Comparison of the Accuracy of the 7-Item HADS Depression Subscale and 14-Item Total HADS for Screening for Major Depression: A Systematic Review and Individual Participant Data Meta-Analysis

Y. Wu, B. Levis, F.M. Daray, J.P.A. Ioannidis, S.B. Patten, P. Cuijpers, R.C. Ziegelstein, S. Gilbody, F.H. Fischer, S.Q. Fan, Y. Sun, C. He, A. Krishnan, D. Neupane, P.M. Bhandari, Z. Negeri, K.E. Riehm, D.B. Rice, M. Azar, X.W. YanM. Imran, M.J. Chiovitti, J.T. Boruff, D. McMillan, L.A. Kloda, S. Markham, M. Henry, Z. Ismail, C.G. Loiselle, N.D. Mitchell, S. Al-Adawi, K.R. Beck, A. Beraldi, C.N. Bernstein, B. Boye, N. Buel-Drabe, A. Bunevicius, C. Can*, G. Carter, C.K. Chen, G. Cheung, K. Clover, R.M. Conroy, G. Costa-Requena, D. Cukor, E. Dabscheck, J. De Souza, M. Downing, A. Feinstein, P.P. Ferentinos, Sebastian Köhler

*Corresponding author for this work

Research output: Contribution to journal(Systematic) Review article peer-review


The seven-item Hospital Anxiety and Depression Scale Depression subscale (HADS-D) and the total score of the 14-item HADS (HADS-T) are both used for major depression screening. Compared to the HADS-D, the HADS-T includes anxiety items and requires more time to complete. We compared the screening accuracy of the HADS-D and HADS-T for major depression detection. We conducted an individual participant data meta-analysis and fit bivariate random effects models to assess diagnostic accuracy among participants with both HADS-D and HADS-T scores. We identified optimal cutoffs, estimated sensitivity and specificity with 95% confidence intervals, and compared screening accuracy across paired cutoffs via two-stage and individual-level models. We used a 0.05 equivalence margin to assess equivalency in sensitivity and specificity. 20,700 participants (2,285 major depression cases) from 98 studies were included. Cutoffs of >= 7 for the HADS-D (sensitivity 0.79 [0.75, 0.83], specificity 0.78 [0.75, 0.80]) and >= 15 for the HADS-T (sensitivity 0.79 [0.76, 0.82], specificity 0.81 [0.78, 0.83]) minimized the distance to the top-left corner of the receiver operating characteristic curve. Across all sets of paired cutoffs evaluated, differences of sensitivity between HADS-T and HADS-D ranged from -0.05 to 0.01 (0.00 at paired optimal cutoffs), and differences of specificity were within 0.03 for all cutoffs (0.02-0.03). The pattern was similar among outpatients, although the HADS-T was slightly (not nonequivalently) more specific among inpatients. The accuracy of HADS-T was equivalent to the HADS-D for detecting major depression. In most settings, the shorter HADS-D would be preferred.Public Significance Statement The present study suggests that the accuracy of 14-item Hospital Anxiety and Depression Scale (HADS-D) and the seven-item HADS Depression subscale (HADS-D) are equivalent for detecting major depression. Using the seven-item HADS-D for depression screening instead of the full 14-item HADS-T has minimal influence on performance of the measure but would reduce patient and participant burden in most clinical and research settings.
Original languageEnglish
Pages (from-to)95-114
Number of pages20
JournalPsychological Assessment
Issue number2
Publication statusPublished - 1 Feb 2023


  • HADS-D
  • HADS-T
  • individual participant data meta-analysis
  • depression screening
  • diagnostic accuracy

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