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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“80 [46].”
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Development of a Population-based Questionnaire to Explore Psychosocial Determinants of Screening for Memory Loss and Alzheimer Disease
Galvin, J. E., Scharff, D. P., Glasheen, C., & Fu, Q. J. (2006) · Alzheimer Disease & Associated Disorders · doi:10.1097/00002093-200607000-00010 · Cited by 21
A double blind randomised controlled clinical trial on the effect of transcutaneous spinal electroanalgesia (TSE) on low back pain
Thompson, J. W., BOWER, S., & Tyrer, S. P. (2007) · European Journal of Pain · doi:10.1016/j.ejpain.2007.07.004 · Cited by 21
“sub-scale (Mykletun et al., 2001).”
Method
Relational memory and self-efficacy measures reveal distinct profiles of subjective memory concerns in older adults.
Lucas, H. D., Monti, J. M., McAuley, E., Watson, P. D., Kramer, A. F., & Cohen, N. J. (2016) · Neuropsychology · doi:10.1037/neu0000275 · Cited by 20
“These values are similar to those reported in formal validations of HADS (e.g., Mykletun et al., 2001).”
Result
Depressive, anxiety, and post-traumatic stress symptoms affecting hospitalized and home-isolated COVID-19 patients: a comparative cross-sectional study
Mohamed, A. E., & Yousef, A. M. (2021) · Middle East Current Psychiatry · doi:10.1186/s43045-021-00105-9 · Cited by 20
“HADS has been used in the HUNT study in Norway, a large community setting study done on the general population [24].”
Method
Understanding the Experience of Myotonic Dystrophy. Mixed Method Study
Geirdal, A. Ø., Lund‐Petersen, I., & Heiberg, A. (2014) · Journal of Genetic Counseling · doi:10.1007/s10897-014-9752-1 · Cited by 20
“The psychometric properties of the Norwegian version of the HADS have been found to be excellent (Mykletun et al. 2001).”
Method
Desire thinking: A risk factor for binge eating?
Spada, M., Caselli, G., Fernie, B., Manfredi, C., Boccaletti, F., Dallari, G., Gandini, F., Pinna, E., Ruggiero, G. M., & Sassaroli, S. (2015) · Eating Behaviors · doi:10.1016/j.eatbeh.2015.03.013 · Cited by 18
Do psychological factors predict symptom severity in patients with subjective food hypersensitivity?
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Intervenir sur les souffrances au travail : acteurs et enjeux dans la durée
Sarnin, P., Chaumon, M.-É. B., Cuvillier, B., & Grosjean, M. (2012) · Bulletin de psychologie · doi:10.3917/bupsy.519.0251 · Cited by 20
Associations of Insomnia Symptoms With Blood Pressure and Resting Heart Rate: The HUNT Study in Norway
Hauan, M., Strand, L. B., & Laugsand, L. E. (2016) · Behavioral Sleep Medicine · doi:10.1080/15402002.2016.1228651 · Cited by 20
Measuring psychological change after trauma: Psychometric properties of a new bi-directional scale.
Nordstrand, A. E., Hjemdal, O., Holen, A., Reichelt, J. G., & Bøe, H. J. (2017) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000270 · Cited by 19
Insomnia as a Partial Mediator of the Relationship Between Personality and Future Symptoms of Anxiety and Depression Among Nurses
Sørengaard, T. A., Karlsen, H. R., Langvik, E., Pallesen, S., Bjorvatn, B., Waage, S., Moen, B. E., & Saksvik‐Lehouillier, I. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.00901 · Cited by 22
“A validated Norwegian language version of the instrument was used (Mykletun et al., 2001).”
Method
Mindfulness-based cognitive therapy for psycho-oncology patients: an exploratory study
Kingston, T., Collier, S., Hevey, D., McCormick, M. M., Besani, C., Cooney, J., & O’Dwyer, A.-M. (2015) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2014.81 · Cited by 23
“The HADS has been found to be both reliable (Mykletun et al. 2001) and valid in cancer patients (Razavi et al.”
BackgroundMethod
Gender differences in psychosocial influence and rehabilitation outcomes for work-disabled individuals with chronic musculoskeletal pain
Lillefjell, M. (2006) · Journal of occupational rehabilitation · doi:10.1007/s10926-006-9056-x · Cited by 28
“than the general population (HUNT population) from the same geographic area [34], both at start and at the end of the rehabilitation period.”
Background
Anxiolytic-like action in mice treated with nitrous oxide and oral triazolam or diazepam
Gries, D. A., Condouris, G. A., Shey, Z., & Houpt, M. I. (2005) · Life Sciences · doi:10.1016/j.lfs.2004.07.028 · Cited by 20
Mindfulness, health symptoms and healthcare utilization: Active facets and possible affective mediators.
