Hospital Anxiety and Depression Scale

Abstract

The Hospital Anxiety and Depression Scale (HADS) is a brief, self-report screening instrument designed to measure the severity of affective symptoms in non-psychiatric populations, particularly those in general hospital settings. A defining feature of the HADS is its deliberate exclusion of items related to somatic symptoms, which prevents the confounding of psychological distress with physical symptoms common in medical illness. The scale consists of 14 items divided equally into two subscales: the Anxiety Subscale (HADS-A) and the Depression Subscale (HADS-D). Respondents typically rate their feelings over the past four weeks, though a version focusing on the last week is also available. Higher scores indicate greater severity of anxiety or depression.

Keywords

Hospital Anxiety and Depression Scale, HADS, Depression, Anxiety, Screening Tool, Affective Disorders, Psychological Assessment, Somatic Symptoms

Authors

Zigmond AS, Snaith RP (1983, 1992, 1994); Dutch version: Pouwer F, Snoek FJ, van der Ploeg HM (1997)

Purpose

The primary purpose of the Hospital Anxiety and Depression Scale is to screen for clinically significant symptoms of anxiety and depression among patients receiving treatment for physical health conditions. It is specifically designed to be used in general medical and surgical settings where traditional psychiatric scales might yield false positives due to the inclusion of overlapping physical complaints (e.g., fatigue, loss of appetite).

The brevity and simplicity of the HADS make it an extremely practical instrument for rapid clinical assessment. It aids clinicians in identifying patients who may require further psychological evaluation or intervention for underlying emotional distress that is independent of their physical diagnosis.

Construct

The HADS is a measure of the psychological components of two distinct affective states: anxiety and depression. The scale operates on a two-factor model. The HADS-A subscale focuses on general feelings of tension, worry, and restlessness. The HADS-D subscale measures core anhedonic symptoms, such as loss of interest, lack of pleasure, and despair.

Crucially, the scale avoids items that measure somatic symptoms (e.g., sleep disturbance, weight change). This design choice ensures that scores reflect genuine psychological distress rather than the physiological consequences or secondary effects of existing medical conditions, thereby enhancing its discriminant validity in medically ill populations.

Validity

The HADS exhibits strong evidence of concurrent and discriminant validity, particularly when used in its intended context—medically ill populations. Studies have demonstrated that HADS scores correlate moderately to strongly with other established measures of anxiety and depression, such as the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI).

Its discriminant validity is upheld by its ability to differentiate between emotional disturbance and physical illness, a key feature of its design. Furthermore, the HADS has been shown to have good criterion validity, effectively identifying patients who meet diagnostic criteria for generalized anxiety disorder or major depressive disorder when clinical interview diagnoses are used as the standard.

Reliability

The internal consistency of the HADS is generally considered acceptable to excellent across diverse populations. Psychometrics research frequently reports Cronbach’s alpha coefficients for the HADS-A subscale ranging from 0.75 to 0.89, and for the HADS-D subscale from 0.77 to 0.90.

Test-retest reliability is also generally high, indicating that the scale provides stable measurements over time, assuming the underlying affective state of the patient remains unchanged. This robust reliability supports the use of the HADS as a consistent tool for monitoring changes in emotional state during treatment.

Factor Analysis

Extensive factor analysis studies have largely supported the original two-factor structure proposed by Zigmond and Snaith. These analyses confirm that the 14 items reliably load onto two distinct, yet correlated, factors corresponding to Anxiety (A) and Depression (D).

While some studies in specific clinical populations have suggested alternative models (e.g., a three-factor model incorporating a General Distress factor), the predominant consensus in academic literature confirms the utility and validity of interpreting the HADS using its original two separate subscales.

Instrument

Test Type: Self-report questionnaire / Screening Instrument

Format: 14 items, 4-point Likert scale (scores 0-3).

Language Available: English (Original), Dutch (Pouwer et al., 1997), and numerous other translations globally.

Population Group: Clinical and Non-clinical

Age Group: Adults (Volwassenen)

Population Details: Primarily used in general medical settings (hospitals, primary care) to assess psychological disorders in the context of physical illness.

Test Methodology: Patients rate how they have felt over a specified period (typically the last four weeks) based on their emotional experiences.

Keywords

HADS-A, HADS-D, Affective Screening, Medical Psychology, Self-report, Somatic Symptoms Exclusion, Psychometrics

Authors

Author ORCID Identifier: Information not provided in source content.

Affiliation Email addresses: Information not provided in source content.

Correspondence Address: Information not provided in source content.

Permissions & Fee and Test Year

The original scale was first published in 1983. Subsequent revisions occurred in 1992 and 1994. The Dutch version was validated in 1997. The HADS is copyrighted material, and permissions for its use, especially in large-scale research or commercial clinical practice, typically require licensing from the official publishers.

The original PDF of the Explanation Form can be downloaded here: HADS-form.pdf.

The original PDF of the Measurement Instrument can be downloaded here: HADS-meetinstr-KNGF-2018.pdf.

Reference’s

• Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica. 1983;67(6):361-370.
• Snaith RP, Zigmond AS. The Hospital Anxiety and Depression Scale. British Medical Journal. 1994;308:1432.
• Pouwer F, Snoek FJ, van der Ploeg HM. The Hospital Anxiety and Depression Scale: Reliability and validity of the Dutch version. Tijdschrift voor Psychiatrie. 1997;39:354-361.

Items of the Hospital Anxiety and Depression Scale

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

The source content provided the structure of the HADS but did not include the specific text of the 14 items. The scale consists of 7 items for the Anxiety subscale and 7 items for the Depression subscale.