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Assigning Clinical Significance and Symptom Severity Using the Zung Scales: Levels of Misclassification Arising from Confusion between Index and Raw Scores.

1. Introduction

Of the conditions contributing to the global disability burden of mental illness, anxiety and depression are the most prevalent disorders [1, 2]. However, while these are conceptually distinct constructs [3, 4], they present as highly comorbid conditions [5, 6]. Further, while an absence of positive affect is considered unique to depression, and other specific factors are unique to particular anxiety disorders (e.g., physiological arousal to posttraumatic stress disorder and panic disorder), the presence of a high level of general distress and negative affect is common to both types of disorder [7, 8]. For these reasons, researchers and clinicians often concurrently screen for the presence and severity of both disorders using self-report psychometric tools developed for this purpose.

Self-report measures of mental disorders may be criterion-referenced or norm-referenced. Criterion-referenced measures are used to make a diagnosis based on the endorsement of criteria listed in published diagnostic classification systems. Individuals are diagnosed with or without a disorder based upon the presence or absence of these criteria [9, 10]. In contrast to criterion-referenced measures, norm-referenced measures compare individuals' test results to those of an appropriate peer or normative group. These scales typically suggest score ranges linked to symptom severity descriptors and have a "clinically significant" total scale score cut-off point beyond which scores are considered indicative of the presence of a disorder (see Table 1).

The Zung Self-Rating Depression Scale (SDS) [11] is a commonly utilized norm-referenced scale. The SDS is a 20item Likert scale covering symptoms that were identified in factor analytic studies of the syndrome of depression [11]. Items tap psychological and physiological symptoms and are rated by respondents according to how each applied to them within the past week, using a 4-point scale ranging from 1 (none, or a little of the time) to 4 (most, or all of the time). The scale has a raw score range of 20 to 80 points. The raw score is then converted to an index score by dividing the raw score by the maximum score (80) and either expressing this as a decimal or multiplying by 100 to express it as a whole number with an index score range of 25 to 100. Index scores of 25 to 49 indicate nil depression, 50-59 indicate mild to moderate depression, 60-69 indicate moderate to severe depression, and scores over 70 indicate severe depression [12].

Zung [13] also devised a similar 20-item scale to screen for the presence of clinical anxiety: the Self-Rating Anxiety Scale (SAS). Items tap affective and somatic symptoms selected from the diagnostic criteria listed in the Diagnostic and Statistical Manual of Mental Orders (DSM II) current at the time [14]. The scoring structure and index score conversion is similar to that for the SDS. However, for the SAS, the situation regarding cut-off scores is less clear: Zung [6] noted in an early study that all "normal subjects" returned an SAS index score below 50, but later he set an index score of 45 (raw score = 36) as a cut-off point for clinically significant anxiety [15]. Moreover, score ranges for degrees of severity have not been published in the scientific literature.

Unfortunately, the literature reveals a number of discrepancies in the way the Zung scales have been used, reported, and interpreted. In particular, several researchers have mistakenly applied index score cut-offs to raw scores in assigning clinical significance and symptom severity ratings (e.g., [76, 118, 119]). In their Methods sections, these researchers describe the calculation of a total raw score and a "cut-off" score of 50 for morbidity. However, "50" is the index cut-off score set by Zung for the SDS, and this equates a raw score of 40. Using a raw score cut-off of

50 considerably reduces the proportion of cases classed as clinically significant. Another issue is that some researchers have applied severity range descriptors to the SAS when, as stated above, no such descriptors exist in the literature (e.g., [119]).

It is likely that errors in the scoring and interpretation of the Zung scales emanate from two sources that involve a failure to refer to the original publications. One is a reliance on the (erroneous) scale descriptions of other authors. The other is that some clinicians and researchers may have accessed scale information from sourcebooks of psychometric measures where distinctions between index and raw scores are imprecise. For example, both Fischer and Corcoran [120] and Schutte and Malouff [121] fail to clearly specify that recommended cut-off points are based on index and not raw scores.

This paper examines the extent to which these scales have been incorrectly interpreted in the literature. Given the scales' continued application, it is important that these inconsistencies in interpretation are highlighted and corrected.

