Hospital Anxiety and Depression Scale (HADS)

Purpose

The Hospital Anxiety and DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale (HADS) is a self-administered measure used to screen for the presence of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety. The HADS was developed to provide clinicians with an acceptable, reliable, valid and easy to use practical tool for identifying and quantifying depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety. The HADS can be used in a variety of settings (e.g. community, primary care, in-hospital, and psychiatry). The HADS is not intended as a complete diagnostic tool, but as a means for identifying general hospital patients who need further psychiatric evaluation and assistance (Herrmann, 1997).

In-Depth Review

Purpose of the measure

The Hospital Anxiety and DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale (HADS) is a self-administered measure used to screen for the presence of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety. The HADS was developed to provide clinicians with an acceptable, reliable, valid and easy to use practical tool for identifying and quantifying depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety. The HADS can be used in a variety of settings (e.g. community, primary care, in-hospital, and psychiatry). The HADS is not intended as a complete diagnostic tool, but as a means for identifying general hospital patients who need further psychiatric evaluation and assistance (Herrmann, 1997).

Available versions

The HADS was developed by Dr. Phillip Snaith and Anthony Zigmond in 1983.

Features of the measure

Items:
The HADS is a self-administered measure with 14 items in total that ask the client to reflect on their mood in the past week. Seven items assess depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, 5 of which are markers for anhedonia (an inability to experience pleasure), and 2 concern appearance and feelings of slowing down. Seven items assess anxiety, of which 2 assess autonomic anxiety (panic and butterflies in the stomach), and the remaining 5 assess tension and restlessness (Dunbar, Ford, Hunt, & Der, 2000). The HADS can be administered repeatedly without impacting on validityThe degree to which an assessment measures what it is supposed to measure.
, but at least one week should elapse between administrations.

Scoring:
Scores for items in each subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the HADS are summed to produce an anxiety score (HADS-A) or a depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
score (HADS-D), or can be added to produce a total score (HADS-T). Each item is rated on a 4-point scale (ranging from 0 = no not at all, to 3 = yes definitely), for a total score ranging from 0-21 for each subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
. A higher score indicates higher distress. A number of items are reverse scored (ranging from 3 = no not at all, to 0 = yes definitely), including two from the HADS-A and four from the HADS-D.

In the original publication, a score of 0 to 7 for either subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
was regarded as in the normal range, a score of 11 or higher indicating probable presence (‘caseness’) of a mood disorder, and a score of 8 to 10 being suggestive of the presence of the state (Zigmond & Snaith, 1983). A recent publication in individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. determined that an optimal balance is achieved between specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
using a cut-off score of 11 for the total HADS, and 8 for the HADS-D (Aben, Verhey, Lousberg, Lodder, & Honig, 2002).

Time:
The HADS is a brief measure, and can be completed quickly while waiting to be seen by a clinician. Administration time ranges from 2-5 minutes. An experienced clinician can score the HADS in 1 minute (Herrmann, 1997).

Subscales:
The HADS has two subscales, the HADS-A (Anxiety subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
) and the HADS-D (DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
).

Equipment:
Only the questionnaire and a pencil are required to complete the HADS.

Training:
No formal training is required for the HADS.

Alternative forms of the Hospital Anxiety and Depression Scale

The HADS can be interviewer administered in person or over the telephone for clients who may have difficulty with self-administration. However, results from a recent study of the HADS in persons in the general population aged 13-23 demonstrated that individuals aged 16-23 tended to have higher scores when interviewed over the telephone than when self-completed by post, and this was more pronounced in females (Jörngården, Wettergen, von Essen, 2006).

Client suitability

Can be used with:
The HADS can be administered to clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

• However, for clients with communication problems, an aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) specific assessment such as the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Aphasic DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
  Questionnaire (Sutcliffe & Lincoln, 1998) is recommended.

The HADS has also been validated for use with adolescents (White, Leach, Sims, Atkinson, & Cottrell, 1999); somatic and psychiatric cases; primary care patients (Olsson, Mykletun, & Dahl, 2005); and the general population.

