Brighton (King’s College London, London, United Kingdom), Professor Jean-Marie Bruzzese (Columbia University, New York, US), Ms Camilla Fischer Christiansen (University of Southern Denmark, Odense, Denmark), Dr Ingeborg Farver-Vestergaard (University of Southern Denmark, Odense, Denmark), Ms Suzanne Lareau (University of Colorado, Denver, US), Dr Liz Steed (Queen Mary University of London, London, United Kingdom), Professor Clarice Tang (Victory University, Melbourne, Australia), Dr Eleonora Volpato (Università Cattolica del Sacro Cuore, Milan, Italy) and Professor Abebaw Yohannes (University of Alabama, Birmingham, US).
Anxiety Inventory for Respiratory Disease
| Description | |
| Name of Questionnaire | Anxiety Inventory for Respiratory Disease (AIR) scale1 |
| Abbreviation/Alternate Name | AIR scale |
| Description: | A measure for screening for non-somatic aspects of anxiety in patients with COPDs. |
| Developers | TG Willgoss, |
| amyohnn@uab.edu OR yohannesam25@gmail.com | |
| Cost | Please contact authors/developers for permission to use the questionnaire. |
| License required | AIR © Thomas Willgoss and Manchester Metropolitan University, 2013. All rights reserved. |
| Self-or rater-administered | Self-administered |
| Time to complete | 3 minutes |
| Number of items | 10 |
| Domains & categories (#) | 1 |
| Name of domains/categories | Anxiety |
| Scaling of items | 0 to 3 |
| Scoring | 0-30, higher scores indicate higher levels of anxiety. > 8 indicates a ‘case’ for symptoms of anxiety.3 |
| Test-retest/ reproducibility | · Test-retest: ICC = 0.811 ; ICC = 0.604 · Internal consistency Cronbach’s α = 0.92.1 |
| Validity | Content1,2,3 Concurrent / divergent
|
| Responsiveness to PR | Yes4 |
| MID | 55 |
| Languages | English, Chinese6, Portuguese7 , Hindi8 , Arabic9 |
| References |
9. Albarrati A et al. Disabil Rehabil 2022; 44: 7297-7303. |
| Date information on this outcome was updated | July, 2026 |
| Description | |
| Name of Questionnaire | Beck Anxiety Inventory |
| Abbreviation/Alternate Name | BAI |
| Description: | Most appropriate as a screening tool for anxiety rather than a diagnostic instrument. 1,2 |
| Developer | Beck A et al. 1988 |
| Not available | |
| Cost | From £114.50 |
| License required | "Beck Anxiety Inventory," and "BAI" are registered trademark(s) in the U.S. and/or other countries, of Pearson Education, Inc., or its affiliate(s). |
| License can be obtained here: https://www.pearsonclinical.co.uk/en-gb/Store/Professional-Assessments/Personality-%26-Biopsychosocial/Brief/Beck-Anxiety-Inventory/p/P100009033 | |
| Self-or rater-administered | Self-administered or interviewer |
| Time to complete | 5-10 minutes |
| Number of items | 21 |
| Domains & categories (#) | 1 |
| Name of domains/ categories | Anxiety symptoms including both subjective and somatic dimensions. 1,2 |
| Scaling of items | 0-3 |
| Scoring | Score Total Score = 63 (high scores correspond to severe anxiety) 1 |
| Cutoff score BAI > 16 Probable clinically relevant anxiety symptoms 1,2 | |
| Test-retest/ reproducibility | Internal consistency α = ICC=0.92 1 |
| Test-retest reliability (1 week) = 0.75 1 | |
| Validity | Content 1 |
| Convergent 1,3 | |
| Concurrent. 4,5 Moderately correlated with the revised Hamilton Anxiety Rating Scale (0.51) and mildly correlated with the Hamilton Depression Rating Scale (0.25). 2 | |
| Discriminant 4 | |
| Responsiveness to PR | In a couple of studies of the effect of PR on anxiety symptoms measured with BAI, the decrease was not significant. 6,7 Other studies, however, found significant effects of PR on the BAI both at short 8,9 and long term (24 months’ follow up) 8 |
