Hospital Anxiety and Depression Scale (HADS)

What is the Hospital Anxiety and Depression Scale (HADS)?

• 14 items, with 7 scoring anxiety and 7 scoring depression

• Each item is scored on a 4-point scale (0-3)

• Higher scores indicate a higher level of anxiety/depression

• Anxiety and depression are scored separately

What are the HADS Anxiety Scale items?

• I feel tense or ‘wound up’

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

• Worrying thoughts go through my mind

• I can sit at ease and feel relaxed

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

• I feel restless as a I have to be on the move

• I get sudden feelings of panic

What are the HADS Depression Scale items?

• I still enjoy the things I used to enjoy

• I can laugh and see the funny side of things

• I feel cheerful

• I feel as if I am slowed down

• I have lost interest in my appearance

• I look forward with enjoyment to things

• I can enjoy a good book or radio or TV program

How is the HADS scored?

• The range for each sub scale is 0-21

• Any individual scoring above 11 on either sub scale, or answering ‘a lot of the time’ to the statement “worrying thoughts go through my mind’ should have a Suicide Risk Assessment

When the patient has no or low suicidal risk, the score on the HADS should be interpreted in the following manner:

• 0-7 Normal

• 8-10 Elevated distress

• 11-14 Abnormal

• 15-21 Severe distress

What is the HAS used for?

• Screening for symptoms of depression and general anxiety in order to contribute to potential diagnosis and treatment

• Monitoring progress of treatment in clinical progress

• Treatment effectiveness studies

• Theoretical research studies investigating anxiety and depression

What was the original development of the HADS?

• Originally designed as a brief self-assessment scale for measuring anxiety and depression in a UK hospital medical outpatient unit

• Aimed at measuring anxiety and depression in individuals with general health problems/illness

• Has subsequently been found to be effective in assessing severity and caseness of anxiety disorders and depression in psychiatric and primary care settings, and the general population

• Authors felt that previous scales such as the General Health Questionnaire were quite long, and did not provide information about the nature of the Psychiatric disorder

• Decided to focus on the two most frequently presenting emotional/psychiatric problems

• Depression items – originally 8

• Items that might be items that could relate to physical disorder only for example dizziness and headaches were not included

• Main focus: core feature of loss of pleasure/enjoyment

• Anxiety items – originally 8

• Based on relevant section of Present State Examination and Hamilton Anxiety Scale

• Administered to adults 16-65 experiencing various physical illnesses, as well as non-clinical participants

• After completing the scale, a separate clinical interview was conducted without knowledge of the scale scores

• Compared scores with clinical ratings to determine cutoff points

• Also determined whether there were any false positives or negatives

• 1 depression item with low internal consistency was removed; the weakest anxiety item was also removed to provide consistency

What did Silverstein et al. (2023) find?

• Found some issues regarding the reliability and validity of the use of the HADS in older adults

• However, Djukanovic et al. (2017) found the HADS was suitable for use with individuals aged 65-80 years old

What did Huang et al. (2023) find?

• Found HADS had demonstrated adequate psychometric properties

• However, it was found to be more suitable for measuring moderate (rather than high or low) depression levels

What did Wu et al. (2021) find?

• Systematic review and meta-analysis investigating the HADS and the SCID for assessing depression

• Recommended lower cutoff levels for the lower end of the scale to reduce false negatives and higher cutoff levels at the higher end of the scale to reduce false positives for individuals with higher symptom levels

What are other measures of anxiety?

• The Generalised Anxiety Disorder (GAD-7)

• Beck Anxiety Inventory

• The State-Trait Anxiety Scale (STAI) - two 20-item scale, State Anxiety and Trait Anxiety

What are other measures of depression?

• The Patient Health Questionnaire 9 (PHQ-9)

• Beck Depression Inventory (BDI) - 21 items