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.



Bowel Dysfunction SCI Studies: One cross-sectional survey.

  1. Glickman S, Kamm MA. Bowel dysfunction in spinal-cord-injury patients. Lancet 1996;347:1651-3.

Sensitivity to Impact: Glickman and Kamm (1996) administered the Hospital Anxiety and Depression Scale (HADS) along with a study-specific questionnaire to out-patients with SCI (N = 115) in order to determine the prevalence, nature, and effect of SCI on bowel dysfunction. Bowel dysfunction was found to be a source of considerable psychological distress in 54% of the patients and was associated with time required for bowel management and frequency of incontinence. HADS scores significantly correlated with time taken for bowel management.

Suggestions for Use: The HADS has acceptable psychometric properties for the SCI population and appears to be sensitive to the impact of bowel dysfunction.  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 Affect and Negative Affect Scale (PANAS) may be 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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