| MID | No established minimal important difference has been consistently defined for the BAI |
| Languages | Translated into 20 or more languages |
| References | 1. Beck, A.T et al. Journal of Consulting and Clinical Psychology. 1998, 56,893-897. |
| 2. Osman, A., et al. Journal of Psychopathology and Behavioral Assessment, 1993 ; 15 (4), 287–297. | |
| 3. Dozois DJ, et al. Psychol Assess 1998;10:83 | |
| 4. Phan T, et al. J Psychom R 2019;120:60-65. | |
| 5. Phan T, et al. Chron Respir Disease 2016;13:220-228. | |
| 6. Pirraglia P A et al. J Psychosom Res. 2011; 71: 45-49 | |
| 7. De Souza, R M et al. Int J Sports Exercise Med. 2017; 3: 061. | |
| 8. De Godoy, R F et al.. J Bras Pneumol. 2009; 35. | |
| 9. Tavares, C M R et al. EC Psychology and Psychiatry 2020; 9: 53-60. | |
| Date information on this outcome was updated | May, 2026 |
Breathlessness Beliefs Questionnaire
| Description | |
| Name of Questionnaire | Breathlessness Beliefs Questionnaire 1 |
| Abbreviation/Alternate Name | BBQ |
| Description: | Evaluates breathlessness beliefs and dyspnoea-related anxiety. |
| Developer | Giardino ND et al. 2004 (original) 1 |
| steven.depeuter@psy.kuleuven.be | |
| Modifications | Reduction from 17 items 1 to 11 items 2 |
| Cost | Free |
| License required | No |
| Self-or rater-administered | Self-reported |
| Time to complete (minutes) | 7-May |
| Number of items | 11 |
| Domains & categories | 2 domains |
| Name of domains/categories | Somatic Focus (BBQ-SF); Activity Avoidance (BBQ-AA). |
| Scaling of items | 5-point 1 (“strongly disagree”) -5 (“strongly agree”) Likert scale. |
| Scoring | The 11-item version has 2 total scores for Somatic Focus (BBQ-SF, 5 items) and Activity Avoidance (BBQ-AA, 6 items). Higher scores suggest increased perceived level of breathlessness (and a signal to engage in avoidance activities such as exercising). |
| Test-retest/reproducibility | Test-retest |
| over 2-weeks: r = 0.80 3 | |
| ICC 0.96-0.98 4 and 0.97-0.98 5 | |
| BBQ-SSc over 1 week, ICC 0.83, 95% CI:0.702-0.907 2 | |
| Internal consistency : | |
| α = 0.85, 3 0.82, 5 0.78 5 | |
| BBQ-SSc, α = 0.86 2 | |
| Validity | BBQ 2 significant associations with functional status, emotional distress, and health-related quality of life, supporting its construct and convergent validity. |
| Correlation with HADS r=0.39 5 | |
| Responsiveness to PR | Reduction in scores post PR, particularly on BBQ-AA 6 |
| MID | Not available. |
| Languages | Translated into English, Dutch, Chinese and Turkish. |
| References | 1. Giardino ND et al. Society for Behavioral Med Annual Meeting, Baltimore, MD 2004. |
| 2. De Peuter S et al. Chron Respir Dis. 2001; 8:11-19. | |
| 3. Janssens T et al. Chest. 2011; 140:618–625. | |
| 4. Wu Q et al. Chron Respir Dis. 2018; 15:114-122. | |
| 5. Gurses HN et al. Physiother Theory Pract. 2023; 39:834-839. | |
| 6. Janssens T et al. Chest. 2011; 140: 618–625. | |
| Date information on this outcome was updated | July, 2026 |
Breathlessness Catastrophizing Scale
| Description | |
| Name of Questionnaire | Breathlessness catastrophizing Scale 1 |
| Abbreviation/Alternate Name | BCS |
| Description: | Adapted from the Pain Catastrophizing Scale, scale measures maladaptive catastrophic thoughts related to breathlessness, reflecting cognitive-emotional responses that are associated with anxiety, fear, distress and avoidance behaviours. |
| Developer | BK Soloman et al. |
| brahm.solomon@gmail.com | |
| Cost | Free |
| License required | N/A |
