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  2. Hospital Anxiety and Depression Scale

Hospital Anxiety and Depression Scale

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Purpose

The Hospital Anxiety and Depression Scale (HADS) is a two dimension scale used to assess levels of depression and anxiety in hospital patients.

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instrument details

Acronym HADS  

Area of Assessment

Mental Functions
Bodily Functions

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Not Free

Cost Description

Contact information and permission to use:
MAPI Research Trust, Lyon, France:
Email: PROinformation@mapi-trust.org
Internet: www.mapi-trust.org

CDE Status

NeuroRehab Supplemental – Highly Recommended (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)

 

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Cardiac Dysfunction
  • Parkinson's Disease & Movement Disorders
  • Spinal Cord Injury
  • Stroke Recovery

Populations

Arthritis and Joint Conditions
Cardiovascular Disease
Mixed Conditions
Spinal Cord Injuries
Stroke

Key Descriptions

  • The HADS consists of 14 items, divided into two 7 item subscales:
    Anxiety (HADS-A); items reflect a state of generalized anxiety, and Depression (HADS-D); focuses on the concept of anhedonia (Roberts et al, 2001; Flint and Rifat, 2002).
  • The respondent rates each item on a 4-point Likert scale ranging from 0 (no symptoms reported) to 3 (symptoms very often reported).
  • Items do not assess somatic complaints.
  • Five of the 14 items are reverse coded.
  • The total score is out of 42 (21 per subscale). Scores are derived by summing responses for each of the two subscales to compute the total score.
  • Higher scores on each subscale indicate higher levels of anxiety and/or depression.
  • The total HADS score may be regarded as a global measure of psychological distress (Roberts et al, 2001; Johnston et al, 2000).

Number of Items

14

Equipment Required

  • Copy of HADS measure
  • Writing utensil

Time to Administer

2-6 minutes

Required Training

No Training

Age Ranges

Adolescent

17 +

years

Adult

18 - 64

years

Older Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad, MS and the Rehabilitation Measures Team; Updated with a CHD population by Avani Desai, SPT and Fleur Langner, SPT in 2011. Updated 4/21/2026 by Illinois Institute of Technology psychology students Amirah Al-Suleiman, Emily Litovchenko, and Karly Tyree under the direction of Nicole Ditchman, PhD, LCPC, CRC, CVE

ICF Domain

Body Function

Measurement Domain

Emotion

Professional Association Recommendation

None found -- last searched 4/21/2026

Considerations

  • The GHQ-28 and the GDS were found to be better screening instruments for depression than the HADS-D (Johnson et al, 1995)
  • Self-assessment scales are only valid for screening purposes
  • The HADS may perform better in male compared to female acute stroke patients (Aben, 2002)
  • Cognitive impairments, debilitating comorbid illnesses, and impaired physical states all interfere with the efficiency of the HADS to identify depression and anxiety in a target population (Roberts et al, 2001)
  • The HADS is not recommended for those with severe cognitive or communication difficulties (Cameron et al., 2008; Ayis et al., 2018)
  • The HADS may be administered as an interview or over the phone if a patient is unable to report for themselves on the questionnaire.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Mixed Conditions

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Cut-Off Scores

Primary Care Patients: (Wilkinson & Barczak, 1988; n = 100; mean age = 37.4 (17.4) years)

  • > 8 was found to be optimal for detecting DSM-III-defined psychiatric morbidity

 

Meta-analysis: (Brennan et al., 2010; n = 3244, median = 108 (69-1078) across 16 studies

  • > 8 indicates depression (sensitivity = 0.72, specificity = 0.86)

Primary Care: (Cameron et al., 2008; baseline n = 1063, end of treatment n = 544, mean age = 37.7 (13.2); patients referred to primary care mental health worker)

  • Score of ≥ 8 on HADS-D indicated “any depressive disorder”
  • Score of ≥ 9 on HADS-D indicated “major depression”

