Journal of Affective Disorders 155 (2014) 104–109

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Journal of Affective Disorders

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Research report

Adaptation and validation of the depression, anxiety and stress scale

(DASS) to Brazilian Portuguese
Rose Claudia Batistelli Vignola a, Adriana Marcassa Tucci b,n
a
Federal University of São Paulo, Brazil
b
Department of Health, Education and Society, Federal University of São Paulo, Brazil

art ic l e i nf o a b s t r a c t

Article history: Background: Depression and anxiety have been associated with a range of symptoms that often overlap.
Received 24 September 2013 Depression, Anxiety and Stress Scale‐21 (DASS-21) is a single instrument to assess symptoms of
Accepted 22 October 2013 depression, anxiety and stress. This study aimed to adapt and validate the DASS-21 for use in the
Available online 28 October 2013
Brazilian Portuguese language.
Keywords: Methods: The DASS-21 has been adapted following the translation–back translation methodology from
Depression English to Portuguese. 242 subjects completed the following assessments: the DASS-21, the Beck
Anxiety Depression Index (BDI), Beck Anxiety Index (BAI) and the Inventory of Stress Symptoms of Lipp (ISSL).
Stress Results: The Kaiser–Meyer–Olkin (KMO) result was .949, indicating that the adequacy of the model was
Scales
high. Cronbach's alpha was .92 for the depression, .90 for the stress, and .86 for the anxiety, indicating a
Validity
good internal consistency for each subscale. The correlations between DASS scale and BDI scale, BAI scale
and ISSL inventory were strong. The factorial analysis and distribution of factors among the subscales
indicated that the structure of three distinct factors is adequate.
Limitations: Older subjects over 65 years of age were not largely represented in this sample. A study
specific to this elderly population should be conducted. Another limitation of the study was education
level. The impact of low education in its applicability should be considered.
Conclusions: The findings support the validity of the Brazilian Portuguese version of the DASS-21 and add
to the evidence of the DASS-21 quality and ability to assess emotional states separately, eliminating the
use of different instruments to assess these states.
& 2013 Elsevier B.V. All rights reserved.

1. Introduction and physiological hyperactivation (FH), which is common in

The diagnosis of depression or anxiety is associated with a
range of symptoms and organic diseases that often overlap (Clark
and Watson, 1991; den Hollander-Gijsman et al., 2012). In addic-
tion, stress has been demonstrated to be a risk factor for the
development of anxiety and depression, affecting quality of life
and hampering productivity (Kehne, 2007; Kehne and Cain, 2010).
Anxiety and depression may be described as different points on
the same “continuum”, different manifestations of the same pathol-
ogy, different syndromes associated with other mood disorders,
distinct phenomena which may develop from one to the other over
a period of time, or as different pathologies (Clark and Watson, 1991).
Clark and Watson (1991) proposed the Tripartite Model of
Anxiety and Depression that considers the following factors:
negative affect (NA), which is present in both anxiety and depres-
sion; reduced positive affect (PA), which is common in depression;
n
Correspondence to: Departamento de Saúde, Educação e Sociedade, Universi-
dade Federal de São Paulo, Rua Silva Jardim, 136, Vila Mathias, Santos/SP,
CEP 11015-020, Brazil. Tel.: þ55 13 3878 3700.
E-mail addresses: atucci@unifesp.br, adritucci@uol.com.br (A.M. Tucci).
anxiety. Issues associated with mood and affective disorders often
encompass the aspect of subjective wellbeing (or lack thereof),
such as anxiety and depression. In this sense, affectivity is related
to wellbeing, psychological distress and suffering that may or may
not be experienced by the individual (Clark and Watson, 1991).
The conceptual basis of the Depression, Anxiety, and Stress
Scale (DASS) was based on the tripartite model of anxiety and
depression. This model proposes that the disorder of affect (and its
subtypes) is a continuum between depression, anxiety and stress.
Depression is characterized by low positive affect, hopelessness,
low self-esteem and low encouragement. Anxiety is associated
with physiological hyperstimulation and stress resulting from
persistent tension, irritability and a low threshold for frustration
or disruption (Apóstolo, 2010). Thus, depression, anxiety and stress
have common features, including negative affect, emotional dis-
tress and physiological changes in the hypothalamic-pituitary-
adrenal axis (HPA) (Mello et al., 2007).
Although there are many definitions of stress, the concept of
stress has conventionally been defined as an emotional experience
accompanied by biochemical, physiological, cognitive and beha-
vioral aspects. Originally, the concept of stress arose from the

