Use of the Hospital Anxiety and Depression Scale (HADS) to evaluate anxiety and depression in fibromyalgia patients | Revista de Psiquiatría y Salud Mental (English Edition)

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Among the various relevant emotional factors in fibromyalgia, anxiety and depression are the most prominent pathologies associated with the illness. Some authors<a class="elsevierStyleCrossRef" href="#bib0045">9</a> have shown that 60% of fibromyalgia patients suffer from depression. Consequently, the possible presence of anxiety and depression in fibromyalgia patients should be assessed.The Hospital Anxiety and Depression Scale (HADS)<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> has been used widely to measure levels of anxiety and depression in samples of patients with arthritis or cancer, women with postpartum depression and patients with traumatic cerebral lesions, among others.<a class="elsevierStyleCrossRefs" href="#bib0060">12–16</a> In these samples, good psychometric properties have been observed.<a class="elsevierStyleCrossRefs" href="#bib0070">14,16,17</a> Although there are many questionnaires for evaluating depression and anxiety, the HADS is considered useful<a class="elsevierStyleCrossRef" href="#bib0015">3</a> in assessing fibromyalgia. Given the existing overlap between medical and psychological symptoms of the illness, this questionnaire is more appropriate as it focuses on evaluating the cognitive aspects of anxiety and depression,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> thus accrediting its sensitivity as well.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Despite its usefulness, no studies have been published to date that describe its use with patients with fibromyalgia.Psychological factors, such as anxiety and depression, should be compared with severity and syndrome development criteria. Objective criteria are not part of patient-completed questionnaires, making clarification of the comparison easier. Even though other authors have questioned the usefulness of considering the number of tender points, the scientific community<a class="elsevierStyleCrossRef" href="#bib0095">19</a> widely accepts the use of this count. The second index is the patient's work situation; this index assesses the severity of the syndrome and shows how it affects the patient's social and personal life.The objective of this study was to ascertain the usefulness of the HADS in evaluating emotional aspects related to patients with fibromyalgia.MethodsParticipantsThe sample consisted of a total of 301 patients, 10 males and 291 females, with a mean age of 48.7years. The patients lived in cities and had been diagnosed with fibromyalgia according to classification by the American College of Rheumatology (ACR).<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The sample was recruited from 15 rheumatology clinics across the country. Patients were excluded if they displayed severe functional limitations and cardiovascular or respiratory disorders that limited their aerobic capacity. Patients were also excluded if they suffered from uncontrolled psychiatric disorders, had a legal claim in process related to their illness or were participating in another clinical study at the time. After patients were accepted for the study, they signed an informed consent form to participate. The patients formed part of a broad study<a class="elsevierStyleCrossRef" href="#bib0100">20</a> in which various different questionnaires were used, in addition to an exploratory examination of the symptoms of the illness. Demographic characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The clinical research ethics committee at the Gregorio Marañon Hospital (Madrid, Spain) approved the study protocol.ProcedureThe study was carried out between January and April of 2007. Data were obtained in 2 stages. In the first, an interview was performed and the patient's clinical history was reviewed to determine their suitability for the study. They were then informed and asked to participate. In the second stage, they were given various different questionnaires and tests, as previously mentioned.The variables to consider in this study were the HADS scores, the number of tender points—according to the ACR—and the patient's work situation: no occupational disability, temporary occupational disability and permanent occupational disability. The HADS used was the version by Tejero et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>Data were analysed with the SPSS program, version 16.0. A confirmatory factor analysis was performed using AMOS version 16 to verify the structure of the scale. The adjustment of data to various different models was studied, including the original 2-factor model proposed by Zigmond and Snaith<a class="elsevierStyleCrossRef" href="#bib0055">11</a> and a series of 3-factor models: McCue et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Dunbar et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Cacci et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> and Friedman et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> In all the analyses, the goodness-of-fit test (GOF) was statistically significant (P<.001), which revealed that 1 part of the variance was not explained by the model. In addition, other indexes were considered, such as that proposed by Byrne,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> the GOF<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> and Bentler's<a class="elsevierStyleCrossRef" href="#bib0145">29</a> Comparative Fit Index (CFI) Values higher than 0.90 show a good fit on the CFI, Adjusted Goodness-of-Fit Index (AGFI), Normalised Fit Index (NFI) and CFI indexes.<a class="elsevierStyleCrossRefs" href="#bib0150">30–32</a> A value lower than Akaike's Information Criterion (AIC), Root Mean Square Error of Approximation (RMSEA) and Consistent AIC (CAIC) showed good adjustment to the model.<a class="elsevierStyleCrossRefs" href="#bib0160">32–34</a>In an effort to study the differences between HADS scores related to the number of tender points and work situation, a t-test analysis was used. A regression analysis was also used to explain the relationship between those variables.ResultsOn the HADS anxiety scale, patients achieved a mean score of 12.68 with a standard deviation (SD) of 4.35. On the depression scale, the mean score was 10.12 (SD=4.96). Regarding their work situation, a total of 171 patients had not lost their job (56%), 36 were on leave (12%) and the rest were mostly homemakers. Finally, regarding the number of tender points, the mean was 15.23 (SD=2.55, range 11–18). Applying the cut-off values proposed by Snaith and Zigmond<a class="elsevierStyleCrossRef" href="#bib0050">10</a> for anxiety scores, 240 patients (79.7%) showed possibly clinically relevant levels of anxiety (scores of 8 or higher) and 172 (57.1%) showed probably clinically relevant levels of anxiety (score of 11 or higher). Regarding the depression scores, applying the same cut-off points, 169 patients (55.8%) showed possibly clinically relevant levels of depression and 105 (34.9%) showed probably clinically relevant levels of depression.According to the results of the confirmatory factor analysis, shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, the model that was best adapted to the data from our study was that proposed by Cacci et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> given that it complied with the largest number of goodness-of-fit criteria. This model accounted for the existence of 3 factors designated as anxiety (items 1, 5, 9 and 13), agitation (7, 11 and 14) and depression (2, 4, 6, 8, 10, 12 and 14). The resulting model is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Reliability was studied with the use of Cronbach's alpha coefficient. A value of 0.83 was obtained for the anxiety subscale and 0.87 for the depression subscale. On the anxiety scale with Cacci et al.’s<a class="elsevierStyleCrossRef" href="#bib0120">24</a> model, a value of 0.79 was obtained for anxiety and 0.63 for agitation. All of the anxiety items showed significant correlations with the complete scale. The depression items also presented a significant correlation with the complete scale. All were positive correlations. The correlation between the anxiety scale and the depression scale was 0.65 (P<.01). On the 3-factor scale, the correlations were 0.63 (P<.01) for the anxiety and agitation scales, 0.65 (P<.01) for the depression and anxiety scales and 0.71 (P<.01) for the depression and agitation scales. The correlation between the anxiety scale with the 2-factor solution and the anxiety and agitation factors was 0.94 (P<.01) and 0.76 (P<.01), respectively.Tender pointsThe sample was analysed using the number of tender points as a criterion for characterising the syndrome. The distribution of the sample according to this variable was spread out (kurtosis g2=−1.26, which indicates a platykurtic distribution). It was thought that dividing the sample according to the number of tender points would contribute to its segmentation by using a criterion relevant to its own definition as an illness. Three groups were used, corresponding to the 3 quartiles on the distribution of the number of tender points. The first quartile included patients with 15 points or less and the third quartile included patients with 18 points.2-factor solutionBelow the first quartile, the mean was 12.34 (SD=4.58) on the anxiety scale and 9 (SD=4.79) on the depression scale. On the third quartile, the mean was 12.68 (SD=4.35) for the anxiety scale and 10 (SD=4.96) for the depression scale. The t-test did not identify any statistically significant differences.In a multiple regression analysis with tender points as a dependent variable and anxiety and HADS depression scores as the independent variables, a model was obtained that included depression but explained a small percentage of variance: R2=0.26, adj. R2=0.22 with a beta of 0.85, t=2.803, P<.005 (CI 95%, 0.025–0.145).3-factor solutionBelow the first quartile, the mean was 9.1 (SD=3.38) for anxiety and 4.67 (SD=4.1) for agitation. On the third quartile, the mean was 9.3 (SD=1.77) for anxiety and 4.87 (SD=1.97) for agitation. The depression scores were the same as in the 2-factor solution. The t-test did not identify any statistically significant differences.In a multiple regression analysis with tender points as a dependent variable and HADS scores for anxiety, agitation and depression as independent variables, a model was obtained that included agitation: R2=0.43, adj. R2=0.39 with a beta of 0.274, t=3.648, P<.000 (CI 95%, 0.126–0.422).Work situationThe sample was also analysed regarding the patients’ work situations. The descriptive data are presented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>2-factor solutionIn the t-test, statistically significant differences were observed regarding depression between no occupational disability and temporary occupational disability (t=−2.694, P<.008, CI 95% −3.803 to −0.589). There were also significant differences between no occupational disability and permanent occupational disability regarding anxiety (t=−2.839, P<.005, CI 95% −3.691 to −0.666) and depression (t=−4.633, P<.000, CI 95% −5.599 to −2.257).3-factor solutionThere were also significant differences between no occupational disability and temporary occupational disability regarding depression (t=−2.041, P<.008, CI 95% −3.803 to −0.589) and anxiety (t=−2.041, P<.042, CI 95% −1.213 to −0.594). Likewise, there were significant differences between no occupational disability and permanent occupational disability regarding anxiety (t=−2.914, P<.004, CI 95% −1.828 to 0.627), depression (t=−4.633, P<.000, CI 95% −5.599 to −2.257) and agitation (t=−3.157, P<.002, CI 95% −1.073 to 0.340).The multivariate logistic analysis showed that only depression was associated with work situation: temporary occupational disability (odds ratio 1.16, CI 95% 1.03–1.30) and permanent occupational disability (odds ratio 1.2, CI 95% 1.08–1.33).DiscussionThis study revealed the usefulness of the HADS questionnaire in its application to patients with fibromyalgia. The confirmatory factor analysis showed that the 3-model factor by Cacci et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> gave the best statistical adaptation. This model modified the anxiety scale, identifying the anxiety and agitation scales instead. However, its high correlation with the original scale, as well as its inability to differentiate patients with fibromyalgia brought the usefulness of the structure into question. The Dunbar et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> model, based on patients with chronic fatigue, did not add anything to the variables being studied, either. It may thus be more sensible to maintain the 2 original subscales.