Hospital Anxiety and Depression Scale (HADS)

Abstract

The Hospital Anxiety and Depression Scale (HADS) is a self-report psychometric instrument developed specifically to screen for the presence and severity of mood disorders, namely anxiety and depression, among individuals in non-psychiatric clinical settings. Developed by Zigmond and Snaith in 1983, the primary innovation of the HADS is its deliberate exclusion of items related to somatic symptoms (such as fatigue or sleep disturbance). This design feature prevents the confounding influence of physical illness symptoms common in hospital patients from inflating the scores of psychological distress, thereby ensuring a cleaner measure of the patient’s emotional state. The scale is widely recognized for its brevity and utility in general medical and community populations globally.

Keywords

HADS, Anxiety, Depression, Screening tool, Self-report questionnaire, Psychological assessment, Psychometrics, Mood disorder screening.

Authors

A. S. Zigmond, R. P. Snaith.

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Purpose

The fundamental purpose of the Hospital Anxiety and Depression Scale (HADS) is to provide a rapid and reliable screening method for identifying clinically significant levels of anxiety and depression in patients within medical or primary care settings. It was specifically created to overcome the limitations of earlier scales, which often included items describing physical symptoms that overlap significantly with symptoms of physical disease. By focusing exclusively on the psychological manifestations of distress, the HADS allows clinicians to accurately differentiate between physical discomfort related to illness and true underlying mood disorders.

This instrument is crucial for early detection, enabling timely referral for specialized psychological treatment. It is frequently employed both for initial assessment and for monitoring changes in emotional state during treatment for physical conditions, enhancing holistic patient care.

Construct

The HADS measures two distinct psychological constructs: Anxiety (HADS-A) and Depression (HADS-D). It is rooted in the dimensional model of psychopathology, treating anxiety and depression as separate, yet often co-occurring, dimensions of psychological distress rather than purely categorical diagnoses. The scale consists of 14 items, equally divided into seven items for the Anxiety subscale and seven items for the Depression subscale.

The Anxiety subscale focuses on generalized anxiety, panic, tension, and restlessness (e.g., feeling tense or having ‘butterflies’ in the stomach). The Depression subscale measures anhedonia (loss of pleasure), low mood, and lack of enjoyment (e.g., loss of interest in appearance or inability to enjoy things). This clear separation of constructs, achieved by eliminating somatic overlap, is central to the scale’s conceptual integrity.

Validity

The HADS demonstrates generally strong psychometric properties, particularly regarding its validity across diverse populations. Construct validity is well-supported by extensive research, which consistently confirms the two-factor structure (Anxiety and Depression) originally proposed by the authors. This factor structure holds up well across various clinical and cultural groups.

Furthermore, criterion validity is high, with HADS scores showing significant correlation with clinical diagnoses derived from structured interviews, such as the Structured Clinical Interview for DSM (SCID). The comprehensive literature review by Bjelland et al. (2002) confirmed that HADS is a valid screening tool, particularly effective when using cutoff scores (typically 8 or above) to identify cases of probable clinical anxiety or depression. The scale’s ability to exclude somatic symptoms enhances its discriminant validity in medically ill populations.

Reliability

The reliability of the HADS subscales is consistently reported as excellent. Internal consistency, measured primarily using Cronbach’s alpha, typically exceeds the acceptable threshold of 0.70 for both the HADS-A and HADS-D subscales across different studies and settings. This indicates that the items within each subscale are highly homogeneous and measure the same underlying construct.

Test-retest reliability is also satisfactory, suggesting that the scores are stable over short time intervals when the patient’s underlying emotional state is not expected to have changed. This stability makes the HADS suitable for monitoring patient progress over the course of treatment.

Factor Analysis

The seminal factor analysis of the HADS confirmed the intended two-factor model, supporting the distinct measurement of anxiety and depression. Subsequent large-scale factor analytic studies have largely replicated this finding, reinforcing the scale’s internal structure.

Although some research has proposed alternative models, such as a three-factor solution (often separating psychic anxiety from motor tension) or a single general distress factor, the two-factor structure remains the most clinically useful and widely supported interpretation of the HADS data. The successful loading of items onto their designated subscales validates the scale’s ability to differentiate between these two common forms of psychological distress without contamination from physical symptoms.