2. Method

To investigate the extent to which the Zung scales are being wrongly applied, a search of the ProQuest full text database was conducted. Searches were done for each of the six calendar years from 2010 to 2015, using the terms "Zung Depression Scale," "Zung Self-Rating Depression Scale," "Zung Anxiety Acale," "Zung Self-Rating Anxiety Scale," and "Zung Self-Rating Scale." Searches were limited to scholarly articles. For each calendar year, the results were examined in the order presented by the database search engine and, for both the SDS and the SAS, the first ten articles that used that scale to collect new data were selected to form a "convenience" sample indicative of recent use of these scales. Articles reporting on studies using both the SDS and the SAS were included, but theoretical articles and meta-analyses were not. In total, 102 articles were sourced and explored for misinterpretation of both scales. The disciplines covered in the articles were psychiatry (25%), psychology (9%), cardiology (6%), oncology (5%), neurology (5%), and gynecology (5%). The remaining 45% were other medical disciplines.

The results for each paper were recorded against a checklist. Examination initially focused on whether cut-off scores and severity ranges were applied. When this was done, the usage was coded according to the following categories:

(1) Consistent use of raw scores: paper uses raw scores only with cut-off scores and/or severity ranges appropriately modified.

(2) Consistent use of index scores: paper details conversion to index scores and uses index score cut-offs/severity ranges.

(3) Incorrect application: index cut-off scores/severity ranges are specifically applied to raw scores.

(4) Unclear application: paper uses index cut-off/severity ranges without mention of conversion from raw scores: however, there was no conclusive evidence that this was not done.

(5) Not utilized: cut-off scores/severity ranges are not stated or used.

Notes were also taken where the cut-of and severity ranges applied were different from Zung's [12, 15] recommendations.

3. Results

Cut-offs for the presence of a disorder were applied in 45 of the 60 papers where the SDS was used and in 40 of the 60 where the SAS was used. For the SDS, index cut-offs were incorrectly applied to raw scores in 16 (35%) of these 45 papers, with a further 7 (16%) papers in which application was unclear. For the SAS, 8 (20%) of the 40 papers revealed incorrect application, with a further 10 (25%) being unclear (Table 2).

As shown in Table 3, the level at which cut-offs were set did not always accord with Zung's recommendations. In particular, alternative norms have been developed for use in Chinese populations with the cut-off for the SDS set at an index score of 53 (raw score, 42) and, for the SAS, at 50 (raw score, 40). Further, one of the SDS papers used the SAS cutoff (index 45, raw 36) and three of the SAS papers used the SDS cut-off (index 50, raw 40). Another three papers used the newly developed SDS cut-offs for a Chinese population but applied these to European samples. Finally, one of the SDS papers set a much higher cut-off index score of 60 (raw 48).

Severity ranges were utilized considerably less often. Specifically 23 of the 60 SDS papers included them but in 9 (39%) of these cases, index score ranges were incorrectly applied to raw scores, with a further 5 (22%) cases falling into the unclear category. Figures for the SAS followed a similar pattern despite the absence of any official ranges in the scientific literature. Twenty of the 60 SAS papers include such scales, with index score ranges being incorrectly applied to raw scores in 7 (35%) of these cases, with a further 7 (35%) falling into the unclear category (Table 4).

The most common severity range applied to the SAS is based on the recommended cut-off of 45 (index). In index score terms, severity ranges are 45-59 mild to moderate anxiety, 60-74 moderate to severe anxiety, and 75+ severe anxiety. Thirteen of the 20 SAS papers utilizing severity ranges employed the above. A further four used the SDS severity ranges, while two utilized different ranges altogether and the final paper merely specified descriptors without detailing the numerical criteria. The recommended SDS severity ranges were applied in all SDS papers but two, which instead used the "unofficial" SAS ranges detailed above.

4. Discussion

This study examined a sample of recent scientific publications for the application of raw scores, index scores, and symptom severity ranges when interpreting total scores on the Zung SDS and SAS. Although the findings were based on a "convenience" rather than a random sample of papers, they provide clear evidence of a significant problem in the application of Zung scales across the literature. On the basis of the papers examined here, confusion between raw and index scores means that when cut-offs are applied to indicate the presence/absence of disorder, they are applied incorrectly in 35-51% of cases for the SDS and 20-45% of cases for the SAS (depending on the proportion of unclear cases that involve incorrect application).