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a>The reliability observed according to Cronbach's alpha coefficient was considered appropriate and similar to that observed in other studies.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> The correlations observed between the anxiety and depression scales were also congruent with those indicated in the references,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> all of which verified the usefulness of the HADS in patients with fibromyalgia.As shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>, comparing the results in descriptive terms, there were higher levels of anxiety and depression in patients with fibromyalgia compared to the normal population (adults and students). It was even more notable that, in the cases of a physical condition (patients with traumatic cerebral lesions or laryngeal cancer), the levels of anxiety and depression were lower than in patients with fibromyalgia. Still more surprising was the observation that patients with a psychiatric diagnosis (adaptive disorder or depression) presented lower levels of anxiety than patients with fibromyalgia. This was especially interesting because of its practical repercussions for the clinician, as it confirmed the need to assess the psychological aspects of the illness (anxiety and depression), given the high levels in these patients compared to those in other samples.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The mean anxiety score was higher than that observed in other studies. Of all those reviewed, only 1 study<a class="elsevierStyleCrossRef" href="#bib0180">36</a>—performed with eating disorder patients—showed a similar figure: 12.11 (4.69) compared to 12.26 (4.34) in our study. It should also be considered that our study included a patient population consisting of practically all females. This could be a factor to consider, since other authors<a class="elsevierStyleCrossRef" href="#bib0120">24</a> have observed higher scores in females (8.57) compared to males (6.74), with a statistically significant difference. Consequently, can not only the type of illness be relevant (fibromyalgia or eating disorders) but also the sex of the patient.The data obtained regarding depression were in accordance with those from other authors. McCue et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> observed similar scores in their study of patients with chronic fatigue, in that 55% of the patients presented possibly clinically relevant levels of depression and 32% presented probably clinically relevant levels of depression, compared with the 55.8% and 34.9% observed in our study. The depression scale seemed to be more stable and less subject to influence of the patient's sex (see Ref.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>).The usefulness of the HADS in clarifying the complexity of fibromyalgia syndrome depends on the state of emotional factors in this syndrome. In our study, significant differences were not observed regarding anxiety and depression when the number of tender points was used as a criterion. The regression analysis accounted for all subjects, not just those in the outermost quartiles. This analysis revealed a relationship between tender points and depression (2-factor solution), as well as depression, anxiety and agitation (3-factor solution). In this case, dividing the original anxiety scale could help clarify the relationship between emotional state and work situation.This showed that the number of tender points truly corresponds to the patient's emotional state in the terms assessed by the questionnaire, although the relationship is weak. In line with those indicated in the Thieme et al.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> study, our data seemed to suggest that anxiety and depression in fibromyalgia were relatively independent of other physical factors associated with the syndrome.Other studies, such as that of McCracken et al.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> have observed a relationship between disability and specific measurements of anxiety and fear of pain. However, the disability scores obtained by McCracken were based on the patients’ self-assessments. In our study, the determination of tender points was an objective procedure. Axford et al.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> observed that measurements of anxiety and depression with the HADS were not good predictors of arthritis severity determined by a radiological score. However, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index showed that anxiety and depression had a weak association with disability, which was measured by self-assessments. In our study, we obtained a weak relationship, and this relationship was stronger when the HADS anxiety scale was completed, differentiating the specific components of anxiety and agitation.Nonetheless, an interesting result relevant to the patients’ work situations was that the lack of work assistance correlated with the presence of anxiety and depression. It seemed that in this case, the more serious the work situation, the higher the levels of anxiety and depression measured by the HADS. The presence of depression in fibromyalgia seemed to be explained by learning principles: the loss of reinforcements produced by the difficulties in leading a normal life and the anticipation of pain can cause behavioural inhibition. This, in turn, leads to a loss of reinforcements.Another question of interest is the consideration of the HADS structure. Some authors argue that the 3-dimensional structure, which corresponds to Clark and Watson's<a class="elsevierStyleCrossRef" href="#bib0195">39</a> 3-part model is better. Surely, from a statistical point of view, the confirmatory factor analysis provides better adjustment for the 3-factor model. However, these indexes cannot be considered determinant, since they themselves show inconsistencies, such as the χ2, for example. It may be necessary to compare the usefulness of the 3-factor HADS with external criteria. In our study, the 3 exploratory factors were a bit more useful than the 2 conventional factors in differentiating the number of tender points or the patients’ work situations. The 3-factor model may be more useful, as shown in McCue et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> but this should be justified by data. Meanwhile, the application of the 2 classical factors may be more prudent. Another reason to maintain this orthodox position is the existing empirical support for the 2-factor structure and its extensive use.<a class="elsevierStyleCrossRefs" href="#bib0075">15–17,36,40–42</a>The sample was recruited in different public and private hospitals throughout Spain. The objective was to make it representative of the country's population of patients with fibromyalgia. There is a broad representation of public hospitals (see the ICAF [Combined Index of Severity of Fibromyalgia] group in the declaration of interests and acknowledgments paragraph), but it is possible that this sample was not representative of all patients with fibromyalgia.Another aspect that requires more research is the role and possible influence of the patient's sex on anxiety. It would be necessary to determine to what extent these high scores are due to the patients’ suffering from fibromyalgia. The influence of sex—not only in mean scores but also in the scale structure itself—should also be determined. At the same time, the high anxiety scores show that the emotional impact of the illness should be acknowledged.The sample in this study was formed by 291 females and 10 males. This proportion reflects that which normally exists between men and women in the patient population with fibromyalgia syndrome.This study showed the usefulness of the HADS in evaluating patients with fibromyalgia, but was not designed to validate this instrument. The HADS has been validated in the Spanish population.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> The objective of this study was to ascertain its usefulness in evaluating emotional aspects relevant to patients with fibromyalgia.ConclusionsIn short, it is possible to conclude, firstly that the HADS is a sensitive instrument for explaining the presence of anxiety and depression in patients that suffer from fibromyalgia. Secondly, the number of tender points did not seem to be related to the severity of the psychological aspects measured with the HADS in our sample. However, there certainly seemed to be a correspondence between the patients’ psychological states and the lack of work assistance.Ethical disclosuresHuman and animal protection. The authors declare that the procedures followed conformed to the ethical norms of the human experimentation committee and were in accordance with the World Medical Association and the Declaration of Helsinki.Data confidentiality. The authors declare that no patient data appear in this article.Right to privacy and informed consent. The authors declare that no patient data appear in this article.FundingThis research was funded by a grant from Pfizer Laboratory and the Health Research Fund (FIS in Spanish) PI 07/0202.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres115308" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec102599" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres115309" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Método" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec102600" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Participants" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Procedure" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0030" "titulo" => "Tender points" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "2-factor solution" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "3-factor solution" ] ] ] 1 => array:3 [ "identificador" => "sec0045" "titulo" => "Work situation" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "2-factor solution" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "3-factor solution" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Ethical disclosures" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interests" ] 12 => array:2 [ "identificador" => "xack37125" "titulo" => "Acknowledgments" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-10-13" "fechaAceptado" => "2012-01-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec102599" "palabras" => array:4 [ 0 => "Fibromyalgia" 1 => "Depression" 2 => "Anxiety" 3 => "Hospital Anxiety and Depression Scale" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec102600" "palabras" => array:4 [ 0 => "Fibromialgia" 1 => "Depresión" 2 => "Ansiedad" 3 => "Hospital Anxiety and Depression Scale" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionThe HADS is a questionnaire widely used to evaluate anxiety and depression, although its use in fibromyalgia patients has not yet been reported. The aim of this study is to know the usefulness of the HADS to evaluate the emotional aspects related to fibromyalgia patients. MethodsThis paper studies a sample of 301 fibromyalgia patients. The scientific goodness of the questionnaire is analysed, and its structure is compared with other models by confirmatory factor analysis. Two external severity indices are used, number of tender points and patient's employment situation. ResultsThe results show higher levels of anxiety than in other disorders, adequate reliability and a three-factor model with better statistical fit. Nevertheless, this structure was not shown more useful than the two-factor structure for the external criteria studied. ConclusionsThe HADS has been shown to be a useful tool for exploring the presence of anxiety and depression in fibromyalgia patients and that the number of tender points does not seem to be related to the severity of the psychological aspects measured by the HADS in our sample, while there does seem to be a correspondence between psychological condition and absence from work." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl cuestionario HADS es ampliamente utilizado en la evaluación de la ansiedad y depresión, sin embargo no hay datos sobre su utilización en pacientes de fibromialgia. El objetivo de este estudio es conocer la utilidad del HADS para evaluar los aspectos emocionales presentes en los pacientes de fibromialgia. MétodoSe estudia a una muestra de 301 pacientes de fibromialgia. Se analiza la bondad cientí-fica del cuestionario y su estructura que es comparada mediante análisis factorial confirmatorio con la obtenida en otras investigaciones. Se utilizan dos índices externos de severidad: número de puntos dolorosos y situación laboral. ResultadosSe obtienen altos niveles de ansiedad, mayores que en otros trastornos. La fiabili-dad es adecuada y un modelo de 3 factores es el que mejor se ajusta a los datos, no obstante, dicha estructura no parece ser más útil que la de 2 factores, considerando los criterios externos utilizados. ConclusiónEl HADS se ha mostrado útil para explorar la presencia de ansiedad y depresión en pacientes de fibromialgia. El número de puntos dolorosos no parece estar relacionado con la severidad de los aspectos psicológicos evaluados por el HADS, sin embargo sí parece haber una correspondencia entre estos y la situación laboral de las pacientes." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Vallejo MA, et al. Uso del cuestionario Hospital Anxiety and Depression Scale (HADS) para evaluar la ansiedad y la depresión en pacientes con fibromialgia. Rev Psiquiatr Salud Ment (Barc.). 2012;5:107–14." ] 1 => array:2 [ "etiqueta" => "◊" "nota" => "The ICAF group members that participated in obtaining information are listed in <a class="elsevierStyleCrossRef" href="#sec0085">Annex 1</a>." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "Members of the ICAF study group: C. Alegre (Vall de Hebrón Hospital, Barcelona), M. Alperi (Asturias General Hospital, Oviedo), F.J. Ballina (Asturias General Hospital, Oviedo), R. Belenguer (October 9 Hospital, Valencia), M. Belmonte (Castellón General Hospital, Castellón), J. Beltrán (Castellón General Hospital, Castellón), J. Blanch (IMAS Hospital, Barcelona), A. Collado (Clinical Hospital, Barcelona), P. Fernández-Dapica (October 12 Hospital, Madrid), F.M. Hernández (Dr. Negrín Hospital, Gran Canaria), A. García-Monforte (Gregorio Marañón Hospital, Madrid), T. González-Hernández (IPR, Madrid), J. González-Polo (La Paz Hospital, Madrid), C. Hidalgo (Rheumatology Centre, Salamanca), J. Mundo (Clinical Hospital, Barcelona), P. Muñoz-Carreño (General Hospital, Guadalajara), R. Queiró (Asturias General Hospital, Oviedo), N. Riestra (Asturias General Hospital, Oviedo), M. Salido (CLINISAS Clinic, Madrid), I. Vallejo (Clinical Hospital, Barcelona), J. Vidal (General Hospital, Guadalajara)." "etiqueta" => "Annex 1" "identificador" => "sec0085" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 895 "Ancho" => 1575 "Tamanyo" => 91182 ] ] "descripcion" => array:1 [ "en" => "The Cacci et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> model was the one best adjusted to the fibromyalgia data." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "SD, standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Work situation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Range \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26–74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evolution period for pain (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5–51.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0–14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tender points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11–18 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab203097.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main demographic characteristics found in the inclusion visit of the study in 301 patients with fibromyalgia." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">λ2 (df) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">λ2/df \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">GFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">AGFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">NFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CFI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">RMSEA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">AIC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CAIC \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">McCue et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>, Dunbar et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">114.00 (73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">178.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">328.63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Zigmond and Snaith.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">130.37 (76) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">188.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">324.87 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cacci et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>, original model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">108.85 (73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">172.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">323.48 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cacci et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>, respecified model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">138.72 (62) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">196.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">333.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Friedman et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126.48 (74) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">188.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">334.40 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab203098.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Structure of the factors from the HADS, determined using fit tests on the models derived from previous factor analysis. All λ2 analyses were statistically significant with a value of P<.001, degrees of freedom in parentheses. The fit indexes of the model are indicated in bold." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2-factor solution</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">3-factor solution</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Agitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Depression \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No work inability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">208 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.79 (4.24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.96 (4.79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.46 (3.49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.29 (1.86) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.96 (4.79) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temporary work inability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.9 (4.65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.16 (4.83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.67 (3.53) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.48 (2.18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.16 (4.83) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Permanent work inability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.97 (4.49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.89 (4.51) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.28 (3.61) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.36 (2.07) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.89 (4.51) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab203096.png" ] ] ] ] "descripcion" => array:1 [ "en" => "HADS scores, mean (standard deviation) according to work situation and factor structure." ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HADS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Controls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="9" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Hospitalised</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laryngeal cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cerebral lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postpartum depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eating disorders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic fatigue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fibromyalgia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Absence of depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Adaptive disorder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.46 (3.3)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.76 (4.59)<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.31 (5.02)<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.06 (4.9)<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.2 (3.4)<a class="elsevierStyleCrossRef" href="#tblfn0030">f</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.86 (5.01)<a class="elsevierStyleCrossRef" href="#tblfn0035">g</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.86 (4.50)<a class="elsevierStyleCrossRef" href="#tblfn0040">h</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.11 (4.6)<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.84 (4.11)<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.26 (4.34) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.02 (4.0)<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.03 (3.2)<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.77 (3.3)<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Depression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.08 (3.9)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.82 (4.32)<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (4.39)<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.59 (3.98)<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.3 (4.1)<a class="elsevierStyleCrossRef" href="#tblfn0030">f</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.23 (4.99)<a class="elsevierStyleCrossRef" href="#tblfn0035">g</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.02 (3.76)<a class="elsevierStyleCrossRef" href="#tblfn0040">h</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.91 (5.1)<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n 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\t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.23 (2.1)<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.44 (2.3)<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab203095.png" ] ] ] "notaPie" => array:8 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Terol et al.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "McCue et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Cacci et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "Quintana et al.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>" ] 4 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "e" "nota" => "Chivite et al.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>" ] 5 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "f" "nota" => "Singer et al.<a 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Original article

