Supportive Care in Cancer

, 19:1899 | Cite as

Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis

  • Andrea VodermaierEmail author
  • Roanne D. Millman
Review Article



The Hospital Anxiety and Depression Scale (HADS) is the most extensively validated scale for screening emotional distress in cancer patients. However, thresholds for clinical decision making vary widely across studies. A meta-analysis was conducted with the aim of identifying optimal, empirically derived cut-offs.


PubMed, Embase, and PsycINFO databases were searched for studies that compared the HADS total and its subscale scores against a semi-structured or structured clinical interview as a reference standard with regard to its screening efficacy for any mental disorders and depressive disorders alone. Separate pooled analyses were conducted for single or two adjacent thresholds. A total of 28 studies (inter-rater agreement, κ = 0.86) were included.


The best thresholds for screening for mental disorders were 10 or 11 on the HADS total (sensitivity 0.80; specificity 0.74), 5 on the HADS depression subscale (sensitivity 0.84; specificity 0.50), and 7 or 8 on the HADS anxiety subscale (sensitivity 0.73; specificity 0.65). Respective thresholds for depression screening were 15 for the HADS total (sensitivity 0.87; specificity 0.88), 7 for the HADS depression subscale (sensitivity 0.86; specificity 0.81), and 10 or 11 for the HADS anxiety subscale (sensitivity 0.63; specificity 0.83).


The HADS anxiety subscale performed worse than the total and the depression subscales for both indicators. Diagnostic accuracy varied widely by threshold but was consistently superior for depression screening than for screening of any mental disorder.


Distress Depression Hospital Anxiety and Depression Scale Meta-analysis Screening 


Conflict of Interest

Neither of the authors have any conflicts of interest or financial interests associated with this work.


This study was supported by the Canadian Institute for Health Research CIHR Team for Supportive Cancer Care (#AQC83559) (AV) and a Quinn Research Assistantship (RDM).


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Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Department of PsychologyUniversity of British ColumbiaVancouverCanada
  2. 2.Department of Obstetrics and Gynaecology—GrosshadernUniversity of MunichMunichGermany

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