0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved.
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 R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109
observation that different types of physical or psychological
conditions threatened homeostasis and initiated a cascade of
physiological reactions, known as the “general adaptation syn-
drome” (Selye, 1936).
The present study examined the four phases of stress that were
defined by Lipp (2005) and were expanded from a three phases
model developed by Selye (1936). The stress phases proposed by
Lipp (2005) include alertness, resistance, exhaustion and near-
exhaustion. This model defines stress as “a complex reaction and
overall body components involving physical, psychological, mental
and hormonal aspects, which develops in stages or phases”.
For the DASS, stress is defined as an emotional state that varies
according to an individual evaluation of the situations experienced
as a threat, harm or challenge. The DASS requires an assessment of
demand and a secondary assessment of coping, with the symp-
toms and emotions serving as the main concept organizer of the
stressful experience as it includes stress and coping strategies
(Apóstolo et al., 2006).
Depression is an emotional and mental disorder that has a very
complex etiology, despite having well-defined symptoms. The
etiology of depression includes genetic, biological and environ-
mental factors. The environment factors model focuses on “the
emergence of depressive symptoms” (Stroud et al., 2008).
According to the conception of the DASS, depression is an
emotional disorder, but has no specific emotion. Depression may
be associated with a range of emotions, such as anxiety, anger,
guilt and shame. Depression is usually trigged by unfavorable
living conditions and may result from the experience of a great
loss or from feelings of hopeless or that life is not worth living
(Apóstolo et al., 2006).
Anxiety is a vague and unpleasant feeling of fear or apprehen-
sion that may be characterized by a tension or discomfort derived
from the anticipation of danger (Graeff, 2007). Anxiety is asso-
ciated with the perception of certain environmental contexts
(places, people, activities, etc.) that are compared to previous
experiences (memory) and that activate specific brain systems
with adaptive functions (Gray, 1987). In this sense, anxiety may be
considered as an emotion that is related to a “behavior risk
evaluation” (Graeff, 2007).
Lovibond and Lovibond (2004) developed the DASS as a single
instrument to assess symptoms of depression and anxiety in an
interactive and empirically oriented process. The authors also
identified a third factor defined as stress. Their research is based
on the tripartite model of anxiety and depression. The DASS was
conceptualized in the form of a 42 items assessment consisting of
three subscales with 14-items each. The items refer to symptoms
experienced by the subject in the previous week and use a Likert
scale ranging from 0 (“does not apply to me at all”) to 4 (“most of
the time applies to me”). Although the full version (DASS-42)
provides data on specific symptoms of each emotional state
assessed, the authors claim that the reduced version of the
instrument (DASS-21) has the same structure as the full version
but only requires half the time to complete the investigation of
symptoms (Lovibond and Lovibond, 2004).
DASS-21 has already been translated to Portuguese from
Portugal (Apóstolo et al., 2006). However, Brazilian Portuguese is
slightly different from that spoken in Portugal. Furthermore, the
sociocultural context of Brazil is quite different from that present
in Portugal. This study aimed to adapt and validate the DASS-21 for
use in the Portuguese language spoken in Brazil.
2. Method
The present study aimed to measure the properties and psycho-
metric equivalence of the DASS-21 in a Brazilian sociocultural context.
105
The instrument's validity was defined by its ability to demonstrate
that it measures the indicators it is intended to measure, in this case,
emotional state disorders.
2.1. Participants
The study included patients and caregivers in an outpatient
setting in the city of Santo André/São Paulo, Brazil. Data were
collected from November 2011 to May 2012. Inclusion criteria
included an age between 18 and 75 years and frequent visits to the
clinic.
2.2. Procedures
The DASS-21 original English version was sent to a bilingual
teacher (English – Portuguese) for translation to Portuguese
(version 1, V1). V1 was given to a teacher of Portuguese language
for semantic adjustments and idiosyncratic differences (version 2,
V2). Together with the researcher and other mental health care
professionals, V2 was compared to the final Portuguese version
tested in Portugal. Analysis of content, meaning and adaptations
were made to the Portuguese language used in Brazil to ensure an
understanding of the content (Beaton et al., 2000). The scale was
then translated back to the original language (English). In this
sense, the goal was to minimize semantic interpretations and
misunderstandings, to ensure the best possible adaptation to the
Brazilian culture.
A pre-test was conducted with a sample of six subjects during
an outpatient medical visit, which revealed no difficulties in
understanding the content of the statements. The scale was later
applied to a pilot group (N ¼48) with similar characteristics to the
final sample. The assessment was answered pertinently, thereby
demonstrating the subjects had a comprehension and under-
standing of the propositions.
A back or reverse translation of the scale from Brazilian
Portuguese to the original form written in Australian English was
performed. This back translation was performed by a native
teacher of the English language without prior knowledge of the
original scale.
2.3. Subjects
Participants were invited to participate in the study during the
period in which they visited an outpatient clinic for consultations
and examinations. The subjects completed the following assess-
ments: the DASS 21, the Beck Depression Inventory (BDI), the Beck
Anxiety Inventory (BAI) and the Inventory of Stress Symptoms of
Lipp (ISSL). The completion of all four instruments lasted 30 min
on average.
2.4. Instruments
To validate the DASS, other previously validated instruments were
included in the assessment: the BDI for depression (Beck et al., 1961;
Gomes-Oliveira et al., 2012; Gorenstein and Andrade, 1996;
Gorenstein et al., 1999;), the BAI for anxiety (Beck et al., 1988;
Gorenstein and Andrade, 1996) and ISSL for stress (Lipp, 2005). Beck
instruments were used in the construction of the full version DASS
that consists of 42 items. There is no instrument in the literature that
is comparable to the DASS stress subscale. This subscale has affinities
with measures of negative affect and was originally compared to
scales that measure risk for coronary heart disease (Lovibond and
Lovibond, 2004). The emphasis in these previous studies was to
evaluate certain traits or symptoms, not the emotional state itself
(Lovibond and Lovibond, 2004). The stress subscale was compared to
a developed and validated Brazilian instrument known as the
106 R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109