Use of the Hospital Anxiety and Depression Scale (HADS) to evaluate anxiety and depression in fibromyalgia patients

Uso del cuestionario Hospital Anxiety and Depression Scale (HADS) para evaluar la ansiedad y la depresión en pacientes con fibromialgia

Miguel A. Vallejoa,

Corresponding author

mvallejo@psi.uned.es

Corresponding author.

, Javier Riverab, Joaquim Esteve-Vivesc, María F. Rodríguez-Muñoza, ICAF group ◊

a Facultad de Psicología, Universidad Nacional de Educación a Distancia, Madrid, Spain

b Unidad de Reumatología, Instituto Provincial de Rehabilitación, Hospital Universitario Gregorio Marañón, Madrid, Spain

c Sección Reumatología, Hospital General Universitari d’Alacant, Alicante, Spain

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        "titulo" => "Uso del cuestionario <span class="elsevierStyleItalic">Hospital Anxiety and Depression Scale</span> &#40;HADS&#41; para evaluar la ansiedad y la depresi&#243;n en pacientes con fibromialgia"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The Cacci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> model was the one best adjusted to the fibromyalgia data&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fibromyalgia syndrome &#40;FMS&#41; is characterised by heterogeneous symptoms&#58; generalised musculoskeletal pain&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> sleep disorders and various somatic symptoms&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> along with emotional disturbances<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> that significantly affect the patient&#39;s family life overall&#44; as well as their work and personal environments&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The FMS diagnosis is based on present clinical manifestations in the patient and on the classification criteria<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> used to homogenise the populations in clinical studies&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The significance of psychological coping with the illness as well as its emotional aspects have been widely recognised in this syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In addition&#44; the relevance of negative moods<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the influence of these factors throughout the course of the illness have been highlighted&#46; Among the various relevant emotional factors in fibromyalgia&#44; anxiety and depression are the most prominent pathologies associated with the illness&#46; Some authors<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> have shown that 60&#37; of fibromyalgia patients suffer from depression&#46; Consequently&#44; the possible presence of anxiety and depression in fibromyalgia patients should be assessed&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Hospital Anxiety and Depression Scale &#40;HADS&#41;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> has been used widely to measure levels of anxiety and depression in samples of patients with arthritis or cancer&#44; women with postpartum depression and patients with traumatic cerebral lesions&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;16</span></a> In these samples&#44; good psychometric properties have been observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;16&#44;17</span></a> Although there are many questionnaires for evaluating depression and anxiety&#44; the HADS is considered useful<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> in assessing fibromyalgia&#46; Given the existing overlap between medical and psychological symptoms of the illness&#44; this questionnaire is more appropriate as it focuses on evaluating the cognitive aspects of anxiety and depression&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> thus accrediting its sensitivity as well&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Despite its usefulness&#44; no studies have been published to date that describe its use with patients with fibromyalgia&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Psychological factors&#44; such as anxiety and depression&#44; should be compared with severity and syndrome development criteria&#46; Objective criteria are not part of patient-completed questionnaires&#44; making clarification of the comparison easier&#46; Even though other authors have questioned the usefulness of considering the number of tender points&#44; the scientific community<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> widely accepts the use of this count&#46; The second index is the patient&#39;s work situation&#59; this index assesses the severity of the syndrome and shows how it affects the patient&#39;s social and personal life&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study was to ascertain the usefulness of the HADS in evaluating emotional aspects related to patients with fibromyalgia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Participants</span><p id="par0030" class="elsevierStylePara elsevierViewall">The sample consisted of a total of 301 patients&#44; 10 males and 291 females&#44; with a mean age of 48&#46;7<span class="elsevierStyleHsp" style=""></span>years&#46; The patients lived in cities and had been diagnosed with fibromyalgia according to classification by the American College of Rheumatology &#40;ACR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The sample was recruited from 15 rheumatology clinics across the country&#46; Patients were excluded if they displayed severe functional limitations and cardiovascular or respiratory disorders that limited their aerobic capacity&#46; Patients were also excluded if they suffered from uncontrolled psychiatric disorders&#44; had a legal claim in process related to their illness or were participating in another clinical study at the time&#46; After patients were accepted for the study&#44; they signed an informed consent form to participate&#46; The patients formed part of a broad study<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> in which various different questionnaires were used&#44; in addition to an exploratory examination of the symptoms of the illness&#46; Demographic characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical research ethics committee at the Gregorio Mara&#241;on Hospital &#40;Madrid&#44; Spain&#41; approved the study protocol&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Procedure</span><p id="par0040" class="elsevierStylePara elsevierViewall">The study was carried out between January and April of 2007&#46; Data were obtained in 2 stages&#46; In the first&#44; an interview was performed and the patient&#39;s clinical history was reviewed to determine their suitability for the study&#46; They were then informed and asked to participate&#46; In the second stage&#44; they were given various different questionnaires and tests&#44; as previously mentioned&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The variables to consider in this study were the HADS scores&#44; the number of tender points&#8212;according to the ACR&#8212;and the patient&#39;s work situation&#58; no occupational disability&#44; temporary occupational disability and permanent occupational disability&#46; The HADS used was the version by Tejero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Data were analysed with the SPSS program&#44; version 16&#46;0&#46; A confirmatory factor analysis was performed using AMOS version 16 to verify the structure of the scale&#46; The adjustment of data to various different models was studied&#44; including the original 2-factor model proposed by Zigmond and Snaith<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and a series of 3-factor models&#58; McCue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Dunbar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Cacci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and Friedman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In all the analyses&#44; the goodness-of-fit test &#40;GOF&#41; was statistically significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; which revealed that 1 part of the variance was not explained by the model&#46; In addition&#44; other indexes were considered&#44; such as that proposed by Byrne&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> the GOF<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> and Bentler&#39;s<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Comparative Fit Index &#40;CFI&#41; Values higher than 0&#46;90 show a good fit on the CFI&#44; Adjusted Goodness-of-Fit Index &#40;AGFI&#41;&#44; Normalised Fit Index &#40;NFI&#41; and CFI indexes&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;32</span></a> A value lower than Akaike&#39;s Information Criterion &#40;AIC&#41;&#44; Root Mean Square Error of Approximation &#40;RMSEA&#41; and Consistent AIC &#40;CAIC&#41; showed good adjustment to the model&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#8211;34</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In an effort to study the differences between HADS scores related to the number of tender points and work situation&#44; a <span class="elsevierStyleItalic">t</span>-test analysis was used&#46; A regression analysis was also used to explain the relationship between those variables&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">On the HADS anxiety scale&#44; patients achieved a mean score of 12&#46;68 with a standard deviation &#40;SD&#41; of 4&#46;35&#46; On the depression scale&#44; the mean score was 10&#46;12 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;96&#41;&#46; Regarding their work situation&#44; a total of 171 patients had not lost their job &#40;56&#37;&#41;&#44; 36 were on leave &#40;12&#37;&#41; and the rest were mostly homemakers&#46; Finally&#44; regarding the number of tender points&#44; the mean was 15&#46;23 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;55&#44; range 11&#8211;18&#41;&#46; Applying the cut-off values proposed by Snaith and Zigmond<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> for anxiety scores&#44; 240 patients &#40;79&#46;7&#37;&#41; showed <span class="elsevierStyleItalic">possibly</span> clinically relevant levels of anxiety &#40;scores of 8 or higher&#41; and 172 &#40;57&#46;1&#37;&#41; showed <span class="elsevierStyleItalic">probably</span> clinically relevant levels of anxiety &#40;score of 11 or higher&#41;&#46; Regarding the depression scores&#44; applying the same cut-off points&#44; 169 patients &#40;55&#46;8&#37;&#41; showed <span class="elsevierStyleItalic">possibly</span> clinically relevant levels of depression and 105 &#40;34&#46;9&#37;&#41; showed <span class="elsevierStyleItalic">probably</span> clinically