Hospital Anxiety and Depression Scale (HADS)

Evidence Reviewed as of before: 19-08-2008
Author(s): Lisa Zeltzer, MSc OT; Lorie Kloda, PhD
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Hospital Anxiety and Depression Scale (HADS) is a self-administered measure used to screen for the presence of 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 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 Depression Scale (HADS) is a self-administered measure used to screen for the presence of 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 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 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 validity, but at least one week should elapse between administrations.

Scoring:

Scores for items in each subscale of the HADS are summed to produce an anxiety score (HADS-A) or a 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 subscale. 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 subscale 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 stroke determined that an optimal balance is achieved between specificity 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 subscale) and the HADS-D (Depression subscale).

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 stroke.

  • However, for clients with communication problems, an aphasia specific assessment such as the Stroke Aphasic 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 validity of this form of administration in clients with stroke.

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 screening 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? 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 stroke.
Is this a screening or assessment tool? Screening.
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
Reliability
  • Out of 2 studies examining internal consistency of the HADS in a stroke clientele, 1 reported excellent and 1 adequate to excellent internal consistency.
  • No studies have examined the test-retest reliability of the HADS in clients with stroke.
Validity

Criterion:

The concurrent validity of the HADS has not been examined in a stroke population. Studies that have examined the concurrent validity of the HADS in other populations report excellent correlations between the HADS and Beck Depression Inventory, the General Health Questionnaire, the Clinical Anxiety Scale, the Spielberger’s State-Trait Anxiety Inventory, and the Montgomery Asberg 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 correlation between the HADS-A and HADS-D. In another review, 7 studies found adequate to excellent correlations between HADS-A and HADS-D in non-patient samples, and 2 studies reported adequate correlations in psychiatric patients.

Does the tool detect change in patients? In a study of 200 clients with stroke, the mean correlation between the 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 screening 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 stroke. 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 stroke.

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 depression). This was done to enhance sensitivity of the HADS to mild cases, thus avoiding the potential for a ceiling effect often encountered with psychiatric questionnaires used for medical patients.

Reliability

Internal consistency:

Aben, Verhey, Lousberg, Lodder, and Honig (2002) administered the HADS to 200 patients one month following a first ever ischemic stroke and found the 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 stroke 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 consistency (alpha = 0.87; 0.89, respectively) and the HADS-D was adequate (alpha = 0.76).

Test-retest:

To date, the test-retest reliability 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 validity of the HADS in individuals with stroke.

Criterion:

Concurrent:

The concurrent validity of the HADS has not been examined in a stroke population. Below we present the findings of studies that have examined the concurrent validity of the HADS in other populations.

In a review by Bjelland et al. (2002), concurrent validity of the HADS was examined against existing anxiety and depression questionnaires and interview instruments (Beck Depression Inventory (BDI), Beck Depression Inventory for Primary Care, Clinical Anxiety Scale, Hamilton Anxiety Scale, Montgomery-Asberg 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 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 correlation (Pearson correlation r = 0.73) with the 13-item Cognitive-Affective Subscale of the Beck Depression Inventory in a study to discriminate between depressed and non-depressed hospitalized patients.

Construct:

Convergent/Discriminant:

Aben et al. (2002) found the mean correlation between the depression and anxiety subscales of the HADS to be excellent (r = 0.67). Herrmann (1997) asserts that the correlation between the two subscales is a result of the existing overlap between the symptoms of depression and anxiety and not a reflection of a flaw in the instrument.

Sensitivity and Specificity:

O’Rourke, MacHale, Signorini, and Dennis (1998) administered the HADS to 105 individuals with stroke 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 stroke was suggested, which produces an improved balance between specificity for both the HADS-A (sensitivity, 0.83; specificity, 0.68) and the HADS-D (sensitivity, 0.8; specificity, 0.79).

Aben et al. (2002) administered the HADS to 200 patients one month following a first ever ischemic stroke. They found that at the optimal cutoff of 5 for the HADS-A produced a sensitivity of 91.7 and a specificity of 56.1 for major depression only (area under the curve (AUC) = 0.78), and a sensitivity of 88.5 and specificity of 71.8 for detecting both major and minor depression (AUC = 0.77). An optimal cutoff of 8 for the HADS-D produced a sensitivity of 73.1 and a specificity of 81.6 for detecting major depression only (AUC = 0.82), and a sensitivity of 72.5 and specificity of 78.9 for detecting both major and minor depression (AUC = 0.83). Finally, for the total HADS, the optimal cutoff of 11 produced a sensitivity of 91.7 and a specificity of 65.3 for detecting major depression only (AUC = 0.83), and a sensitivity of 86.8 and specificity of 69.9 for detecting both major and minor depression (AUC = 0.84).

Johnson, Burvill, Anderson, Jamrozik, Stewart-Wynne, and Chakera (1995) administered the HADS to 93 post-stroke patients and found a sensitivity 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 stroke 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

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