Table 1
DASS subscales and assessed symptoms.

Subscales Depression Anxiety Stress

Symptoms Inertia; Excitation of the autonomous nervous system; Difficulty to relax;

Anhedonia; Musculoskeletal effects; Nervous excitation;
Dysphoria; Situational anxiety; Easy perturbation/agitation;
Lack of interest/involvement; Subjective anxiety Irritability/exaggerated reaction Impatience.
Self-depreciation; Experiences.
Devaluation of life;
Discouragement.

Table 2 confidentiality regarding identifying information, the possibility

DASS severity ratings (Lovibond and Lovibond, 2004). of access to the final data from the study and option to end
participation at any time during the study.
Z Escore Percentile DEPRESSION ANXIETY STRESS

Normal o0,5 0–78 0–9 0–7 0–14 2.6. Statistical analysis

Mild 0,5–1,0 78–87 10–13 8–9
Moderate 1,0–2,0 87–95 14–20 10–14
Severe 95–98 21–27 15–19
2,0–3,0
Extremely severe 4 3,0 98–100 28 þ 20 þ
Inventory of Stress Symptoms of Lipp (Lipp, 2005), which is widely
used in research in Brazil to evaluate stress.
The DASS-21 is a self-report assessment that contains three
subscales scored on a Likert four point scale (0, 1, 2 and 3), ranging
from 0 (“Strongly Disagree”) to 3 (“Totally Agree”). Each subscale
of the DASS consists of seven items that evaluate the emotional
states of depression, anxiety and stress.
Table 1 shows the symptoms evaluated by the DASS assessment
by each subscale: depression, anxiety and stress.
The individual questions rate how the individual was feeling in
the last week. There are four possible answers for severity or
frequency, ranging on a scale from 0 to 3. The final result is
obtained by summing the scores of the items on each subscale.
Table 2 shows the cutoff points given by the authors (Lovibond
and Lovibond, 2004) to evaluate the level of severity through the
sum of scores. To calculate the final score of the DASS-21, total
scores for each subscale were multiplied by two.
The BDI was created by Beck et al., (1961) and consists of a self-
report questionnaire with 21 multiple-choice items. It is an instru-
ment used to measure the severity of depressive episodes. This
instrument is widely used by health professionals and researchers in
a variety of clinical and research settings.
The BAI was created by Beck et al., (1988) and consists of a self-
report questionnaire with 21 questions used to measure the
severity of an individual's anxiety. There are four possible answers
in terms of severity or frequency, including “Absolutely not”,
“Lightly”, “Moderately” and “Severely”. The final result is obtained
by summing the individual scores, ranging from 0 (absence of
anxiety) to 3 (severe anxiety).
The ISSL was developed by a Brazilian researcher, Marilda Lipp
(2005). This assessment is a questionnaire that evaluates stress in
four levels – alert, resistance, almost exhaustion and exhaustion.
The instrument assesses the presence of symptoms and how the
individual has felt in the last 24 h, in the last month and in the last
3 months. For each period of time, a set of 15 physical and
emotional symptoms is evaluated for the first 2 periods and 23
symptoms are evaluated for the last period.
15–18
19–25
26–33
Data were processed and analyzed using the Statistical Package
34 þ for the Social Sciences – SPSS version 18.0 for Windows (SPSS Inc.
Released, 2009). The Pearson correlation test (r) and the Kaiser–
Meyer–Olkin (KMO) Bartlett's test were used to evaluate the
psychometric properties (reliability and validity) with a confi-
dence level of 95% and a p o.05. The Cronbach's alpha coefficient
was used to evaluate the internal consistency of the instrument.
Exploratory factor analysis of principal components with
orthogonal varimax rotation (Streiner and Norman, 2003) assessed
