How is the Hospital Anxiety and Depression Scale (HADS) scored and interpreted, and what clinical actions are recommended for scores ≥ 8?

Hospital Anxiety and Depression Scale (HADS): Scoring and Clinical Action

The HADS is a 14-item self-report measure with separate 7-item subscales for anxiety and depression, where a score ≥ 8 on either subscale indicates caseness for a disorder and requires further diagnostic assessment to determine the nature and extent of symptoms. 1

Scoring Structure

• The HADS contains 14 total items: 7 items assess anxiety symptoms and 7 items assess depression symptoms 1
• Each subscale is scored separately from 0-21, with higher scores indicating greater symptom severity 1
• Physical symptom items are deliberately excluded from the HADS to avoid confounding with medical illness 1
• The scale demonstrates high internal consistency with Cronbach's alpha of 0.83 for anxiety and 0.82 for depression 2

Interpretation Thresholds

A score ≥ 8 on either the anxiety or depression subscale is the validated cutoff that indicates caseness for a disorder based on ICD-9 criteria 1. This threshold achieves optimal balance between sensitivity and specificity of approximately 0.80 for detecting both anxiety disorders and depression 2.

The ASCO guidelines explicitly state this cutoff applies to both subscales equally, making interpretation straightforward 1.

Clinical Actions for Scores ≥ 8

When either subscale scores ≥ 8, the following algorithmic approach is recommended:

Immediate Safety Assessment

• Evaluate for risk of harm to self or others immediately - if present, refer for emergency psychiatric evaluation regardless of total score 1, 3
• Facilitate a safe environment and initiate appropriate harm-reduction interventions 1

Rule Out Medical Causes First

Before attributing symptoms to psychiatric disorders, systematically evaluate and treat:

• Uncontrolled pain and fatigue 1, 4
• Delirium from infection or electrolyte imbalance 1, 4
• Thyroid disorders 4
• Medication side effects (e.g., interferon administration) 1

Comprehensive Diagnostic Assessment

• Perform further diagnostic evaluation to identify the nature and extent of symptoms and determine presence or absence of a mood or anxiety disorder 1
• Use the PHQ-9 as the primary tool for detailed depression assessment if depression subscale ≥ 8 1
• Use the GAD-7 for detailed anxiety assessment if anxiety subscale ≥ 8 4
• Consider structured clinical interview if available 4

Determine Need for Specialist Referral

• The clinical team must decide when referral to a psychiatrist, psychologist, or equivalently trained professional is necessary as a shared responsibility 1
• This decision should be based on symptom severity, functional impairment, and response to initial interventions 1

Initiate Treatment

For confirmed cases requiring intervention:

• Use pharmacologic and/or non-pharmacologic interventions (psychotherapy, psychoeducational therapy, cognitive-behavioral therapy, exercise) delivered by appropriately trained individuals 1
• First treat medical causes of symptoms before initiating psychiatric treatment 1
• Provide education and support to patients and families about symptoms and when to contact providers 1

Important Clinical Considerations

The HADS performs consistently well across diverse populations including somatic illness patients, psychiatric patients, primary care patients, and the general population 2. This makes it particularly valuable in medical settings where physical symptoms might confound other depression scales.

The two-factor structure (separate anxiety and depression subscales) has been consistently validated across multiple studies and languages 5, 2, 6, though some research suggests the anxiety subscale may contain distinct components of autonomic anxiety and restlessness 6, 7.

For missing items, use the "half rule": calculate individual subscale means only when at least 4 of 7 items are answered for screening purposes 8. Never analyze only individuals with complete data, as this performs worst 8.