Cited by 908Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychometric Methodologies and TestingHealth Education and Validation

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Hospital Anxiety and Depression (HAD) scale: Factor structure, item analyses and internal consistency in a large population

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Mykletun, Arnstein, Stordal, Eystein, Dahl, Alv A.·2001·British Journal of Psychiatry

DOI 10.1192/bjp.179.6.540

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Abstract

Background: The Hospital Anxiety and Depression (HAD) rating scale is a commonly used questionnaire. Former studies have given inconsistent results as to the psychometric properties of the HAD scale. Aims: To examine the psychometric properties of the HAD scale in a large population. Method: All inhabitants aged 20–89 years (n=92 100) were invited to take part in The Nord-Tr⊘ndelag Health Study, Norway. A total of 65 648 subjects participated, and only completed HAD scale forms (n=51 930) formed the basis for the psychometric examinations. Results: Principal component analysis extracted two factors in the HAD scale that accounted for 57% of the variance. The anxiety and depression sub-scales shared 30% of the variance. Both sub-scales were found to be internally consistent, with values of Cronbach's coefficient (a) being 0.80 and 0.76, respectively. Conclusions: Based on data from a large population, the basic psychometric properties of the HAD scale as a self-rating instrument should be considered as quite good in terms of factor structure, intercorrelation, homogeneity and internal consistency.