| Self-or rater-administered | Self-administered |
| Time to complete | 5-10 minutes 1 |
| Number of items | 13 |
| Domains & categories (#) | NA |
| Name of domains/ categories | NA |
| Scaling of items | 5-point scale 0=not at all, 4= all the time. |
| Scoring | Total=sum of 13 items. Range from 0-52 (52 more severe). |
| Test-retest/ reproducibility | Internal consistency Cronbach’s α 0.96 2 |
| Validity | Content validity demonstrated with item-level ICC values >0.69 2 |
| Evidence of convergent validity through significant associations with anxiety sensitivity, depressive symptoms (Beck Depression Inventory), and COPD self-efficacy 2 | |
| Lack of association with physical performance measures (e.g. 6MWT, non-stop walk test and stair climbing tests) 2 | |
| Responsiveness to PR | Significant reductions in BCS scores following pulmonary rehabilitation have been reported (mean change −6.14; p<0.01) 1 |
| Improvements in breathlessness catastrophizing occurred alongside improvements in depressive symptoms (BDI-II, PHQ-9), self-efficacy, and exercise capacity 1 | |
| MID | NA |
| Languages | English |
| References | 1. Ong WJ et al. Clin Rheumatol. 2021; 40:295-301. |
| 2. Solomon BK et al. J Psychosom Res. 2015; 79:62-68. | |
| Date information on this outcome was updated | July, 2026 |
COPD Anxiety Questionnaire -Revised
| Description | |||
| Name of Questionnaire/Instrument | COPD Anxiety Questionnaire - Revised 1 | ||
| Abbreviation/Alternate Name | CAF-R | ||
| Description: | A 20 item questionnaire to assess disease-related anxiety in COPD. | ||
| Developer | Keil 1 building on original CAF 2 | ||
| daniel.keil@uni-marburg.de | |||
| Cost | No cost 2 | ||
| License required | Please contact authors / developers for permission to use the questionnaire. | ||
| Self-or rater-administered | Self administered | ||
| Time to complete (minutes) | 5-10 minutes | ||
| Number of items | 20 items | ||
| Domains & categories | 5 domains | ||
| Name of domains/categories | Fear of social isolation, Fear of dyspnea, Fear of physical activity, Fear of progression, Sleep-related worries. | ||
| Materials/equipment needed* | Can be paper or computer administered | ||
| Scaling of items | 5-point Likert scale (0-4 – never to always) | ||
| Scoring | Scores are totalled and range from 0 (low anxiety) -80 (high anxiety). | ||
| Modifications | Superseded versions: CAF 2 , | ||
| Changes included: reduction from 27 to 20 items, Original CAF published in German but not data on responsiveness in PR | |||
| Test-retest/reproducibility | Moderate to high reliability (Cronbach’s α ranging from 0.78 to 0.87). 1 | ||
| Validity | Construct: | ||
| Item-total correlations for the scales were assessed and ranged from 0.47 (FPA) to 0.82 (FP), showing adequate selectivity. 1 | |||
| Convergent / divergent validity: | |||
| Moderate to high correlations to disease-related fears ( r = 0.31–0.61). 1 | |||
| Correlations with discriminant constructs were generally lower ( r = −0.15 to 0.34). An exception was a higher correlation between PHQ-15 and sleep-related worries ( r = 0.47). 1 | |||
| Responsiveness to PR | Responsive to change in PR (Cohen’s d= 0.32) 3,4 | ||
| MID | MID not yet reported 3 | ||
| Languages | The CAF-R has been translated into Danish, 5 Chinese 6 (25 items, 6 factor solution) and Brazilian 7 | ||
| References | 1. Keil DC et al. Chronic Respiratory Disease. 2014;11(1):31-40. doi:10.1177/1479972313516881 | ||
| 2. Kuhl, K et al. Psychother.Pschosom. Med. Psychol. 2011; 61. | |||