the construct validity. To complement the factor analysis, the
correlation between the items and the total scores of each subscale
were analyzed. This analysis was used to indicate the structural
validity and to demonstrate that each construct measured speci-
fically what it was intended to measure. A good validity for the
item was demonstrated by a substantially higher correlation of
the item with the subscale to which it belonged compared to the
correlation with the other subscales for which it did not belong.
3. Results
A total of 242 subjects, aged 18–75 years (mean¼ 39.9 years;
standard deviation ¼ 12.4 years), participated in the study. The
majority of subjects were women (62%).
The KMO test result was .949 (x² ¼3542.253, p o.01), indicating
that the adequacy of the model was high.
Cronbach's alpha was .92 for the depression subscale, .90 for
the stress subscale and .86 for the anxiety subscale, indicating a
good internal consistency for each subscale. These results also
provide evidence that each subscale measured what it proposed to
measure and that subjects who responded to the questions under-
stood them in the same way. The variable distribution according to
its factorial loading in each of the three factors (subscales) is
shown in Table 3.
The findings also indicate a strong correlation between the
DASS-21 and the others scales, BDI, BAI and ISSL. The correlation
between the depression subscale and the BDI was .86. The
correlation between the anxiety subscale and the BAI was .80.
The correlation between the stress subscale and the ISSL was .74.
The results provide evidence for the convergence between theo-
retically equivalent concepts.

2.5. Ethical considerations 4. Discussion

This study was approved by the Ethics in Research Committee The relationship between anxiety and depression has been
of the Federal University of São Paulo, Brazil (1749/11) and written complex despite several decades of research aimed at under-
informed consent was obtained. Participants were guaranteed standing this interaction. They might be different points on the
 R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109 107

Table 3
Main component matrix with varimax rotation forced to three factors (depression, stress and anxiety) and correlation matrix of DASS-21 items (n¼ 242).

ITEM Factor loadings

Depression Stress Anxiety

D16 I didn't feel enthusiastic about anythinga .747 .417 .264

D17 I felt like i was worthless as a persona .743 .347 .222
D10 I felt I had no desire for anythinga .728 .308 .258
D13 I felt depressed and had no motivationa .707 .397 .307
D21 I felt there was no meaning to lifea .657 .219 .471
D3 I didn't experience any positive feelingsa .622 .387 .193
D5 It was hard for me to have the iniciative to do thingsa .494 .386 .259
D18 I felt like I was being a little too emotional/sensitiveb .572 .497 .307
D6 I intended to exaggerate when I reacted to situationsb .217 .749 .163
D8 I felt I was always nervousb .299 .675 .393
D12 I found it difficult to relaxb .397 .671 .236
D11 I felt restless .363 .665 .255
D1 I found it difficult to calm myselfb .299 .657 .332
D14 I was intolerant of the things that kept me from continuing to do what I had been doingb .403 .653 .205
D20 I felt afraid for no reasonc .364 .205 .730
D9 I got worried about situations in which I could have panicked and looked ridiculousc .248 .335 .688
D19 I knew my heartbeat had changed even though I hadn't done anything physically rigorous (for exemple. increased heart rate. .493 .094 .605
irregular heartbeat)c
D2 My mouth felt dryc .064 .399 .586
D15 I felt like I was going to panicc .371 .381 .585
D7 I felt shaky (for example. in my hands)c .123 .351 .585
D4 I had difficulty brething at times (such as wheezing and breathlessness without having made any physical effort)c .453 .028 .560