 

Normative Data

Primary Care: (Cameron et al., 2008)

  • Mean (SD) HADS-D at baseline: 8.85 (4.52)
  • Mean (SD) HADS-D at end of treatment: 4.31 (4.02)

 

Test/Retest Reliability

Test-retest reliability: (Herrmann, 1996; meta-analytic results)

  • Excellent at 0-2 weeks (n = 79; r = 0.84 - 0.85)
  • Adequate to Excellent at >2-6 weeks (n = 111; r = 0.73- 0.76)
  • Adequate at >6 weeks (n = 901; r = 0.70)

Internal Consistency

Meta-analytic Evidence: (Bjelland et al, 2002; literature review of 747 papers)

  • Adequate to Excellent (0.68 to 0.93)
  • Adequate to Excellent (0.67 to 0.90)

Primary Care: (Cameron et al., 2008)

  • Excellent internal consistency at baseline and end of treatment (α = 0.84 and 0.89, respectively)

 

Criterion Validity (Predictive/Concurrent)

Concurrent Validity: (Bjelland et al, 2002) 

Correlations between the HADS and other measures of depression and Anxiety:

 

 

 

Scale

HADS-A

HADS-D

Study

BDI

.64*

.71*

Lisspers et al, 1997

BDI

.68*

.70*

Savard et al, 1998

BDI

.61*

.73*

Tedman et al, 1997

GHQ-28

.50

.50

Chandarana et al, 1987

CAS

.69*

.44

Snaith & Taylor, 1985

MADRS

.37

.81*

Snaith & Taylor, 1985

BDI = Beck Depression Inventory
GHQ-28 = General Health Questionnaire 28
CAS = Clinical Anxiety Scale
MADRS = Montgomery - Asberg Depression Rating Scale

*indicates excellent correlation

 

 

 

Construct Validity

Primary Care: (Cameron et al., 2008)

Intercorrelations* between HADS-A, HADS-D, and PHQ-9

Scale

HADS-A

HADS-D

PHQ-9

At baseline (n = 454)

HADS-A

-

0.49

0.48

HADS-D

-

-

0.68

PHQ-9

-

-

-

At end of treatment (n = 491)

HADS-A

-

0.74

0.77

HADS-D

-

-

0.81

PHQ-9

-

-

-

*p < 0.01 for all correlations

  • Using William’s test, the correlations were significantly higher between the HADS-D and the PHQ-9 than between either of these measures and the HADS-A.

 

Responsiveness

Meta-analytic Evidence: (Bjelland et al, 2002)

  • Scores of 8 on both the HADS-A and HADS-D demonstrated an optimal balance between sensitivity and specificity

Primary Care: (Cameron et al., 2008)

  • Large Change: effect size for HADS-D = 1.0 compared to 0.99 for the PHQ-9

 

Cardiovascular Disease

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Standard Error of Measurement (SEM)

Coronary Heart Disease: (calculated from Wang, 2009)

  • HADS-A = 1.37
  • HADS-D = 1.44
  • HADS-T=2.05

Minimal Detectable Change (MDC)

Coronary Heart Disease: (calculated from Wang, 2009)

  • HADS-A= 3.80
  • HADS-D= 3.99
  • HADS-T= 5.68

Cut-Off Scores

Coronary Heart Disease Patients: (Stafford et al, 2007, n=193; mean age = 64.14 (10.37) years)

  • 6 indicates depressive disorder; lower cut off score than recommended cut off score to improve test sensitivity while maintaining specificity (sensitivity = 80; specificity=77.8)

Test/Retest Reliability

Coronary Heart Disease:(Wang, 2008; n=173 with coronary heart disease)

  • Excellent at 2 weeks (r=0.86-0.90)

Coronary Heart Disease: (Roberts et al, 2001; n=130 people with coronary heart disease)

  • Adequate at 8 weeks (r=0.63-0.79)

