Hospital Anxiety and Depression Scale (HADS)

Abstract

The Hospital Anxiety and Depression Scale (HADS) is a highly utilized 14-item, self-report screening tool developed by Zigmond and Snaith in 1983. Its primary function is to quantify the severity of symptoms related to Anxiety and Depression specifically within medically ill patient populations. A crucial design feature of the HADS is the intentional exclusion of items referencing physical or somatic symptoms (such as fatigue or sleep disturbance) that could otherwise be attributed to the patient’s underlying medical condition, thereby ensuring a purer measure of psychological distress.

The instrument generates two independent subscale scores, allowing for separate assessment of both affective dimensions. Due to its brevity, ease of administration, and robust psychometric properties, the HADS is widely deployed in various clinical environments, including general hospitals, oncology units, cardiology wards, and primary care settings, serving as an effective initial filter for identifying clinically significant emotional morbidity.

Keywords

HADS, Hospital Anxiety and Depression Scale, screening tool, depression, anxiety, psychological assessment, medical patients, HADS-A, HADS-D, affective disorder, psychological distress.

Authors

A. S. Zigmond, R. P. Snaith

Purpose

The chief objective of the HADS is to provide rapid and reliable screening for clinically significant anxious and depressive states among individuals receiving treatment in non-psychiatric medical environments. The scale addresses a fundamental challenge in medical psychology: accurately distinguishing between psychological distress and physical symptoms that mimic psychiatric conditions but are instead consequences of physical disease or treatment side effects.

By exclusively focusing on cognitive and affective manifestations—such as worry, anhedonia, and restlessness—the HADS successfully isolates psychological morbidity within hospital populations. This makes it an indispensable preliminary screening tool for medical staff, enabling the efficient identification of patients who require subsequent specialized psychological evaluation or intervention.

Construct

The HADS is fundamentally a two-dimensional measure, assessing two distinct, though correlated, psychological constructs. It is comprised of two separate seven-item subscales:

• Anxiety Subscale (HADS-A): This subscale focuses on symptoms of generalized anxiety, including feelings of tension, panic, restlessness, and apprehension. The items capture the subjective experience of being ‘wound up’ or having impending dread.
• Depression Subscale (HADS-D): This subscale measures the core elements of depression, specifically focusing on anhedonia (the inability to experience pleasure), loss of interest, and psychomotor retardation (feelings of being slowed down). Crucially, the HADS-D deliberately avoids common somatic symptoms of depression (e.g., changes in weight or sleep) that are often confounded by physical illness.

The successful differentiation between these two affective states, even in the context of physical illness, is the central theoretical premise of the scale, which has been consistently validated through subsequent empirical research.

Validity

The validity of the HADS has been rigorously established across a wide spectrum of clinical and cross-cultural populations. Research consistently demonstrates strong concurrent validity, showing high correlations between HADS scores and scores derived from other gold-standard instruments used to measure anxiety and depression, such as the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI).

Furthermore, the scale exhibits excellent discriminant validity, confirming its ability to effectively differentiate between patients who genuinely suffer from clinically significant anxious or depressive disorders and those who do not. Its clinical utility is highlighted by its efficacy in identifying individuals requiring formal psychiatric consultation or referral. A pivotal literature review by Bjelland et al. (2002) confirmed that the established cut-off scores provide reliable sensitivity and specificity for case identification of affective disorders in non-psychiatric clinical environments.

Reliability

The HADS is characterized by consistently high measures of reliability. Internal consistency, the measure of how well items within a subscale correlate with each other, is typically assessed using Cronbach’s alpha. For both the Anxiety and Depression subscales, alpha values frequently exceed the standard threshold of 0.80, indicating that the items reliably measure their intended underlying construct.

In addition to internal consistency, test-retest reliability for the HADS is generally strong. This suggests that the scale provides stable measurements of the patient’s psychological state over brief intervals, provided there have been no significant changes in their clinical condition or treatment regimen.

Factor Analysis

The structural integrity of the HADS has been extensively investigated using Factor Analysis. Although some localized or specialized studies have occasionally proposed alternative models, such as a three-factor solution, the overwhelming majority of international research supports the original, dominant two-factor structure: one distinct factor corresponding to Anxiety and another distinct factor corresponding to Depression.

This consistent replication of the two-factor solution across diverse patient groups, linguistic translations, and clinical settings strongly reinforces the scale’s foundational principle: the ability to measure anxious and depressive symptomatology as separate, clinically meaningful dimensions, even when they co-occur.

Instrument

Test Type: Self-report questionnaire, Screening tool

Format: 14 items in total, structured across two 7-item subscales. Responses are scored using a 4-point Likert scale, ranging from 0 (Not at all) to 3 (Most of the time), resulting in a maximum possible score of 21 for each subscale (HADS-A and HADS-D).

Language Available: Widely translated, with documented versions in over 60 languages, facilitating global research and clinical application.

Population Group: Primarily Clinical populations (including general medical, surgical, primary care, oncology, and cardiology patients), but also validated for use in Non-clinical populations.

Age Group: Typically utilized for adults and adolescents aged 16 years and older.

Population Details: Specifically developed for use in settings where the physical symptoms of the patient’s illness might interfere with the accurate assessment of psychological distress if traditional psychiatric scales containing somatic items were used.

Test Methodology: Separate scores are derived by summing the responses for the 7 items in the Anxiety subscale and the 7 items in the Depression subscale. Interpretation guidelines generally follow these cut-offs: 0–7 (Normal/Non-case), 8–10 (Borderline/Mild distress), 11–21 (Clinical Case/Moderate to Severe distress requiring intervention).

Keywords

HADS-A, HADS-D, anhedonia, discriminant validity, concurrent validity, psychometrics, screening instrument, hospital setting, cognitive symptoms.

Authors

Author ORCID Identifier: N/A (Information not provided in source)

Affiliation Email addresses: N/A (Information not provided in source)

Correspondence Address: N/A (Information not provided in source)

Permissions & Fee and Test Year

The Hospital Anxiety and Depression Scale (HADS) was first published in 1983. The scale is protected by copyright and is typically managed commercially by international publishing houses, such as GL Assessment or Hogrefe, depending on the geographical region and specific translation. Users, particularly those in large clinical or major research environments, are generally required to seek formal permission and may be subject to a licensing fee for reproducible copies or electronic administration. However, permissions for non-commercial academic research use are sometimes granted under specific terms.

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 for an earlier version of the instrument can be downloaded here: www.a4ebm.org/sites/default/files/Measuring%20Health.pdf

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.

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)

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