Validation of the Dzongkha version of the Hospital Anxiety and Depression Scale in the Bhutanese population.

OBJECTIVES: To validate the Dzongkha version of the Hospital Anxiety and Depression Scale (HADS-Dz) among outpatients attending a hospital for anxiety and depression. METHODS: Patients aged 18 to 65 years who were proficient in Dzongkha, had no history of mental illness or psychiatric treatment, and attended the Jigme Dorji Wangchuk National Referral Hospital outpatient clinic were recruited through convenience sampling. They were asked to complete the HADS-Dz, which was developed through forward and backward translation and pre-tested in 30 participants. Exploratory factor analysis, confirmatory factor analysis (CFA), and exploratory structural equation modelling (ESEM) were performed for construct validity, internal consistency, and test-retest reliability. RESULTS: In total, 134 men and 209 women (mean age, 26 years) were included in the exploratory factor analysis (n = 140), CFA (n = 344), and ESEM (n = 344). The two-factor structure was retained. CFA showed poor fit, whereas ESEM displayed good fit (root mean square error of approximation = 0.048, comparative fit index = 0.945, Tucker-Lewis index = 0.922, weighted root mean square residual = 0.767). Internal consistency was modest (Cronbach's α = 0.59 for anxiety and 0.64 for depression; McDonald's ω = 0.66 and 0.67, respectively; average variance extracted = 0.26 and 0.24, respectively); factor loadings were low for items 7, 9, and 11. Discriminant validity was supported (heterotrait-monotrait ratio = 0.62), and test-retest reliability was strong (intraclass correlation coefficient = 0.87). No diagnostic cut-off was established. CONCLUSION: The HADS-Dz reproduces the two-factor structure of the original HADS and shows good test-retest stability. However, internal consistency was modest, and diagnostic cut-offs were not established or validated. The HADS-Dz may serve as a preliminary screening tool for the Bhutanese population.