This incorrect application of index score cut-offs to raw scores substantially elevates the score required to be classified in the clinical range: in index terms, from 50 to 63 on the SDS and from 45 to 56 on the SAS. The potential impact on study findings does not need elaboration.

Quite apart from the issue of cut-off scores being incorrectly applied, the inconsistency introduced by the use of two distinct sets of scores to represent the same scale makes cross-study comparisons unnecessarily difficult. (Across the studies in our sample, raw scores were used approximately 40% of the time and index scores on 60% of occasions.) Given that the transformation to index scores achieves no purpose other than to decimalize the maximum score, the simplest solution might be to abolish the use of index scores altogether.

Additionally, some confusion exists between the two Zung scales with SDS cut-offs applied to the SAS and vice versa. The same applies to severity ranges for the two scales, if one accepts that an unofficial scale for the SAS has evolved in the literature. The scientific basis of this scale remains highly questionable.

The Zung scales continue to be widely used and potentially remain a valuable means of screening for the presence of anxiety and depression. However, if scale scores are to be reliably interpreted, it is a matter of some urgency that current confusion regarding scale cut-off and severity ranges is resolved and the application of these scales is standardized in future studies.

https://doi.org/10.1155/2018/9250972

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors thank Natalya O'Keefe for her work as a research assistant during the data collection phase of the study.

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Debra A. Dunstan (ID) and Ned Scott (ID)

School of Behavioural, Cognitive and Social Sciences, University of New England, Armidale, NSW 2351, Australia

Correspondence should be addressed to Debra A. Dunstan; ddunstan@une.edu.au

Received 20 June 2017; Accepted 19 December 2017; Published 21 January 2018

Academic Editor: Bernard Sabbe
Table 1: Clinical cut-off and severity ranges.

                    SDS (1)         SAS (2)

                     Raw    Index   Raw   Index

Clinical cut-off     40      50     36     45
Severity range
  Mild-moderate     40-47   50-59
  Moderate-severe   48-55   60-69
  Severe             56+     70+

Note. (1) Zung (1974, pp. 176-177); (2) Zung (1980, p. 18).

Table 2: Number of papers applying cut-offs correctly and
incorrectly.

                                SDS (n = 60)   SAS (n = 60)

Cut-offs not used                   15             20
Consistent use: raw scores           9              8
Consistent use: index scores        13             14
Incorrect use                       16              8
Unclear application                  7             10

Table 3: Articles and evaluation of the use of the Zung Self-Rating
Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS).

Reference details                  Discipline       Used?    Cut-off

Chagas et al., 2010 [16]         Neuro science     [check]      2
Friebe et al., 2010 [17]           Psychiatry      [check]      2
Lande et al., 2010 [18]            Psychiatry      [check]      2
Saban et al., 2010 [19]            Psychiatry
Ohira, 2010 [20]                 Cardiovascular    [check]      1
Lombardi et al., 2010 [21]         Immunology      [check]      5
Podlipny et al., 2010 [22]          Psychiatry     [check]      2
Ostojic et al., 2010 [23]          Rheumatology
Sonikian et al., 2010 [24]          Nephrology     [check]      3

Biggs et al., 2010 [25]             Psychiatry     [check]      3
Alimohammadi et al.,                 Health
  2010 [26]
Oishi et al., 2010 [27]            Audiology       [check]      1

Bitsika et al., 2010 [28]         Counselling
Sharpleyetal., 2010 [29]            Oncology
Klemenc-Ketis et al.,            Mental health
  2010 [30]

Tang et al., 2010 [31]           Mental health
Fernandes et al.,                Psychometrics
  2010 [32]

Wang et al., 2010 [33]              Urology

Pascazio et al.,                   Nephrology
  2010 [34]
Herbert et al.,                    Psychology      [check]      3
  2010 [35]

2011

Ide, 2011 [36]                     Orthopedic                   1
Lande et al., 2011 [37]            Psychiatry      [check]      5
Li et al., 2011 [38]               Psychology      [check]      5

