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Rehab Measures: Depression Anxiety Stress Scale

Link to instrument

Depression Anxiety Stress Scale 

Title of Assessment

Depression Anxiety Stress Scale 

Acronym

DASS

Instrument Reviewer(s)

Initially reviewed by Daniel Chellette, SPT, Jarod Hill, SPT, Emily Kemp, SPT, Claire McCormick, SPT, Anne McLean, SPT, Stacie Morris, SPT, Morgan Mowery, SPT, Matt Rossman, SPT, Elizabeth Schuppert, SPT, Justin Zych, SPT, and Rebecca Schuck, SPT

Summary Date

12/11/2013 

Purpose

A 21 or 42 item measure designed to assess the fundamental symptoms of depression, anxiety and tension/stress.

Description

The DASS assesses negative emotional symptoms by using a 4-point Likert scale, ranging from 0 to 3. It has 3 subscales (depression, anxiety, and stress) with 14 items in each subscale for the DASS 42. These subscales are scored by the addition of the total item scores, which can range from 0 to 42. The DASS 21 is a simplified version of the full test with 7 items in each subscale. A higher score on the DASS indicates greater severity or frequency of these negative emotional symptoms. Maximum score: 63 for the 21-item DASS; 126 for the 42-item DASS

Area of Assessment

 

Body Part

 

ICF Domain

 

Domain

 

Assessment Type

Patient Reported Outcomes 

Length of Test

05 Minutes or Less 

Time to Administer

5 - 10 minutes

Number of Items

42 or 21 (depending on test chosen) 

Equipment Required

None

Training Required

None

Type of training required

no training 

Cost

Free 

Actual Cost

Questionnaire is free. Manual is 55 Australian dollars ($55.20 USD)

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

 

Populations Tested

  • War Veterans and War Widow(er)s
  • Acuqired Brain Injury patients with elevated psychological distress
  • Patients presenting for assessment and treatment at the Phobia and Anxiety Disorders Clinic, Center for Stress and Anxety Disorders
  • Undergraduate students with no history of head injury of neurological impairment
  • Patients with lower back pain
  • First year psychology students at the University of New South Wales
  • Patients diagnosed with chronic fatigue syndrome (CFS) at the Fatigue service at the Royal Free Hospital in London, UK (> 18 years old)
  • Patients diagnosed with a spinal cord injury being evaluated for despression, stress or anxiety (ages 19 - 82)
  • Undergraduate students from 2 public universities receiving partial credit for taking survey
  • Adults referred for psychotherapy with symptoms of depression
  • 484 adolescents, age 11.83 to 15.67, with an average age of 13.62 years
  • Individuals with chronic pain, psychology clinic patients with similar overall levels of depression and anxiety, and general population sample

Standard Error of Measurement (SEM)

Patients Diagnosed with Chronic Fatigue Syndrome:

(Lovibond et al, 1995; n = 717 people who were administered the Beck Depression Inventory and the Beck Anxiety Inventory)

  • Anxiety Subscale: SEM** = 2.08
  • Depression Subscale: SEM** = 1.72
  • Stress Subscale: SEM** = 1.94

Adults Referred for Psychotherapy with Symptoms of Depression:

(Ruwaard et al, 2012; n = 1500 total adult participants with a GP referral for psychotherapy were treated at a Dutch online mental health clinic for symptoms of depression (n = 413), panic disorder (n = 139), posttraumatic stress (n = 478), or burn out (n = 470); mean age = 40 years)

  • SEM** = 3.65

Patients Presenting for Assessment and Treatment at the Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety Disorders:

(Brown et al, 1997; n = 437 patients presenting for assessment and treatment at the Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety Disorders; average age = 36.1 years (10.55) and range = 18 - 65 years; 63.6% were women)

  • A SEM was not established but a reference point to evaluate the goodness of fit was established to help to decrease the error of measurement

**Calculated from SD, using Cronbach's alpha for ICC

Minimal Detectable Change (MDC)

Adults Referred for Psychotherapy with Symptoms of Depression:

(Ruwaard et al, 2012)