| 3. Farver-Vestergaard I et al, Front Rehabil Sci. 2024 Aug 7;5:1428893. | |||
| 4. Farver-Vestergaard I et al Front. Psychol. 2022. 13:907939. | |||
| 5. Miao, X et al. International Journal of COPD. 2024;19:1047-1060. | |||
| Date information on this outcome was updated | July, 2026 |
Depression Anxiety Stress Scale-21
| Description | |
| Name of Questionnaire | Depression Anxiety Stress Scale 1 |
| Abbreviation/Alternate Name | DASS-42, DASS-21© |
| Description: | Measure of depression, anxiety and stress both in general population, and respiratory diseases. Not intended to be used as a diagnostic instrument. 2 |
| Modifications | Original 42 items, 1 reduced to 21 items (most commonly in use) |
| Developer | Lovibond SH and Lovibond PF 1 |
| https://www2.psy.unsw.edu.au/groups/dass/ | |
| Cost | Manual $55.00 USD. “…scales may not be modified or sold for profit.” |
| License required | Copyrighted DASS-21© Lovibond SH and Lovibond PF. |
| Self-or rater-administered | Self-administered |
| Time to complete (mins) | 10-May |
| Number of items | 21 (7 items in each domain) |
| Domains & categories (#) | 3-Depression, Anxiety, and Stress |
| Name of domains/categories | Depressive symptoms (DASS-D), anxiety symptoms (DASS-A) and stress symptoms (DASS-S) |
| Scaling of items | 4-point Likert Scale from 0-3 (does not apply to them to does apply). Higher scores reflect more symptomatology. |
| Scoring | 0-21 per subscale (scores multiplied by two making them comparable to the original DASS-42 scoring system) 1 . Range 0-126. |
| Clinically relevant levels in COPD 3 | |
| ≥9 DASS-D | |
| >7 DASS-A | |
| >14 DASS-S | |
| Test-retest/reproducibility | ICC=0.94 1 |
| Internal consistencies α=0.91 for depression, 0.80 anxiety, 0.84 stress. 1 | |
| Validity | Content, 1 Convergent, 4,5 Divergent, 1,4 |
| Responsiveness to PR | DASS-S 3,6 |
| MID | 3.6 on DASS-A 6 |
| 5.4 on DASS-D score of >9 at baseline 6 | |
| Languages | Translated into several languages |
| References | 1. Lovibond SH and Lovibond PF (1995). Manual for the Depression Anxiety Stress Scales. Sydney, Psychology Foundation. |
| 2. Osman A et al. J of Clin Psych. 2012; 68: 1322-1338. | |
| 3. Yohannes AM et al. Respir Med. 2022; 197:106850. | |
| 4. Norton PJ. Anxiety Stress and Coping. 2007; 20:253-265. | |
| 5. Sinclair SJ et al. Eval Health Prof. 2012; 35:259-279. | |
| 6. Yohannes AM et al. Chest. 2019; 155:1166-1177. | |
| Date information on this outcome was updated | February, 2026 |
General Anxiety Disorder Questionnaire
| Description | |
| Name of Questionnaire/Instrument | General Anxiety Disorder-7 1 |
| Abbreviation/Alternate Name | GAD-7 |
| Description: | Screening tool for generalized anxiety disorder (GAD) and assesses severity of symptoms 1 |
| Developer | Spitzer RL et al 1 |
| RLS8@Columbia.edu or obtain copy at https://www.phqscreeners.com/select-screener | |
| Cost | None |
| License required | No |
| Self-or rater-administered | Self administered |
| Time to complete (minutes) | 3 |
| Number of items | 7 |
| Domains & categories | 1 |
| Name of domains/categories | Anxiety |
| Materials/equipment needed* | Paper or computer administered |
| Scaling of items | 0-3 (0=not at all to 3=nearly every day) |
| Scoring | Total Score = 0-21 (higher scores, more severe anxiety symptoms) |
| ≥ 10= probable case of GAD 1 | |
| Grading of symptom level 1 | |
| >5= no anxiety | |
| 5-9= mild | |
| 10-14= moderate | |
| 15-21= severe | |
| Test-retest/reproducibility | ICC=0.83, Internal consistency α= 0.92 1 |
| COPD ICC=0.70, Internal consistency α=0.89 2 | |