Should not be used in:
Completion of the HADS requires that the client have adequate reading comprehension and visual ability, as it is a self-administered measure. However, in the case of illiteracy or poor vision, the items and possible responses may be read to the respondent (Snaith, 2003). Note: although a number of studies do use interviewer-administration of the HADS, to our knowledge no studies have examined the validityThe degree to which an assessment measures what it is supposed to measure.
of this form of administration in clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

If the client’s literacy is in question, it is advised that prior to allowing the client to self-administer the HADS, the clinician ask the respondent to read out a phrase from the questionnaire as a means of screeningTesting for disease in people without symptoms.
for illiteracy, as some individuals may pretend to read the statements and haphazardly underline responses (Snaith, 2003).

In what languages is the measure available?

The HADS has been translated by the MAPI Research Institute into the following languages:

Afrikaans	Finnish	Lithuanian	Swedish
Arabic	French	Malay	Tagalog
Bengali	German*	Malayalam	Tamil
Brazilian	Greek	Marathi	Telugu
Bulgarian	Gujurati	Norwegian	Thai
Chinese – Cantonese	Hungarian	Polish	Turkish
Chinese – Mandarin	Icelandic	Portugal	Urdu
Croatian	Indonesian	Punjabi	Ukrainian
Czech	Italian	Romanian	Xhosa
Danish	Japanese	Russian	Yoruba
Dutch	Kannada	Slovak
Estonian	Korean	Slovenian
Farsi	Latvian	Spanish

* The copyright for the German translations is held by Verlag Hans Huber, Bern, Switzerland. Please consult http://www.testzentrale.de/

The HADS has been translated and validated in:

• Greek (Michopoulos, Douzenis, Kalkavoura, Christodoulou, Michalopoulou, Kalemi et al., 2008)
• Hungarian (Muszbek, Szekely, Balogh, Molnar, Rohanszky, et al., 2006)
• Iranian (Montazeri, Vahdaninia, Ebrahimi, & Jarvandi, 2003)
• Punjabi living in United Kingdom (Lane, Jajoo, Taylor, Lip, Jolly, & BRUM Steering Committee, 2007)

Summary

What does the tool measure?	DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. and anxiety.
What types of clients can the tool be used for?	General hospital patients. Can be used, but is not limited to, persons with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	The HADS is a brief measure, and can be completed quickly while waiting to be seen by a clinician. Administration time ranges from 2-5 minutes. An experienced clinician can score the HADS in 1 minute (Herrmann, 1997).
Versions	The HADS was developed by Dr. Phillip Snaith and Anthony Zigmond in 1983. It is intended to be self-administered but can be interview administered in person or over the telephone for clients who may have difficulty self-administering the measure.
Other Languages	Translated and validated in: Greek; Hungarian; Iranian; Punjabi living in United Kingdom The HADS has been translated but not necessarily validated in 51 languages (see HADS module for the full list of translations).
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: Out of two studies examining internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the HADS in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. clientele, one reported excellent and one adequate to excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.. Test-retest: No studies have examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the HADS in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Concurrent: The concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the HADS has not been examined in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population. Studies that have examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the HADS in other populations report excellent correlations between the HADS and Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Inventory, the General Health Questionnaire, the Clinical Anxiety Scale, the Spielberger’s State-Trait Anxiety Inventory, and the Montgomery Asberg DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Rating Scale. Adequate to excellent correlations found between the HADS and the Symptom Checklist-90 Scale. Adequate correlations between the HADS-A and the Hamilton Anxiety Rating Scale. Construct: One review article of 18 studies found excellent mean correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the HADS-A and HADS-D. In another review, seven studies found adequate to excellent correlations between HADS-A and HADS-D in non-patient samples, and two studies reported adequate correlations in psychiatric patients.
Does the tool detect change in patients?	In a study of 200 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., the mean correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. and anxiety subscales of the HADS was found to be excellent.
Acceptability	HADS is typically self-administered, however it can be interview administered in person or by telephone for clients who are unable to self-administer the measure. The HADS is not recommended for use with clients with communication problems.
Feasibility	The HADS is a short, self-administered screeningTesting for disease in people without symptoms. tool. It takes only one minute to score by an experienced clinician and no special equipment is required.
How to obtain the tool?	The original HADS is available as an appendix in Zigmond and Snaith (1983). A copy of the article is available by clicking here. The HADS is also available from the following website: http://shop.gl-assessment.co.uk/home.php?cat=417.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the HADS in individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Although the psychometric properties of the HADS have been well established in other patient populations, there are few studies to date that have examined the psychometric properties of the HADS in individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Floor/Ceiling Effects

According to the commentary by Herrmann (1997) in his review, the HADS does not include severe pathological symptoms of the two disorders (anxiety and depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
). This was done to enhance sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of the HADS to mild cases, thus avoiding the potential for a ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." often encountered with psychiatric questionnaires used for medical patients.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Aben, Verhey, Lousberg, Lodder, and Honig (2002) administered the HADS to 200 patients one month following a first ever ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and found the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the HADS to be excellent, with a Cronbach’s alpha = 0.85.

