Prevalence and Types of Anxiety Disorders in Cardiac Patients With Elevated HADS-A Scores

Clinician-facing synopsis: Parsing the initial screening phase of Heart and Mind in Denmark

The study sought to determine, in a cardiac patient population presenting with anxiety symptoms per a standardized screen, the prevalence of clinically defined anxiety disorders when assessed with a structured psychiatric interview, and to categorize identified disorders by type according to DSM criteria.

The overarching intent is to evaluate how well a commonly used anxiety screen translates into DSM-confirmed anxiety diagnoses among people with arrhythmia, heart failure, or ischaemic heart disease.

The investigators identified adults with primary cardiac conditions—arrhythmia, heart failure, or ischaemic heart disease—through routine screening.

All eligible patients completed the Hospital Anxiety and Depression Scale (HADS).

Those with an anxiety subscale (HADS-A) score of 8 or higher were invited to proceed to a structured clinical interview to establish whether an anxiety disorder was present and, if so, which subtype, using the Structured Clinical Interview for DSM disorders (SCID).

This report presents the initial screening data from a randomized clinical trial (Heart and Mind).

The trial protocol had previously been published.

The current analysis focuses on those who screened positive for anxiety (HADS-A ≥8) and then underwent SCID assessment by trained cardiac nurses supervised by a psychologist.

Interviews were conducted by cardiac nurses who had completed a dedicated 10-day training in cognitive-behavioral therapy and SCID interviewing.

Interviews used the DSM-based SCID (non-patient edition, DSM-IV-TR, Axis I, with Module F psychotic screen) to determine whether anxiety disorders were present and to specify the type of anxiety disorder.

Adjustment Disorder with anxiety was considered as a potential diagnosis in light of living with chronic heart disease.

• Objective framing.
• Setting and screening approach.
• Study design and population scope.
• Interviewers and diagnostic framework.

The Hospital Anxiety and Depression Scale (HADS) comprises two subscales (anxiety and depression), each with seven questions.

A total score per subscale ranges from 0 to 21.

In this study, a HADS-A score of 8 or higher indicated clinically significant anxiety symptoms warranting further evaluation.

The HADS is designed for use in medical settings and excludes somatic symptoms attributable to physical illness.

The SCID was used to determine whether participants met criteria for an anxiety disorder, and to classify the specific anxiety disorder type if criteria were met.

Adjustment Disorder with anxiety was included as a potential diagnostic category in recognition of the chronic disease context and its potential psychological impact.

The study population encompassed adults with arrhythmia, heart failure, or ischaemic heart disease who had completed the HADS questionnaire following hospital discharge.

Participants were recruited across multiple Danish sites, and data elements included demographic and clinical information drawn from patient records and national registries.

• Screening instrument.
• Diagnostic reference standard.
• Population descriptors.

Out of 7,816 patients who completed the HADS, 1,803 individuals (23%) had a HADS-A score of 8 or higher, indicating clinically significant anxiety symptoms.

Among those with positive HADS-A screens, 398 individuals (22%) consented to undergo the SCID interview.

This subset represents those who proceeded to a structured diagnostic assessment.

Of those who completed the SCID, 336 participants (84%) fulfilled criteria for an anxiety disorder according to DSM-based assessment.

This indicates that a substantial majority of SCID-interviewed, screen-identified anxious cardiac patients met DSM criteria for an anxiety disorder or an adjustment disorder with anxiety.

The mean age of those who underwent SCID was in the early sixties, with approximately four in ten participants being female.

The mean HADS-A score among interviewed individuals was 11.3, with a standard deviation of 2.7, suggesting moderate to higher levels of anxiety on the screen within this group.

Among the DSM-confirmed cases, generalized anxiety disorder (GAD) accounted for the majority (about six in ten).

Panic disorder comprised roughly a quarter of cases, and specific phobias represented a smaller fraction (around one-tenth).

Adjustment Disorder with anxiety, while a consideration in DSM classification, was not reported as a primary category in the most frequently observed patterns within this sample; nevertheless, the interview framework encompassed this potential diagnosis within the DSM schema for precision.

• Screening yield.
• SCID participation rate.
• DSM-defined anxiety disorder prevalence within screened positives.
• Demographic and symptom profile of the interviewed group.
• Predominant anxiety disorder subtypes.

The majority of participants who screened positive for anxiety on HADS-A and subsequently completed a DSM-based interview met criteria for an anxiety disorder, underscoring a convergence between screening results and structured diagnostic categories within this cardiac population.

Generalized anxiety disorder emerged as the most common DSM subtype among validated cases, followed by panic disorder and specific phobias.

These patterns align with prior investigations that have highlighted GAD and panic as prominent anxiety presentations in cardiac cohorts, though direct comparability is limited by differences in study designs and diagnostic frameworks.

The cohort illustrates that clinically significant anxiety symptoms are relatively common among patients with arrhythmia, heart failure, or ischaemic heart disease who present with anxiety on screening tools.