Internal Consistency

Coronary Heart Disease: (Stafford et al, 2007)

  • Excellent internal consistency (Cronbach’s alpha = 0.81)

Construct Validity

Coronary Heart Disease: (Wang et al, 2009)

  • Factor analysis reveals a three-factor solution (depression, psychic anxiety, and psychomotor anxiety) in CHD patient population

Responsiveness

Coronary Heart: (Bambauer et al, 2005)

  • Scores of 8 on the HADS measures showed lower sensitivity and high specificity.
  • Using a cutoff of 7 (Bambauer et al, 2005) demonstrates a balance between sensitivity and specificity.
  • Using a cutoff of 6 (Stafford et al, 2007) demonstrates a balance between sensitivity and specificity.

Stroke

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Standard Error of Measurement (SEM)

Stroke: (Ayis, et al., 2018; n = 1443, meanage = 68.07(14.2) years)

  • SEM for items on the Depression scale ranged from 0.07 to 0.18
  • SEM for items on the Anxiety scale ranged from 0.08 to 0.17

 

Cut-Off Scores

Acute Stroke: (Aben et al, 2002; n = 202; mean age = 68.5 (11.6) years; assessed <1 month post-stroke; Dutch sample)

  • > 8 indicates depression (sensitivity: 73.1, specificity: 81.6)

Normative Data

Stroke: (Jones et al., 2021; functional stroke, n = 56, mean age = 50.9 (13.7); vascular stroke, n = 39, mean age = 55.6 (15.1)

Functional Stroke:

  • Mean (SD) HADS-A: 9.24 (4.91)
  • Mean (SD) HADS-D: 6.42 (4.22)

Vascular Stroke:

  • Mean (SD) HADS-A: 11.08 (2.88)
  • Mean (SD) HADS-D: 7.72 (1.87)

 

Internal Consistency

Acute Stroke: (Aben et al, 2002)

  • Excellent internal consistency (Cronbach’s alpha  = 0.85)

Stroke: (Ayis et al., 2018)

  • Excellent  internal consistency for HADS-A (α = 0.84)
  • Excellent  internal consistency for HADS-D (α = 0.81)
 

Construct Validity

Acute Stroke: (Aben et al. 2002)

  • Excellent convergent validity (r = 0.67) between HADS-A and HADS-D subscales

Spinal Cord Injuries

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Standard Error of Measurement (SEM)

Spinal Cord Injury (SCI): (Muller et al., 2012; n = 102; mean age = 56.5 (16.7); male = 74.5%; time since onset = 43.6 (13.5) months; German translation of HADS)

  • SEM (n = 100) for items on Anxiety subscale ranged from 0.148 to 0.174
  • SEM (n = 100) for items on Depression subscale ranged from 0.162 to 0.185
  • SEM (n = 100) for items on the HADS Total scale ranged from 0.141 to 0.174

 

Normative Data

Chronic SCI: (Woolrich et al, 2006; n = 963; mean age = 48.1 (12.7) years; mean time since injury = 19.5 (12.26) years; 65.2% = paraplegic, 34.8% = tetraplegic, 94% used a wheelchair) 

 
 

Hospital Anxiety and Depression Scale Norms:

 

 

 

Sample

HADS-A

HADS -D

HADS-total

Total

6.9 (4.2)

5.5 (3.7)

12.3 (7.1)

Male

6.7 (4.2)

5.5 (3.8)

12.1 (7.1)

Female

8.1 (4.2)

5.5 (3.7)

13.2 (7.2)

Tetraplegic

7.0 (4.0)

5.9 (3.5)

12.7 (6.6)

Paraplegic

6.9 (4.3)

5.4 (3.8)

12.1 (7.4)

HADS-A = Hospital Anxiety and Depression Scale anxiety
HADS-D = Hospital Anxiety and Depression Scale depression

 

 

 

Internal Consistency

Chronic SCI: (Woolrich et al. 2006) 