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The Hospital Anxiety and Depression Scale
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“A total score ranging from 0 to 7 represents normal symptom levels, a total score ranging from 8 to 10 indicates probable anxiety or depression symptoms, and a total score $11 indicates clinically elevated anxiety or depression.(23,24) The HADS is widely used to assess anxiety and depression, with good validity and re…”
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“Hospital Anxiety and Depression Scale The Hospital Anxiety and Depression Scale (HADS) consists of 14 items, seven comprising the depression subscale and seven comprising the anxiety subscale.(33,34) Each item is scored from 0 (minimally present) to 3 (maximally present).”
MethodSelf-citation
The quality of life and factors associated with it in the medically hospitalised elderly
Helvik, A., Engedal, K., & Selbæk, G. (2010) · Aging & Mental Health · doi:10.1080/13607861003801003 · Cited by 48
“The HAD questionnaire has been validated in Norway and used in several studies including some among the elderly (Mykletun, Stordal, & Dahl, 2001 ; Olsson, Mykletun, & Dahl, 2005 ; Stordal et al, 2001 ).”
Method
Assessment of Biopsychosocial Complexity and Health Care Needs: Measurement Properties of the INTERMED Self-Assessment Version
Dortland, A. K. B. V. R., Peters, L. L., Boenink, A. D., Smit, J. H., Slaets, J. P. J., Hoogendoorn, A. W., Joos, A. A. B., Latour, C. H. M., Stiefel, F., Burrus, C., et al. (2016) · Psychosomatic Medicine · doi:10.1097/psy.0000000000000446 · Cited by 49
“76, respectively) internal consistency (25).”
The Polycystic Ovary Syndrome Quality of Life scale (PCOSQOL): Development and preliminary validation
Williams, S., Sheffield, D., & Knibb, R. C. (2018) · Health Psychology Open · doi:10.1177/2055102918788195 · Cited by 49
“The subscales for HADS have demonstrated good internal consistency, with Cronbach’s alpha of 0.80 for the Anxiety subscale and 0.76 for the Depression subscale (Mykletun et al., 2001).”
MethodInfluential
Screening for depression in elderly medical inpatients from rural area of Norway: prevalence and associated factors
Helvik, A., Skancke, R. H., & Selbæk, G. (2009) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.2312 · Cited by 47
“The HAD inventory has been validated in Norway and used in several studies (Mykletun et al., 2001; Stordal et al., 2001; Olsson et al., 2005) and so has the MADRS (Thommessen et al.”
Method
Dimensionality of the Hospital Anxiety and Depression Scale (HADS) in Cardiac Patients
Emons, W. H. M., Sijtsma, K., & Pedersen, S. S. (2010) · Assessment · doi:10.1177/1073191110384951 · Cited by 49
Insomnia and the Risk of Breast Cancer: The HUNT Study
Sen, A., Opdahl, S., Strand, L. B., Vatten, L. J., Laugsand, L. E., & Janszky, I. (2016) · Psychosomatic Medicine · doi:10.1097/psy.0000000000000417 · Cited by 50
“Scores on both anxiety and depression subscales ranged from 0 point (no symptoms) to 21 points, and increasing scores indicated increased symptom load (25,26).”
Background
Psychological distress in women at risk of hereditary breast/ovarian or HNPCC cancers in the absence of demonstrated mutations
Geirdal, A. Ø., Reichelt, J. G., Dahl, A. A., Heimdal, K., Mæhle, L., Stormorken, A. T., & Møller, P. (2005) · Familial Cancer · doi:10.1007/s10689-004-7995-y · Cited by 48
“Caseness indicates possible anxiety or depressive disorder that would give reason for further clinical examination [ 28 , 29].”
BackgroundSelf-citation
Metacognitions across the continuum of drinking behaviour
Spada, M. M., & Adrian Wells, A. (2010) · Personality and Individual Differences · doi:10.1016/j.paid.2010.04.011 · Cited by 48
Overlap and distinctiveness of psychological risk factors in patients with ischemic heart disease and chronic heart failure: Are we there yet?
Pelle, A. J., Denollet, J., Zwisler, A.-D., & Pedersen, S. S. (2009) · Journal of Affective Disorders · doi:10.1016/j.jad.2008.05.017 · Cited by 47
“The dimensional structure and reliability of the HADS has shown to be stable in various samples and age groups (Mykletun et al., 2001).”
Background
Protective Effect of Regular Physical Activity on Depression After Myocardial Infarction: The HUNT Study
Ernstsen, L., Rangul, V., Nauman, J., Nes, B. M., Dalen, H., Krokstad, S., Lavie, C. J., Blair, S. N., & Wisløff, U. (2015) · The American Journal of Medicine · doi:10.1016/j.amjmed.2015.08.012 · Cited by 47
Prevalence and risk factors of mental distress in China during the outbreak of COVID‐19: A national cross‐sectional survey
Wu, M., Han, H., Lin, T.-K., Min, C., Wu, J., Su, G., Su, G., Wu, D., Chen, F., Zhang, Q., et al. (2020) · Brain and Behavior · doi:10.1002/brb3.1818 · Cited by 46
Symptoms in the cancer patient – Of importance for their caregivers' quality of life and mental health?
Valeberg, B. T., & Grov, E. K. (2012) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2012.01.009 · Cited by 46
Sense of coherence as a predictor of work reentry following multidisciplinary rehabilitation for individuals with chronic musculoskeletal pain.
Lillefjell, M., & Jakobsen, K. (2007) · Journal of Occupational Health Psychology · doi:10.1037/1076-8998.12.3.222 · Cited by 46
Widespread pain and medically certified disability pension in the H ordaland H ealth S tudy
Øverland, S. N., Harvey, S. B., Knudsen, A. K., Mykletun, A., & Hotopf, M. H. (2011) · European Journal of Pain · doi:10.1016/j.ejpain.2011.08.005 · Cited by 46
“In line with previous recommendations, we used seven items each to define anxiety and depression, with scores of 8 to define caseness on the subscales HADS-A and HADS-D (Mykletun et al., 2001).”
MethodSelf-citation
Cardiovascular effects of xenon and nitrous oxide in patients during fentanyl‐midazolam anaesthesia*
Goto, T., Hanne, P., Ishiguro, Y., Ichinose, F., Niimi, Y., & Morita, S. (2004) · Anaesthesia · doi:10.1111/j.1365-2044.2004.03900.x · Cited by 47
The association between history of diabetic foot ulcer, perceived health and psychological distress: the Nord-Trøndelag Health Study
Iversen, M. M., Midthjell, K., Tell, G. S., Moum, T., Østbye, T., Nortvedt, M. W., Uhlving, S., & Hanestad, B. R. (2009) · BMC Endocrine Disorders · doi:10.1186/1472-6823-9-18 · Cited by 48
“Previously, factor analyses of HADS in HUNT have been shown to result in a two-factor solution consistent with the two subscales of anxiety and depression [14].”
Relationship between anxiety and dyspnea on exertion in patients with chronic obstructive pulmonary disease
de Voogd, J. N., Sanderman, R., Klaas Postema, A., van Sonderen, E., & Wempe, J. B. (2010) · Anxiety Stress & Coping · doi:10.1080/10615806.2010.520081 · Cited by 46
“The anxiety subscale of the Dutch version of the Hospital Anxiety and Depression Scale (HADS; Bjelland, Dahl, Haug, & Neckelmann, 2002; Mykletun & Stordal, 2001; Zigmond & Snaith, 1983) was used to assess the degree of general anxiety.”
Method