Huang et al., 2011 [39]            Cardiology      [check]      4

Takayama et al., 2011 [40]         Dentistry       [check]      1

Perugi et al., 2011 [41]           Psychiatry      [check]      4

Ogawa et al., 2011 [42]            Gynecology      [check]      5
Uji et al., 2011 [43]            Psychotherapy     [check]      5

Davidson et al., 2011 [44]         Psychology
Sharpley et al., 2011 [45]          Oncology       [check]      1
Wan et al., 2011 [46]              Psychiatry
Weigold and Robitschek,            Psychiatry
  2011 [47]
Li et al., 2011 [48]              Opthalmology
Liao et al., 2011 [49]               Drugs

Nassiri et al., 2011 [50]         Env. science

De Tommaso et al.,                 Neurology
  2011 [51]
Chiaffarino et al.,                Gynecology
  2011 [52]

Richards et al.,                   Psychology      [check]      4
  2011 [53]

2012

Yu et al., 2012 [54]               Cardiology      [check]      2
Lei et al., 2012 [55]              Psychiatry      [check]      2

Mammadova et al.,                  Psychiatry      [check]      5
  2012 [56]

Trento et al., 2012 [57]         Endocrinology     [check]      3

Adogwa et al., 2012 [58]          Orthopaedics     [check]      3
Gao et al., 2012 [59]              Psychiatry

Sawa et al., 2012 [60]             Psychiatry      [check]      5
Chang and Koh, 2012 [61]         Mental health     [check]      5
Sapranaviciute et al.,             Psychology      [check]      5
  2012 [62]
de Pasquale et al.,             General medicine   [check]      3
  2012 [63]
Shen et al., 2012 [64]             Psychiatry

Liu et al., 2012 [65]           Gastroenterology

Huang et al., 2012 [66]            Gynecology

Li et al., 2012 [67]             Mental health
Tang et al., 2012 [68]           Gastroenterology
Campbell et al.,                   Psychiatry      [check]      5
  2012 [69]

2013

Adogwa et al., 2013 [70]             Spinal        [check]      3

Balazs et al., 2013 [71]           Psychology
Li et al., 2014 [72]                Oncology       [check]      1

Lowery et al., 2013 [73]           Psychiatry      [check]      5

Zhang et al., 2013 [74]             Urology        [check]      2
Guo et al., 2013 [75]               Oncology       [check]      2

Nardelli et al.,                   Neurology       [check]      3
  2013 [76]
Siennicki-Lantz et al.,            Geriatric       [check]      2
  2013 [77]

Liu et al., 2013 [78]              Immunology

Deb, 2013 [79]                    Pharmacology     [check]      3

Wang et al., 2013 [80]             Psychiatry      [check]      2

Khorvash et al., 2013 [81]       Neuro science

Quintao et al., 2013 [82]          Psychology
Delibegovic and Sinanovic,          Oncology       [check]      4
  2013 [83]

Klemenc-Ketis and Peterlin,        Psychiatry      [check]      3
  2013 [84]
Carli et al., 2013 [85]          Public health     [check]

Grandi et al., 2013 [86]           Gynecology      [check]      5

2014

Akinsulore et al.,                 Psychology                   2
  2014 [88]
Banth and Sharma,                  Psychology      [check]      3
  2014 [89]
Bhatti et al., 2013 [90]             Spinal

Kaess et al., 2014 [91]            Psychiatry

Atteritano et al.,                 Gynecology      [check]      3
  2014 [92]
Lee et al., 2014 [93]            Endocrinology     [check]      5

Vlachos et al., 2014 [94]       Gastroenterology   [check]      3
Ding et al., 2014 [95]             Psychiatry

Trento et al., 2014 [96]         Endocrinology

Fernandez-Matarrubia et            Neurology       [check]      5
  al., 2014 [97]
Feng et al., 2014 [98]           Public health     [check]      4

Hou et al., 2014 [99]              Nephrology      [check]      2

Khorvash et al.,                   Neurology
  2014 [100]
Liu et al., 2014 [101]            Respiratory      [check]      4