  • Excellent Internal consistency HADS-A (Cronbach's alpha = 0.85)
  • Adequate Internal consistency HADS-D (Cronbach's alpha = 0.79)

Spinal Cord Injury (SCI): (Muller et al., 2012; n = 102; German translation of HADS)

  • Acceptable Person Reliability Index for HADS-A: 0.72
  • Good Person Reliability Index for HADS-D (0.82) and Total HADS (0.86)

 

 

 

Construct Validity

Chronic SCI: (Woolrich et al. 2006) 

  • Excellent Divergent Validity between the Life Satisfaction Questionnaire (LSQ) and HADS-D (r = -0.660)
  • Adequate Divergent validity between the LSQ and HADS-A (r = -0.419) and HADS total score (r = -0.585)

Floor/Ceiling Effects

Spinal Cord Injury (SCI): (Muller et al., 2012; n = 102; German translation of HADS)

  • Adequate floor effects for HADS-A (11%), HADS-D (4%), and Total HADS (5%)

 

Arthritis and Joint Conditions

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Cut-Off Scores

Rheumatoid Arthritis (RA): (Hitchon et al., 2020; n = 150, female (n = 127), mean age = 59.8 (11.7) years; mean age at RA diagnosis = 41.7 (14.9) years)

  • HADS-D: >8 or 11
  • HADS-A: >8 or 11

 

Test/Retest Reliability

Rheumatoid Arthritis: (Hitchon et al., 2020; n = 115, test-retest interval = 2 weeks)

  • Acceptable test-retest reliability for HADS-D: ICC (95% CI) = 0.85 (0.79, 0.90)
  • Acceptable test-retest reliability for HADS-A: ICC (95% CI) = 0.79 (0.71, 0.85)

 

Internal Consistency

Rheumatoid Arthritis: (Hitchon et al., 2020)

  • Excellent internal consistency for HADS scales (α (95% CI):
    • HADS-D: 0.84 (0.74, 0.94)
    • HADS-A: 0.84 (0.74, 0.94)

 

Face Validity

Arthritis: (Hitchon et al., 2020)

  • Acceptable face validity as judged by mental health clinicians on the team

 

Bibliography

Aben, I., Verhey, F., et al. (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: 386-393. Find it on PubMed

Ayis, S. A., Ayerbe, L., Ashworth, M., & Wolfe, C. D. A. (2018). Evaluation of the Hospital Anxiety and Depression Scale (HADS) in Screening Stroke Patients for Symptoms: Item Response Theory (IRT) Analysis. Journal of Affective Disorders, 228, 33-40. https://doi.org/10.1016/j.jad.2017.11.037

Bambauer, K. Z., Locke, S. E., et al. (2005). Using the Hospital Anxiety and Depression Scale to screen for depression in cardiac patients. Gen Hosp Psychiatry 27(4): 275-284. Find it on PubMed

Bjelland, I., Dahl, A. A., et al. (2002). The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res 52: 69-77. Find it on PubMed

Brennan, C., Worrall-Davies, A., et al. (2010). The Hospital Anxiety and Depression Scale: a diagnostic meta-analysis of case-finding ability. J Psychosom Res 69(4): 371-378. Find it on PubMed

Cameron, I. M., Crawford, J. R., Lawton, K., & Reid, I. C. (2008, January). Psychometric comparison of PHQ-9 and Hads for measuring depression severity in primary care. The British Journal of General Practice, 58: 32-36. https://pmc.ncbi.nlm.nih.gov/articles/PMC2148236/pdf/bjgp58-032.pdf

Chandarana, P. C., Eals, M., et al. (1987). The detection of psychiatric morbidity and associated factors in patients with rheumatoid arthritis. Can J Psychiatry 32(5): 356-361. Find it on PubMed

Flint, A. J. and Rifat, S. L. (2002). Factor structure of the hospital anxiety and depression scale in older patients with major depression. Int J Geriatr Psychiatry 17(2): 117-123. Find it on PubMed