Consedine, N. S., & Butler, H. F. (2014) · Psychology, Health & Medicine · doi:10.1080/13548506.2013.824596 · Cited by 19
Examining the Rates of Anxiety, Depression, and Burnout Among Providers at a Regional Burn Center
Markiewitz, N., Cox, C. A., Krout, K., McColl, M., & Caffrey, J. A. (2018) · Journal of Burn Care & Research · doi:10.1093/jbcr/iry042 · Cited by 19
Associations between device use before bed, mood disturbance, and insomnia symptoms in young adults
Walsh, N. A., Rodriguez, N., Repa, L. M., King, E., & Garland, S. N. (2020) · Sleep Health · doi:10.1016/j.sleh.2020.04.004 · Cited by 19
Associations between continuity of care, perceived control and self‐care and their impact on health‐related quality of life and hospital readmission—A structural equation model
Säfström, E., Årestedt, K., Liljeroos, M., Nordgren, L., Jaarsma, T., & Strömberg, A. (2023) · Journal of Advanced Nursing · doi:10.1111/jan.15581 · Cited by 19
“Since previous studies have shown problems with overlapping items and strong correlation between the two subscales (Djukanovic et al., 2017 ; Helvik et al., 2011 ; Mykletun et al., 2001 ), only the depression subscale was used in the present study.”
Method
Factors associated with perceived health in elderly medical inpatients: A particular focus on personal coping recourses
Helvik, A., Engedal, K., Bjørkløf, G. H., & Selbæk, G. (2012) · Aging & Mental Health · doi:10.1080/13607863.2011.651436 · Cited by 19
“The HAD questionnaire has been validated in Norway and used in several studies including a few among the elderly (Helvik, Engedal, Skancke, & Selbaek, 2011 ; Helvik, et al, 2010 ; Mykletun, Stordal, & Dahl, 2001 ; Olsson, Mykletun, & Dahl, 2005 ; Stordal et al, 2001 ).”
Method
Cognitive Dysfunction in Older Adults Hospitalized for Acute Heart Failure
Arslanian‐Engoren, C., Giordani, B., Algase, D. L., Schuh, A. L., Lee, C., & Moser, D. K. (2014) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2014.06.003 · Cited by 20
The prospective management of women with newly diagnosed vulval intraepithelial neoplasia: Clinical outcome and quality of life
McFadden, K., Sharp, L., & Cruickshank, M. E. (2009) · Journal of Obstetrics and Gynaecology · doi:10.3109/01443610903191285 · Cited by 19
“Scores of 11 or more out of 21 are used to identify a clinically significant case on either subscale, and published normative data are available (Zigmond and Snaith 1983; Crawford et al. 2001; Mykletun et al. 2001) .”
Method
Malondialdehyde and advanced oxidation protein products are not increased in psoriasis: a controlled study
Skoie, I. M., Dalen, I., Omdal, R., & Jonsson, G. (2019) · Archives of Dermatological Research · doi:10.1007/s00403-019-01903-2 · Cited by 19
Associations of Changes in Cardiorespiratory Fitness and Symptoms of Anxiety and Depression With Brain Volumes: The HUNT Study
Zotcheva, E., Pintzka, C. W. S., Salvesen, Ø. O., Selbæk, G., Haberg, A. K., & Ernstsen, L. (2019) · Frontiers in Behavioral Neuroscience · doi:10.3389/fnbeh.2019.00053 · Cited by 19
“The Norwegian version of the HADS included in HUNT2 and HUNT3 has good psychometric properties and is in close agreement with the original questionnaire developed by Zigmond and Snaith (Mykletun et al., 2001).”
Result
Metabolic analysis of amino acids and vitamin B6 pathways in lymphoma survivors with cancer related chronic fatigue
Fosså, A., Smeland, K. B., Fluge, Ø., Tronstad, K. J., Loge, J. H., Midttun, Ø., Ueland, P. M., & Kiserud, C. E. (2020) · PLoS ONE · doi:10.1371/journal.pone.0227384 · Cited by 19
“Each item was scored from 0 (not present) to 3 (highly present) [28].”
Background
The relationship between coping strategies and anxiety in women from families with familial breast–ovarian cancer in the absence of demonstrated mutations
Geirdal, A. Ø., & Dahl, A. A. (2007) · Psycho-Oncology · doi:10.1002/pon.1198 · Cited by 19
Self-citation
Level of Distress Among Workers Undergoing Work Rehabilitation for Musculoskeletal Disorders
Coutu, M., Durand, M., Loisel, P., Goulet, C., & Gauthier, N. (2007) · Journal of Occupational Rehabilitation · doi:10.1007/s10926-007-9079-y · Cited by 18
“91) [47] and the General Health Questionnaire (GHQ-12) (Cronbach’s alpha coefficient = 0.”