| Validity | Content, 1,2 Convergent, 1,2 Concurrent 1,2 |
| Responsiveness to PR | Yes 3,4,5 |
| MID | COPD 2 points 2 |
| Languages | Translated into several langauges |
| References | 1. Spitzer RL et al. JAMA Intern Med. 2006; 166:1092-1097. |
| 2. Baker A et al. Ann Am Thorac Soc. 2018; 15: 926-934. | |
| 3. Reijnders T et al. RespirMed. 2019;146:87-95. | |
| 4. Shi XY et al. Medicine. 2024; 103: e37778. | |
| 5. Alsubheen S et al. Can J Respir Crit Care Sleep Med. 2024; 8:245-253. | |
| Date information on this outcome was updated | February, 2026 |
| Description | |
| Name of Questionnaire | Hamilton Anxiety Rating Scale 1 |
| Abbreviation/Alternate Name | HAM-A, HARS-A |
| Description: | Assesses severity of anxiety symptoms in individuals who have already been diagnosed with an anxiety disorder. 1 |
| Developer | Max Hamilton, MD (1959) |
| Not available | |
| Cost | May involve fees depending on distributor and language version. |
| License required | Copyrighted managed by Mapi Research Trust. https://eprovide.mapi-trust.org/instruments/hamilton-anxiety-scale |
| Self-or rater-administered | Clinician-rated: Administrator must be experienced in clinical psychopathology. |
| Time to complete (minutes) | 10-15 minutes |
| Number of items | 14 |
| Domains & categories | 3 |
| Name of domains/categories | · Global |
| · Psychic anxiety (mental agitation and psychological distress) | |
| · Somatic anxiety (physical complaints related to anxiety) | |
| Scaling of items | 5 point Likert scale (0-4) from no symptoms (0) to very severe (4). 2 |
| Scoring | Total score = 0 to 56, higher scores indicating worse severity. |
| Clinical cut-off for grading of symptom severity have been reported. 3 | |
| Mild severity: <17 | |
| Mild to moderate severity: 18-24 | |
| Moderate to severe: 25-30 | |
| Test-retest/reproducibility | Internal Consistency: those with and without generalized anxiety disorder: 0.85 4 |
| Inter-rater reliability | |
| - 0.74-0.96 2 | |
| - Patients with/without generalized anxiety disorder: 0.86 (ICC) 4 | |
| Test-retest: Patients with/without generalized anxiety disorder: 0.98 (ICC) 4 | |
| Validity | Construct validity (Concurrent validity) |
| - Correlated to Covi Anxiety Scale (r=0.63) 5 | |
| - Correlated to Beck’s Anxiety Inventory (r=0.53) 4 | |
| Sensitivity to change | |
| - PR patients with COPD had decreased HAM-A scores following 2 months of PR compared to no PR. 6 | |
| Responsiveness to PR | Decreased HAM-A scores following 2 months of treatment compared to controls (<.05) . 6 |
| MID | Not available. |
| Languages | 14 languages. |
| References | 1. Hamilton M. Br J Med Psychol 1959; 32:50–55. |
| 2. Bruss GS et al. Psychiatry Research 1994; 53:191-202. | |
| 3. Thompson E. Occupational Med 2015; 65:601. | |
| 4. Shear MK et al. Depression & Anxiety 2001;13:166-178. | |
| 5. Maier W, et al. J Affect Disord 1988; 14:61–68. | |
| 6. Kayahan B. Respir Med 2006; 100:1050-1057. | |
| Date information on this outcome was updated | July, 2026 |
Hamilton Depression Rating Scale
| Description | |
| Name of Questionnaire/Instrument | Hamilton Depression Rating Scale 1 |
| Abbreviation/Alternate Name | HAM-D or HDRS |
| Description: | Assesses the severity of depressive symptoms based on the patient's clinical status at the time of assessment. 1, 2, 3 |
| Developer | Max Hamilton |
| Not available. | |
| Cost | None |
| License required | No |
| Modifications | Several versions are available 4 , ranging from 6 to 29 items. The 17-item version (HAM-D-17/HDRS-17) is the most widely used. |