Herrmann, C. (1997). International experiences with the Hospital Anxiety and Depression Scale--a review of validation data and clinical results. J Psychosom Res 42: 17-41. Find it on PubMed

Hitchon, C., Zhang, L., Peschken, C., Lix, L., Graff, L., Fisk, J., Patten, S., Bolton, J., Sareen, J., El-Gabalawy, R., Mariott, J., Bernstein, C., & Marie, R. A. (2020). Validity and reliability of screening measures for depression and anxiety disorders in rheumatoid arthritis. Arthritis Care and Research, 72(8), 1130-1139. https://pmc.ncbi.nlm.nih.gov/articles/PMC7496677/pdf/ACR-72-1130.pdf

Johnson, G., Burvill, P. W., et al. (1995). Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study. Acta Psychiatr Scand 91: 252-257. Find it on PubMed

Johnston, M., Pollard, B., & Hennessey, P. (2000). Construct validation of the hospital anxiety and depression scale with clinical populations. Journal of Psychosomatic Research, 48(6), 579-584. https://doi.org/10.1016/S0022-3999(00)00102-1

Jones, A., Smakowski, A., Hughes, A., David, A. S., & Chalder, T. (2022). Illness-Related Cognition, Distress and Adjustment in Functional Stroke Symptoms, Vascular Stroke, and Chronic Fatigue Syndrome. European Journal of Health Psychology, 29(3), 145-155. https://doi.org/10.1027/2512-8442/a000093

Karlsson, J., Hammarström, E., Fogelkvist, M., & Lundqvist, L.-O. (2024, August 26). Psychometric characteristics of the hospital anxiety and depression scale in stroke survivors of working age before and after inpatient rehabilitation. PloS ONE, 19(8): e0306754 https://doi.org/10.1371/journal.pone.0306754

Lisspers, J., Nygren, A., et al. (1997). Hospital Anxiety and Depression Scale (HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 96(4): 281-286. Find it on PubMed 

Müller, R., Cieza, A., & Geyh, S. (2012). Rasch analysis of the Hospital Anxiety and Depression Scale in spinal cord injury. Rehabilitation Psychology, 57(3), 214–223. https://doi.org/10.1037/a0029287

Roberts, S. B., Bonnici, D. M., et al. (2001). Psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) among female cardiac patients. Br J Health Psychol 6(Part 4): 373-383. Find it on PubMed

Savard, J., Laberge, B., et al. (1998). Evaluating anxiety and depression in HIV-infected patients. J Pers Assess 71(3): 349-367. Find it on PubMed

Snaith, R. P. and Taylor, C. M. (1985). Rating scales for depression and anxiety: a current perspective. Br J Clin Pharmacol 19 Suppl 1: 17S-20S. Find it on PubMed

Spinhoven, P., Ormel, J., et al. (1997). A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 27(2): 363-370. Find it on PubMed

Stafford, L., Berk, M., et al. (2007). Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease. Gen Hosp Psychiatry 29(5): 417-424. Find it on PubMed

Tedman, B. M., Young, C. A., et al. (1997). Assessment of depression in patients with motor neuron disease and other neurologically disabling illness. J Neurol Sci 152 Suppl 1: S75-79. Find it on PubMed

Wang, W., Chair, S. Y., et al. (2009). A psychometric evaluation of the Chinese version of the Hospital Anxiety and Depression Scale in patients with coronary heart disease. J Clin Nurs 18(17): 2436-2443. Find it on PubMed

Wilkinson, M. J. and Barczak, P. (1988). Psychiatric screening in general practice: comparison of the general health questionnaire and the hospital anxiety depression scale. J R Coll Gen Pract 38(312): 311-313. Find it on PubMed

Woolrich, R. A., Kennedy, P., et al. (2006). A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury. Psychol Health Med 11(1): 80-90. Find it on PubMed

 

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