  • Depression subscale = 5
  • Stress subscale = 7 ("reliable change" values)
  • Total score (calculated) = 10.12

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Adults Screened for Depression with Lower Back Pain (LBP):

(Haggman et al, 2004; n = 232 participants with nonspecific lower back pain from metropolitan areas of Sydney and New South Wales, Australia; 44% were female; mean age = 43 (15), and range = 17 – 79 years)

  • Normal = 0 - 9, mild = 10 - 12, moderate = 13 - 20, severe = 21 - 27, extremely severe = 28 - 42

Normative Data

Patients Presenting for Assessment and Treatment at the Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety Disorders:

(Brown et al, 1997)

  • Reliability of the DASS with repeated trials of same participants concluded the following: Depression mean = 10.65 (9.3), Anxiety mean = 10.9 (8.12), Stress mean = 21.1 (11.15)
  • In the second study DASS-Stress was shown to correlate more with PANAS-Negative Affect (r = 0.72) than did DASS-Depression (r = 0.57) & DASS-Anxiety (r = 0.63). Likewise it was also concluded that Stress correlated more strongly with measures of worry than did anxiety or depression.

Depression, Anxiety and Stress as Predictors of Postconcussion - Like Symptoms:

(Edmed et al, 2012; n = 71 nonclinical undergraduate students from Queensland University of Technology; mean age = 24.27 (8.93); age range = 17 – 54 years )

  • Depression subscale = 8.62 (8.96); Anxiety subscale = 7.76 (6.63); Stress subscale = 13.88 (9.69)

Screening for Depression and Anxiety in SCI Patients:

(Mitchell et al, 2008; n = 40 paraplegic or tetraplegic patients with SCI participated, 33 inpatient and 7 outpatient; mean age = 49.1 (16.7) and age range = 19 – 82 years)

  • Depression subscale = 7.8 (9.33), Anxiety subscale = 6.4 (5.87) Stress subscale = 10.4 (10)

Depression Correlated in Individuals with Chronic Pain:

(Taylor et al, 2005; n = 398 individuals with chronic pain, 179 males and 219 females, mean age = 46.1 (14.4), average duration of pain = 6 years and 2 months; n = 313 psychology clinic patients with similar levels of depression, 83 males and 228 females, mean age = 39.1 (12.2); n = 491 general population sample, 219 males and 272 females, mean age = 42.3 (17.7); all participants from Australian population)

  • Chronic Pain sample: Depression subscale = 15.15 (12.22); Anxiety subscale = 9.70 (8.71); Stress subscale = 17.13 (11.36)
  • Psychology Clinic sample: Depression subscale = 17.24 (11.79); Anxiety subscale = 15.42 (9.22); Stress subscale = 21.59 (10.25)
  • General population sample: Depression subscale = 5.06 (7.57); Anxiety subscale = 3.41 (5.13); Stress subscale = 8.18 (8.40)

Test-retest Reliability

Patients Presenting for Assessment and Treatment at the Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety Disorders:

(Brown et al, 1997)

  • Excellent test retest reliability indicated that all 3 scales evidenced favorable temporal stability (r = 0.71 - 0.81). Out of the 437 patients initially given the DASS, 20 patients were randomly selected to come back and were given the DASS 2 weeks following their intake evaluation. Test retest correlations failed to detect any systematic increase or decrease in scores over time, therefore paired t tests were conducted as another test of temporal stability: these t tests were not significant for all 3 DASS scales

Interrater/Intrarater Reliability

Not Established

Internal Consistency

Acquired Brain Injury Patients with Elevated Psychological Distress:

(Arundine et al, 2012; n = 17 chronic acquired brain injury (ABI) patients with elevated psychological distress; mean age = 42.94 (11.23); 9 males; years of education = 12.71 (1.57); years post injury = 9.65 (8.35))

  • Lacks internal consistency for TBI patients

Patients Presenting for Assessment and Treatment at the Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety Disorders:

(Brown et al, 1997)

  • Excellent internal consistency for the entire sample for Depression, Anxiety and Stress, as well as within each diagnostic group (Cronbach’s alpha = 0.96, 0.89, 0.93)

Undergraduate Students with no History of Head Injury of Neurological Impairment:

(Edmed et al, 2012)

  • Depression subscale: excellent internal consistency (Cronbach alpha = 0.95)
  • Anxiety subscale: excellent internal consistency (Cronbach alpha = 0.85)
  • Stress subscale: excellent internal consistency (Cronbach alpha = 0.93).