The median age and gender distribution provide a sense of the demographic spread within the screened-and-scored subgroup who underwent diagnostic interviews.

A notable limitation lies in the participation funnel: only about one-f fifth of those with elevated HADS-A agreed to SCID assessment.

This introduces potential selection bias if participants differ systematically from non-participants.

Additional limitations include reliance on non-patient edition SCID aligned to DSM-IV-TR, which may influence diagnostic categorization relative to contemporary DSM-5 criteria.

The initial report emphasizes that information on several potentially relevant clinical variables—education, employment, anthropometrics, health behaviors, prior mental health contact, psychiatric treatment history, alongside cardiac functional indices—was collected and could influence interpretation, though detailed results for these covariates are not provided in the current screening summary.

The data suggest that routine anxiety screening in cardiac settings can identify individuals who, upon structured psychiatric evaluation, show DSM-defined anxiety disorders.

This supports considerations for integrating diagnostic follow-up and targeted psychological interventions into standard cardiac care pathways, where anxiety is prevalent and can affect quality of life and functional status.

• Translation of screening into DSM diagnoses.
• Subtype distribution and clinical implications.
• Cross-cutting patient characteristics.
• Limitations and potential biases.
• Practical relevance for clinical pathways.

Screening with HADS occurred at least eight weeks after hospital discharge, and a HADS-A threshold of 8+ with higher anxiety than depression signals eligibility for SCID interviewing.

The interview process was conducted by trained cardiac nurses under psychologist supervision, ensuring a standardized diagnostic approach within the trial framework.

The study utilized DSM-IV-TR criteria via SCID-I (with an emphasis on non-patient edition) to ascertain anxiety disorders and to identify the presence of Adjustment Disorder with anxiety as a potential diagnosis, recognizing the psychosocial burden of living with chronic heart disease.

The current screening results are part of a larger randomized trial exploring an anxiety-focused intervention versus usual care for patients with cardiac conditions.

The primary trial outcomes related to treatment effects were not reported in the current screening article.

• Screening-to-interview workflow.
• Diagnostic taxonomy employed.
• Context of the Heart and Mind trial.

The subset of HADS-A positive individuals who consented to SCID evaluation may differ in meaningful ways from those who declined, potentially biasing prevalence estimates of DSM-defined anxiety disorders within the screened population.

The SCID was administered using DSM-IV-TR criteria, which may not align perfectly with current DSM-5 diagnoses.

The implications of any reclassification under DSM-5 are not addressed in the reported data.

This document focuses on initial screening findings and DSM-based diagnoses, with limited reporting on long-term outcomes, treatment responses, or mortality implications tied to the anxiety diagnoses in this cohort.

While the study includes arrhythmia, heart failure, and ischaemic heart disease, the extent to which these results generalize across all cardiac conditions or to other healthcare settings remains uncertain.

• Participant representativeness.
• Diagnostic criteria evolution.
• Scope of reported outcomes.
• Generalizability across cardiac strata.

This reinforces the notion that anxiety is a common comorbidity across diverse cardiac conditions and supports the rationale for routine psychological evaluation in cardiac care settings.

The outcomes of that intervention, however, are not presented in this analysis.

• A substantial share of cardiac patients flagged for anxiety on a screen meet DSM-based criteria for an anxiety disorder upon structured assessment, with generalized anxiety disorder and panic disorder as the predominant subtypes.
• The finding that roughly four of ten patients with elevated anxiety screen scores proceeded to SCID evaluation, and that the vast majority of those evaluated demonstrated an anxiety disorder, underscores the screening tool’s potential utility as an initial triage step in practice, while also signaling the need to optimize engagement with follow-up diagnostic assessment.
• The results establish a baseline for the Heart and Mind trial’s experimental arm, where participants with DSM-defined anxiety or adjustment disorder with anxiety were allocated to either cognitive-behavioral therapy or usual care.

• It remains unclear how many patients with psychological distress who did not meet the HADS-A threshold nonetheless possessed DSM-qualifying anxiety disorders, or whether other subthreshold presentations were clinically meaningful.
• The degree to which DSM-IV-TR diagnoses would map onto DSM-5 categories in this population is not addressed, leaving a hurdle for direct translation to current diagnostic conventions.
• The extent to which demographic, clinical, or social factors (beyond those captured in the screening and interview processes) influence the likelihood of meeting DSM criteria for an anxiety disorder remains to be clarified from the presented data.
• Practical implications for routine clinical practice—such as specifics of how screening followed by SCID-confirmed diagnoses could be integrated into cardiac care workflows, resources required, and potential implications for patient outcomes—are not directly evaluated in the screening report.

The findings highlight anxiety as a prevalent comorbidity in cardiac disease and support the importance of structured diagnostic follow-up after initial screening to guide potential targeted interventions within cardiac care settings.

• In a Danish cardiac cohort with prior anxiety symptoms, a sizeable proportion of screened individuals who completed a DSM-based diagnostic interview met criteria for an anxiety disorder, with generalized anxiety disorder and panic disorder being the most common subtypes.