Interpreting the Hospital Anxiety and Depression Scale (HADS) for individuals with traumatic brain injury: Clinical correlates and empirical severity cutoffs.

Abstract

Anxiety and depression symptoms are more prevalent in individuals with moderate-severe traumatic brain injury (TBI) than in the general population, underscoring the need for effective screening. The Hospital Anxiety and Depression Scale (HADS) is widely used for this purpose, yet how best to use and interpret the HADS in individuals with TBI remains an open question. This study evaluated the HADS total score, subscale scores, and individual items in 402 individuals with moderate-severe TBI. The sample was on average 13 years postinjury, originally recruited during inpatient rehabilitation. HADS scores were regressed against five clinically important variables to determine their concurrent criterion validity, and regression tree analyses were used to establish severity cutoffs for the total and subscale scores. Results indicated that while the HADS subscale scores provided no meaningful advantage over the total score in accounting for variance in suicidal ideation, self-harm, or mental health treatment, the subscales—particularly depression subscale items—were more informative with respect to functional disability and life satisfaction. Benchmarked against these clinically important variables, we established graded severity cutoffs (“normal,” “mild,” “moderate,” and “severe”) for both the HADS total and subscale scores. This study provides clinicians and researchers with empirically derived guidance for using and interpreting the HADS when assessing emotional distress in individuals with moderate-severe TBI. (PsycInfo Database Record (c) 2025 APA, all rights reserved) This study offers evidence-based guidance on how to use the Hospital Anxiety and Depression Scale with people who have experienced a moderate-severe traumatic brain injury. By comparing different scoring approaches and developing severity cutoffs, the findings give clinicians and researchers practical support in using the Hospital Anxiety and Depression Scale to identify and monitor emotional distress in individuals with moderate-severe traumatic brain injury. (PsycInfo Database Record (c) 2025 APA, all rights reserved)