Johnston, Pollard, and Hennessey (2000) administered the HADS to 68 individuals with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. within 10-20 days of the study. At 1 month post-stroke, cronbach’s alpha was adequate for the HADS-A (alpha = 0.76); HADS-D (alpha = 0.79), and overall HADS (alpha = 0.79). At 6 months post-stroke, the HADS-A and overall HADS had excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (alpha = 0.87; 0.89, respectively) and the HADS-D was adequate (alpha = 0.76).

Test-retest:
To date, the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the HADS has not been examined in a stroke population.

Validity

To our knowledge, the study by Aben et al. (2002) is the only study to date that has examined the validityThe degree to which an assessment measures what it is supposed to measure.
of the HADS in individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Criterion:
Concurrent:
The concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the HADS has not been examined in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population. Below we present the findings of studies that have examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the HADS in other populations.

In a review by Bjelland et al. (2002), concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the HADS was examined against existing anxiety and depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
questionnaires and interview instruments (Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Inventory (BDI), Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Inventory for Primary Care, Clinical Anxiety Scale, Hamilton Anxiety Scale, Montgomery-Asberg DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Rating Scale, Symptom Checklist 90 Scale, Spielberger State-Trait Anxiety Inventory, and Visual Analogue Scale). Correlations between the HADS and the BDI were excellent, ranging from r = 0.61 to 0.83. Correlations between the General Health Questionnaire and HADS ranged from adequate to excellent (r = 0.50 to 0.68). Correlations between the HADS and the Clinical Anxiety Scale were excellent, ranging from r = 0.69 to 0.75. Correlations between the HADS and the Spielberger’s State-Trait Anxiety Inventory were excellent, ranging from r = 0.64 to 0.81. Correlations between the HADS and the Symptom Checklist 90 Scale ranged from adequate to excellent (r = 0.49 to 0.73). Correlations between the HADS and the Montgomery Asberg DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Rating Scale were excellent, ranging from r = 0.62 to 0.81. Finally, adequate correlations were found between the HADS-A and the Hamilton Anxiety Rating Scale (r = 0.34 to 0.44).

Clark and Steer (1994) reported that the HADS had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
r = 0.73) with the 13-item Cognitive-Affective SubscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Inventory in a study to discriminate between depressed and non-depressed hospitalized patients.

Construct:
Convergent/Discriminant:
Aben et al. (2002) found the mean correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety subscales of the HADS to be excellent (r = 0.67). Herrmann (1997) asserts that the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the two subscales is a result of the existing overlap between the symptoms of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety and not a reflection of a flaw in the instrument.

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
O’Rourke, MacHale, Signorini, and Dennis (1998) administered the HADS to 105 individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. 6 months after onset. They found the typical cutoffs for the HADS to be suboptimal when compared to the results of a blinded psychiatric assessment in which the Schedule for Affective Disorders and Schizophrenia was used to determine a DSM-IV diagnosis. A different cutoff of 6/7 for patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. was suggested, which produces an improved balance between specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
for both the HADS-A (sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
, 0.83; specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
, 0.68) and the HADS-D (sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
, 0.8; specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
, 0.79).

Aben et al. (2002) administered the HADS to 200 patients one month following a first ever ischemic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. They found that at the optimal cutoff of 5 for the HADS-A produced a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 91.7 and a specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 56.1 for major depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
only (area under the curve (AUC) = 0.78), and a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 88.5 and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 71.8 for detecting both major and minor depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(AUC = 0.77). An optimal cutoff of 8 for the HADS-D produced a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 73.1 and a specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 81.6 for detecting major depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
only (AUC = 0.82), and a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 72.5 and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 78.9 for detecting both major and minor depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(AUC = 0.83). Finally, for the total HADS, the optimal cutoff of 11 produced a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 91.7 and a specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 65.3 for detecting major depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
only (AUC = 0.83), and a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 86.8 and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 69.9 for detecting both major and minor depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(AUC = 0.84).

