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To systematically evaluate the latent structure of the Hospital Anxiety and Depression Scale (HADS) through reanalysis of previous studies and meta confirmatory factor analysis (CFA).

Data from 28 samples were obtained from published studies concerning the latent structure of the HADS. Ten models were considered, including eight previously identified models and two bifactor models. The fit of each model was assessed separately in each sample and by meta CFA. Meta CFA was conducted using all samples and using subgroups consisting of community samples, cardiovascular disease samples and samples from studies administering the English language version of the HADS.

A bifactor model including all items loading onto a general distress factor and two orthogonal anxiety and depression group factors provided the best fit for the majority of samples. Meta CFA provided …