Instruments
HADS (Hospital Anxiety and Depression Scale). A 14-item scale is divided into anxiety and depression subscales of 7 items each (even for depression and odd for anxiety). Each item is graded on a Likert scale of 0 to 3, with higher scores indicating more severe anxiety and despair. The combined HADS-A and HADS-D scores ranged from 0 to 21.HADS anxiety was defined as a HADS-A score ≥ 8, and HADS depression was defined as a HADS-D score ≥ 8. Anxiety and depression severity was further graded as follows: (1) mild, 8-10; (2) moderate,11-14; and (3) severe ,15-21 [26] .
The combined Zung SAS and SDS scores ranged from 0 to 100, and the Zung SAS score ≥50 was considered to indicate SAS anxiety, while the Zung SDS score ≥ 50 indicated SAD depression. Gradings for the intensity of anxiety and depression were mild (50-59), moderate (60-69), and severe (70-100) [27,28]. After thoroughly learning the contents of the scales, the participants would independently complete the HADS and SAS/SDS self-reports. The HADS and SAS/SDS scores would then be calculated and recorded by the nurses who were blind to the design of the study.