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Hospital Anxiety and Depression Scale

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A two dimension scale developed to identify depression and anxiety among physically ill patients.

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instrument details

Acronym HADS  

Area of Assessment

Mental Health

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil


Not Free

Cost Description

Contact information and permission to use:
MAPI Research Trust, Lyon, France:


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

Key Descriptions

  • The HADS consists of 14 items, divided into two 7 item subscales:
    Anxiety (HADS-A); items reflect a state of generalized anxiety
    Depression (HADS-D); focus on the concept of anhedonia (Roberts et al, 2001; Flint and Rifat, 2002).
  • The respondent rates each item on a 4-point scale ranging from 0 (absence) to 3 (extreme presence).
  • 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 or for the scale as a whole
    Higher scores indicate greater levels of anxiety 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


Time to Administer

2-6 minutes

Required Training

No Training

Age Ranges


13 - 17



18 - 64


Elderly Adult

65 +


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

ICF Domain

Body Function

Measurement Domain



  • 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).

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Non-Specific Patient Population

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Minimal Detectable Change (MDC)


Cut-Off Scores

Primary Care Patients: (Wilkinson & Barczak, 1988; = 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)

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)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity: (Bjelland et al, 2002) 

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











Lisspers et al, 1997




Savard et al, 1998




Tedman et al, 1997




Chandarana et al, 1987




Snaith & Taylor, 1985




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


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

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


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.


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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)

Internal Consistency

Acute Stroke: (Aben et al, 2002)
  • Excellent internal consistency (Cronbach’s alpha  = 0.85)

Construct Validity

Acute Stroke: (Aben et al. 2002)

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

Spinal Injuries

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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:









6.9 (4.2)

5.5 (3.7)

12.3 (7.1)


6.7 (4.2)

5.5 (3.8)

12.1 (7.1)


8.1 (4.2)

5.5 (3.7)

13.2 (7.2)


7.0 (4.0)

5.9 (3.5)

12.7 (6.6)


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)


Construct Validity

Chronic SCI: (Woolrich et al. 2006) 

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


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

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

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

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

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 \

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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