Occupational Medicine 2015;65:601
doi:10.1093/occmed/kqv054
QUESTIONNAIRE REVIEW
Hamilton Rating Scale for Anxiety (HAM-A)
The Hamilton Anxiety Rating Scale (HAM-A, sometimes
termed HARS) [1], dating back to 1959, is one of the first
rating scales to measure the severity of perceived anxiety
symptoms. It is still in use today, being considered one of
the most widely used rating scales, and has been translated
into Cantonese, French and Spanish. It has been used as a
benchmark for more recently devised scales [2–4].
The author’s original intent for this scale was for its use
in individuals with anxiety neurosis (in contrast to the anxi-
ety inherent in the response to a threat or stress)—i.e. not a
means of diagnosing anxiety concomitant with other pathol-
ogy or problems. One year later, Hamilton also published a
similar scale for depressive symptoms [5].
The HAM-A is a clinician-based questionnaire; how-
ever, being available in the public domain, it has been
employed as a self-scored survey. It consists of 14 symp-
tom-defined elements, and caters for both psychological
and somatic symptoms, comprising anxious mood; ten-
sion (including startle response, fatigability, restlessness);
fears (including of the dark/strangers/crowds); insomnia;
‘intellectual’ (poor memory/difficulty concentrating);
depressed mood (including anhedonia); somatic symp-
toms (including aches and pains, stiffness, bruxism);
sensory (including tinnitus, blurred vision); cardiovascu-
lar (including tachycardia and palpitations); respiratory
(chest tightness, choking); gastrointestinal (including
irritable bowel syndrome-type symptoms); genitourinary
(including urinary frequency, loss of libido); autonomic
(including dry mouth, tension headache) and observed
behaviour at interview (restless, fidgety, etc.). Each item
is scored on a basic numeric scoring of 0 (not present)
to 4 (severe): >17/56 is taken to indicate mild anxiety;
25–30 is considered moderate–severe.
As to efficacy, although it is still often used in clinical
research trials (both of medication and psychological interven-
tions), it has been criticized [6] for its apparent inaccuracy in
discriminating between anxiolytic or antidepressant effects,
and between somatic anxiety compared to side-effects—thus,
the authors concluded that it was of limited usage in the evalu-
ation of anxiolytics. Maier et al. [6] tested the scale’s reliability
and validity in two samples of 97 anxious and 101 depressed
individuals and concluded that the reliability and concurrent
validity of the HAM-A and its subscales were sufficient: there
is reasonable inter-rater reliability and good one-week retest
reliability.
More recently [7], it has been pointed out that the
way clinicians assess symptom severity may reduce the
reliability of the original semistructured assessment.
Therefore, a structured interview guide (the Hamilton
Anxiety Rating Scale Interview Guide (HARS-IG),
© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
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standardizing the interview questions) was developed
and evaluated by joint interview and test–retest in 30
inpatients. HARS-IG has emerged as a more reliable
assessment tool than the original.
How does this relate to occupational practice? The
research applications are more evident: it has been used
in a number of occupational health-related studies [8]
and to measure the efficacy of occupational therapy.
And for the consulting room? It is reported to take
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12–15 min to administer—longer than the Hospital Anxiety
and Depression Score—and is considered to be of more use
as a monitoring tool (i.e. for sequential testing) than as a
single-use diagnostic or screening test. The length of time to
administer, the experience and training needed, may make
this test less practical for everyday clinical practice.
The questionnaire and operating instructions are
freely available on the internet [9].
Euan Thompson
E-mail: euanthompson@doctors.net.uk
References
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J Med Psychol 1959;32:50–55.
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A. The neuroanatomical correlates of anxiety in a healthy
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