Duke Anxiety-Depression Scale (DUKE-AD)

Abstract

The Duke Anxiety-Depression Scale (DUKE-AD) is a concise, self-report instrument developed specifically for the rapid screening of symptoms related to anxiety and depression. Designed for use in non-psychiatric environments, the DUKE-AD is highly utilized within primary care settings where time efficiency is critical. The scale consists of seven items extracted from the broader Duke Health Profile (DUKE), focusing on the most common affective and behavioral manifestations of psychological distress. Its primary function is to quickly identify adult patients who require subsequent, more comprehensive diagnostic evaluation.

Keywords

anxiety screening, depression screening, primary care, Duke Health Profile, psychological assessment, health status, psychometrics, affective dysfunction, screening tool, ROC analysis, mental health assessment.

Authors

G.R. Parkerson, Jr., W.E. Broadhead, C.K.J. Tse

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Purpose

The fundamental purpose of the DUKE-AD is to provide an efficient and low-burden method for identifying clinically significant symptoms of both anxiety and depression among adults presenting in general medical contexts. Its brief, seven-item format is intentionally designed to minimize respondent time, making it exceptionally practical for routine incorporation into high-volume clinical workflows, such as those found in family medicine and primary care clinics.

By offering a quick indicator of underlying psychological distress, the scale empowers healthcare providers to make informed decisions regarding the necessity of specialist referral, in-depth psychiatric assessment, or immediate mental health intervention. This is particularly valuable since these common mental health issues often manifest initially as ambiguous somatic complaints in general practice. Further details on the measure can be found at the Duke Health Measures website: https://cfm.duke.edu/research/duke-health-measures.

Construct

The DUKE-AD is designed to measure the psychological construct of affective dysfunction, which encompasses the severity and presence of core symptomatic features shared by both anxiety and depression. The seven items are carefully selected to capture a range of manifestations, including cognitive-behavioral indicators (such as difficulty concentrating or giving up easily) and specific somatic or emotional complaints (including nervousness, sadness, and sleep disturbance).

It is crucial to understand that the DUKE-AD functions strictly as a measure of psychological symptoms and general distress, rather than a definitive diagnostic tool. The scale’s design reflects the high degree of symptom overlap inherent to these two common disorders when observed in non-psychiatric populations, consolidating the measurement into a single, unidimensional score of overall psychological distress.

Validity

The validity of the DUKE-AD has been rigorously established through various psychometrics studies. Developers, notably Parkerson and colleagues (1997), employed Receiver operating characteristic curves (ROC) analysis to identify optimal cutoff thresholds. This method is fundamental for demonstrating the scale’s capacity to accurately discriminate between patients who possess clinically significant levels of depression or anxiety and those who do not, thereby maximizing both sensitivity and specificity for clinical screening.

The scale exhibits acceptable criterion validity, showing strong correlation when compared against results from established, structured diagnostic interviews and other comprehensive psychiatric instruments. This supports its quick utility as a reliable indicator of mental health distress within diverse primary care patient groups. Furthermore, its heritage as a subset of the extensively validated Duke Health Profile (DUKE) bolsters its underlying construct validity regarding the broader measurement of functional health status.

Reliability

Reliability for the DUKE-AD is primarily demonstrated through measures of internal consistency. Validation research consistently reports good internal consistency estimates, affirming that the seven individual items cohere effectively to measure the single latent construct of affective distress. This psychometric stability, combined with its brevity, ensures the scale is a robust tool suitable for time-constrained clinical environments.

The scale’s sufficient reliability supports its application in longitudinal research, particularly in tracking fluctuations in symptom severity over time. It is frequently employed in clinical trials and outcome measurement studies where brief, repeated assessments of anxiety and depression symptoms are necessary to monitor treatment efficacy and patient recovery.

Factor Analysis

Despite addressing symptoms of both anxiety and depression, the DUKE-AD is typically treated as a unidimensional measure. Factor analysis conducted on the parent instrument, the Duke Health Profile, supports the grouping of these specific seven items into a single, cohesive affective dysfunction factor. This finding justifies the use of a unified total score representing general psychological distress.

The effectiveness of using a single cutoff score for determining the need for further assessment is further supported by the application of Receiver operating characteristic curves (ROC) analysis. This approach confirms that the combined score serves as a highly effective screening metric encompassing core anxious and depressive features.

Instrument

Test Type: Self-report screening questionnaire for affective symptoms.