Patients Diagnosed with Chronic Fatigue Syndrome:

(Lovibond et al, 1995)

  • Depression subscale: excellent internal consistency (Cronbach alpha = 0.93)
  • Anxiety subscale: excellent internal consistency (Cronbach alpha = 0.84)
  • Stress subscale: excellent internal consistency (Cronbach alpha = 0.88)

Undergraduate students:

(Osman et al, 2012; n = 887 undergraduate students, 363 men; age range = 18 – 35 years; mean age = 19.46 (2.71))

  • Excellent internal consistency (Cronbach alpha = 0.82 - 0.97)
  • Poor and Adequate depression factor associated with anxiety factor = 0.66 and with stress factor = 0.77
  • Adequate anxiety factor associated with stress factor = 0.75 10

Adults Referred for Psychotherapy with Symptoms of Depression:

(Ruwaard et al, 2012)

  • Excellent internal consistency (Cronbach alpha = 0.97)

Adolescents with Depression, Anxiety and Stress: 

(Szabo et al, 2010; n = 484 high school students; mean age = 13.62 years; age range = 11.83 – 15.67 years; 52% were boys)

  • Depression subscale: excellent internal consistency (Cronbach alpha = 0.87)
  • Anxiety subscale: adequate internal consistency (Cronbach alpha = 0.79)
  • Stress subscale: excellent internal consistency (Cronbach alpha = 0.83)

Individuals with chronic Pain, Psychology Clinic Patients with Similar Overall Levels of Depression, Anxiety and a General Population Sample:

(Taylor et al, 2005)

Chronic Pain sample:

  • Depression subscale: excellent internal consistency (Cronbach alpha = 0.96)
  • Anxiety subscale: excellent internal consistency (Cronbach alpha = 0.89)
  • Stress subscale: excellent internal consistency (Cronbach alpha = 0.95)

Psychology Clinic sample:

  • Depression subscale: excellent internal consistency (Cronbach alpha = 0.96)
  • Anxiety subscale: excellent internal consistency (Cronbach alpha = 0.90)
  • Stress subscale: excellent internal consistency (Cronbach alpha = 0.94)

General Population sample:

  • Depression subscale: excellent internal consistency (Cronbach alpha = 0.95)
  • Anxiety subscale: excellent internal consistency (Cronbach alpha = 0.88)
  • Stress subscale: excellent internal consistency (Cronbach alpha = 0.94)

Criterion Validity (Predictive/Concurrent)

Depression and Anxiety with SCI:

(Mitchell et al, 2008)

  • Excellent correlation with the depression subscale when compared to the BC - PSI (r = 0.69)
  • Excellent correlation with the anxiety subscale when compared to the BC - PSI (r = 0.67)
  • Excellent correlation with the stress subscale when compared to the BC - PSI (r = 0.83)
  • Excellent correlations with the stress subscale compared to the anxiety subscale (r = 0.70) and the depression subscale (r = 0.66)
  • Excellent correlation with the DASS - 21 depression subscale and the BSI Depression (r = 0.70, P < 0.01)
  • Excellent correlation between the DASS - 21 anxiety subscale and the BSI Anxiety (r = 0.61, P < 0.01)

Depression, Anxiety and Stress:

(Edmed et al, 2012)

  • The researchers predicted that relative to the other DASS scales, DASS - Depression would correlate more strongly with other measures of depression (ratings of mood disorders). Relative to the other DASS scales, DASS - Anxiety would correlate more strongly with indices of fearfulness/autonomic arousal (ratings of panic disorders). Relative to other DASS scales, DASS - Stress would correlate more strongly with measures of worry (ratings of GAD). Additionally, DASS - Stress was predicted to correlate more strongly with PANAS - Negative Affect than did DASS - Depression and DASS - Anxiety. Criterions of GAD encompass a lot of the symptoms of the stress scale of DASS and therefore the symptoms of GAD were reformulated to differentiate the 2 disorders in DSM -IV.
  • Excellent correlation with the anxiety subscale compared to the depression subscale (r = 0.60)