La Fianza et al.,                  Radiology       [check]      1
  2014 [102]

2015

Bobic et al., 2015 [103]           Psychiatry      [check]      1

Chen et al., 2015 [104]            Orthopedic      [check]      4

Jiang et al., 2015 [105]          Rheumatology     [check]      5
Rus Makovec et al.,              Public health     [check]      2
  2015 [106]
Kourkoveli et al.,                  Cardiac        [check]      1
  2015 [107]
Shi et al., 2015 [108]             Psychiatry
Stefanidou et al.,                 Psychiatry      [check]      3
  2015 [109]
Pozzi et al., 2015 [110]           Psychiatry
Yuan et al., 2015 [111]            Neurology

Yin et al., 2015 [112]             Psychiatry      [check]      3

Li et al., 2015 [113]                Spinal        [check]      3

Hirao, 2015 [114]                Occupational      [check]      5
                                    therapy
Lou et al., 2015 [115]              Cardiac

Yang et al., 2015 [116]            Psychiatry      [check]      2

Trento et al., 2015 [117]        Endocrinology

                                   SDS
                                Severity
Reference details                 range          Notes          Used?

Chagas et al., 2010 [16]            5
Friebe et al., 2010 [17]            2
Lande et al., 2010 [18]             2
Saban et al., 2010 [19]
Ohira, 2010 [20]                    5
Lombardi et al., 2010 [21]          5
Podlipny et al., 2010 [22]          2
Ostojic et al., 2010 [23]                                       [check]
Sonikian et al., 2010 [24]          3

Biggs et al., 2010 [25]             5
Alimohammadi et al.,                                           [check]
  2010 [26]
Oishi et al., 2010 [27]             5        Cut-off of 48
                                              used (i.e.,
                                              index of 60)
Bitsika et al., 2010 [28]                                      [check]
Sharpleyetal., 2010 [29]                                       [check]
Klemenc-Ketis et al.,                                          [check]
  2010 [30]

Tang et al., 2010 [31]                                         [check]
Fernandes et al.,                                              [check]
  2010 [32]

Wang et al., 2010 [33]                                         [check]

Pascazio et al.,                                               [check]
  2010 [34]
Herbert et al.,                     3
  2010 [35]

2011

Ide, 2011 [36]                      1
Lande et al., 2011 [37]             5
Li et al., 2011 [38]                5        Short 10-item
                                             version of SDS
                                                  used
Huang et al., 2011 [39]             4          Used index
                                            classifications
                                                with no
                                             indication of
                                               conversion
Takayama et al., 2011 [40]          1        Mentions index
                                             conversion but
                                            uses raw scores
                                               correctly
Perugi et al., 2011 [41]            4          Used index
                                             scores with no
                                             indication of
                                               conversion

Ogawa et al., 2011 [42]             5
Uji et al., 2011 [43]               5         Only used 7
                                              statements:
                                               "affective
                                               subscale"
Davidson et al., 2011 [44]                                     [check]
Sharpley et al., 2011 [45]          5         SAS cut-off
Wan et al., 2011 [46]                                          [check]
Weigold and Robitschek,                                        [check]
  2011 [47]
Li et al., 2011 [48]                                           [check]
Liao et al., 2011 [49]                                         [check]

Nassiri et al., 2011 [50]                                      [check]

De Tommaso et al.,                                             [check]
  2011 [51]
Chiaffarino et al.,                                            [check]
  2011 [52]

Richards et al.,                    4       Uses Index scores: [check]
  2011 [53]                                  no mention of
                                               conversion

2012

Yu et al., 2012 [54]                2                          [check]
Lei et al., 2012 [55]               5       Chinese cut-offs   [check]
                                            used (53 index)

Mammadova et al.,                   5         Calculating
  2012 [56]                                   appropriate
                                              cut-off for
                                               different
                                               population
Trento et al., 2012 [57]            3                          [check]

Adogwa et al., 2012 [58]            5
Gao et al., 2012 [59]                                          [check]

Sawa et al., 2012 [60]              5
Chang and Koh, 2012 [61]            5
Sapranaviciute et al.,              5
  2012 [62]
de Pasquale et al.,                 5                          [check]
  2012 [63]
Shen et al., 2012 [64]                                         [check]