relevant levels of depression&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">According to the results of the confirmatory factor analysis&#44; shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; the model that was best adapted to the data from our study was that proposed by Cacci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> given that it complied with the largest number of goodness-of-fit criteria&#46; This model accounted for the existence of 3 factors designated as anxiety &#40;items 1&#44; 5&#44; 9 and 13&#41;&#44; agitation &#40;7&#44; 11 and 14&#41; and depression &#40;2&#44; 4&#44; 6&#44; 8&#44; 10&#44; 12 and 14&#41;&#46; The resulting model is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Reliability was studied with the use of Cronbach&#39;s alpha coefficient&#46; A value of 0&#46;83 was obtained for the anxiety subscale and 0&#46;87 for the depression subscale&#46; On the anxiety scale with Cacci et al&#46;&#8217;s<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> model&#44; a value of 0&#46;79 was obtained for anxiety and 0&#46;63 for agitation&#46; All of the anxiety items showed significant correlations with the complete scale&#46; The depression items also presented a significant correlation with the complete scale&#46; All were positive correlations&#46; The correlation between the anxiety scale and the depression scale was 0&#46;65 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; On the 3-factor scale&#44; the correlations were 0&#46;63 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; for the anxiety and agitation scales&#44; 0&#46;65 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; for the depression and anxiety scales and 0&#46;71 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; for the depression and agitation scales&#46; The correlation between the anxiety scale with the 2-factor solution and the anxiety and agitation factors was 0&#46;94 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; and 0&#46;76 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; respectively&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Tender points</span><p id="par0075" class="elsevierStylePara elsevierViewall">The sample was analysed using the number of tender points as a criterion for characterising the syndrome&#46; The distribution of the sample according to this variable was spread out &#40;kurtosis <span class="elsevierStyleItalic">g</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;1&#46;26&#44; which indicates a platykurtic distribution&#41;&#46; It was thought that dividing the sample according to the number of tender points would contribute to its segmentation by using a criterion relevant to its own definition as an illness&#46; Three groups were used&#44; corresponding to the 3 quartiles on the distribution of the number of tender points&#46; The first quartile included patients with 15 points or less and the third quartile included patients with 18 points&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">2-factor solution</span><p id="par0080" class="elsevierStylePara elsevierViewall">Below the first quartile&#44; the mean was 12&#46;34 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;58&#41; on the anxiety scale and 9 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;79&#41; on the depression scale&#46; On the third quartile&#44; the mean was 12&#46;68 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;35&#41; for the anxiety scale and 10 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;96&#41; for the depression scale&#46; The <span class="elsevierStyleItalic">t</span>-test did not identify any statistically significant differences&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In a multiple regression analysis with tender points as a dependent variable and anxiety and HADS depression scores as the independent variables&#44; a model was obtained that included depression but explained a small percentage of variance&#58; <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;26&#44; adj&#46; <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;22 with a beta of 0&#46;85&#44; t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;803&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;005 &#40;CI 95&#37;&#44; 0&#46;025&#8211;0&#46;145&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">3-factor solution</span><p id="par0090" class="elsevierStylePara elsevierViewall">Below the first quartile&#44; the mean was 9&#46;1 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;38&#41; for anxiety and 4&#46;67 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;1&#41; for agitation&#46; On the third quartile&#44; the mean was 9&#46;3 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;77&#41; for anxiety and 4&#46;87 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;97&#41; for agitation&#46; The depression scores were the same as in the 2-factor solution&#46; The <span class="elsevierStyleItalic">t</span>-test did not identify any statistically significant differences&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In a multiple regression analysis with tender points as a dependent variable and HADS scores for anxiety&#44; agitation and depression as independent variables&#44; a model was obtained that included agitation&#58; <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;43&#44; adj&#46; <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;39 with a beta of 0&#46;274&#44; t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;648&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000 &#40;CI 95&#37;&#44; 0&#46;126&#8211;0&#46;422&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Work situation</span><p id="par0100" class="elsevierStylePara elsevierViewall">The sample was also analysed regarding the patients&#8217; work situations&#46; The descriptive data are presented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">2-factor solution</span><p id="par0105" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">t</span>-test&#44; statistically significant differences were observed regarding depression between no occupational disability and temporary occupational disability &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;694&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;008&#44; CI 95&#37; &#8722;3&#46;803 to &#8722;0&#46;589&#41;&#46; There were also significant differences between no occupational disability and permanent occupational disability regarding anxiety &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;839&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;005&#44; CI 95&#37; &#8722;3&#46;691 to &#8722;0&#46;666&#41; and depression &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;4&#46;633&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#44; CI 95&#37; &#8722;5&#46;599 to &#8722;2&#46;257&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">3-factor solution</span><p id="par0110" class="elsevierStylePara elsevierViewall">There were also significant differences between no occupational disability and temporary occupational disability regarding depression &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;041&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;008&#44; CI 95&#37; &#8722;3&#46;803 to &#8722;0&#46;589&#41; and anxiety &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;041&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;042&#44; CI 95&#37; &#8722;1&#46;213 to &#8722;0&#46;594&#41;&#46; Likewise&#44; there were significant differences between no occupational disability and permanent occupational disability regarding anxiety &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;914&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;004&#44; CI 95&#37; &#8722;1&#46;828 to 0&#46;627&#41;&#44; depression &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;4&#46;633&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;000&#44; CI 95&#37; &#8722;5&#46;599 to &#8722;2&#46;257&#41; and agitation &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;3&#46;157&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;002&#44; CI 95&#37; &#8722;1&#46;073 to 0&#46;340&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The multivariate logistic analysis showed that only depression was associated with work situation&#58; temporary occupational disability &#40;odds ratio 1&#46;16&#44; CI 95&#37; 1&#46;03&#8211;1&#46;30&#41; and permanent occupational disability &#40;odds ratio 1&#46;2&#44; CI 95&#37; 1&#46;08&#8211;1&#46;33&#41;&#46;</p></span></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">This study revealed the usefulness of the HADS questionnaire in its application to patients with fibromyalgia&#46; The confirmatory factor analysis showed that the 3-model factor by Cacci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> gave the best statistical adaptation&#46; This model modified the anxiety scale&#44; identifying the anxiety and agitation scales instead&#46; However&#44; its high correlation with the original scale&#44; as well as its inability to differentiate patients with fibromyalgia brought the usefulness of the structure into question&#46; The Dunbar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> model&#44; based on patients with chronic fatigue&#44; did not add anything to the variables being studied&#44; either&#46; It may thus be more sensible to maintain the 2 original subscales&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The reliability observed according to Cronbach&#39;s alpha coefficient was considered appropriate and similar to that observed in other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The correlations observed between the anxiety and depression scales were also congruent with those indicated in the references&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> all of which verified the usefulness of the HADS in patients with fibromyalgia&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#44; comparing the results in descriptive terms&#44; there were higher levels of anxiety and depression in patients with fibromyalgia compared to the normal population &#40;adults and students&#41;&#46; It was even more notable that&#44; in the cases of a physical condition &#40;patients with traumatic cerebral lesions or laryngeal cancer&#41;&#44; the levels of anxiety and depression were lower than in patients with fibromyalgia&#46; Still more surprising was the observation that patients with a psychiatric diagnosis &#40;adaptive disorder or depression&#41; presented lower levels of anxiety than patients with fibromyalgia&#46; This was especially interesting because of its practical repercussions for the clinician&#44; as it