What is the Hospital Anxiety and Depression Scale?

The Hospital Anxiety and Depression Scale (HADS) is a 14-item self-report questionnaire developed by Zigmond and Snaith (1983) for detecting anxiety and depression in medical outpatients. It is unique in deliberately excluding somatic symptoms that overlap with physical illness, making it the most widely used psychological screening tool in medical settings.

How is the HADS scored?

HADS has two 7-item subscales scored separately: HADS-A (anxiety, items A1-A7, range 0-21) and HADS-D (depression, items D1-D7, range 0-21). For each subscale: 0-7 = normal; 8-10 = borderline/possible case; 11-21 = probable case. Clinical decisions use subscale scores, not the total (0-42).

What HADS score indicates depression or anxiety?

A score of ≥8 on HADS-A (anxiety subscale) indicates a possible anxiety case requiring clinical follow-up. A score of ≥8 on HADS-D (depression subscale) indicates a possible depressive case. Scores ≥11 on either subscale indicate a probable case requiring formal diagnostic evaluation and treatment planning.

Why was HADS designed for hospital patients?

HADS excludes somatic symptoms (fatigue, sleep problems, appetite changes, weight) that are common in medical illnesses but also core depression and anxiety symptoms. By removing somatic items, HADS avoids falsely elevating psychiatric scores in medically ill patients, providing a cleaner measure of psychological rather than physical symptoms.

How does HADS compare to PHQ-9 for depression screening?

HADS-D focuses on anhedonia and avoids somatic items, making it more specific for depression in physically ill patients. PHQ-9 includes somatic items (sleep, energy, appetite) which may be confounded by medical illness. PHQ-9 is preferred in primary care; HADS-D is preferred in oncology, cardiology, and other medical specialty settings.

What are the HADS anxiety and depression subscales?

HADS-A (anxiety subscale, 7 items) measures psychic anxiety symptoms: tension, fearfulness, panic, worry, and inability to relax. HADS-D (depression subscale, 7 items) measures anhedonia: reduced enjoyment, laughter, cheerfulness, slowing, and loss of interest. Each subscale is interpreted independently.

Is HADS appropriate for oncology patients?

Yes. HADS is extensively validated in cancer patients and is widely recommended in oncology psychological distress screening guidelines (NCCN, British Psychosocial Oncology Society). Its somatic-free design is especially valuable in cancer, where fatigue and physical symptoms are ubiquitous and would confound PHQ-9 or BDI scores.

Can HADS be used in primary care?

Yes, but PHQ-9 and GAD-7 are more commonly used in primary care due to broader validation, simpler scoring, and greater clinician familiarity. HADS is particularly valuable in primary care patients with significant medical comorbidities (COPD, heart failure, diabetes) where somatic symptom overlap is a specific concern.

What are the psychometric properties of HADS?

Bjelland et al. (J Psychosom Res 2002) meta-analysis of 747 studies found HADS-A and HADS-D each achieve AUC ~0.80 at threshold ≥8, indicating good discriminative ability. Sensitivity ~0.80, specificity ~0.74 at this threshold, with moderate to high internal consistency (α = 0.68-0.93 across studies).

What should happen after a positive HADS screen?

A positive HADS screen (≥8 on either subscale) warrants: clinical follow-up interview to determine if DSM-5 anxiety or depressive disorder criteria are met; assessment of symptom duration, severity, and functional impact; assessment of suicidal ideation (HADS doesn't include this); and treatment planning if criteria are met.

What is the MCID for HADS subscales?

The minimum clinically important difference (MCID) for HADS subscales is approximately 1.5-2 points, representing a meaningful change beyond measurement error. This threshold is useful when monitoring HADS serially during treatment — changes below 1.5-2 points may not represent true clinical improvement.

What treatments are effective for anxiety and depression in medically ill patients?

Evidence-based treatments include: SSRIs/SNRIs (first-line pharmacotherapy with safety in medical comorbidities, avoiding paroxetine in cardiac patients); CBT adapted for medically ill patients; collaborative care models (integrated psychiatric and medical care); and psychoeducation. Treatment of the underlying medical condition also improves psychological outcomes.

Online Medical Tools — HADS

Printed on 9/4/2026

For informational purposes only. This is not medical advice.

Mental Health

HADS

HADS is a 14-item questionnaire with two 7-item subscales: anxiety (HADS-A) and depression (HADS-D). It is commonly used in outpatient and medically ill populations because it limits heavy somatic weighting.

Formula: HADS-A = sum of 7 anxiety items (0-21); HADS-D = sum of 7 depression items (0-21); total = 0-42.

I feel tense or wound up

Frightened feeling as if something awful may happen

Worrying thoughts go through my mind

I can sit at ease and feel relaxed

Frightened feeling like butterflies in the stomach

I feel restless as if I have to be on the move

I get sudden feelings of panic

I still enjoy the things I used to enjoy

I can laugh and see the funny side of things

I feel cheerful

I feel as if I am slowed down

I have lost interest in my appearance

I look forward with enjoyment to things

I can enjoy a good book or TV/radio program

Save your results with a free account

Keep a history of calculations, favorite tools, and access your dashboard anytime.

Create free account Sign in

How It Works

Patient Self-Completes 14 Items About the Current Week

The patient independently completes 14 questions about how they have felt during the past week. Items alternate between anxiety (A1-A7, odd-numbered) and depression (D1-D7, even-numbered) questions, each rated on a 4-point scale (0-3) with subscale-specific response anchors.