 (Osman et al, 2012)

  • Excellent correlation with MASQ - Anhedonic Depression (r = 0.65)
  • Adequate correlation with MASQ - Anxious Arousal (r = 0.50)
  • Excellent correlation with Perceived Stress Scale (r = 0.73)
  • Excellent correlation with MASQ - General Distress Depression (r = 0.68)
  • Excellent correlation with MASQ - General Distress Anxiety (r = 0.64)
  • Excellent correlation with MASQ-Mixed Depression-Anxiety (r = 0.73)
  • Excellent correlation with Beck Depression Inventory - II (r = 0.80)
  • Excellent correlation with Beck Anxiety Inventory (r = 0.69)

Construct Validity (Convergent/Discriminant)

Patients Presenting for Assessment and Treatment at the Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety Disorders:

(Brown et al, 1997)

  • There is an intercorrelation between the three DASS scales in study 1 and study 2. The zero-order intercorrelations among the three DASS scales were similar in magnitude to the completely standardized phi coefficients obtained in the confirmatory factor analysis of a three-factor model
  • After analyzing the scales from both studies, the DASS-Depression correlated strongly with depression severity, but only weakly with PD and GAD severity which demonstrated excellent discriminant validity of the scale and potential utility for discrimination among disorders
  • There is a high degree of overlap between measures of anxiety and depression. This led researchers to explore the possibility that the considerable overlap, evidenced by these measures, reflects poor discriminant validity of these domains. Anxiety and depression are considered on the same continuum

Study with First Year Psychology Students at the University of New South Wales:

(Lovibond et al, 1995)

  • The present research provides support for the psychometric properties of the DASS scales and their convergent and discriminant validity with other instruments developed on clinical populations. The DASS scales not only provide measures of anxiety and depression that have been specifically designed to maximize internal consistency and differentiation, but both of these scales are further differentiated from the related state of tension/stress

DASS - Anxiety:

  • Excellent correlation against DASS - Depression (r = 0.72)
  • Excellent correlation against DASS - Stress (r = 0.78)
  • Adequate correlation against MCQ - 30 - 1 (r = 0.48)
  • Adequate correlation against MCQ - 30 - 2 (r = 0.57)
  • Adequate correlation against MCQ - 30 - 3 (r = 0. 55)
  • Adequate correlation against MCQ - 30 - 4 (r = 0.59)
  • Poor correlation against MCQ - 30 - 5 (r = 0.27)
  • Adequate correlation against CFQ - Mental (r = 0.46)
  • Poor correlation against CFQ - Physical (r = 0.28)
  • Adequate correlation against RAND SF - 36 PF (r = 0.38)

DASS - Depression:

  • Excellent correlation against DASS - Stress (r = 0.78)
  • Adequate correlation against DASS - MCQ -30 - 1 (r = 0.43)
  • Adequate correlation against MCQ - 30 - 2 (r = 0.55 )
  • Adequate correlation against MCQ - 30 - 3 (r = 0.59)
  • Adequate correlation against MCQ - 30 - 4 (r = .54)
  • Poor correlation against MCQ - 30 - 5 (r = 0.29)
  • Adequate correlation against CFQ - Mental (r = 0.51)
  • Adequate correlation against CFQ - Physical (r = 0.38)
  • Adequate correlation against RAND - SF - 36 PF (r = 0.46)

DASS - Stress:

  • Adequate correlation against MCQ - 30 - 1 (r = 0. 45)
  • Excellent correlation against MCQ - 30 - 2 (r = 0.64)
  • Adequate correlation against MCQ - 30 - 3 (r = 0.53)
  • Adequate correlation against MCQ - 30 - 4 (r = 0.57)
  • Adequate correlation against MCQ - 30 - 5 (r = 0.37)
  • Adequate correlation against CFQ - Mental (r = 0.49 )
  • Adequate correlation against CFQ - Physical (r = 0.31)
  • Adequate correlation against RAND - SF - 36 PF (r = 0.42)