Individual Cognitive Stimulation Therapy for dementia (iCST): study protocol for a randomized controlled trial
Orrell, M. W., Yates, L., Burns, A. S., Russell, I. T., Woods, B. T., Hoare, Z., Moniz-Cook, E. D., Henderson, C., Knapp, M. R. J., Spector, A. E., et al. (2012) · Trials · doi:10.1186/1745-6215-13-172 · Cited by 49
“Anxiety and depression will be assessed using the Hospital Anxiety and Depression Scale (HADS) [40], a widely used measure of self-reporting consisting of 14 questions, validated in several age groups, which identifies caseness for clinically significant depression and anxiety [41].”
Method
Symptoms, clusters and quality of life prior to surgery for breast cancer
Denieffe, S., Cowman, S., & Gooney, M. (2013) · Journal of Clinical Nursing · doi:10.1111/jocn.12430 · Cited by 46
“…population, it was shown that the basic psychometric properties of the © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2491–2502 2493 HADS as a self-rating instrument are good in terms of factor structure, intercorrelation, homogeneity and internal consistency (Mykletun et al. 2001).”
Background
Rasch analysis of the Hospital Anxiety and Depression Scale among caregivers of cancer survivors: implications for its use in psycho‐oncology
Lambert, S., Pallant, J., & Girgis, A. (2010) · Psycho-Oncology · doi:10.1002/pon.1803 · Cited by 46
“Multidimensionality was clearly evident and although anxiety and depression are related concepts, these results imply they should remain separate constructs in the assessment of caregivers’ levels of distress [12,33].”
Result
Preoperative Pain, Symptoms, and Psychological Factors related to Higher Acute Pain Trajectories during Hospitalization for Total Knee Arthroplasty
Lindberg, M. F., Miaskowski, C. A., Rustøen, T., Rosseland, L. A., Paul, S. M., & Lerdal, A. (2016) · PLoS ONE · doi:10.1371/journal.pone.0161681 · Cited by 46
“Patients and study procedures This study is part of a longitudinal study of pain, symptoms, and health-related quality of life (QOL) in patients who underwent a TKA for OA at a surgical clinic in Oslo, Norway.”
MethodInfluential
Cognitive and anxiety symptoms in screening for clinical depression in diabetes A systematic examination of diagnostic performances of the HADS and BDI-SF
Sultan, S., Luminet, O., & Hartemann, A. (2009) · Journal of Affective Disorders · doi:10.1016/j.jad.2009.09.022 · Cited by 54
“These factor structures justify the comparison of the six scales and subscales in further analyses (Mykletun et al., 2001; Shafer, 2006).”
Method
Psychometric properties of the Urdu version of the World Health Organization's quality of life questionnaire (WHOQOL-BREF)
Lodhi, F. S., Raza, O., Montazeri, A., Nedjat, S., Yaseri, M., & Holakouie‐Naieni, K. (2017) · Medical Journal of the Islamic Republic of Iran · doi:10.14196/mjiri.31.129 · Cited by 45
“Intraclass correlation (ICC) is an estimation of the portion of the total measurement variability due to modification among individuals (23).”
Background
Night work and symptoms of anxiety and depression among nurses: A longitudinal study
Thun, E., Bjorvatn, B., Torsheim, T., Moen, B. E., Magerøy, N., & Pallesen, S. (2014) · Work & Stress · doi:10.1080/02678373.2014.969362 · Cited by 47
The ineffectiveness of the Hospital Anxiety and Depression Scale for diagnosis in an Omani traumatic brain injured population
Al‐Adawi, S., Dorvlo, A. S. S., Al‐Naamani, A., Glenn, M. B., Karamouz, N., Chae, H., Zaidan, Z. A. J., & Burke, D. T. (2007) · Brain Injury · doi:10.1080/02699050701311059 · Cited by 44
“Its psychometric properties have generally been found to be appropriate [18, 19].”
Background
Analysis of psychological characteristics impacting spinal cord stimulation treatment outcomes: a prospective assessment.
Sparkes, E., Duarte, R. V., Mann, S. A., Lawrence, T. R., & Raphael, J. H. (2015) · PubMed · Cited by 44
A 4-year follow-up study of syndromal and sub-syndromal anxiety and depression symptoms in the general population
Bjerkeset, O. A., Nordahl, H. M., Larsson, S. M., Dahl, A. A., & Linaker, O. M. (2007) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-007-0289-6 · Cited by 44
“The psychometric properties of the Norwegian version of the HADS have been found to be excellent in HUNT 2 [45].”
MethodResultSelf-citation
'Patient Satisfaction' in Hospitalized Cancer Patients
Skarstein, J., Dahl, A. A., Laading, J., & Fosså, S. D. (2002) · Acta Oncologica · doi:10.1080/028418602321028256 · Cited by 44
Self-citation
What do nursing home residents with mental-physical multimorbidity need and who actually knows this? A cross-sectional cohort study
van den Brink, A. M. A., Gerritsen, D. L., de Valk, M. M. H., Mulder, A. T., Voshaar, R. C. O., & Koopmans, R. T. C. M. (2018) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2018.02.008 · Cited by 43
“, 2002); the basic psychometric properties of the HADS were considered as quite good to very good (Bjelland et al., 2002; Mykletun et al., 2001).”
Psychometric Properties of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue) in Chinese Patients Receiving Maintenance Dialysis
Wang, S., Zang, X., Liu, J., Gao, M., Cheng, M., & Zhao, Y. (2014) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2014.04.011 · Cited by 43
The factor structure of a Polish language version of the hospital anxiety depression scale (HADS)
Nezlek, J. B., Rusanowska, M., Holas, P., & Krejtz, I. (2019) · Current Psychology · doi:10.1007/s12144-019-0164-0 · Cited by 43
“2009) and in non-clinical populations (Mykletun et al. 2001; Andrea et al. 2004).”
BackgroundMethodResultInfluential
A controlled study of mental distress and somatic complaints after risk-reducing salpingo-oophorectomy in women at risk for hereditary breast ovarian cancer
Michelsen, T. M., Dørum, A., & Dahl, A. A. (2009) · Gynecologic Oncology · doi:10.1016/j.ygyno.2008.12.024 · Cited by 43
Self-citation
Desire thinking across the continuum of nicotine dependence
Caselli, G., Nikčević, A. V., Fiore, F., Mezzaluna, C., & Spada, M. M. (2012) · Addiction Research & Theory · doi:10.3109/16066359.2011.644842 · Cited by 46
“Overall, the scale possesses good validity and reliability (Caci et al., 2003; Herrmann, 1997; Mykletun et al., 2001; Zigmond & Snaith, 1983).”
BackgroundResultInfluential
Body ideals in women after viewing images of typical and healthy weight models
Owen, R. Y., & Spencer, R. M. C. (2013) · Body Image · doi:10.1016/j.bodyim.2013.04.005 · Cited by 42
The simulation heuristic and visual imagery in pessimism for future negative events in anxiety
Raune, D., MacLeod, A. K., & Holmes, E. A. (2005) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.455 · Cited by 42
Impact of perioperative hyperbaric oxygen therapy on the quality of life of maxillofacial patients who undergo surgery in irradiated fields
Harding, S. A., Hodder, S. C., Courtney, D. J., & Bryson, P. (2008) · International Journal of Oral and Maxillofacial Surgery · doi:10.1016/j.ijom.2008.04.004 · Cited by 42

