Scientists Validate a Standard Test for Depression and Anxiety Before Breast Reduction Surgery

For thousands of women each year, breast reduction surgery is not simply a cosmetic decision. Many patients with breast hypertrophy, or macromastia, live with chronic pain, posture problems and a psychological burden that can include symptoms of depression and anxiety. Surgeons and health systems have long recognised that these emotional symptoms matter, both when deciding who qualifies for surgery and when judging whether an operation truly helped. Yet a persistent problem has undermined the field: the questionnaires used to measure depression and anxiety in these patients were never actually validated for them. A new study from Sahlgrenska University Hospital in Sweden, published in BMC Plastic and Reconstructive Surgery, set out to close that gap by rigorously testing one of the most widely used mental health questionnaires in medicine, the Hospital Anxiety and Depression Scale, known as HADS.

The research team, led by Emma Hansson with Catrin Wessman and Anna Paganini, recruited 276 women who were referred for breast reduction within Sweden’s publicly financed health care system. All participants met the Swedish national guidelines for the procedure, which specify criteria such as a body mass index under 30 and a minimum breast volume of more than 800 millilitres per breast, adjusted upward for higher BMI ranges. Each woman completed the HADS questionnaire before surgery, and a subset of 52 patients filled it in a second time two weeks later to test how stable the scores were over time. Another 52 patients completed the questionnaire again twelve months after their operation, allowing the researchers to see whether the instrument could detect the change in psychological symptoms that surgery is expected to produce.

The choice of HADS was deliberate and scientifically motivated. Many familiar depression measures, including the Beck Depression Inventory and the Hamilton rating scales, were originally developed for psychiatric populations. Women seeking breast reduction, by contrast, typically do not have primary psychiatric disorders; their distress is linked to a somatic condition. HADS was designed precisely for medically ill patients. Its fourteen items, split evenly between an anxiety subscale and a depression subscale, deliberately exclude symptoms that could be confused with physical illness, such as fatigue and dizziness, and it omits items on suicidal ideation. Each item is scored on a four-point scale, giving subscale scores from 0 to 21, where 0 to 7 suggests no significant symptoms, 8 to 10 indicates possible cases, and above 10 suggests probable cases. Despite its validation for breast cancer reconstruction, HADS had never been validated for benign breast conditions such as macromastia, a distinction the authors argued warrants separate testing.

The technical heart of the study was a battery of psychometric analyses reported according to the COSMIN checklist, an international standard for studies of patient-reported outcome measures. Confirmatory factor analysis was used to test whether the questionnaire’s underlying structure held up in this specific population. The researchers compared the classic two-factor model, with separate anxiety and depression factors, against a three-factor model that adds a dimension of negative affectivity, reflecting the theoretical overlap between anxiety and depression. Both models showed satisfactory or near-acceptable fit across standard indices, including the comparative fit index, the nonnormal fit index, the root mean square error of approximation and the standardised root mean squared residual. All factor loadings were statistically significant and above 0.30. Because both structures fit comparably well, the team judged the models using the Akaike information criterion and, weighing clinical usefulness and comparability with prior research, proceeded with the original two-factor structure.

The reliability results were reassuring. Internal consistency, measured by Cronbach’s alpha, came out at 0.85 for the anxiety subscale and 0.87 for the depression subscale, comfortably within the accepted range of 0.70 to 0.95 and short of the level that would suggest redundant items. Every item correlated sufficiently with the total score of its subscale, with corrected item-total correlations ranging from 0.45 to 0.73, all above the recommended threshold of 0.3. Inter-item correlations fell between 0.2 and 0.8 for both subscales, indicating that the questions hang together without duplicating one another. In plain terms, the questionnaire measures what it claims to measure consistently, without wasted or contradictory questions.

Stability over time, known as test-retest reliability, was assessed in the 52 women who repeated the questionnaire after two weeks. The intraclass correlation coefficient was 0.81 for anxiety and 0.75 for depression, values classified as good reliability under widely used benchmarks. Bland-Altman plots showed mean differences between the two time points close to zero, and the limits of agreement stayed within the seven-point margin the researchers had prespecified, corresponding to the clinical cut-off between non-cases and probable cases. This matters because a screening tool that gives wildly different answers on consecutive occasions cannot be trusted to guide individual treatment decisions.

Construct validity was tested by comparing HADS against instruments that should, in theory, produce related results. The depression subscale correlated strongly with the Beck Depression Inventory and the anxiety subscale correlated strongly with the Beck Anxiety Inventory, both at a Spearman coefficient of about 0.7, exactly matching the researchers’ pre-registered hypotheses. The team also compared HADS with the psychosocial well-being domain of the BREAST-Q, the most widely used quality-of-life instrument in breast surgery, which asks about feelings such as self-confidence and happiness with one’s body. Here the correlation was moderate and negative, around minus 0.5, meaning that higher breast-related psychosocial well-being goes hand in hand with fewer symptoms of anxiety and depression. Importantly, the authors note, this moderate relationship shows that the two instruments capture related but distinct constructs, supporting the case for measuring depression and anxiety separately rather than assuming a breast-specific quality-of-life questionnaire covers them adequately.

The questionnaire also proved responsive, meaning it could detect real change over time. Twelve months after surgery, patients reported significantly fewer symptoms on both subscales, with mean decreases of 1.1 points for anxiety and 1.2 points for depression, each statistically significant. No floor or ceiling effects were observed, so the scale retains its ability to distinguish between patients at both the healthy and severely symptomatic ends of the spectrum. Together, these findings paint a picture of an instrument that is valid, reliable and sensitive enough to serve both halves of the clinical workflow: pre-operative evaluation and post-operative outcome assessment.

The authors are candid about the limits of generalisability. Their sample comprised women treated in the Swedish public system, excluding patients with a BMI over 30, a group that is operated on in some countries, particularly the United States, and one in which obesity and comorbidity are known to influence HADS scores. The post-operative sample was relatively small, and cultural factors can affect questionnaire scores, although the authors argue this matters most when creating norm data rather than when validating an instrument for a specific condition. They also caution that because both the two-factor and three-factor structures fit the data acceptably, and because anxiety and depression symptoms clinically overlap, HADS should be used carefully when attempting to differentiate the two conditions in individual patients.

Even with those caveats, the study delivers something the field has lacked: a validated, reliability-tested standard for measuring depression and anxiety in women with breast hypertrophy undergoing reduction. Because different clinics and countries have historically used a patchwork of unvalidated instruments, comparisons between studies and meta-analyses have been difficult, slowing the accumulation of evidence about the psychological benefits of the surgery. A common, psychometrically sound yardstick changes that. It gives clinicians a defensible tool for documenting the emotional indications for surgery and for demonstrating, with patient-reported data, that the operation relieved psychological as well as physical suffering. For a procedure that has often had to justify itself against perceptions of being cosmetic, that standard may prove as consequential as any surgical technique.

Subject of Research: Validation of the Hospital Anxiety and Depression Scale for assessing depression and anxiety symptoms in women undergoing breast reduction surgery

Article Title: Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS

Article References: Hansson, E., Wessman, C., & Paganini, A. (2025). Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS. BMC Plastic and Reconstructive Surgery, 1(1), Article 2. https://doi.org/10.1186/s44452-025-00001-9

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00001-9

Keywords: breast reduction, breast hypertrophy, HADS, depression, anxiety, patient-reported outcomes, psychometric validation, plastic surgery, macromastia, questionnaire reliability, BREAST-Q, Sweden