confirmed the need to assess the psychological aspects of the illness &#40;anxiety and depression&#41;&#44; given the high levels in these patients compared to those in other samples&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The mean anxiety score was higher than that observed in other studies&#46; Of all those reviewed&#44; only 1 study<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#8212;performed with eating disorder patients&#8212;showed a similar figure&#58; 12&#46;11 &#40;4&#46;69&#41; compared to 12&#46;26 &#40;4&#46;34&#41; in our study&#46; It should also be considered that our study included a patient population consisting of practically all females&#46; This could be a factor to consider&#44; since other authors<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> have observed higher scores in females &#40;8&#46;57&#41; compared to males &#40;6&#46;74&#41;&#44; with a statistically significant difference&#46; Consequently&#44; can not only the type of illness be relevant &#40;fibromyalgia or eating disorders&#41; but also the sex of the patient&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The data obtained regarding depression were in accordance with those from other authors&#46; McCue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> observed similar scores in their study of patients with chronic fatigue&#44; in that 55&#37; of the patients presented possibly clinically relevant levels of depression and 32&#37; presented probably clinically relevant levels of depression&#44; compared with the 55&#46;8&#37; and 34&#46;9&#37; observed in our study&#46; The depression scale seemed to be more stable and less subject to influence of the patient&#39;s sex &#40;see Ref&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The usefulness of the HADS in clarifying the complexity of fibromyalgia syndrome depends on the state of emotional factors in this syndrome&#46; In our study&#44; significant differences were not observed regarding anxiety and depression when the number of tender points was used as a criterion&#46; The regression analysis accounted for all subjects&#44; not just those in the outermost quartiles&#46; This analysis revealed a relationship between tender points and depression &#40;2-factor solution&#41;&#44; as well as depression&#44; anxiety and agitation &#40;3-factor solution&#41;&#46; In this case&#44; dividing the original anxiety scale could help clarify the relationship between emotional state and work situation&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This showed that the number of tender points truly corresponds to the patient&#39;s emotional state in the terms assessed by the questionnaire&#44; although the relationship is weak&#46; In line with those indicated in the Thieme et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> study&#44; our data seemed to suggest that anxiety and depression in fibromyalgia were relatively independent of other physical factors associated with the syndrome&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Other studies&#44; such as that of McCracken et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> have observed a relationship between disability and specific measurements of anxiety and fear of pain&#46; However&#44; the disability scores obtained by McCracken were based on the patients&#8217; self-assessments&#46; In our study&#44; the determination of tender points was an objective procedure&#46; Axford et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> observed that measurements of anxiety and depression with the HADS were not good predictors of arthritis severity determined by a radiological score&#46; However&#44; the Western Ontario and McMaster Universities Osteoarthritis &#40;WOMAC&#41; Index showed that anxiety and depression had a weak association with disability&#44; which was measured by self-assessments&#46; In our study&#44; we obtained a weak relationship&#44; and this relationship was stronger when the HADS anxiety scale was completed&#44; differentiating the specific components of anxiety and agitation&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Nonetheless&#44; an interesting result relevant to the patients&#8217; work situations was that the lack of work assistance correlated with the presence of anxiety and depression&#46; It seemed that in this case&#44; the more serious the work situation&#44; the higher the levels of anxiety and depression measured by the HADS&#46; The presence of depression in fibromyalgia seemed to be explained by learning principles&#58; the loss of reinforcements produced by the difficulties in leading a normal life and the anticipation of pain can cause behavioural inhibition&#46; This&#44; in turn&#44; leads to a loss of reinforcements&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Another question of interest is the consideration of the HADS structure&#46; Some authors argue that the 3-dimensional structure&#44; which corresponds to Clark and Watson&#39;s<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> 3-part model is better&#46; Surely&#44; from a statistical point of view&#44; the confirmatory factor analysis provides better adjustment for the 3-factor model&#46; However&#44; these indexes cannot be considered determinant&#44; since they themselves show inconsistencies&#44; such as the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#44; for example&#46; It may be necessary to compare the usefulness of the 3-factor HADS with external criteria&#46; In our study&#44; the 3 exploratory factors were a bit more useful than the 2 conventional factors in differentiating the number of tender points or the patients&#8217; work situations&#46; The 3-factor model may be more useful&#44; as shown in McCue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> but this should be justified by data&#46; Meanwhile&#44; the application of the 2 classical factors may be more prudent&#46; Another reason to maintain this orthodox position is the existing empirical support for the 2-factor structure and its extensive use&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17&#44;36&#44;40&#8211;42</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The sample was recruited in different public and private hospitals throughout Spain&#46; The objective was to make it representative of the country&#39;s population of patients with fibromyalgia&#46; There is a broad representation of public hospitals &#40;see the <span class="elsevierStyleItalic">ICAF</span> &#91;Combined Index of Severity of Fibromyalgia&#93; group in the declaration of interests and acknowledgments paragraph&#41;&#44; but it is possible that this sample was not representative of all patients with fibromyalgia&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Another aspect that requires more research is the role and possible influence of the patient&#39;s sex on anxiety&#46; It would be necessary to determine to what extent these high scores are due to the patients&#8217; suffering from fibromyalgia&#46; The influence of sex&#8212;not only in mean scores but also in the scale structure itself&#8212;should also be determined&#46; At the same time&#44; the high anxiety scores show that the emotional impact of the illness should be acknowledged&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The sample in this study was formed by 291 females and 10 males&#46; This proportion reflects that which normally exists between men and women in the patient population with fibromyalgia syndrome&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study showed the usefulness of the HADS in evaluating patients with fibromyalgia&#44; but was not designed to validate this instrument&#46; The HADS has been validated in the Spanish population&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The objective of this study was to ascertain its usefulness in evaluating emotional aspects relevant to patients with fibromyalgia&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">In short&#44; it is possible to conclude&#44; firstly that the HADS is a sensitive instrument for explaining the presence of anxiety and depression in patients that suffer from fibromyalgia&#46; Secondly&#44; the number of tender points did not seem to be related to the severity of the psychological aspects measured with the HADS in our sample&#46; However&#44; there certainly seemed to be a correspondence between the patients&#8217; psychological states and the lack of work assistance&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Human and animal protection&#46;</span> The authors declare that the procedures followed conformed to the ethical norms of the human experimentation committee and were in accordance with the World Medical Association and the Declaration of Helsinki&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Data confidentiality&#46;</span> The authors declare that no patient data appear in this article&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent&#46;</span> The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">This research was funded by a grant from Pfizer Laboratory and the Health Research Fund &#40;<span class="elsevierStyleItalic">FIS</span> in Spanish&#41; PI 07&#47;0202&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interests</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The HADS is a questionnaire widely used to evaluate anxiety and depression&#44; although its use in fibromyalgia patients has not yet been reported&#46; The aim of this study is to know the usefulness of the HADS to evaluate the emotional aspects related to fibromyalgia patients&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This paper studies a sample of 301 fibromyalgia patients&#46; The scientific goodness of the questionnaire is analysed&#44; and its structure is compared with other models by confirmatory factor analysis&#46; Two external severity indices are used&#44; number of tender points and patient&#39;s employment situation&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The results show higher levels of anxiety than in other disorders&#44; adequate reliability and a three-factor model with better statistical fit&#46; Nevertheless&#44; this structure was not shown more useful than the two-factor structure for the external criteria studied&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The HADS has been shown to be a useful tool for exploring the presence of anxiety and depression in fibromyalgia patients and that the number of tender points does not seem to be related to the severity of the psychological aspects measured by the HADS in our sample&#44; while there does seem to be a correspondence between psychological condition and absence