| Self-or rater-administered | Clinician administered; interviewer training is recommended. |
| Time to complete (minutes) | 15-20 |
| Number of items | 6-29 (depending on the version administered) 4, 5 : |
| Domains & categories | 1 |
| Name of domains/categories | Depression |
| Scaling of items | 9 items are scored on a 0–4 scale; the remaining 8 items are scored on a 0–2 scale. |
| Scoring | HAM-D-17 (most commonly used) total score ranges 0-52. |
| Total scores are summed and commonly interpreted according to severity thresholds: 5 | |
| 0-7= No depression. | |
| 8-16= Mild | |
| 17-23= Moderate | |
| ≥24=Severe | |
| Test-retest/reproducibility | Inter-rater reliability= 0.88-0.98, ICC=0.94. 2 |
| Validity | Psychometric analyses suggest that the 6-item Hamilton Depression subscale (HAM-D6) demonstrated good internal validity, while psychometric analyses suggested that the full 17-item scale was less internally consistent in patients with COPD. 6 |
| Responsiveness to PR | Clinically significant alleviation of depression in patients with COPD in some studies 7, 8 while another study did not find a significant effect on measure post PR. |
| MID | 3–5 points 8 |
| Languages | Multiple languages including French, German, Italian, Thai, and Turkish. |
| References | 1. Hamilton M. J Neurol Neurosurg Psychiat. 1960; 23:56-62. |
| 2. Bech P et al. Acta Psychiatr Scand. 1975; 51:161-170. | |
| 3. Bech P et al., Acta Psychiatrica Scandinavica (1981). | |
| 4. Carrozzino D et al., Psychother Psychosom. 2020; 89:133-150 | |
| 5. Zimmerman M et al. J Affective Dis. 2013; 150:384-388. | |
| 6. Stage KB et al. Nord J Psychiatry. 2003; 57:297-301. | |
| 7. Kayahan B et al. Respir Med. 2006; 100:1050-7. | |
| 8. Hengartner, M. P., & Plöderl, M. BMJ Evidence-Based Medicine. 2022; 27 (2), 69-73. | |
| Date information on this outcome was updated | July, 2026 |
Hospital Anxiety Depression Scale
| Description | |
| Name of Questionnaire | Hospital Anxiety Depression Scale 1 |
| Abbreviation/Alternate Name | HADS |
| Description: | Developed to detect probable states of depression (HADS-D) and anxiety (HADS-A) in outpatients. Largely excludes somatic symptoms. Assesses severity of symptoms. |
| Developer | Zigmond AS and Snaith RP |
| Not available | |
| Cost | User fee required. Cost depends on context of use. https://eprovide.mapi-trust.org/instruments/hospital-anxiety-and-depression-scale |
| License required | UK contact: permissions@gl-assessment.co.uk; other countries: https://eprovide.mapi-trust.org. |
| Self-or rater-administered | Self-administered |
| Time to complete (minutes) | 5 |
| Number of items | 14 |
| Domains & categories (#) | 2 |
| Name of domains/categories | Anxiety and depression |
| Scaling of items | Four-point Likert scale (0-3) |
| Scoring | 7 items each HADS-A & HADS-D. Scores range from 0-21. |
| HADS-D ≥8 elevated depressive symptoms | |
| HADS-A ≥8 elevated anxiety symptoms | |
| Test-retest/ reproducibility | General population ICC=0.81 1 |
| In COPD ICC (meta-analysis) =0.86-0.90 2 | |
| Validity | Content 1 |
| General population internal consistency α=0. 91; 1 | |
| COPD (meta-analysis) α=0.73-0.87 2 | |
| Convergent, 2 Concurrent 1,2 | |
| Responsiveness to PR | Yes 3-6 |
| MID | In COPD 1.5 7 |
| Languages | Available in several languages |
| References | 1. Zigmond AS et al. Acta Psychiatr Scand . 1983; 67:361-170. |
| 2. Nikolovski A et al. Disab Rehabil. 2024; 46:1230-1238. | |
| 3. von Leupoldt A et al. Chest. 2011; 140:730-736. | |
| 4. Wynne SC et al. Chronic Respir Dis. 2020; 7:1-9. | |
| 5. Smid et al. J Am Med Dir Assoc. 2017; 18:53-58. | |
