Quality of Life Concepts

Secondary Health Conditions

Hospital Anxiety and Depression Scale (HADS)

Description: The HADS is a screening tool for anxiety and depression in non-psychiatric clinical populations [1]. It is thought to tap into the construct of affect [2].

Format: The scale consists of 14 items (7 each for anxiety and depression). Each item is rated on a four point scale ranging from 0 (not at all) to 3 (very often). Responses are based on the relative frequency of symptoms over the preceding week.

Scoring: Possible scores range from 0 to 21 for each subscale. An analysis of scores on the two subscales supported the differentiation of each mood state into four ranges: ‘mild cases’ (scores 8-10), ‘moderate cases’ (scores 11-15), and ‘severe cases’ (scores 16 or higher).

Administration and Burden: Interviewer-administered; Approximately 5 minutes to complete.

Psychometrics for SCI: For the SCI population, the internal consistency has been found to be excellent for the anxiety scale (α= .85), and adequate for the depression scale (α = .79) [3]. The anxiety subscale has adequate validity, whereas that of the depression scale is excellent when correlated with the Life Satisfaction Questionnaire (LSQ; r = -.42 for the anxiety scale and r = -.66 for the depression scale) [4].

Languages: The HADS has been translated into all major European languages in addition to Arabic, Hebrew, Chinese, Japanese, and Urdu.

QoL Concept: The HADS assesses presence of depression and anxiety, and is arguably a measure of Affect, which corresponds to Box E (subjective evaluations and reactions) on Dijker’s Model.

Permissions/Where to Obtain: Copyrighted; The HADS scale and its manual can be purchased at the GL Assessment website at: http://shop.gl-assessment.co.uk/home.php?cat=417.


  1. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361-70.

  2. Crawford JR, Henry JD. The Positive and Negative Affect Schedule (PANAS): Construct validity, measurement properties and normative data in a large non-clinical sample. Br J Clin Psych 2004;43:245-65.

  3. Heinrich RK, Tate DG. Latent variable structure of the Brief Symptom Inventory in a sample of persons with spinal cord injuries. Rehabil Psychol 1996;41:131-47.

  4. Woolrich RA, Kennedy P, Tasiemski T. A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury. Psychol Health Med 2006;11:80-90.



Pain SCI Studies: Two cross-sectional surveys, one multi-center, parallel-group, double-blind, randomized clinical trial.

  1. Norrbrink Budh C, Hultling C, Lundeberg T. Quality of sleep in individuals with spinal cord injury: a comparison between patients with and without pain. Spinal Cord 2005;43:85-95.

  2. Norrbrink Budh C, Lundeberg T. Use of analgesic drugs in individuals with spinal cord injury. J Rehabil Med 2005;37:87-94.

  3. Norrbrink Budh C, Osteraker A-L. Life satisfaction in individuals with a spinal cord injury and pain. Clin Rehabil 2007;21:89-96.

  4. Siddall PJ, Cousins MJ, Otte A, Griesing T, Chambers R, Murphy TK. Pregabalin in central neuropathic pain associated with spinal cord injury. A placebo-controlled trial. Neurol 2006; 67:1792-1800.

  5. Lundqvist C, Siosteen A, Blomstrand C, Lind B, Sullivan M. Spinal cord injuries. Clinical, functional, and emotional status.Spine 1991;16:78-83.

  6. Nicholson Perry K, Nicholas MK, Middleton J, Siddall P. Psychological characteristics of people with spinal cord injury-related persisting pain referred to a tertiary pain management center. J Rehabil Res Dev 2009;46:57-68.

Sensitivity to Impact: Norrbrink Budh and colleagues (2005) used the  Hospital Anxiety and Depression Scale (HADS) to assess and describe the subjective quality of sleep in patients with spinal cord injury (SCI; N = 191) with and without pain. Persons with continuous pain rated their anxiety and depression scores on the HADS as being higher than persons with intermittent or no pain. Persons with continuous pain reported the poorest sleep than those with intermittent or no pain.

Norrbrink Budh and Lundeberg (2005) used the HADS and the Life Satisfaction 9 (LISAT-9) to elucidate which factors are associated with or predictive for the use of analgesic drugs in patients with SCI (N = 90). Regression analyses showed that the affective component was the main variable associated with the use of analgesic drugs, followed by a low score on leisure activities, and by the presence of stabbing/cutting pain. Non-analgesic users had higher scores on whole life satisfaction, leisure, and sexual life than analgesic users. In addition, anxiety and depression were higher in analgesic users compared to non-users.

Norrbrink Budh and Osteraker (2007) used the HADS and the LISAT-9 to assess and describe the impact of pain on life satisfaction in individuals with SCI (N = 191). The sample was divided into 3 groups: no pain, intermittent pain, and continuous pain. There were significant group different for 6 of the 9 variables on the LISAT-9 scale, with patients with pain scoring lower than patients without pain on life as a whole, financial situation, leisure, contact with friends, activities of daily living, and family life. In general, patients with SCI and pain reported lower satisfaction with life compared to patients with SCI without pain.

Siddall and colleagues (2006) used the Medical Outcomes Study (MOS)-sleep scale and the HADS to elucidate which factors are associated with or predictive for the use of analgesic drugs in patients with SCI (N = 137). Use of pregabalin was associated with decreases in the overall sleep problems index and higher sleep quantity, compared to the placebo group at endpoint. In addition, mean decrease in anxiety from baseline to endpoint was higher in the pregabalin group than in the placebo group.

Lundqvist and colleagues (1991) used the Sickness Impact Profile (SIP), the HADS, and a non-standardized study-specific questionnaire to define the physical, psychological, and social functioning of patients with SCI (N = 98). Patients who recorded pain severe enough to impair their daily life showed lower quality of life (QoL) perceptions and a significant restriction of mobility issues. Overall QoL perceptions were influenced only by having a history of severe pain.

Nicholson Perry and colleagues (2009) used the Multidimensional Pain Inventory - SCI Version (MPI-SCI), the Short-Form 12 (SF-12), and the HADS to examine the psychological characteristics of a cohort of individuals with SCI and persisting pain (N = 45). Persons with SCI-related chronic pain had less life interference as measured by the sub-scale of the MPI than the general pain population, but received lower scores on the SF-12 mental component sub-scale. Usual pain intensity was significantly, but weakly, associated only with the MPI-SCI Life Interference sub-scale. There were no differences on the SF-12 physical functioning sub-scale between the group with SCI and pain, and the general pain sample.  However, there were low to moderate levels of associations between the HADS, SF-12 mental component sub-scale in the SCI pain sample, and the HADS depression score was correlated with other key variables (self-efficacy as assessed by the Moorong Self-Efficacy Scale [MSES] and SCI acceptance measured via the Spinal Cord Lesion-Related Coping Strategy Questionnaire [SCL CSQ]).

Suggestions for Use: The HADS has acceptable psychometric properties for the SCI population and appears to be sensitive to the impact of pain.  In addition, the HADS has been endorsed by persons with acute SCI [1]. However, the HADS has been primarily used to assess depression and anxiety, and not affect per se. It may be that other affect measures, such as the Positive and Negative Affect Scale (PANAS), are more appropriate if interested in the construct of affect. 

Additional References:

  1. Dunn J, Sinnott KA, Nunnerley J, Scheuringer M. Utilisation of patient perspective to validate clinical measures of outcome following spinal cord injury. Disabil Rehabil 2009;31:967-75.
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