• Assesses anxiety and depression in a non-psychiatric population
  • Has 2 subscales: Depression and Anxiety, both with 7 items
  • Other than physically ill individuals, the HADS is also used with community samples/populations.

Clinical Considerations

  • It is unclear if the few somatic items influence the reliability and validity of this measure with an SCI population. Further research is needed to confirm psychometric properties within this population.
  • The HADS should only be used as a screening instrument. It is one of two instruments with an anxiety-specific scale that has had its measurement properties evaluated for the SCI population.

ICF Domain

Body Function ▶ Mental Function


  • Self-report format
  • Responses are based on the relative frequency of symptoms over the past week, using a four point Likert scale ranging from 0 (not at all) to 3 (very often indeed).
  • Can be completed in around 5 minutes

Number of Items





Responses are summed to provide separate scores for anxiety and depression symptomology; each of anxiety or depression scale have a score range of 0-21.


Versions of the scale are available in English, Arabic, Dutch, French, German, Hebrew, Swedish, Italian, and Spanish.

Training Required



Can be found here.

# of studies reporting psychometric properties: 9


  • Higher scores indicate greater likelihood of depression or anxiety.
  • A cut-off point of 8/21 for the Anxiety subscale gave a specificity of 0.78 and sensitivity of 0.9; a cut-off point of 8/21 for the Depression subscale gave a specificity of 0.79 and a sensitivity of 0.83.
  • No normative data for the SCI population has been established.
  • Published data is available to compare results for individuals with SCI (see interpretability section of Study Details sheet).

MCID: not established in SCI
SEM: not established in SCI
MDC: not established in SCI


  • Internal consistency of the Anxiety subscale of the HADS is High (Cronbach’s a = 0.8463-0.85)
  • Internal consistency of the Depression subscale of the HADS is High (Cronbach’s a = 0.79-0.8122).

(Woolrich et al. 2006, Berry & Kennedy 2003)


  • Correlation of the total HADS scale is Moderate with the:
    • Life Satisfaction Questionnaire (Pearson’s r = -0.585)
    • Sexual Adjustment Scale (Pearson’s r = -0.49)
    • Emotional Quality of the Relationship scale (-0.38).
  • Correlation of the Anxiety subscale of the HADS is Moderate with the:
    • Spinal Cord Lesion Coping Strategies – Acceptance subscale (Pearson’s r = -0.45)
    • Spinal Cord Lesion Coping Strategies – Fighting Spirit subscale (Pearson’s r = -0.40)
  • Correlation of the Depression subscale of the HADS is Moderate with the:
    •  Spinal Cord Lesion Coping Strategies – Acceptance subscale (Pearson’s r = -0.58)
    •  Spinal Cord Lesion Coping Strategies –Fighting Spirit subscale (Pearson’s r = -0.49).

(Woolrich et al. 2006, Berry & Kennedy 2003, Elfstrom et al. 2007, Kreuter et al. 1996)


No values were reported for the responsiveness of the HADS for the SCI population.

Floor/Ceiling Effect

No values were reported for the presence of floor/ceiling effects in the HADS for the SCI population.


Dr. Vanessa Noonan, John Zhu, Jeremy Mak

Date Last Updated

1 December 2016

Berry C, Kennedy P. A psychometric analysis of the Needs Assessment Checklist (NAC). Spinal Cord, 2002; 41: 490-501.

Ebrahimzadeh MH, Soltani-moghaddas SH, Birjandinejad A, Omidi-kashani F, Bozorgnia S. Quality of life among veterans with chronic spinal cord injury and related variables. Arch Trauma Res. 2014;3(2):e17917.

Elfstrom ML, Kennedy P, Lude P, Taylor N. Condition-related coping strategies in persons with spinal cord injury: a cross-national validation of the Spinal Cord Lesion-related Coping Strategies Questionnaire in four community samples. Spinal Cord, 2007; 45: 420-428.

Kreuter M, Sullivan M, Siosteen A. Sexual adjustment and quality of relationships in spinal paraplegia: A controlled study. Arch Phys Med Rehabil 1996;77:541-548.

Middleton JW, Tate RL, Geraghty TJ. Self-Efficacy and Spinal Cord Injury: Psychometric Properties of a New Scale. Rehabil Psychol. 2003; 48(4):281-288

Munce SE, Straus SE, Fehlings MG, et al. Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury. Spinal Cord. 2016;54(1):29-33.

Menon N, Gupta A, Khanna M, Taly AB, Thennarasu K. Prevalence of depression, fatigue, and sleep disturbances in patients with myelopathy: Their relation with functional and neurological recovery. J Spinal Cord Med. 2016.

Paker N, Bugdayci D, Midik M, Celik B, Kesiktas N. Reliability of the Turkish version of the hospital anxiety and depression scale in the people with traumatic spinal cord injury. NeuroRehabilitation. 2013;33(2):337-41.

Snaith RP. The Hospital Anxiety And Depression Scale. Health and Quality of Life Outcomes, 2003; 1: 29.

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.

Zigmond AS, Snaith RP. The Hospital Anxiety and Depression scale. Acta Psychiatr Scand 1983; 67: 361–370.