α (total: .95) .92 .90 .85

% Explained variance (total: 63.679) 23.850 21.416 18.414

n
Kaiser–Meyer–Olkin measure of sampling adequacy: 949.
Bartlett's test of sphericity (Approx. χ2): p ¼.000 3542.253.
a
Depression items.
b
Stress items.
c
Anxiety items.

same “continuum” mood/affective disorders or distinct disorders.
On the other hand, stress is closely related to both depression and
anxiety and may lead to the onset of either or both disorders
(Kehne, 2007; Kehne and Cain, 2010). The DASS-21 scale was
based on the tripartite model of anxiety and depression, which
indicates a continuum between depression, anxiety and stress
(Clark and Watson, 1991).
This study aimed to validate the DASS-21 to Brazilian Portu-
guese. The strong correlations (.86, .80 and .74) between instru-
ments provided evidence for the validity of measuring depression,
anxiety and stress as emotional states.
Furthermore, the factor analysis indicated that the most sui-
table structure included three factors according to the original
scale (Lovibond and Lovibond, 2004). The factor loadings, which
measure the correlation of the item with an individual factor,
distributed the items in the subscales in a very similar way
compared to the original scale: .81 for depression, .83 for anxiety
and .81 for stress (Lovibond and Lovibond, 2004).
The results obtained in the current study support a positive
evaluation of the quality of the DASS-21 compared to other
validation studies of the same scale. In an earlier Spanish study
(Daza et al., 2002), the alpha values were .96 for the total scale, .93
for depression, .86 for anxiety and .91 for stress.
An evaluation study of the psychometric properties of the DASS-
21 applied to 222 older patients in Houston (EUA) had an alpha equal
to .94 for the total scale and .87, .89 and .69 for the subscales of
depression, anxiety and stress, respectively (Gloster et al., 2008).
Other studies supported favorable psychometric properties of the
DASS when applied to adults with anxiety and/or mood disorders
(Antony et al., 1998; Brown et al., 1997; Clara et al., 2001; Crawford
and Henry, 2005); Covic et al., 2012). The studies showed good
internal consistency with the DASS in its full version (DASS-42) and
its short version (DASS-21), which had values ranging from .91 to .97
for depression, .81 to .92 for anxiety and .88 to .95 for stress.
Considering the three factors proposed by the original scale, as
mentioned above, the structure of the current construct had a very
similar distribution of the subscales compared to the original model.
However, item 18 which stated “I felt I was emotional/too sensitive”
was characterized as a depressive symptom in this study but was
initially proposed as a stress symptom. Factor loading was used to
indicate how each item (variable) contributed to the formation of the
factor. Thus, this item had a factor loading of .572 in factor 1, which
grouped the variables that measure depression, and a factor loading
of .497 in factor 2, which grouped the variables that measure stress
(the original location of the item). This difference may have occurred
due to cultural differences in Brazil, given that it is possible the
emotional sensitivity was related to the excessive sadness and
unpleasant events characteristic of depression.
Furthermore, the phrase on the original scale written as “I felt I
was rather touchy” was translated to “I felt I was very irritable” in
the Portugal version (Apóstolo et al., 2006) and “I felt that I was a
bit emotional/too sensitive” in this Brazilian version. When the
same phrase was written in the back-translated version, the
translation “I felt like I was being a little too emotional/sensitive”
was quite different from the original meaning. Thus, the original
English expression did not have an equivalent term in the
semantics of Portuguese language in either Brazil or Portugal.
In the validation study of the DASS-21 for the Spanish language
(Daza et al., 2002), the three-factor structure explained the data
more clearly. The depression subscale was highly correlated with
the BDI (.86). The anxiety subscale was highly correlated with the
BDI (.82). Comparing the correlation results between the stress
subscale and the Beck Anxiety and Depression Inventories, the
correlation index was highest between stress and depression (.74).
108 R.C.B. Vignola, A.M. Tucci / Journal of Affective Disorders 155 (2014) 104–109
The results of this study indicate that the structure of three
separate factors is closer to that originally proposed by the authors
of the DASS-21 as a means to evaluate three different but
correlated emotional states.
From a phenomenological standpoint, anxiety and depression
are clearly distinct phenomena. However, it has been very difficult
to compare and understand both constructs empirically and to
understand the relationship between the two emotional states.