Adolescents with Depression, Anxiety and Stress:

(Szabo et al, 2010)

  • These correlation values are pertinent to the 3 factor structure that the authors deemed "the best fit" for this population (which turned out to be the same factor -loading structure of the adult DASS). Correlations among the factors remained very high, with correlation coefficients of (utilizing Pearson's r):
    • Excellent correlation between DASS -Depression and DASS - Anxiety (r = 0.83)
    • Excellent correlation between DASS-Depression and DASS - Tension/Stress (r = 0.89)
    • Excellent correlation between DASS -Tension/Stress and DASS - Anxiety (r = 0.94)

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Acquired Brain Injury Patients with Elevated Psychological Distress Tested Pretreatment, Posttreatment, and 6 months Posttreatment:

(Arundine et al, 2012)

  • Pretreatment vs. immediately post treatment: 1.52
  • Pretreatment vs. 6 months post treatment: 1.37
  • The greatest improvement occurred immediately post treatment. The scores actually dropped from the time immediately post treatment to 6 months post treatment. Overall, there was still improvement

Patients with Low Back Pain:

(Pengel et al, 2007; n = 259 people with subacute low back pain lasting greater than 6 weeks and less than 3 months)

  • Large effect size (baseline/6wk follow up): Depression = 1.6; Stress = 1.3; Total = 1.6
  • Large Effect size (baseline/1yr follow up): D = 1.5; Stress = 1.4; Total = 1.5

Professional Association Recommendations

(From the DASS Website)

  • If there is only one missing item, one can average over the remaining items for the scale in question. Too many missing items (>2 missing items per 14-item scale) may compromise the validity of the DASS and the subject should be omitted
  • To educate users on depression, anxiety and stress, consider listing key symptoms and pointing out that everyone occasionally experiences some degree of each scale, but they should ask for help if they feel them strongly or frequently. If taking a test on a computer, do not provide automated interpretation/calculation to users
  • It is unlikely that the factor structure will vary between groups; therefore norms are irrelevant for special populations. Instead, focus on whether the group in question is capable of understanding items and responding in an unbiased way
  • Beware of exaggerations and disguising of symptoms- no lie scale built into the DASS; consider a different measure if this is suspected in order to counteract this type of bias
  • Patient must be able to speak, understand, and read the language of the test. Also, must be able to write and fill out the measure

Considerations

Patients with low back pain (LBP):

(Haggman et al, 2004)

An initial evaluation should consist of two questions to screen for depression in LBP

1. “During the past month, have you often been bothered by feeling down, depressed or hopeless?”

2. “During the past month, have you been bothered by little interest or pleasure in doing things?” Positive responses to these questions should recommend that the clinician needs to pay close attention to the progress and effectiveness of the interventions given. If progress seems stunted by depressive symptoms administering the DASS - 21 is then used as a follow - up. If a patient scores in the severe to extremely severe categories (21 - 42), the clinician should consider a psychological referral. DASS - 21 can also be used if someone with a negative response to the 2 question screen is failing to respond to an intervention or if other clinical signs of depression are observed (insomnia, fatigue, weight change)

Patients Diagnosed with Chronic Fatigue Syndrome (CFS) at the Fatigue Service at the Royal Free Hospital in London, UK (>18 y/o):

(Lovibond et al, 1995), (Maher-Edwards et al, 2010)

Metacognitions (or negative beliefs about one’s own thoughts concerning uncontrollability, cognitive confidence, and beliefs about the need to control thoughts) can be used independently of negative emotions to predict symptom severity. As a result, it may be a better use of time and resources to implement questionnaires that assess metacognitions, rather than simply depressive state or negative affect. Thus, the 30-Item Metacognitions Questionnaire may be a better predictor of CFS severity than implementation of the DASS

Undergraduate students from 2 Public Universities Receiving Partial Credit for Taking Survey:

(Osman et al, 2012)