Format: Paper-and-pencil or electronic administration; 7 items utilizing variable response scales (3-point ordinal).

Language Available: Primarily English; translations are generally available for the parent Duke Health Profile, suggesting potential availability for the DUKE-AD.

Population Group: General adult population seeking medical care.

Age Group: Adults (18+).

Population Details: Validation studies focused on patients receiving care in family medicine and primary care settings, confirming its suitability for general and medically ill adult populations.

Test Methodology: Scoring involves the summation of item responses. One item (Item 3) is reverse-scored to maintain consistency, resulting in a total affective dysfunction score. Higher scores correspond to greater severity of symptoms.

Keywords

affective dysfunction, screening tool, Duke University, psychometrics, mental health assessment, ROC analysis, psychological distress, criterion validity.

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Authors

Author ORCID Identifier: Unavailable.

Affiliation Email addresses: Unavailable.

Correspondence Address: Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina, USA.

Permissions & Fee and Test Year

The DUKE-AD is considered an integral component of the Duke Health Measures suite, developed primarily by G.R. Parkerson, Jr. Prospective users, particularly those seeking commercial usage rights or large-scale implementation, must obtain specific information regarding permissions and associated fees directly from the Department of Community and Family Medicine at Duke University Medical Center. The scale is frequently permitted for non-commercial academic research without charge.

While the item pool originated from the Duke Health Profile (DUKE), first published in 1990, the specific seven-item DUKE-AD was formally established and validated as a dedicated anxiety and depression screening instrument through publications in 1996 and 1997.

Reference’s

• Parkerson‚ G.R.‚ Jr.‚ Gehlbach‚ S.H.‚ Wagner‚ E.H.‚ et al. (1981). The Duke-UNC Health Profile: an adult health status instrument for primary care. Med Care‚ 19:806–828.
• Parkerson‚ G.R.‚ Jr.‚ Broadhead‚ W.E.‚ Tse‚ C.K.J. (1990). The Duke Health Profile: a 17-item measure of health and dysfunction. Med Care‚ 28(11):1056–1072.
• Parkerson‚ G.R Jr.‚ Broadhead‚ W.E.‚ Tse C-K.J. (1991). Development of the 17-item Duke Health Profile. Family Practice‚ 8(4); 396-401.
• Parkerson‚ G.R.‚ Jr.‚ Broadhead‚ W.E‚ Tse‚ C.K.J. (1991). Comparison of the Duke Health Profile and the MOS Short-Form in healthy young adults. Med Care‚ 29:679–683.
• Parkerson‚ G.R.‚ Jr.‚ Broadhead‚ W.E.‚ Tse‚ C.K.J. (1992). Quality of life and functional health of primary care patients. J Clin Epidemiol‚ 45:1303–1313.
• Parkerson‚ G.R.‚ Jr. (1994). User’s guide for the Duke Health Profile (DUKE). Durham‚ North Carolina: Duke University Medical Center.
• Parkerson‚ G.R.‚ Jr.‚ Broadhead‚ W.E.‚ Tse‚ C.K. (1995). Health status and severity of illness as predictors of outcomes in primary care. Med Care‚ 33:53–66.
• Parkerson‚ G.R.‚ Jr.‚ Broadhead. W‚E.‚ Tse‚ C.K.J. (1996). Anxiety and depressive symptom identification using the Duke Health Profile. J Clin Epidemiol‚ 49(1):85-93.
• Parkerson‚ G.R.‚ Jr.‚ Broadhead‚ W.E. (1997). Screening for anxiety and depression in primary care with the Duke Anxiety-Depression Scale. Family Medicine‚ 29(3):177-181.
• Parkerson‚ G.R.‚ Jr. (2002). Users guide for Duke health measures. Durham‚ N.C.: Department of Community and Family Medicine‚ Duke University Medical Center.
• McDowell‚ Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires‚ Third Edition. OXFORD UNIVERSITY PRESS.

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Items of the Duke Anxiety-Depression Scale (DUKE-AD)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

• Responses: (2) Yes‚ describes me exactly; (1) Somewhat describes me; (0) No‚ doesn’t describe me at all
• 1. I give up too easily
• 2. I have difficulty concentrating
• 3. I am comfortable being around people* (Item 3 is reversed)
• During the past week: (Responses: (0) None; (1) Some; (2) A Lot)
• How much trouble have you had with:
• 4. Sleeping
• 5. Getting tired easily
• 6. Feeling depressed or sad
• 7. Nervousness