Authors: Mykletun, A., Stordal, E., & Dahl, A. A.
Affiliations: University of Bergen (NO)
University of Oslo (NO)
Corresponding author: Mykletun, Arnstein
ORCID: Mykletun, Arnstein
Stordal, Eystein
Dahl, Alv A.
Venue: British Journal of Psychiatry
Publisher: Royal College of Psychiatrists
Published: 2001-12
Volume: 179
Issue: 6
Pages: 540-544
ISSN: 0007-1250 (ISSN-L)
1472-1465
DOI: 10.1192/bjp.179.6.540
OpenAlex: W2106572906
Cited by: 908
References: 23
Citations by year: 2026: 16 · 2025: 28 · 2024: 33 · 2023: 31 · 2022: 39 · 2021: 31 · 2020: 28 · 2019: 31 · 2018: 36 · 2017: 38 · 2016: 48 · 2015: 60 · 2014: 58 · 2013: 61 · 2012: 56
FWCI: 21.49
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.cambridge.org/core/terms (unspecified, 5876 d)
Locations: The British Journal of Psychiatry (publishedVersion)
PubMed (publishedVersion)
Funders: Norges Teknisk-Naturvitenskapelige Universitet
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
Health Sciences › Nursing › Research and Theory › Health Education and Validation
Keywords: Hospital Anxiety and Depression Scale, psychometric properties, factor structure, internal consistency, anxiety, depression, self-report questionnaire, Nord-Trøndelag Health Study, item analysis
MeSH terms: Adult, Aged, Aged, 80 and over, Anxiety Disorders, Mental Disorders, Depressive Disorder, Female, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Psychometrics, Reproducibility of Results

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Hospital Anxiety and Depression (HAD) scale: Factor structure, item analyses and internal consistency in a large population

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