Hospital Anxiety and Depression Scale: Test Review and Critique

Hospital Anxiety and Depression Scale:

Test Review and Critique

Mark Todd

CO545, Dr. Melissa (Hager) Barker

University of West Alabama

November 5, 2021
 Hospital Anxiety and Depression Scale: Test Review and Critique

Test Review and Critique of the Hospital Anxiety and Depression Scale

I. GENERAL INFORMATION

The Hospital Anxiety and Depression Scale (HADS) was first published in 1983 by AS Zigmund

and RP Snaith in the international journal Acta Psychiatrica Scandinavica. It has been translated

into most European languages as well as others around the world (Zigmund and Smith, 1983).

The test has been disseminated widely and is freely available. It can be downloaded in many

languages including English and Arabic. The test is also offered for sale by the publisher.

II. TEST DESCRIPTION

A. Test Content

The HADS is especially useful because it measures both Anxiety and Depression, which are often

comorbid. HADS Anxiety and Depression are unidimensional measures ( Djukanovic et. al 2017).

The instrument does not measure all of the diagnostic criteria of depression in the Diagnostic and

Statistical Manual of Mental Disorders (DSM-5) which limits its use as a comprehensive diagnostic

tool (Stern 2014).

B. Purpose of Test

The “Hospital” designation refers to its use in screening patients who may be also suffering physical

injury. The test is designed to ask questions in a way which differentiates mental health symptoms

from physical ailments. Anxiety often precedes depression, and early detection allows treatment to
 Hospital Anxiety and Depression Scale: Test Review and Critique
begin at a stage that might be missed by a tool such as the Patient Health Questionnaire (PHQ9)

which only assesses depression (Stern, 2014).

C. Test Structure

The HADS contains 14 questions which are answered in a Likert-type scale of 0-3 degrees. The

response indicates how often the symptom occurs. While the responses are not always worded in the

same way for each question, they generally indicate degrees similar to “Not at all,” “Sometimes,”

“Very Often,” and “Almost all the time.” Seven of the questions are about anxiety, and seven about

depression, and are scored separately (Terkawi, et al. 2017). The anxiety questions are all odd

numbered (1-13) and the depression questions are all even numbered (2-14).

D. Test Administration

The test is administered in normal clinical settings, but the ease of use allows it to be administered in

field settings such as refugee camps. The simplicity of the test requires no training to administer but

does recommend a key to grade the test. The test can easily be administered online and is available

online. Because the test does not require any feedback from clients other than checking a box, it can

be administered in group settings, so long as clients cannot look on one another’s sheets.

E. Test Scoring

Both anxiety and depression are scored on a scale of 0-21, with 0-7 indicating non-cases. 8-10 mild

cases, 11-14, moderate cases, 15-21 severe cases. A key is recommended to grade the test because

questions alternate between anxiety and depression, and scales are reversed on some questions. The

anxiety and depression scores are independent and not additive (Terkawi, et al. 2017). The HADS can

be taken and scored online (anxietytesting.com 2021).

 Hospital Anxiety and Depression Scale: Test Review and Critique
III. TECHNICAL EVALUATION

A. Standardization/Normative Sample

Djukanovic et. al (2017) sampled a population of 6659 Swedish Senior Citizens (3436 women and

3223 men) 65-80 years of age (mean = 71.2 SD=4.5). Questionnaires were mailed by post to names

randomly selected from a national registry. The response rate after follow-up mailers was 67%

(66.6% for women and 67.1% for men). The large sample and high rate of return give an adequate

randomized sample. A wide array of demographic information was normed, by gender, including

marriage education, work, and medications.

B. Reliability

According to Djukanovic the test showed a high level of internal consistency reliability which show

acceptable internal consistency of 0.92 for HADS Anxiety and 0.88 for HADS Depression. Score

distributions for related questions were used to demonstrate internal consistency reliability.

(Djukanovic et. al 2017).

C. Validity

An evaluation of an Arabic translation of the HADS validity by Terkawi et al. (2017) examined face

validity by asking client to evaluate the instrument, with 84.5% agreeing or strongly agreeing that is

covered all of their depression and anxiety problem areas. Regarding construct validity, Terkawi et al.

examined the correlations between patients’ HADS Anxiety with the Generalized Anxiety Disorder

7-Item (GAD-7 Arabic, correlation = .67) and Depression scores with the Major Depression

Inventory (MDI Arabic, correlation =.71).