Johnson, Burvill, Anderson, Jamrozik, Stewart-Wynne, and Chakera (1995) administered the HADS to 93 post-stroke patients and found a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 0.95 for the HADS-A and 0.83 for the HADS-D, with specificities of 0.46 and 0.44, respectively. The optimal cutoff scores used in this study were not disclosed, however, they were estimated by Bjelland et al. (2002) to be 5+ for HADS-A and 4+ for HADS-D.

Responsiveness

Not yet examined in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.

References

• Aben, I., Verhey, F., Lousberg, R., Lodder, J., & Honig, A. (2002). Validity of the Beck Depression Inventory, Hospital Anxiety and Depression Scale, SCL-90, and Hamilton Depression Rating Scale as screening instruments for depression in stroke patients. Psychosomatics, 43(5), 386-393.
• Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale: An updated literature review. Journal of Psychosomatic Research, 52, 69-77.
• Clark, D. A., & Steer, R. A. (1994). Use of nonsomatic symptoms to differentiate clinically depressed and non-depressed hospitalized patients with chronic medical illnesses. Psychological Reports, 75(3, Pt 1), 1089-1090.
• Dunbar, M., Ford, G., Hunt, K., & Der, G. (2000). A confirmatory factor analysis of the Hospital Anxiety and Depression Scale: Comparing empirically and theoretically derived structures. Br J Clin Psychol, 39, 79-94.
• Herrmann, C. (1997). International experiences with the hospital anxiety and depression scale: A review of validation data and clinical results. Journal of Psychosomatic Research, 42(1), 17-41.
• Johnson, G., Burvill, P. W., Anderson, C. S., Jamrozik, K., Stewart-Wynne, E. G., Chakera, T. M. (1995). Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study. Acta Psychiatr Scand, 91, 252- 257.
• Johnston, M., Pollard, B., & Hennessey, P. (2000). Construct validation of the hospital anxiety and depression scale with clinical populations. Journal of Psychosomatic Research, 48, 579-584.
• Jörngården, A., Wettergen, L., von Essen, L. (2006). Measuring health-related quality of life in adolescents and young adults: Swedish normative data for the SF-36 and the HADS, and the influence of age, gender, and method of administration. Health and Quality of Life Outcomes, 4(91), 1-10.
• Lane, D. A., Jajoo, J., Taylor, R. S., Lip, G.Y., Jolly, K., Birmingham Rehabilitation Uptake Maximisation (BRUM) Steering Committee (2007). Cross-cultural adaptation into Punjabi of the English version of the Hospital Anxiety and Depression Scale. BMC Psychiatry, 7, 5.
• Michopoulos, I., Douzenis A., Kalkavoura, C., Christodoulou, C., Michalopoulou, P., Kalemi, G., et al. (2008). Hospital Anxiety and Depression Scale (HADS): Validation in a Greek general hospital sample. Annals of General Psychiatry, 7(1), 4.
• Montazeri, A., Vahdaninia, M., Ebrahimi, M., Jarvandi, S. (2003). The Hospital Anxiety and Depression Scale (HADS): translation and validation study of the Iranian version. Health and Quality of Life Outcomes, 1, 14.
• Muszbek, K., Szekely, A., Balogh, E. M., Molnar, M., Rohanszky, M., Ruzsa, et al. (2006). Validation of the Hungarian Translation of Hospital Anxiety and Depression Scale. Quality of Life Research, 15(4), 761-766.
• Olsson, I., Mykletun, A., & Dahl, A. A. (2005). The hospital anxiety and depression rating scale: A cross-sectional study of psychometrics and case finding abilities in general practice. BMC Psychiatry, 14(5), 46.
• O’Rourke, S., MacHale, S., Signorini, D., & Dennis, M. (1998). Detecting Psychiatric Morbidity After Stroke: Comparison of the GHQ and the HAD Scale. Stroke, 29, 980-985.
• Snaith, R. P. (2003). The hospital anxiety and depression scale. Health and Quality of Life Outcomes, 1(1), 29.
• White, D., Leach, C., Sims, R., Atkinson, M., & Cottrell, D. (1999). Validation of the Hospital Anxiety and Depression Scale for use with adolescents. British Journal of Psychiatry, 175, 452-454.
• Zigmond, A. S., & Snaith, R. P. (1983). Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.

See the measure

How to obtain the HADS?

The original is available as an appendix in Zigmond and Snaith (1983). A copy of the article is available by clicking here.

The HADS is also available from the following website: http://shop.gl-assessment.co.uk/home.php?cat=417.