Occupational Medicine 2014;64:393–394
doi:10.1093/occmed/kqu024
Questionnaire Review
The Hospital Anxiety and Depression Scale
Brief history
The Hospital Anxiety and Depression Scale (HADS)
was devised 30  years ago by Zigmond and Snaith [1]
to measure anxiety and depression in a general medical
population of patients. It has become a popular tool, for
clinical practice and research: a PubMed search returned
1961 papers!
Description
The beauty of the HADS score is its simplicity, speed and
ease of use. Very few (literate) people have difficulty com-
pleting it, on paper or electronically. It assesses both anxi-
ety and depression, which commonly coexist [2]. Anxiety
is poorly recognized by clinicians, so should be actively
sought [3]. Anxiety often precedes depression in response
to stressors, and identifying the employee with high or ris-
ing anxiety before depression allows occupational health
practitioners to advise on early intervention measures while
the employee is still at work and potentially avoid sickness
absence. This would be missed using a depression only
questionnaire such as the Patient Health Questionnaire
(PHQ9). HADS focuses on non-physical symptoms so that
it can be used to diagnose depression in people with signifi-
cant physical ill-health. Any overlap, for instance impaired
concentration secondary to pain rather than depression,
is usually easy to separate on an individual basis. HADS
does not include all of the diagnostic criteria of depression
(Diagnostic and Statistical Manual of Mental Disorders,
Fourth/Fifth Edition (DSM IV/V)) or all those required
by the Health and Work Development Unit (HWDU)
National Depression and Long Term Sickness Absence
Screening Audit [4]. For this, additional questions on appe-
tite, sleep and self-harm/suicidal thoughts have to be asked.
A risk assessment for self-harm or suicide should of course
be carried out in appropriate cases.
Items
The questionnaire comprises seven questions for anxiety
and seven questions for depression, and takes 2–5 min to
complete. Although the anxiety and depression questions
are interspersed within the questionnaire, it is vital that these
are scored separately. Cut-off scores are available for quan-
tification, for example a score of 8 or more for anxiety has a
specificity of 0.78 and a sensitivity of 0.9, and for depression
a specificity of 0.79 and a sensitivity of 0.83 [5] (Table 1).
© The Author 2014. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
Table 1.  HADS score
For both scales, scores of less than 7 indicate non-cases
8–10 Mild
11–14 Moderate
15–21 Severe
Downloaded from https://academic.oup.com/occmed/article/64/5/393/1436876 by guest on 16 May 2021
Note: Score anxiety and depression separately.
Validity
The HADS questionnaire has been validated in many
languages, countries and settings including general prac-
tice and community settings [5–7]. It is useful for initial
diagnosis and to track progression (or resolution) of psy-
chological symptoms. It is one of the National Institute
for Health and Care Excellence (NICE) recommended
tools for diagnosis of depression and anxiety [3].
Key research in which the questionnaire
has been used
HADS has been investigated extensively in a general
medical setting. In occupational health, a paper on the
use of evidence-based clinical tools in occupational
medicine by Bailey [8] concluded that over half the
(214) Society of Occupational Medicine members who
responded to the study used HADS. In the Hordaland
Health Study (17 384 workers in Norway), occupa-
tional differences in the levels of anxiety and depres-
sion were investigated using HADS score. HADS levels
showed an inverse association with skill level especially
for depression. Screening for depression in low-skill
workers was recommended for consideration [9].
Source
The questionnaire was historically freely available. It
is currently available to purchase from http://shop.gl-
assessment.co.uk.
Acknowledgements
I would like to thank Judy Sharpey-Schafer for helpful
discussion, comments and references.
Anna F. Stern
e-mail: annastern@doctors.org.uk
394  OCCupational medicine

References
1. Zigmond AS, Snaith RP. The Hospital Anxiety and
Depression Scale. Acta Psychiatr Scand 1983;67:361–370.
2. McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins
R, eds. Adult Psychiatric Morbidity in England 2007. Results
of Household Survey. http://www.hscic.gov.uk/catalogue/
PUB02931/adul-psyc-morb-res-hou-sur-eng-2007-rep.pdf
(February 2014, date last accessed).
3. National Collaborating Centre for Mental Health. Common
Mental Health Disorders: The NICE Guideline on Identification
and Pathways to Care. National Clinical Guideline Number 123.
http://www.nice.org.uk/nicemedia/live/13476/54604/54604.
pdf (February 2014, date last accessed).
4. Occupational Health Clinical Effectiveness Unit Audit
http://www.nhshealthatwork.co.uk/depression-longterm.asp
(February 2014, date last accessed).
5. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity
of the Hospital Anxiety and Depression Scale. An updated
literature review. J Psychosom Res 2002;52:69–77.
6. Snaith RP. The Hospital Anxiety and Depression
Scale. Health Qual Life Outcomes 2003;1:29.
doi:10.1186/1477-7525-1-29
7. Herrmann C. International experiences with the Hospital
Anxiety and Depression Scale—a review of validation data
and clinical results. J Psychosom Res 1997;42:17–41.
8. Bailey K. The use of evidence-based clinical tools in occu-
pational medicine. Occup Med (Lond) 2008;58:556–560.
9. Sanne B, Mykletun A, Dahl AA, Moen BE, Tell GS;
Hordaland Health Study. Occupational differences in levels

Downloaded from https://academic.oup.com/occmed/article/64/5/393/1436876 by guest on 16 May 2021

Development Group. NHS Health at Work Network / Clinical of anxiety and depression: the Hordaland Health Study. J
Excellence / Audit / Depression and Long-term Sickness Absence. Occup Environ Med 2003;45:628–638.

Wanted: Questionnaires and Questionnaire Reviewers

Occupational Medicine, the journal of the Society of Occupational Medicine, is running a series of articles
­covering questionnaires used in OH clinical practice. If you use a particular questionnaire in your ­practice and
would be willing to review it and submit it for consideration for publication please contact Angela Burnett at
om@som.org.uk to check we haven’t already got a review of that questionnaire underway and for guidance on
the review content we are looking for.