Liu et al., 2012 [65]                                          [check]

Huang et al., 2012 [66]                                        [check]

Li et al., 2012 [67]                                           [check]
Tang et al., 2012 [68]
Campbell et al.,                    5
  2012 [69]

2013

Adogwa et al., 2013 [70]            5         Other ranges
                                             used based on
                                               quartiles
Balazs et al., 2013 [71]                                       [check]
Li et al., 2014 [72]                5       Chinese cut-offs
                                             used (42 raw)

Lowery et al., 2013 [73]            5       Brief instrument   [check]
                                              used. Score
                                            range indicated
                                            index scores (25
                                            to 100) but only
                                            raw range given
                                            (1 to 4 Likert)
Zhang et al., 2013 [74]             5
Guo et al., 2013 [75]               5       Chinese version    [check]
                                                  used
Nardelli et al.,                    5
  2013 [76]
Siennicki-Lantz et al.,             2        SAS "severity
  2013 [77]                                 rating" applied
                                              (i.e., mild
                                              depression
                                                 45-59)
Liu et al., 2013 [78]                                          [check]

Deb, 2013 [79]                      3                          [check]

Wang et al., 2013 [80]              5       Chinese version
                                                  used
Khorvash et al., 2013 [81]                                     [check]

Quintao et al., 2013 [82]                                      [check]
Delibegovic and Sinanovic,          4                          [check]
  2013 [83]

Klemenc-Ketis and Peterlin,         3
  2013 [84]
Carli et al., 2013 [85]                                        [check]

Grandi et al., 2013 [86]            5        "Higher scores
                                            indicating worst
                                               depressive
                                             symptoms." Raw
                                              score range
                                            given (20 to 80)

2014

Akinsulore et al.,                  2
  2014 [88]
Banth and Sharma,                   3
  2014 [89]
Bhatti et al., 2013 [90]                                       [check]

Kaess et al., 2014 [91]                                        [check]

Atteritano et al.,                  3
  2014 [92]
Lee et al., 2014 [93]               5       "Severity score
                                             was calculated
                                               by formula
                                            conversion" and
                                              link to Zung
                                                article
Vlachos et al., 2014 [94]           5
Ding et al., 2014 [95]                                         [check]

Trento et al., 2014 [96]                                       [check]

Fernandez-Matarrubia et             5                          [check]
  al., 2014 [97]
Feng et al., 2014 [98]              5       Chinese cut-offs      S
                                            used (53 index)
Hou et al., 2014 [99]               5         "Each scale         S
                                             consists of 40
                                                items,"-
                                               incorrect
                                             description of
                                            scales provided.
                                            Chinese version
                                                 used:
                                              non-Chinese
                                                cut-off
Khorvash et al.,                                               [check]
  2014 [100]
Liu et al., 2014 [101]              5       Chinese version    [check]
                                                  used
La Fianza et al.,                   5                          [check]
  2014 [102]

2015

Bobic et al., 2015 [103]            5       Chinese cut-offs
                                             used (42 raw)
Chen et al., 2015 [104]             5       Chinese cut-offs   [check]
                                            used (53 index)
Jiang et al., 2015 [105]            5                          [check]
Rus Makovec et al.,                 2                          [check]
  2015 [106]
Kourkoveli et al.,                  5
  2015 [107]
Shi et al., 2015 [108]                                         [check]
Stefanidou et al.,                  5
  2015 [109]
Pozzi et al., 2015 [110]                                       [check]
Yuan et al., 2015 [111]                                        [check]

Yin et al., 2015 [112]              3         SAS severity     [check]
                                             ranges quoted
                                            but Chinese cut-
                                             offs used (53
                                                 index)
Li et al., 2015 [113]               3         SDS standard     [check]
                                            indices applied
                                             to raw scores
Hirao, 2015 [114]                   5        Mentioned the
                                            Japanese version
Lou et al., 2015 [115]                                         [check]

Yang et al., 2015 [116]             5        Mentioned the
                                            Chinese version
                                                but used
                                             standard index
                                              cut-off (50)
Trento et al., 2015 [117]                                         S

