Outcome Measure
Depression Anxiety Stress Scales – 21-Item
What it measures?
- Three self-report subscales assess the emotional states of depression, anxiety and stress.
- Depression subscale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia and inertia.
- The anxiety subscale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect.
- The stress subscale assesses difficulty relaxing, nervous arousal, and being easily upset / agitated, irritable / over-reactive and impatient.
Who is it for?
Adults and adolescents aged 17 years +
Instrument Quality
- The DASS-21 has well-established psychometric properties and is among the most common instruments used to assess symptoms of depression, anxiety and stress (Ronke et al., 2013).
Structure
- 21 items
- 4-point Likert scale
- Respondents indicate how frequently (0 = "Did not apply to me at all"; 3 = "Applied to me very much or most of the time") they have been bothered by the problems listed in each item (e.g. "I couldn’t seem to experience any positive feeling at all")
Scoring instructions
- Sum the item responses for each subscale
- Multiply the subscale score by 2
| Subscale | Item number |
|---|---|
Anxiety |
2,4,7,9,15,19,20 |
Depression |
3,5,10,13,16,17,21 |
Stress |
1,6,8,11,12,14,18 |
Score Interpretation
What higher scores mean?
- More severe symptoms of depression, anxiety and stress over the past week. Greater likelihood of meeting criteria for a DSM-5 depressive- or anxiety- disorder. Optimal cut-off scores will vary across settings and populations. As general guidelines, cut-off scores have been provided for each of the three subscales indicating 'normal', 'mild', 'moderate', 'severe', and 'extremely severe' symptoms.
Identifying risk
A patient may be at risk if they endorse any of the following ‘red flag’ items. Further risk assessment should be undertaken.
| Item number | Item content |
|---|---|
| 21 | I felt that life was meaningless |
How to assess symptom severity & change?
| Description | Score Range | |
|---|---|---|
| Normal | 0 | |
| Mild | 8 | |
| Moderate | 10 | |
| Severe | 15 | |
| Extremely Severe | 20 | |
| Maximum | 42 |
| Description | Score Range | |
|---|---|---|
| Normal | 0 | |
| Mild | 10 | |
| Moderate | 14 | |
| Severe | 21 | |
| Extremely Severe | 28 | |
| Maximum | 42 |
Severity ranges
The ranges of ‘normal’, ‘mild’, ‘moderate’, ‘severe’ and ‘extremely severe’ were identified by the instrument developer and are widely used (Lovibond & Lovibond, 1995).
Reliable change and clinically significant improvement
Ronk, Korman, Hooke and Page (2013) obtained the reliable raw score change value using on an Australian outpatient sample (N = 1000). The calculation of this value was based on the standard two distribution method for calculating clinical significance described by Jacobson and Truax (1991).
Mean
| Sample | Mean | Comments |
|---|---|---|
| Clinical | 13.32 | Based on an American outpatient sample (N = 1000) consisting of patients attending a private behavioural and cognitive therapy clinic (Ronk, Korman, Hooke & Page, 2013). |
| Normative | 6.34 | Based on heterogeneous non-clinical sample of 1044 males and 1870 females (Lovibond & Lovibond, 1995). |
Standard Deviation
| Sample | Mean | Comments |
|---|---|---|
| Clinical | 11.1 | Based on an American outpatient sample (N = 1000) consisting of patients attending a private behavioural and cognitive therapy clinic (Ronk, Korman, Hooke & Page, 2013). |
| Normative | 6.97 | Based on heterogeneous non-clinical sample of 1044 males and 1870 females (Lovibond & Lovibond, 1995). |
Reliability
| Value | Comments |
|---|---|
| 0.96 | The value reported is Cronbach's Alpha (not test-retest reliability; Page, Hooke & Morrison, 2007). It is very difficult to obtain reliable test-retest reliability statistics for the English version of the DASS-21 full-scale and subscales. |
| Description | Score Range | |
|---|---|---|
| Normal | 0 | |
| Mild | 15 | |
| Moderate | 19 | |
| Severe | 26 | |
| Extremely Severe | 34 | |
| Maximum | 42 |
Severity ranges
The ranges of ‘normal’, ‘mild’, ‘moderate’, ‘severe’ and ‘extremely severe’ were identified by the instrument developer and are widely used (Lovibond & Lovibond, 1995).
