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Hospital Anxiety and Depression Scale (HADS)
Availability
Please visit this website for more information about the instrument: Hospital Anxiety Depression Scale
Classification
NeuroRehab Supplemental - Highly Recommended
Recommendations for use: Indicated for studies requiring a measure for mood/anxiety.
 
Supplemental - Highly Recommended: Huntington's Disease (HD)
 
Supplemental: Amyotrophic Lateral Sclerosis (ALS), Headache, Mitochondrial Disease (Mito), Parkinson's Disease (PD), Spinal Cord Injury (SCI), and SCI-Pediatric (ages 12 and older)
 
Exploratory: Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)
Short Description of Instrument
Summary/Overview of Instrument: The HADS is a 14-item self-report scale that consists of a depression and an anxiety scale, each with 7 items. The scale was designed to screen for mood disorders in general (non-psychiatric) medical outpatients. It is comprised of two subscales: Depression and Anxiety. It focuses on subjective disturbances of mood rather than physical signs and aims at distinguishing depression from anxiety. Compared to other instrument scales, it focuses on emotional aspects of anxiety disturbances, as opposed to somatic and cognitive symptoms.
 
Construct measured: Anxiety and depression.
 
Generic vs. disease-specific: Generic.
 
Intended use of instrument/ purpose of tool: Clinical Trials, Observational Studies.
 
Means of administration: Self- administered.
 
Location of administration: Clinic, home, telephone.
 
Intended respondent: Patient.
 
# of items: 14 - Anxiety (7 items), Depression (7 items).
 
# of subscales and names of sub-scales: 2 - Anxiety, Depression.
 
Special Requirements for administration: None.
 
Administration time: About 2-5 minutes.
 
Translations available: Over 80 translations available.
Comments/Special Instructions
The HADS is presented as a reliable instrument for screening for clinically significant anxiety and depression in patients attending a general medical clinic. This scale has also been shown to be a valid measure of the severity of these disorders of mood and therefore the repeated administration of the scale at subsequent visits to the clinic will give the physician useful information concerning progress.
 
SAH-Specific: Recommended cutoffs are: 8-10: mild cases (possible depression), 11-15: moderate cases (probable depression) and 16 or above: severe cases (definitive depression) (Snaith & Zigmond, 1994).
 
NeuroRehab-Specific: Very popular in Europe and Australia so using it can help in international studies. However, the measure is not tied to current diagnostic criteria.
 
Parkinson's Disease-Specific: Maximum discrimination between depressed and non-depressed PD patients was reached at a cut-off score of 10/11 for both in the HADS. This scale is an appropriate screening instrument for depression in PD.
Scoring and Psychometric Properties
Scoring: The HADS is comprised of two subscales, Depression and Anxiety. Each subscale has a score ranging from 0-21. Items are rated on a 4-point Likert-type scale ranging from 0 to 3, generating a scale range of 0 to 42 points, with higher scores representing greater symptom severity. The anxiety subscale has 3 items that refer to panic and 4 to generalized anxiety. Add the A questions to get a score for anxiety and the D questions for depression. Scores of 0-7 indicate normal levels of anxiety and depression; 8-10 indicate borderline abnormal anxiety and depression levels and 11-21 suggest abnormal levels of anxiety and depression.
 
Standardization of scores to a reference population (z scores, T scores): Not available.
 
If scores have been standardized to a reference population, indicate frame of reference for scoring (general population, HD subjects, SAH patients, and other disease groups): Not available.
 
Psychometric Properties:
Reliability: Internal consistency described for patients with cancer (Moorey et al., 1991): Anxiety subscale Cronbach's alpha = 0.93; Depression subscale alpha = 0.9. In healthy UK sample, internal consistency for Anxiety, Depression and Total scores were 0.82, 0.77 and 0.86 respectively (Crawford et al., 2001). Test-retest reliability for healthy sample: correlation for Depression scale = 0.92; Anxiety subscale 0.89 (Snaith & Zigmond, 1994 test manual)
 
Validity: Concurrent validity established in several studies (see Snaith & Zigmond, 1994 test manual). This scale has been validated for use in PD (Mondolo et al., 2006; Rodriguez-Blazques et al., 2009).  Marinus et al. (2002) found the reliability and construct validity of the HADS in PD to be adequate.
 
Sensitivity to Change/ Ability to Detect Change (over time or in response to an intervention): Not available.
 
Known Relationships to Other Variables: HADS depression scores differentiate between patients taking/ not taking antidepressants, and male patients and older patents at time of diagnosis had higher HADS depression scores; HADS anxiety scores differentiated between patients with and without a psychiatric history and those taking/ not taking antidepressants (Wicks et al., 2007). HADS Depression scores correlated with limb impairment, overall disease severity scores and, also with Anxiety scores with impairment on domains of the Sickness Impact Scale (Goldstein et al., 1998). Anxiety and depression subscale scores correlated with subscales of the Sickness Impact Scale; Depression subscale scores correlated with speech and mobility scores on the Barthel Index and Anxiety scores correlated with Barthel speech items.
 