from work&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El cuestionario HADS es ampliamente utilizado en la evaluaci&#243;n de la ansiedad y depresi&#243;n&#44; sin embargo no hay datos sobre su utilizaci&#243;n en pacientes de fibromialgia&#46; El objetivo de este estudio es conocer la utilidad del HADS para evaluar los aspectos emocionales presentes en los pacientes de fibromialgia&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudia a una muestra de 301 pacientes de fibromialgia&#46; Se analiza la bondad cient&#237;-fica del cuestionario y su estructura que es comparada mediante an&#225;lisis factorial confirmatorio con la obtenida en otras investigaciones&#46; Se utilizan dos &#237;ndices externos de severidad&#58; n&#250;mero de puntos dolorosos y situaci&#243;n laboral&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se obtienen altos niveles de ansiedad&#44; mayores que en otros trastornos&#46; La fiabili-dad es adecuada y un modelo de 3 factores es el que mejor se ajusta a los datos&#44; no obstante&#44; dicha estructura no parece ser m&#225;s &#250;til que la de 2 factores&#44; considerando los criterios externos utilizados&#46;</p> <span class="elsevierStyleSectionTitle">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El HADS se ha mostrado &#250;til para explorar la presencia de ansiedad y depresi&#243;n en pacientes de fibromialgia&#46; El n&#250;mero de puntos dolorosos no parece estar relacionado con la severidad de los aspectos psicol&#243;gicos evaluados por el HADS&#44; sin embargo s&#237; parece haber una correspondencia entre estos y la situaci&#243;n laboral de las pacientes&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Vallejo MA&#44; et al&#46; Uso del cuestionario <span class="elsevierStyleItalic">Hospital Anxiety and Depression Scale</span> &#40;HADS&#41; para evaluar la ansiedad y la depresi&#243;n en pacientes con fibromialgia&#46; Rev Psiquiatr Salud Ment &#40;Barc&#46;&#41;&#46; 2012&#59;5&#58;107&#8211;14&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">The ICAF group members that participated in obtaining information are listed in <a class="elsevierStyleCrossRef" href="#sec0085">Annex 1</a>&#46;</p>"
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            "apendice" => "<p id="par0225" class="elsevierStylePara elsevierViewall">Members of the ICAF study group&#58; C&#46; Alegre &#40;Vall de Hebr&#243;n Hospital&#44; Barcelona&#41;&#44; M&#46; Alperi &#40;Asturias General Hospital&#44; Oviedo&#41;&#44; F&#46;J&#46; Ballina &#40;Asturias General Hospital&#44; Oviedo&#41;&#44; R&#46; Belenguer &#40;October 9 Hospital&#44; Valencia&#41;&#44; M&#46; Belmonte &#40;Castell&#243;n General Hospital&#44; Castell&#243;n&#41;&#44; J&#46; Beltr&#225;n &#40;Castell&#243;n General Hospital&#44; Castell&#243;n&#41;&#44; J&#46; Blanch &#40;<span class="elsevierStyleItalic">IMAS</span> Hospital&#44; Barcelona&#41;&#44; A&#46; Collado &#40;Clinical Hospital&#44; Barcelona&#41;&#44; P&#46; Fern&#225;ndez-Dapica &#40;October 12 Hospital&#44; Madrid&#41;&#44; F&#46;M&#46; Hern&#225;ndez &#40;Dr&#46; Negr&#237;n Hospital&#44; Gran Canaria&#41;&#44; A&#46; Garc&#237;a-Monforte &#40;Gregorio Mara&#241;&#243;n Hospital&#44; Madrid&#41;&#44; T&#46; Gonz&#225;lez-Hern&#225;ndez &#40;<span class="elsevierStyleItalic">IPR</span>&#44; Madrid&#41;&#44; J&#46; Gonz&#225;lez-Polo &#40;La Paz Hospital&#44; Madrid&#41;&#44; C&#46; Hidalgo &#40;Rheumatology Centre&#44; Salamanca&#41;&#44; J&#46; Mundo &#40;Clinical Hospital&#44; Barcelona&#41;&#44; P&#46; Mu&#241;oz-Carre&#241;o &#40;General Hospital&#44; Guadalajara&#41;&#44; R&#46; Queir&#243; &#40;Asturias General Hospital&#44; Oviedo&#41;&#44; N&#46; Riestra &#40;Asturias General Hospital&#44; Oviedo&#41;&#44; M&#46; Salido &#40;<span class="elsevierStyleItalic">CLINISAS</span> Clinic&#44; Madrid&#41;&#44; I&#46; Vallejo &#40;Clinical Hospital&#44; Barcelona&#41;&#44; J&#46; Vidal &#40;General Hospital&#44; Guadalajara&#41;&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The Cacci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> model was the one best adjusted to the fibromyalgia data&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Evolution period for pain &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Number of comorbidities&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">McCue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; Dunbar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">114&#46;00 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;93</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">178&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Zigmond and Snaith&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">130&#46;37 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">188&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">324&#46;87&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cacci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#44; original model&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">108&#46;85 &#40;73&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">1&#46;49</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;04</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cacci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#44; respecified model&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">196&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">333&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Friedman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&#46;48 &#40;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">188&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">334&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab203098.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Structure of the factors from the HADS&#44; determined using fit tests on the models derived from previous factor analysis&#46; All <span class="elsevierStyleItalic">&#955;</span><span class="elsevierStyleSup">2</span> analyses were statistically significant with a value of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; degrees of freedom in parentheses&#46; The fit indexes of the model are indicated in bold&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2-factor solution</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3-factor solution</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Agitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No work inability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">208&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;79 &#40;4&#46;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;96 &#40;4&#46;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;46 &#40;3&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;29 &#40;1&#46;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;96 &#40;4&#46;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temporary work inability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;9 &#40;4&#46;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;16 &#40;4&#46;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;67 &#40;3&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;48 &#40;2&#46;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;16 &#40;4&#46;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Permanent work inability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;97 &#40;4&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;89 &#40;4&#46;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;28 &#40;3&#46;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;36 &#40;2&#46;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;89 &#40;4&#46;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab203096.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">HADS scores&#44; mean &#40;standard deviation&#41; according to work situation and factor structure&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HADS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="9" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Patients</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Hospitalised</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laryngeal cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cerebral lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postpartum depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eating disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic fatigue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibromyalgia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Absence of depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Adaptive disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;46 &#40;3&#46;3&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;76 &#40;4&#46;59&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">10&#46;31 &#40;5&#46;02&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">10&#46;06 &#40;4&#46;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;2 &#40;3&#46;4&#41;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">7&#46;86 &#40;5&#46;01&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">g</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">6&#46;86 &#40;4&#46;50&#41;<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">h</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">12&#46;11 &#40;4&#46;6&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">8&#46;84 &#40;4&#46;11&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">12&#46;26 &#40;4&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;02 &#40;4&#46;0&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">7&#46;03 &#40;3&#46;2&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#46;77 &#40;3&#46;3&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8&#46;08 &#40;3&#46;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;82 &#40;4&#46;32&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;4&#46;39&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">11&#46;59 &#40;3&#46;98&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;3 &#40;4&#46;1&#41;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;23 &#40;4&#46;99&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">g</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;02 &#40;3&#46;76&#41;<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">h</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;91 &#40;5&#46;1&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">8&#46;58 &#40;4&#46;11&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;83 &#40;4&#46;80&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;56 &#40;3&#46;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735050
Original language: English