| 6. Harrison SL et al. Res Med.2012;838-844 | |
| 7. Puhan MA et al. Health Qual Life Outcomes. 2008; 6:46. | |
| Date information on this outcome was updated | July, 2026 |
Patient Health Questionnaire-9
| Description | |
| Name of Questionnaire | Patient Health Questionnaire-9 1 |
| Abbreviation/Alternate Name | PHQ-9 |
| Description: | Screens for probable depression (based on the DSM-IV criteria) and monitoring of symptom severity over time. 1 |
| Developers | Kroenke K et al. |
| Not available | |
| Cost | No |
| License required | PHQ-9 © 1999 Pfizer inc. www.phqscreeners.com |
| Self-or rater-administered | Self- or interviewer-administered |
| Time to complete (mins) | 5 |
| Number of items | 9 |
| Domains & categories (#) | 1 |
| Name of domains/ categories | Depressive symptoms |
| Scaling of items | Likert scale 0-3 over the last two weeks. |
| Scoring | Total Score =0-27 (high scores more severe depressive symptoms) |
| > 10 clinically relevant depressive symptoms 1,2 | |
| Symptom severity: 2 | |
| 0-4= none | |
| 5-9= mild | |
| 10-14= moderate | |
| 15-19= moderately severe | |
| ≥20= severe | |
| COPD ≥7 3 | |
| Test-retest/ reproducibility | ICC=0.94 1 |
| Validity | Content |
| General: internal consistency α=0.91 1 | |
| COPD: internal consistency α=0.75 4 | |
| Convergent, 4 Concurrent 4,5,6 | |
| Responsiveness to PR | Yes 2,7,8 |
| MID | 5 points in PR 3 |
| Languages | Available in numerous languages |
| References | 1. Kroenke K et al. J Gen Intern Med. 2001; 16:606-13. |
| 2. Kroenke K et al. Psychiatr Ann. 2013; 32:509-515. | |
| 3. Ubhi et al. BMC Pulm Med. 2025; 25:249. | |
| 4. Drawl KR et al. TeleMed J E Health. 2024; 30:2456-2465. | |
| 5. Liu M et al. J COPD. 2023; 20:144-152. | |
| 6. Liu et al. BMC Psychiatry. 2025; 25: 37. | |
| 7. Reijnders T et al. Respir Med. 2019; 146:87-95. | |
| 8. Schuler M et al. J Affective Disorders. 2018; 232:268-275. | |
| Date information on this outcome was updated | July, 2026 |
| Description | |
| Name of Questionnaire/Instrument | Self-Rating Anxiety Scale 1,2 |
| Abbreviation/Alternate Name | SAS |
| Description: | Developed to measure levels of anxiety in individuals and to screen for the risk of anxiety disorder. |
| Developer | William WK Zung, MD |
| Not available | |
| Cost | https://eprovide.mapi-trust.org/instruments/zung-self-rating-anxiety-scale |
| License required | Can be obtained via eProvide. https://eprovide.mapi-trust.org/instruments/zung-self-rating-anxiety-scale |
| Self-or rater-administered | Self-administered |
| Time to complete (minutes) | 10 |
| Number of items | 20 |
| Domains & categories | 1 |
| Name of domains/categories | Anxiety |
| Scaling of items | 4 point scale (1-4) |
| Scoring | Range 20-80, higher scores indicating worse anxiety 1,2 |
| Cut-off scores of 36 used in clinical screening 2 and scores of 40 used in research 1 | |
| Test-retest/reproducibility | ICC=0.82-0.83 1,2 |
| Validity | Concurrent |
| Relates to TMAS (Taylor Manifest Anxiety Scale) r=0.30. | |
| Those diagnosed with an anxiety disorder on ASI (Anxiety Status Inventory) r=0.74. 1 | |
| Responsiveness to PR | Scores reduced post PR for lung cancer. 3 |
| MID | Not available |
| Languages | Translation into multiple languages: https://eprovide.mapi-trust.org/instruments/zung-self-rating-anxiety-scale |
| References | 1. Zung WWK. Psychosomatics.1971; 12:371–9. |
| 2. Dunstan D et al. BMC Psychiatr. 2020; 20:90. | |
| 3. Wang Q et al. BMC Pulm Med. 2025; 25:315. | |
| Date information on this outcome was updated | July, 2026 |