 Hospital Anxiety and Depression Scale: Test Review and Critique
IV. PRACTICAL EVALUATION

A. Quality of Test Materials

The test page is laid out in a relatively straightforward manner and is easy to use. The arrangement of

questions into two columns on the page, with possible answers below the questions, allows for ease of

tabulation of results, and also fits the text onto a single page. The original Arabic copy provided by

Terkawai, et al. (2017) conforms to the same design, however the additional wording required in

translation of some questions yielded a small font size.

B. Ease of Administration, Scoring and Interpretation

The test is easily administered, requiring only a simple explanation that clients check one answer box

for each question. It can be administered in about 15-20 minutes, based on our experience with the

Arabic language version (Todd, 2021). Scoring is done by adding the odd numbered question scores

for anxiety, and the even numbered question scores for depression. Care must be taken to note that

several questions are “reverse scored” meaning that the 0-3 scores are presented in a 3-0 format. Ease

of scoring is aided by a key, but the simple design does not require the key.

In our experience in Tyre, Lebanon, using the Arabic version in refugee camps, the font of the Arabic

text was too small. Arabic requires the use of small diacritical marks to differentiate some of the

letters of the alphabet from one another. Many of the older refugees had trouble reading and required

assistance. We solved this by reading the questions aloud to all participants. Since all participants

were answering questions together in the same proximity, we did make folders available to shield

responses from view (Todd, 2021).

 Hospital Anxiety and Depression Scale: Test Review and Critique
V. SUMMARY EVALUATION AND CRITIQUE

A. Strengths and Weaknesses of the Test

Strengths of the HADS include ease of administration, the short time required for administration, and

suitability for hospitals as a screening tool. The weakness of the HADS is the lack of some questions

required to address symptoms found in the DSM-5, making it less useful as a definitive diagnostic

tool in clinical mental health settings.

B. Recommendations

The HADS is very appropriate as a screening tool in hospitals as a part of patient intake processing. It

is also useful in response situations where large numbers of people need to be screened for anxiety or

depression. It also allows for the evaluation of treatment efficacy by administering the evaluation 3-6

months after treatments (Molero, J. et al., 2021).

There are multicultural elements of the test which deserve further study and evaluation. Question 14,

which asks about the enjoyment of a good book, or radio or TV program has very limited application

and understanding in a Bedouin society. They spend much of their life living in tents and are often

illiterate. Their answer to the question may indicate cultural norms rather than depression. Question

11 asks about feelings of restlessness and a desire to be on the move. This is much more normal in

Bedouin culture, where frequent relocation is an expected and necessary way of life, rather than a

symptom of anxiety (Todd 2021).

 Hospital Anxiety and Depression Scale: Test Review and Critique

VI. REFERENCES

anxietytesting.com (2021) Hospital Anxiety and Depression Scale. Last accessed 11/9/2021

at https://www.anxietytesting.com/free-anxiety-depression-test.php

Djukanovic I. ; Carlsson J.; and Årestedt K. (2017) Is the Hospital Anxiety and Depression Scale

(HADS) a valid measure in a general population 65–80 years old? A psychometric evaluation

study. Health and Quality of Life Outcomes 15:193

Molero, J.; Jarero, I; Givaudan, M. (2019) Longitudinal Multisite Randomized Controlled Trial

on the Provision of the EMDR-IGTP-OTS to Refugee Minors in Valencia, Spain American

Journal of Applied Psychology 8(4): 77-88

Stern, A (2014). The Hospital Anxiety and Depressions Scale Questionnaire Review.

Occupational Medicine 2014;64:393–394

Terkawi, A.; Tsang, S.; AlKahtani, G.; Al-Mousa, S.; Al Musaed, S.; AlZoraigi, U.; Alasfar, E.;

Doais, K.; Abdulrahman, A.; & Altirkawi, K. (2017). Development and Validation of Arabic

Version of the Hospital Anxiety and Depression Scale. Saudi Journal of Anaesthesia, 11 (Suppl

1), S11–S18

Todd, M., (2021) Personal observations. Tyre, Lebanon.

Zigmond, A; Snaith, R (1983). "The hospital anxiety and depression scale". Acta Psychiatrica

Scandinavica. 67 (6): 361–370. 
 Hospital Anxiety and Depression Scale: Test Review and Critique

Arabic Instrument: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5463562/

English Instrument: https://www.svri.org/sites/default/files/attachments/2016-01-13/HADS.pdf