DASS-21: Depression Anxiety Stress Scales

Reviewed by: Constantin Rezlescu | Associate Professor | UCL Psychology

Introduction

The DASS-21 (Depression Anxiety Stress Scales-21) is a comprehensive self-report questionnaire designed to measure the three related negative emotional states of depression, anxiety, and stress. Developed by Lovibond and Lovibond (1995) as a shortened version of the original 42-item DASS, this efficient 21-item measure provides a thorough assessment of psychological distress across these three key dimensions.

Tripartite Model of Emotional Distress

The DASS-21 is grounded in the tripartite model of anxiety and depression, which recognizes that while depression, anxiety, and stress are distinct constructs, they also share common features and frequently co-occur. This theoretical framework emphasizes the importance of assessing all three dimensions simultaneously to understand the full spectrum of emotional difficulties an individual may be experiencing.

Theoretical Foundation

The scale’s development was informed by extensive research on the structure of negative emotional states. Unlike many measures that focus on a single construct, the DASS-21 simultaneously evaluates three interconnected aspects of mental health based on Clark and Watson’s tripartite model. This approach recognizes that:

• Depression is characterized primarily by low positive affect and anhedonia
• Anxiety is marked by physiological hyperarousal and acute fear responses
• Stress reflects chronic non-specific arousal, tension, and difficulty relaxing

The DASS-21’s factor structure consistently demonstrates that these three states, while correlated, represent distinguishable dimensions of psychological distress, making it valuable for both differential assessment and treatment planning.

📊 Comprehensive Assessment: The DASS-21 provides separate scores for depression, anxiety, and stress, allowing for nuanced understanding of an individual’s psychological profile rather than a single “distress” score.

Key Features

Assessment Characteristics

• 21 items total (7 items per subscale)
• 5-10 minutes administration time
• Ages 12+ through adult with adolescent and adult norms available
• 4-point severity scale for response options
• Free to use for clinical and research purposes

Emotional Distress Dimensions Assessed

Depression:

• Dysphoric mood and hopelessness
• Anhedonia and lack of positive affect
• Self-depreciation and worthlessness
• Lack of interest and motivation
• Inertia and low energy

Anxiety:

• Autonomic arousal and panic symptoms
• Situational anxiety responses
• Subjective anxious affect
• Skeletal muscular effects
• Physical tension and trembling

Stress:

• Chronic non-specific arousal
• Nervous tension and agitation
• Difficulty relaxing
• Irritability and impatience
• Easy upset and overreaction

Research and Clinical Applications

Cross-cultural research on emotional disorders

Mental health screening in clinical and community settings

Treatment outcome monitoring across therapy sessions

Research studies on emotional disorders and comorbidity

Workplace wellbeing assessments and stress management

Student counseling services and campus mental health

Primary care screening for psychological distress

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Assess the three dimensions of emotional distress: depression, anxiety, and stress.

Scoring and Interpretation

Response Format

Participants rate how much each statement applied to them over the past week using a 4-point severity scale:

• 0 = Did not apply to me at all
• 1 = Applied to me to some degree, or some of the time
• 2 = Applied to me to a considerable degree, or a good part of time
• 3 = Applied to me very much, or most of the time

Complete DASS-21 Items by Subscale

Depression Items (7 items):

1. “I couldn’t seem to experience any positive feeling at all”
2. “I just couldn’t seem to get going”
3. “I felt that I had nothing to look forward to”
4. “I felt sad and depressed”
5. “I felt that I had lost interest in just about everything”
6. “I felt I wasn’t worth much as a person”
7. “I felt that life wasn’t worthwhile”

Anxiety Items (7 items):

1. “I was aware of dryness of my mouth”
2. “I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness)”
3. “I had a feeling of shakiness (e.g., legs going to give way)”
4. “I found myself in situations that made me so anxious I was most relieved when they ended”
5. “I had a feeling of faintness”
6. “I perspired noticeably (e.g., hands sweaty) in the absence of high temperatures or physical exertion”
7. “I was worried about situations in which I might panic and make a fool of myself”

Stress Items (7 items):

1. “I found myself getting upset by quite trivial things”
2. “I was aware of the action of my heart in the absence of physical exertion”
3. “I found it hard to wind down”
4. “I tended to over-react to situations”
5. “I felt that I was using a lot of nervous energy”
6. “I found myself getting impatient when I was delayed in any way”
7. “I found myself getting agitated”

Scoring Procedure

1. Sum items for each subscale (7 items per subscale)
2. Multiply each subscale sum by 2 to match DASS-42 normative data
3. Apply severity cut-offs using the table below
4. Higher scores indicate greater severity of symptoms

DASS-21 Severity Ratings

Severity	Depression	Anxiety	Stress
Normal	0-9	0-7	0-14
Mild	10-13	8-9	15-18
Moderate	14-20	10-14	19-25
Severe	21-27	15-19	26-33
Extremely severe	28+	20+	34+