Results may be skewed/influenced since students received extra credit for completing the survey

484 Adolescents with Depression, Anxiety and Stress:

(Szabo et al, 2010)

Originally designed for adults, the DASS contains a number of expressions and words that may not be familiar to adolescents. The results of the series of Confirmatory Factor Analyses in this study indicate that while the constructs of Depression and Anxiety are similar between adults and 11,15 year old adolescents, the validity of the Tension/Stress construct, as measured by the adult DASS - 21, is questionable in this age group. It is possible that this specific emotional state is still emerging during early adolescence. The DASS - 21 needs to be used in young adolescent samples with caution, and it is perhaps best seen as a measure of Anxiety and Depression until further evidence for the construct validity of the Tension/Stress scale becomes available. Because of its demonstrated association with worry and GAD in adults (Brown et al., 1997; Szabo ́ & Lovibond, 2000), an ability to delineate the lowest age group at which the tension/stress syndrome is experienced by young people would make an important contribution towards a better understanding of the development of worry and its disorders in youth (Tracey et al, 1997)

Bibliography

Allen, J. and Annells, M. (2009). "A literature review of the application of the Geriatric Depression Scale, Depression Anxiety Stress Scales and Post-traumatic Stress Disorder Checklist to community nursing cohorts." J Clin Nurs 18(7): 949-959. Find it on PubMed

Arundine, A., Bradbury, C. L., et al. (2012). "Cognitive behavior therapy after acquired brain injury: maintenance of therapeutic benefits at 6 months posttreatment." J Head Trauma Rehabil 27(2): 104-112. Find it on PubMed

Brown, T. A., Chorpita, B. F., et al. (1997). "Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples." Behav Res Ther 35(1): 79-89. Find it on PubMed

Edmed, S. and Sullivan, K. (2012). "Depression, anxiety, and stress as predictors of postconcussion-like symptoms in a non-clinical sample." Psychiatry Res 200(1): 41-45. Find it on PubMed

Haggman, S., Maher, C. G., et al. (2004). "Screening for symptoms of depression by physical therapists managing low back pain." Phys Ther 84(12): 1157-1166. Find it on PubMed

Lovibond, P. F. and Lovibond, S. H. (1995). "The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories." Behav Res Ther 33(3): 335-343. Find it on PubMed

Lovibond, S. and Lovibond, P. F. (1996). Manual for the depression anxiety stress scales, Psychology Foundation of Australia. Maher-Edwards, L., Fernie, B. A., et al. (2011). "Metacognitions and negative emotions as predictors of symptom severity in chronic fatigue syndrome." J Psychosom Res 70(4): 311-317. Find it on PubMed

Mitchell, M. C., Burns, N. R., et al. (2008). "Screening for depression and anxiety in spinal cord injury with DASS-21." Spinal Cord 46(8): 547-551. Find it on PubMed

Osman, A., Wong, J. L., et al. (2012). "The Depression Anxiety Stress Scales-21 (DASS-21): further examination of dimensions, scale reliability, and correlates." J Clin Psychol 68(12): 1322-1338. Find it on PubMed

Pengel, L. H., Refshauge, K. M., et al. (2007). "Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial." Ann Intern Med 146(11): 787-796. Find it on PubMed

Ruwaard, J., Lange, A., et al. (2012). "The effectiveness of online cognitive behavioral treatment in routine clinical practice." PLoS One 7(7): e40089. Find it on PubMed

Szabo, M. (2010). "The short version of the Depression Anxiety Stress Scales (DASS-21): factor structure in a young adolescent sample." J Adolesc 33(1): 1-8. Find it on PubMed

Taylor, R., Lovibond, P. F., et al. (2005). "The utility of somatic items in the assessment of depression in patients with chronic pain: a comparison of the Zung Self-Rating Depression Scale and the Depression Anxiety Stress Scales in chronic pain and clinical and community samples." Clin J Pain 21(1): 91-100. Find it on PubMed

Year published

July 2013 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 12/11/2013 3:47 PM  by Jason Raad 
Last modified at 1/8/2014 5:10 PM  by Jason Raad