DOI:10.1016/j.rpsmen.2012.01.004

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Year/Month	Html	Pdf	Total

2024 November	17	0	17
2024 October	76	9	85
2024 September	103	13	116
2024 August	91	6	97
2024 July	88	6	94
2024 June	85	7	92
2024 May	141	10	151
2024 April	126	18	144
2024 March	164	17	181
2024 February	160	12	172
2024 January	165	10	175
2023 December	195	13	208
2023 November	190	19	209
2023 October	150	20	170
2023 September	74	14	88
2023 August	26	4	30
2023 July	30	23	53
2023 June	37	13	50
2023 May	66	6	72
2023 April	34	5	39
2023 March	27	7	34
2023 February	26	13	39
2023 January	37	22	59
2022 December	38	19	57
2022 November	37	14	51
2022 October	35	17	52
2022 September	32	26	58
2022 August	52	37	89
2022 July	36	10	46
2022 June	48	15	63
2022 May	58	11	69
2022 April	86	21	107
2022 March	144	15	159
2022 February	174	19	193
2022 January	137	7	144
2021 December	96	11	107
2021 November	101	14	115
2021 October	45	18	63
2021 September	49	14	63
2021 August	48	8	56
2021 July	63	20	83
2021 June	48	12	60
2021 May	88	23	111
2021 April	223	53	276
2021 March	100	15	115
2021 February	98	15	113
2021 January	64	26	90
2020 December	92	31	123
2020 November	148	16	164
2020 October	87	17	104
2020 September	58	6	64
2020 August	49	7	56
2020 July	40	7	47
2020 June	39	12	51
2020 May	49	13	62
2020 April	43	12	55
2020 March	71	14	85
2020 February	93	17	110
2020 January	92	20	112
2019 December	67	25	92
2019 November	55	14	69
2019 October	83	15	98
2019 September	67	15	82
2019 August	59	18	77
2019 July	50	23	73
2019 June	135	24	159
2019 May	326	52	378
2019 April	137	9	146
2019 March	94	10	104
2019 February	54	5	59
2019 January	47	12	59
2018 December	37	7	44
2018 November	58	7	65
2018 October	54	5	59
2018 September	41	8	49
2018 August	44	10	54
2018 July	37	3	40
2018 June	22	1	23
2018 May	44	8	52
2018 April	26	3	29
2018 March	28	1	29
2018 February	10	1	11
2018 January	18	0	18
2017 December	19	3	22
2017 November	34	3	37
2017 October	19	1	20
2017 September	29	6	35
2017 August	27	4	31
2017 July	43	3	46
2017 June	70	12	82
2017 May	60	9	69
2017 April	39	5	44
2017 March	34	11	45
2017 February	39	9	48
2017 January	45	2	47
2016 December	31	5	36
2016 November	43	4	47
2016 October	36	6	42
2016 September	62	6	68
2016 August	36	8	44
2016 July	28	3	31
2016 June	24	4	28
2016 May	24	16	40
2016 April	18	6	24
2016 March	26	9	35
2016 February	17	8	25
2016 January	16	4	20
2015 December	22	2	24
2015 November	14	4	18
2015 October	21	3	24
2015 September	17	3	20
2015 August	15	1	16
2015 July	9	3	12
2015 June	9	0	9
2015 May	15	7	22
2015 April	15	7	22
2015 March	22	9	31
2015 February	12	0	12
2015 January	31	6	37
2014 December	23	4	27
2014 November	13	0	13
2014 October	18	2	20
2014 September	13	1	14
2014 August	10	1	11
2014 July	11	2	13
2014 June	11	1	12
2014 May	13	2	15
2014 April	5	1	6
2014 March	9	2	11
2014 February	3	0	3
2014 January	7	0	7
2013 December	9	0	9
2013 November	12	4	16
2013 October	12	1	13
2013 September	12	2	14
2013 August	22	1	23
2013 July	4	0	4

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