Brief overview of the Hospital Anxiety and Depression Scale (HADS) Overview

The Hospital Anxiety and Depression Scale (HADS) is a short self-report questionnaire designed to measure anxiety and depression in patients with physical illnesses. It contains 14 items and is quick and easy for patients to complete.

HADS is composed of two 7-item subscales for anxiety and depression and is specifically constructed to assess emotional symptoms without being heavily influenced by physical signs of illness (such as illness-related fatigue). This makes it especially useful in hospital and medical settings.

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

HADS was developed by Zigmond and Snaith to assess the emotional state of patients in hospitals and outpatient clinics. One of the main strengths of this scale is that many purely physical symptoms (such as sleep problems caused by illness, fatigue, or appetite changes) are excluded so that the focus remains on the cognitive and emotional aspects of anxiety and depression.

The items ask patients to indicate how often, in recent weeks, they have experienced feelings such as worry, tension, sadness, loss of interest, or reduced enjoyment.

• Instrument type: 14-item self-report questionnaire
• Subscales: 7 anxiety items (HADS-A), 7 depression items (HADS-D)
• Main settings: hospitals, medical clinics, psychosomatic units, and research

What does HADS measure and who is it for? Domains & Target Group

HADS focuses on two core domains:

• Anxiety (HADS-A): feelings of tension, worry, restlessness, nervousness, and mental signs of anxiety.
• Depression (HADS-D): low mood, reduced enjoyment, loss of interest, and decreased drive or motivation.

The scale is suitable for adults and older adolescents who are being treated in hospitals, outpatient clinics, or other medical settings. It is widely used in research on chronic illnesses (such as cancer, cardiovascular disease, diabetes, and others) to understand the emotional impact of physical conditions.

Applications of the HADS Applications

HADS is widely used in health-care systems and medical–psychological research:

• Screening for anxiety and depression in inpatients and outpatients in hospitals.
• Examining how acute and chronic physical illnesses affect patients’ mental health.
• Monitoring changes in anxiety and depression over the course of medical or psychological treatment.
• Research into the links between psychological factors and physical health outcomes.

How is the HADS administered? Administration

The HADS consists of 14 items, and respondents are asked to indicate how often they have experienced particular feelings and states in recent weeks. Responses are usually given on a 4-point scale (0–3).

• Number of items: 14 (7 anxiety, 7 depression)
• Response format: 4-point scale from “not at all” to “most of the time”
• Administration: self-report; can be paper-based or online
• Estimated time: about 5–10 minutes

Before you complete the HADS Before You Start

• Think about your feelings and thoughts over the last few weeks, not just today.
• Try to distinguish between symptoms of the physical illness itself (for example pain, fatigue) and emotional reactions.
• There are no “right” or “wrong” answers; what matters is that your responses reflect your inner experience.
• If an item feels unclear, choose the option that is closest to how you typically feel.
• If you feel upset while answering, you can pause for a moment and then continue when you are ready.

Interpreting HADS scores Interpretation

HADS scores are usually calculated separately for each subscale (anxiety and depression). The higher the score on a subscale, the greater the likelihood of clinically relevant symptoms in that domain.

Scoring guidelines typically define ranges such as “normal”, “borderline”, and “clinical”. These ranges help clinicians identify which patients may need more detailed assessment and possibly specialized intervention.

However, HADS is not a stand-alone diagnostic tool. It is meant for screening and for rating symptom severity; final interpretation and diagnosis must be made by a qualified professional, taking into account medical, family, and social context.

• Higher scores indicate more emotional strain, not personal weakness or failure.
• The pattern of anxiety and depression scores can highlight which area needs more attention.
• Combining HADS results with medical and psychological information gives a fuller picture of the patient’s situation.

Emotional map in the HADS Emotional Map

You can think of HADS results as two main pillars that capture different aspects of the patient’s emotional experience:

Frequently asked questions about the HADS FAQ

Ethical considerations when using the HADS Ethical Considerations

• Patients’ responses should remain confidential and be used only to improve their care.
• Results must not be used to blame, stigmatize, or judge patients.
• Completion of the questionnaire should be as voluntary as possible and its purpose should be clearly explained.
• When scores are high, it is important to offer and facilitate access to psychological support.
• In research, use of HADS must be accompanied by informed consent and adherence to ethical guidelines.

Further reading and research on the HADS References

For more information about HADS and its psychometric properties, the following sources are helpful:

• Original articles on the Hospital Anxiety and Depression Scale by Zigmond & Snaith.
• Validation and norming studies of HADS in various medical and general populations.
• Scientific databases such as PubMed and Google Scholar for recent research using HADS.

In clinical practice, it is important to use a properly translated and culturally adapted version and to interpret scores together with medical and social information about the patient.