Score Each Subscale Separately (0–21 Each)

Sum the 7 anxiety items (HADS-A, range 0-21) and 7 depression items (HADS-D, range 0-21) as separate subscale scores. The total score (0-42) reflects overall emotional distress but clinical interpretation uses the subscales.

Apply Subscale Thresholds

For each subscale: 0-7 = normal/no case; 8-10 = borderline/possible case; 11-21 = probable case. A score ≥8 on either subscale warrants clinical follow-up for the corresponding disorder (anxiety or depression). Probable case (≥11) requires formal diagnostic evaluation.

Who Uses the HADS

Hospital Inpatient Anxiety and Depression Screening

Hospital Nurses & Physicians

HADS was specifically designed for medically ill patients to detect psychological comorbidity without somatic item confounding. It is the most widely used anxiety and depression screening tool in hospital inpatient and outpatient settings globally.

Oncology Patient Psychological Assessment

Oncology Nurses & Palliative Care Teams

HADS is extensively validated in cancer patients, where somatic symptoms (fatigue, weight loss, appetite changes) overlap substantially with depression and anxiety symptoms. Its somatic-free design makes it particularly suited for oncology psychological screening.

Cardiac and Chronic Disease Comorbidity Screening

Cardiologists & Chronic Disease Specialists

Depression after myocardial infarction affects 15-30% of patients and independently worsens outcomes. HADS screens for depression and anxiety in post-MI, heart failure, COPD, and diabetes patients without somatic symptom contamination.

General Medical Outpatient Psychological Comorbidity

General Medicine Physicians

In general medical outpatient settings, HADS provides a validated dual-domain screen for anxiety and depression as psychological comorbidities of physical illness, identifying patients who need mental health referral alongside medical management.

Pre-Surgical Psychological Assessment

Surgeons & Anesthesiologists

Preoperative anxiety and depression predict worse surgical outcomes, longer hospital stays, and higher opioid consumption. HADS administered preoperatively identifies patients who may benefit from psychological support to optimize surgical outcomes.

Pro Tips

HADS Deliberately Excludes Somatic Items

HADS was designed by Zigmond and Snaith (1983) specifically to avoid somatic symptoms (fatigue, sleep disturbance, appetite, weight change) that overlap with medical illness, making it more specific than PHQ-9 or HAM-A for detecting psychological disorders in physically ill patients.

Score Subscales Separately — Not as Total

Clinical interpretation of HADS uses HADS-A and HADS-D as separate subscales (each 0-21), not the combined total (0-42). While total score reflects overall distress, treatment decisions are made based on which subscale is elevated — anxiety treatment vs depression treatment.

PHQ-9 and GAD-7 Are Preferred in Primary Care

While HADS is the gold standard in hospital/medical settings, PHQ-9 and GAD-7 have more robust primary care validation, briefer administration, and are more familiar to primary care teams. Use HADS when somatic item contamination is the specific concern (cancer, cardiac, pulmonary disease patients).

HADS-D Specifically Measures Anhedonia

The HADS depression subscale was deliberately designed around anhedonia (loss of interest and pleasure) — a core DSM feature of major depression — rather than somatic symptoms. This makes HADS-D specifically sensitive to the psychological core of depression.

Hospital Psychological Distress Impacts Clinical Outcomes

Anxiety and depression in hospitalized patients are independently associated with longer lengths of stay, higher readmission rates, worse treatment adherence, and increased mortality in chronic diseases. Systematic HADS screening can identify high-risk patients for early psychological intervention.

MCID Is 1.5-2 Points Per Subscale

The minimum clinically important difference for HADS subscales is approximately 1.5-2 points, meaning changes of this magnitude represent genuine clinical improvement beyond measurement noise. Use this threshold when monitoring HADS serially during treatment.

HADS Correlates Highly With PHQ-9 and GAD-7

HADS-D and PHQ-9 correlate at r=0.74-0.87; HADS-A and GAD-7 correlate at r=0.72-0.85 in validation studies. This means the tools are largely interchangeable for screening purposes — use whichever is most institutionally standard, as training and familiarity improve consistent implementation.

Threshold ≥8 on Either Subscale Warrants Follow-Up

A score of 8-10 on HADS-A or HADS-D represents a 'borderline/possible case' requiring clinical follow-up interview to determine if criteria for an anxiety or depressive disorder are met. Score ≥11 on either subscale represents a 'probable case' requiring formal diagnostic evaluation and likely treatment.

Common Questions About Your Results

Evidence-Based Methodology

HADS developed by Zigmond & Snaith (Acta Psychiatr Scand 1983) specifically for non-psychiatric medical outpatients. Meta-analysis of 747 studies by Bjelland et al. (J Psychosom Res 2002): HADS-A and HADS-D each have AUC ~0.80 at threshold ≥8. Widely validated in oncology, cardiology, and chronic disease populations. HADS excludes somatic items by design to avoid confounding in physically ill patients. WHO-5 and PHQ-9 are alternatives in primary care settings where HADS may be over-inclusive.

Clinical Content Trust

Last reviewed:: April 21, 2026
Guideline version:: General evidence framework v2026.04
Source set version:: Primary-source set v1

How to Interpret Your Result

Higher HADS-A/HADS-D subscale scores indicate stronger anxiety/depression symptom burden and support targeted follow-up assessment.

When to Use This Tool

Use when brief dual-domain anxiety/depression screening is needed, especially in medical settings where somatic symptoms may confound other scales.

Limitations

HADS is a screening tool and may not capture full diagnostic complexity, comorbidity, or disorder-specific criteria without comprehensive interview.

Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.

Changelog

April 21, 2026 · trust-baseline
Clinical trust metadata enabled for this tool page with structured review/version fields.

Related Tools