                                             SAS
                                          Severity
Reference details               Cut-off     range          Notes

Chagas et al., 2010 [16]
Friebe et al., 2010 [17]
Lande et al., 2010 [18]
Saban et al., 2010 [19]            5          5
Ohira, 2010 [20]
Lombardi et al., 2010 [21]
Podlipny et al., 2010 [22]
Ostojic et al., 2010 [23]           2          2
Sonikian et al., 2010 [24]                             "SAS" severity
                                                           ranges
Biggs et al., 2010 [25]
Alimohammadi et al.,               5          5
  2010 [26]
Oishi et al., 2010 [27]

Bitsika et al., 2010 [28]          1          5
Sharpleyetal., 2010 [29]           1          5
Klemenc-Ketis et al.,              1          5
  2010 [30]                                            Cut-off of 50
                                                         raw score
Tang et al., 2010 [31]             5          5
Fernandes et al.,                  1          1
  2010 [32]                                              Raw score
                                                       ranges: up to
                                                      36--no anxiety.
                                                      37-39 -possible
                                                       anxiety: 40+
                                                      '-high anxiety.
Wang et al., 2010 [33]             2          5         cut-off 50
                                                         (Chinese)
Pascazio et al.,                   5          5
  2010 [34]
Herbert et al.,
  2010 [35]

2011

Ide, 2011 [36]
Lande et al., 2011 [37]
Li et al., 2011 [38]

Huang et al., 2011 [39]

Takayama et al., 2011 [40]

Perugi et al., 2011 [41]           4          4          Used index
                                                       scores with no
                                                       indication of
                                                        conversion:
                                                      cut-off of 50.
                                                         SDS ranges
Ogawa et al., 2011 [42]
Uji et al., 2011 [43]

Davidson et al., 2011 [44]         5          5
Sharpley et al., 2011 [45]
Wan et al., 2011 [46]              5          5
Weigold and Robitschek,            5          5
  2011 [47]
Li et al., 2011 [48]               2          5
Liao et al., 2011 [49]             5          5       Chinese cut-off
                                                      used (50 index)

Nassiri et al., 2011 [50]          4          4        Divided into
                                                        normal-low-
                                                       moderate-high
                                                           but no
                                                      indication given
                                                       of cut-offs or
                                                          indexing
De Tommaso et al.,                 5          5
  2011 [51]
Chiaffarino et al.,                1          1       Raw score ranges:
  2011 [52]                                           <40, nonanxious;
                                                       40-60 anxious
                                                       symptoms; >60
                                                         clinically
                                                        significant
                                                          anxiety
Richards et al.,                   4          4          Uses index
  2011 [53]                                            scores with no
                                                         mention of
                                                       conversation.
                                                        "SAS" ranges

2012

Yu et al., 2012 [54]               2          2
Lei et al., 2012 [55]              2          5        "SAS" severity
                                                           ranges

Mammadova et al.,                                     Chinese cut-off
  2012 [56]                                           used (50 index)

Trento et al., 2012 [57]           3          3        "SAS" severity
                                                          ratings
Adogwa et al., 2012 [58]
Gao et al., 2012 [59]              1          5       Use Chinese norm
                                                       cut-off of 40
                                                        (raw score)
Sawa et al., 2012 [60]
Chang and Koh, 2012 [61]
Sapranaviciute et al.,
  2012 [62]
de Pasquale et al.,                5          5
  2012 [63]
Shen et al., 2012 [64]             2          5       Chinese cut-off:
                                                          index 50
Liu et al., 2012 [65]              2          5        Probably used
                                                      Chinese cut-off
Huang et al., 2012 [66]            2          5       Chinese cut-off:
                                                          index 50
Li et al., 2012 [67]               5          5
Tang et al., 2012 [68]              5          5
Campbell et al.,
  2012 [69]

2013

Adogwa et al., 2013 [70]

Balazs et al., 2013 [71]           4          4
Li et al., 2014 [72]                                   "SAS" severity
                                                           ranges

Lowery et al., 2013 [73]           5          5         Score range
                                                      indicated index
                                                       scores (25 to
                                                       100) but only
                                                      raw range given
                                                      (1 to 4 Likert)