Instrument

Test Type: Self-report screening scale

Format: 14 items, 4-point Likert scale (ranging from 0 to 3)

Language Available: Multiple translations (over 40 languages reported in literature)

Population Group: Medically ill patients (inpatient and outpatient), general medical settings, and general population screening.

Age Group: Adolescents (typically 16 years and older) and Adults.

Population Details: Specifically designed for use in non-psychiatric settings where physical symptoms might confound standard mood questionnaires. Scoring ranges from 0 to 21 for each subscale (Anxiety and Depression).

Test Methodology: The scale is administered via self-report. Scores are calculated by summing the responses for the seven Anxiety items (1, 3, 5, 7, 9, 11, 13) and the seven Depression items (2, 4, 6, 8, 10, 12, 14). A score of 0–7 is considered normal, 8–10 indicates mild distress, 11–14 moderate, and 15–21 severe distress, though common cutoff points often target 8 or above for caseness.

Keywords

Psychological distress, Somatic symptoms exclusion, Clinical assessment, Zigmond and Snaith, Healthcare setting, Anhedonia, Affective disorders.

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Authors

Author ORCID Identifier: N/A

Affiliation Email addresses: N/A

Correspondence Address: N/A

Permissions & Fee and Test Year

Test Year: 1983

Permissions and Fee: The Hospital Anxiety and Depression Scale is a proprietary instrument. Permission for use, especially in commercial research or clinical practice, typically requires licensing from the copyright holders, which are often associated with the original publisher or distribution trust (e.g., GL Assessment or MAPI Research Trust). Users should consult the official distributors for current fee structures and licensing requirements.

Reference’s

• Zigmond, AS., Snaith, RP. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand, 67:361–370.
• Bjelland, I., Dahl, AA., Haug, TT., et al. (2002). The validity of the Hospital Anxiety and Depression Scale. An updated literature review. Journal of Psychosomatic Research; 52(2):69-77.
• McDowell, Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires, Third Edition. OXFORD UNIVERSITY PRESS.

The original PDF containing this instrument can be downloaded here: www.a4ebm.org/sites/default/files/Measuring Health.pdf

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Items of the Hospital Anxiety and Depression Scale (HADS)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

Anxiety (items 1, 3, 5, 7, 9, 11, and 13), Depression (items 2, 4, 6, 8, 10, 12, and 14)

1- I feel tense or ‘wound up’

Most of the time (3), A lot of the time (2), From time to time, occasionally (1), Not at all (0)

2- I still enjoy the things I used to enjoy

Definitely as much (0), Not quite so much (1), Only a little (2), Hardly at all (3)

3- I get a sort of frightened feeling as if something awful is about to happen

Very definitely and quite badly (3), Yes, but not too badly (2), A little, but it doesn’t worry me (1), Not at all (0)

4- I can laugh and see the funny side of things

As much as I always could (0), Not quite so much now (1), Definitely not so much now (2), Not at all (3)

5- Worrying thoughts go through my mind

A great deal of the time (3), A lot of the time (2), From time to time but not too often (10), Only occasionally (0)

6- I feel cheerful

Not at all (3), Not often (2), Sometimes (1), Most of the time (0)

7- I can sit at ease and feel relaxed

Definitely (0), Usually (1), Not often (2), Not at all (3)

8- I feel as if I am slowed down

Nearly all the time (3), Very often (2), Sometimes (1), Not at all (0)

9- I get a sort of frightened feeling like ‘butterflies’ in the stomach

Not at all (0), Occasionally (1), Quite often (2), Very often (3)

10- I have lost interest in my appearance

Definitely (3), I don’t take so much care as I should (2), I may not take quite as much care (1), I take just as much care as ever (0)

11- I feel restless as if I have to be on the move

Very much indeed (3), Quite a lot (2), Not very much (1), Not at all (0)

12- I look forward with enjoyment to things

As much as I ever did (0), Rather less than I used to (1), Definitely less than I used to (2), Hardly at all (3)

13- I get sudden feelings of panic

Very often indeed (3), Quite often (2), Not very often (1), Not at all (0)

14- I can enjoy a good book or radio or TV programme

Often (0), Sometimes (1), Not often (2), Very seldom (3)