Diagnostic Sensitivity and Specificity, if applicable (in general population, HD population- premanifest/manifest, SAH, other disease groups): Not available. For the diagnosis of depression in PD, the concurrent validity of the HADS against the "gold standard" Hamilton Depression Scale, showed a high sensitivity and high negative predictive value (Mondolo et al., 2006).
Rationale/Justification
Strengths: Serves as a good screening measure. Has been widely used. Relatively simple to complete.
 
Weaknesses: This scale is not designed for HD or SAH; however, it is a quick screen. Requires insight to provide accurate reflection. No proxy verification.
 
SCI-Pediatric-Specific Notes: The scale is validated in individuals over 17 years; there is some data for children aged 12-17y.
References
Key Reference:
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361-70.
 
Additional References:
Crawford JR, Henry JD, Crombie C, Taylor EP. Normative data for the HADS from a large non-clinical sample. Br J Clin Psychol. 2001 Nov;40(4):429-34.
 
Ferentinos P, Paparrigopoulos T, Rentzos M, Zouvelou V, Alexakis T, Evdokimidis I. Prevalence of major depression in ALS: comparison of a semi-structured interview and four self-report measures. Amyotroph Lateral Scler. 2011 Jul;12(4):297-302.
 
Goldstein LH, Adamson M, Jeffrey L, Down K, Barby T, Wilson C, Leigh PN. The psychological impact of MND on patients and carers. J Neurol Sci. 1998 Oct;160 Suppl 1:S114-21.
 
Goldstein LH, Atkins L, Landau S, Brown RG, Leigh PN. Longitudinal predictors of psychological distress and self-esteem in people with ALS. Neurology. 2006 Nov 14;67(9):1652-8.
 
Kennedy P, Lude P, Elfstroem ML, Smithson E. Cognitive appraisals, coping and quality of life outcomes: a multi-centre study of spinal cord injury rehabilitation. Spinal Cord. 2010 Oct;48(10):762-9.
 
Kennedy P, Sherlock O, McClelland M, Short D, Royle J, Wilson C. A multi-centre study of the community needs of people with spinal cord injuries: the first 18 months. Spinal Cord. 2010 Jan;48(1):15-20.
 
Mondolo F, Jahanshahi M, Grana A, Biasutti E, Cacciatori E, Di Benedetto P. The validity of the hospital anxiety and depression scale and the geriatric depression scale in Parkinson's disease. Behav Neurol. 2006;17(2):109-15.
 
Moorey S, Greer S, Watson M, Gorman C, Rowden L, Tunmore R, Robertson B, Bliss J. The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. Br J Psychiatry. 1991 Feb;158:255-9.
 
Olsson AG, Markhede I, Strang S, Persson LI. Differences in quality of life modalities give rise to needs of individual support in patients with ALS and their next of kin. Palliat Support Care. 2010 Mar;8(1):75-82.
 
Powell J, Kitchen N, Heslin J, Greenwood R. Psychosocial outcomes at three and nine months after good neurological recovery from aneurysmal subarachnoid haemorrhage: predictors and prognosis. J Neurol Neurosurg Psychiatry. 2002 Jun;72(6):772-81.
 
Powell J, Kitchen N, Heslin J, Greenwood R. Psychosocial outcomes at 18 months after good neurological recovery from aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 2004 Aug;75(8):1119-24.
 
Rodriguez-Blazquez C, Frades-Payo B, Forjaz MJ, de Pedro-Cuesta J, Martinez-Martin P; Longitudinal Parkinson's Disease Patient Study Group. Psychometric attributes of the Hospital Anxiety and Depression Scale in Parkinson's disease. Mov Disord. 2009 Mar 15;24(4):519-25.
 
Snaith RP, Zigmond AS. The Hospital Anxiety and Depression Scale Manual. Windsor, Ontario: NFER-Nelson; 1994.
 
Snaith RP. The Hospital Anxiety And Depression Scale. Health Qual Life Outcomes. 2003 Aug 1;1:29.
 
Wicks P, Abrahams S, Masi D, Hejda-Forde S, Leigh PN, Goldstein LH. Prevalence of depression in a 12-month consecutive sample of patients with ALS. Eur J Neurol. 2007 Sep;14(9):993-1001. Erratum in: Eur J Neurol. 2008 Sep;15(9):1009.
 
Woolrich RA, Kennedy P, Tasiemski T. A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury. Psychol Health Med. 2006 Feb;11(1):80-90.
 
Document last updated March 2024