This study provides further support that depression, anxiety and
stress are distinct phenomena. Based on the data obtained, it can
be argued that the constructs under consideration may be differ-
ent points along the same continuum and may share some
common symptoms as proposed by Clark and Watson (1991) in
their Tripartite Model of Anxiety and Depression.
According to Apóstolo et al. (2011), major depression occurs
through a process very similar to a continuous physiological process
and to chronic stress. The authors argued that the experience of
continuous negative effects may cause general distress in the
individual that may result in recurrent disturbances of brain struc-
tures underling some depression disorders (Apóstolo et al., 2011).
In this context, it is possible to assume that there will inevitably
be a substantial comorbidity between the two disorders and their
symptoms.
Anxiety can be defined as an emotional state associated with
the future, which consists of psychological and physiological
components that are part of the normal spectrum of human
experience (Bernik and Lopes, 2011). According to these same
authors, stress may progress to pathological anxiety and/or
depression. In this sense, anxiety or depression may be two
symptoms of the same disease, thereby increasing the difficulty
of diagnosing the symptoms.
However, although stress subscale has some affinities with the
anxiety subscale, it is also related to the depression subscale.
Stress factors may be perceived as negative events, such as social
losses and psychological suffering. However, the meaning of these
events must be considered for each individual.
It is worth mentioning that not all individuals with anxiety
have depressive symptoms or vice versa. Some individuals with
anxiety disorders are free of depressive symptoms or the symp-
toms are insignificant. Pure anxiety without depressive symptoms
is more common than pure depression without anxiety symptoms.
The comorbidity between anxiety and depression was 57% in a
validation study of the Portuguese version of the DASS-21 com-
pleted in Portugal (Apóstolo, 2010). The high co-occurrence of
symptoms of anxiety and depression suggests that the identifica-
tion of these symptoms may clarify the etiology of these two
disorders.
In addition to the affective-emotional states and their respec-
tive contexts, studies of depression, anxiety and stress should
consider the cognitive issues related to thoughts and individual
perceptions of life events.
This study has some limitations that should be considered.
Older subjects over 65 years of age were not largely represented in
this sample. Given the increased prevalence of individuals of
advanced age who suffer from depression and anxiety, a study
specific to this elderly population should be conducted. Another
limitation of the study is education level. In this sample, all
respondents were literate and most individuals had received a
high school degree. Possible difficulties in understanding the scale,
which assesses subjective emotional states, and the impact of low
education in its applicability should be considered.
Despite these limitations, the findings of our study support the
reliability and validity of the DASS-21 to be used in the Portuguese
language spoken in Brazil. The validity of the Brazilian Portuguese
version of the DASS-21 is supported by evidence of its quality and
ability to assess emotional states separately, ensuring the
legitimacy of each subscale as an independent measure. Moreover,
the current findings support the use of the DASS-21 for the initial
diagnosis and evaluation of therapeutic measures. However, cul-
tural and social issues should be considered in understanding
stress as an emotional state, which may predict or aggravate
depression and anxiety disorders.
This study provides further support for methodology aimed at
identifying symptoms of depression, anxiety and stress using a
validated instrument. The DASS-21 enables a more accurate
diagnosis of these disorders by different professionals outside
the field of psychiatry, eliminating the use of different instruments
to assess these states. This also facilitates seeking earlier treatment
and referring an individual for specialized treatment when con-
gruent with the individual's needs.
Role of funding source
First author got a scholarship for her master degree from Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior (CAPES). CAPES had no further role
in study design; in the collection, analysis and interpretation of data; in the writing
of the report; or in the decision to submit the paper for publication.
Conflict of interest
Authors declare that there is no conflict of interest.
Acknowledgments
The authors thank to Souza, A.A.L. for helping in analysis and to the
Cardiologists Partners-Owners of Clinica Eucor, who supported this research and
allowed data collection.
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