Reliable change and clinically significant improvement
Ronk, Korman, Hooke and Page (2013) obtained the reliable raw score change value using on an Australian outpatient sample (N = 1000). The calculation of this value was based on the standard two distribution method for calculating clinical significance described by Jacobson and Truax (1991).
Mean
| Sample | Mean | Comments |
|---|---|---|
| Clinical | 15.01 | Based on an American outpatient sample (N = 1000) consisting of patients attending a private behavioural and cognitive therapy clinic (Ronk, Korman, Hooke & Page, 2013). |
| Normative | 10.11 | Based on heterogeneous non-clinical sample of 1044 males and 1870 females (Lovibond & Lovibond, 1995). |
Standard Deviation
| Sample | Mean | Comments |
|---|---|---|
| Clinical | 10 | Based on an American outpatient sample (N = 1000) consisting of patients attending a private behavioural and cognitive therapy clinic (Ronk, Korman, Hooke & Page, 2013). |
| Normative | 7.91 | Based on heterogeneous non-clinical sample of 1044 males and 1870 females (Lovibond & Lovibond, 1995). |
Reliability
| Value | Comments |
|---|---|
| 0.95 | The value reported is Cronbach's Alpha (not test-retest reliability; Page, Hooke & Morrison, 2007). It is very difficult to obtain reliable test-retest reliability statistics for the English version of the DASS-21 full-scale and subscales. |
Instrument developers
- Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2nd. Ed.) Sydney: Psychology Foundation
Refrences
Crawford, J. R., Garthwaite, P. H., Lawrie, C. J., Henry, J. D., MacDonald, M. A., Sutherland, J., & Sinha, P. (2009). A convenient method of obtaining percentile norms and accompanying interval estimates for self‐report mood scales (DASS, DASS‐21, HADS, PANAS, and sAD). British Journal of Clinical Psychology, 48(2), 163-180 Crawford, J., Cayley, C., Lovibond, P. F., Wilson, P. H., & Hartley, C. (2011). Percentile norms and accompanying interval estimates from an Australian general adult population sample for self‐report mood scales (BAI, BDI, CRSD, CES‐D, DASS, DASS‐21, STAI‐X, STAI‐Y, SRDS, and SRAS). Australian Psychologist, 46(1), 3-14 Henry, J. D., & Crawford, J. R. (2005). The short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample. British journal of clinical psychology, 44(2), 227-239. Ronk, F. R., Korman, J. R., Hooke, G. R., & Page, A. C. (2013). Assessing clinical significance of treatment outcomes using the DASS-21. Psychological assessment, 25(4), 1103 Sinclair, S. J., Siefert, C. J., Slavin-Mulford, J. M., Stein, M. B., Renna, M., & Blais, M. A. (2012). Psychometric evaluation and normative data for the depression, anxiety, and stress scales-21 (DASS-21) in a nonclinical sample of US adults. Evaluation & the health professions, 35(3), 259-279
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Severity ranges
The ranges of ‘normal’, ‘mild’, ‘moderate’, ‘severe’ and ‘extremely severe’ were identified by the instrument developer and are widely used (Lovibond & Lovibond, 1995).
Reliable change and clinically significant improvement
Ronk, Korman, Hooke and Page (2013) obtained the reliable raw score change value using on an Australian outpatient sample (N = 1000). The calculation of this value was based on the standard two distribution method for calculating clinical significance described by Jacobson and Truax (1991).
Mean
Standard Deviation
Reliability