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However, the best factor structure for an oncological setting depending on the time of diagnosis is still unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>The objective of this study was to investigate the factor structure of the German\u2010language version of the HADS in order to review the use of the HADS subscales and the HADS total scale in standard psycho\u2010oncological care for cancer patients.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>\n                      A secondary data analysis of\n                      <jats:italic>N<\/jats:italic>\n                      \u2009=\u20093395 cancer patients receiving psycho\u2010oncological care was conducted to analyze 22 of the most common HADS factor models from the literature using confirmatory factor analysis. Confirmatory factor analysis was performed using weighted least squares with mean and variance adjustment (WLSMV). Additionally, measurement invariance (MI) analysis was conducted.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The results indicate that two bifactorial models (Bifactor Model 1: higher\u2010order factor\u2009+\u2009Anxiety and Depression subscale; Bifactor Model 2: higher\u2010order factor\u2009+\u2009Restlessness, Anxiety, and Depression subscale) exhibit better quality than the original two\u2010factorial structure (independent anxiety and depression scales) of the HADS (CFI: original structure\u2009=\u20090.970\u20130.971; Bifactor Model 1\u2009=\u20090.987\u20130.988; Bifactor Model 2\u2009=\u20090.990\u20130.991; TLI: original structure\u2009=\u20090.964\u20130.966; Bifactor Model 1\u2009=\u20090.982; Bifactor Model 2\u2009=\u20090.985\u20130.986; RMSEA: original structure\u2009=\u20090.082\u20130.086; Bifactor Model 1\u2009=\u20090.065; Bifactor Model 2\u2009=\u20090.053\u20130.054). The MI analysis revealed significant differences in performance between configural, metric, and scalar invariance for all three models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The results support the use of a bifactorial factor structure for the HADS\u2010D, with the original Anxiety and Depression factors\/scales operationalized, as well as an overarching factor in the form of the total sum score.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/cam4.71992","type":"journal-article","created":{"date-parts":[[2026,6,2]],"date-time":"2026-06-02T04:56:46Z","timestamp":1780376206000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Factor Structures of the Hospital Anxiety and Depression Scale in Cancer: Implications of Comprehensive Confirmatory Analysis on the German Version of the HADS in 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