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

Yin Wu, Brooke Levis, Federico M. Daray, John P. A. Ioannidis, Scott B. Patten, Pim Cuijpers, Roy C. Ziegelstein, Simon Gilbody, Felix H. Fischer, Suiqiong Fan, Ying Sun, Chen He, Ankur Krishnan, Dipika Neupane, Parash Mani Bhandari, Zelalem Negeri, Kira E. Riehm, Danielle B. Rice, Marleine Azar, Xin Wei YanMahrukh Imran, Matthew J. Chiovitti, Jill T. Boruff, Dean McMillan, Lorie A. Kloda, Sarah Markham, Melissa Henry, Zahinoor Ismail, Carmen G. Loiselle, Nicholas D. Mitchell, Samir Al-Adawi, Kevin R. Beck, Anna Beraldi, Charles N. Bernstein, Birgitte Boye, Natalie Büel-Drabe, Adomas Bunevicius, Ceyhun Can, Gregory Carter, Chih Ken Chen, Gary Cheung, Kerrie Clover, Ronán M. Conroy, Gema Costa-Requena, Daniel Cukor, Eli Dabscheck, Jennifer De Souza, Marina Downing, Anthony Feinstein, Panagiotis P. Ferentinos, Alastair J. Flint, Pamela Gallagher, Milena Gandy, Luigi Grassi, Martin Härter, Asuncion Hernando, Melinda L. Jackson, Josef Jenewein, Nathalie Jetté, Miguel Julião, Marie Kjærgaard, Sebastian Köhler, Hans Helmut König, Lalit K.R. Krishna, Yu Lee, Margrit Löbner, Wim L. Loosman, Anthony W. Love, Bernd Löwe, Ulrik F. Malt, Ruth Ann Marrie, Loreto Massardo, Yutaka Matsuoka, Anja Mehnert, Ioannis Michopoulos, Laurent Misery, Christian J. Nelson, Chong Guan Ng, Meaghan L. O’Donnell, Suzanne J. O’Rourke, Ahmet Öztürk, Alexander Pabst, Julie A. Pasco, Jurate Peceliuniene, Luis Pintor, Jennie L. Ponsford, Federico Pulido, Terence J. Quinn, Silje E. Reme, Katrin Reuter, Steffi G. Riedel-Heller, Alasdair G. Rooney, Roberto Sánchez-González, Rebecca M. Saracino, Melanie P. J. Schellekens, Martin Scherer, Marcelo L. Schwarzbold, Vesile Senturk Cankorur, Louise Sharpe, Michael Sharpe, Sébastien Simard, Susanne Singer, Lesley Stafford, Jon Stone, Natalie A. Strobel, Serge Sultan, Antonio L. Teixeira, Istvan Tiringer, Alyna Turner, Jane Walker, Mark Walterfang, Liang Jen Wang, Siegfried B. Weyerer, Jennifer White, Birgitt Wiese, Lana J. Williams, Lai-Yi Wong, Andrea Benedetti, Brett D. Thombs*

*Corresponding author for this work

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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.

Original languageEnglish
Pages (from-to)95-114
Number of pages20
JournalPsychological Assessment
Issue number2
Publication statusPublished - Feb 2023


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


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