Background
The role of perfectionism in psychological health: A study of adolescents in Pakistan
Rise, J., & Butt, F. M. (2010) · Europe’s Journal of Psychology · doi:10.5964/ejop.v6i4.227 · Cited by 19
Predictors of entering 24‐h care for people with Alzheimer's disease: results from the LASER‐AD study
Habermann, S., Cooper, C., Katona, C., & Livingston, G. (2009) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.2259 · Cited by 19
“It has good validity and reliability against clinical diagnosis (Mykletun et al., 2001) and has been validated throughout the adult age range and in a wide range of settings to identify clinically significant anxiety and depression.”
Background
Fatigue in persons who have lived with spinal cord injury for >20 years
Lidal, I. B., Jensen, A., Larsen, T. W., & Stanghelle, J. K. (2012) · Spinal Cord · doi:10.1038/sc.2012.110 · Cited by 19
Anxiety, Depression and Health-Related Quality of Life after Jejunoileal Bypass: A 25-Year Follow-up Study of 20 Female Patients
Våge, V., Solhaug, J. H., Viste, A., Bergsholm, P., & Wahl, A. K. (2003) · Obesity Surgery · doi:10.1381/096089203322509264 · Cited by 19
Botulinum toxin type A combined with neurodynamic mobilization for upper limb spasticity after stroke: a case report
Villafañe, J. H., Silva, G. B., Chiarotto, A., & Ragusa, O. L. F. (2012) · Journal of Chiropractic Medicine · doi:10.1016/j.jcm.2012.05.009 · Cited by 19
Anxiety and depression prevalence and associated factors in patients with knee osteoarthritis
Feng, Q., Weng, M., Yang, X., & Zhang, M. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1483570 · Cited by 19
“It demonstrates good internal consistency and test-retest reliability (20).”
Effect of midwife‐led care on birth outcomes of primiparas
Jiang, X., Chen, Q., Guo, S., Jin, L., Huang, X., Liu, X., Hong, J. W., Qu, H., & Hu, R. (2018) · International Journal of Nursing Practice · doi:10.1111/ijn.12686 · Cited by 18
Health-related quality of life (HRQoL), anxiety and depression in patients with ureteral stricture: a multi-institutional study
Li, Z., Wang, X., Ying, Y., Li, X., Zhu, W., Meng, C., Han, G., Liu, J., Wang, J., Huang, Y., et al. (2022) · World Journal of Urology · doi:10.1007/s00345-022-04227-5 · Cited by 18
“2) in patients with US than what was reported in a recent national survey of general psychological status in 2015 [11].”
Background
Adverse and benevolent childhood experiences among adults in the United Kingdom: a latent class analysis
Cain, S. M., Rooney, E., Cacace, S. C., Post, A., Russell, K., Rasmussen, S. A., Baker, J. C., & Cramer, R. J. (2024) · BMC Public Health · doi:10.1186/s12889-024-19448-z · Cited by 18
“Both subscales have been found to be internally consistent (anxiety: α = 0.80 and depression: α = 0.76) [50].”
BackgroundInfluential
Testing of the Hospital Anxiety and Depression Scale in Patients With Chronic Obstructive Pulmonary Disease
Al‐Gamal, E. (2015) · International Journal of Nursing Knowledge · doi:10.1111/2047-3095.12106 · Cited by 18
Chronic fatigue is prevalent and associated with hormonal dysfunction in long-term non-Hodgkin lymphoma survivors treated with radiotherapy to the head and neck region
Seland, M., Holte, H., Bjøro, T., Schreiner, T., Bollerslev, J., Loge, J. H., Fosså, S. D., & Kiserud, C. E. (2015) · Leukemia & lymphoma/Leukemia and lymphoma · doi:10.3109/10428194.2015.1036258 · Cited by 18
A comparison of depressive symptoms in elderly medical inpatients and the elderly in a population-based health study (the Nord-Trøndelag Health Study 3)
Helvik, A., Engedal, K., Krokstad, S., Stordal, E., & Selbæk, G. (2011) · Nordic Journal of Psychiatry · doi:10.3109/08039488.2011.614958 · Cited by 19
Self-citation
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Screening Instruments for Depression in Advanced Cancer Patients: What Do We Actually Measure?
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Anxiety, depression and timing of insulin treatment among people with type 2 diabetes: Nine-year follow-up of the Nord-Trøndelag Health Study, Norway
Iversen, M. M., Nefs, G., Tell, G. S., Espehaug, B., Midthjell, K., Graue, M., & Pouwer, F. (2015) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2015.07.004 · Cited by 19

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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