Zhang et al., 2013 [74]
Guo et al., 2013 [75]              2          5       Chinese cut-off
                                                            used
Nardelli et al.,
  2013 [76]
Siennicki-Lantz et al.,
  2013 [77]

Liu et al., 2013 [78]              2          5       Chinese cut-off
                                                            used
Deb, 2013 [79]                     3          3        SAS "severity
                                                          ratings"
Wang et al., 2013 [80]

Khorvash et al., 2013 [81]         4          4        "SAS" severity
                                                      ratings provided
Quintao et al., 2013 [82]          5          5
Delibegovic and Sinanovic,         4          4           Uses SDS
  2013 [83]                                           severity ratings

Klemenc-Ketis and Peterlin,
  2013 [84]
Carli et al., 2013 [85]            5          5           "A full
                                                       description of
                                                         assessment
                                                      instruments and
                                                       interventions
                                                       was previously
                                                         published"
Grandi et al., 2013 [86]

2014

Akinsulore et al.,
  2014 [88]
Banth and Sharma,
  2014 [89]
Bhatti et al., 2013 [90]           3          3        "SAS" severity
                                                           ranges

Kaess et al., 2014 [91]            4          4        "SAS" severity
                                                           ranges
Atteritano et al.,
  2014 [92]
Lee et al., 2014 [93]

Vlachos et al., 2014 [94]
Ding et al., 2014 [95]             1          5       Chinese cut-off
                                                       used (40 raw)
Trento et al., 2014 [96]           3          3        "SAS" severity
                                                           ranges
Fernandez-Matarrubia et            5          5
  al., 2014 [97]
Feng et al., 2014 [98]             4          5       Chinese cut-offs
                                                      used (50 Index)
Hou et al., 2014 [99]              2          5         "Each scale
                                                       consists of 40
                                                          items,"
                                                         incorrect
                                                       description of
                                                      scales provided.
                                                      Chinese version
                                                       used: Chinese
                                                          cut-off

Khorvash et al.,                   5          5
  2014 [100]
Liu et al., 2014 [101]             4          5       Chinese cut-off
                                                            used
La Fianza et al.,                  1          5
  2014 [102]                                                 1

2015

Bobic et al., 2015 [103]

Chen et al., 2015 [104]            4          5       Chinese cut-off
                                                      used (50 index)
Jiang et al., 2015 [105]           5          5
Rus Makovec et al.,                2          2         SDS severity
  2015 [106]                                            ranges used
Kourkoveli et al.,
  2015 [107]
Shi et al., 2015 [108]             2          5       Chinese cut-off
Stefanidou et al.,                                    used (50 index)
  2015 [109]
Pozzi et al., 2015 [110]           5          5
Yuan et al., 2015 [111]            3          5       Chinese cut-off
                                                      used (50 index)
Yin et al., 2015 [112]             3          3        "SAS" severity
                                                       ranges quoted
                                                      but Chinese cut-
                                                       off used (50)

Li et al., 2015 [113]              3          3         SDS severity
                                                       ranges applied
                                                       to raw scores
Hirao, 2015 [114]

Lou et al., 2015 [115]             2          2       Chinese cut-off
                                                      used (50 index):
                                                      ranges: 50-59;
                                                         60-69; 70+
Yang et al., 2015 [116]

Trento et al., 2015 [117]          3          3        "SAS" severity
                                                           ranges

Notes. Zung analysis classifications; 1: consistent use of raw
scores; 2: consistent use of index scores; 3: inconsistent
application; 4: unclear whether consistent or not; 5: not utilized.

Table 4: Number of papers applying severity ranges correctly and
incorrectly.

                                SDS (n = 60)   SAS (n = 60)

Severity ranges not used            37             40
Consistent use: raw scores           2              2
Consistent use: index scores         7              4
Incorrect use                        9              7
Unclear application                  5              7
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Title Annotation:Research Article
Author:Dunstan, Debra A.; Scott, Ned
Publication:Depression Research and Treatment
Article Type:Report
Geographic Code:9CHIN
Date:Jan 1, 2018
Words:8706
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