Score Interpretation Guidelines

Clinical interpretation:

• Normal range: Typical emotional functioning, no significant distress
• Mild severity: Some emotional difficulties; self-help may be beneficial
• Moderate severity: Noticeable distress; consider professional support
• Severe severity: Significant psychological distress; clinical intervention recommended
• Extremely severe: Very high distress levels; urgent clinical attention indicated

Pattern analysis:

• Single elevated subscale: Specific clinical concern (pure depression, anxiety, or stress)
• Multiple elevated subscales: Complex presentation requiring comprehensive treatment
• All subscales elevated: Generalized psychological distress across domains
• Differential patterns: Help guide treatment focus and intervention selection

Population Norms

Clinical samples: Significantly elevated across subscales (Henry & Crawford, 2005)

Community adults: Depression M=5.5, Anxiety M=3.9, Stress M=9.3 (Lovibond & Lovibond, 1995)

University students: Depression M=7.5, Anxiety M=5.6, Stress M=11.2 (Antony et al., 1998)

Research Evidence and Psychometric Properties

Reliability Evidence

• Internal consistency (Cronbach’s α):
  • Depression: α = 0.88-0.94 (excellent reliability) (Antony et al., 1998; Henry & Crawford, 2005)
  • Anxiety: α = 0.82-0.87 (good to excellent reliability) (Antony et al., 1998; Henry & Crawford, 2005)
  • Stress: α = 0.90-0.91 (excellent reliability) (Antony et al., 1998; Henry & Crawford, 2005)
• Test-retest reliability: r = 0.71-0.81 over 2-week intervals (Brown et al., 1997)
• Split-half reliability: r = 0.81-0.88 across subscales (Antony et al., 1998)
• Clinical sample reliability: Consistently high alphas across diverse clinical groups (Brown et al., 1997; Henry & Crawford, 2005)

Factor Structure and Validity

Factor analysis results:

• Three-factor model: Consistently supported across cultures and populations (Lovibond & Lovibond, 1995; Brown et al., 1997)
• Factorial validity: Clear distinction between depression, anxiety, and stress factors (Antony et al., 1998)
• Confirmatory factor analysis: Strong fit indices for tripartite structure (Henry & Crawford, 2005)
• Cross-cultural invariance: Factor structure replicated in multiple countries (Norton, 2007; Osman et al., 2012)

Convergent validity:

• Beck Depression Inventory: r = 0.74 with DASS-21 Depression (Lovibond & Lovibond, 1995)
• Beck Anxiety Inventory: r = 0.81 with DASS-21 Anxiety (Antony et al., 1998)
• Perceived Stress Scale: r = 0.70 with DASS-21 Stress (Henry & Crawford, 2005)
• Other distress measures: Moderate to high correlations with established scales (Brown et al., 1997)

Discriminant validity:

• Subscales differentiate: Clear discrimination between clinical diagnostic groups (Brown et al., 1997)
• Treatment sensitivity: Each subscale responds specifically to targeted interventions (Antony et al., 1998)
• Diagnostic utility: Helps differentiate pure vs. comorbid presentations (Lovibond & Lovibond, 1995)
• Factor distinctiveness: Moderate inter-subscale correlations (r = 0.5-0.6) (Henry & Crawford, 2005)

Normative Data and Validation

Large-scale normative studies:

• Australian sample: N = 1,794 community adults (Lovibond & Lovibond, 1995)
• UK normative data: N = 1,771 general population (Henry & Crawford, 2005)
• Clinical samples: Multiple studies with depression, anxiety, and mixed disorder groups (Brown et al., 1997)
• Age ranges: Validated from adolescence (12+) through older adults (Norton, 2007)

Cross-cultural validation:

• Multiple languages: Validated translations across diverse linguistic groups (Norton, 2007; Osman et al., 2012)
• Cultural equivalence: Generally equivalent factor structure across cultural groups (Norton, 2007)
• International studies: Psychometric properties confirmed in diverse populations (Osman et al., 2012)

Clinical Utility Studies

Screening accuracy:

• Sensitivity and specificity: Good diagnostic accuracy for detecting clinical disorders (Henry & Crawford, 2005)
• Diagnostic agreement: High concordance with structured clinical interviews (Brown et al., 1997)
• Cutoff performance: Severity categories align well with clinical judgment (Lovibond & Lovibond, 1995)

Treatment sensitivity:

• Pre-post changes: Responsive to psychological and pharmacological interventions (Antony et al., 1998)
• Effect detection: Moderate to large treatment effects detected consistently (Brown et al., 1997)
• Change monitoring: Tracks symptom improvement throughout treatment (Henry & Crawford, 2005)

Comorbidity assessment:

• Mixed presentations: Effective for assessing complex cases with multiple symptoms (Brown et al., 1997)
• Differential patterns: Helps identify primary vs. secondary problems (Lovibond & Lovibond, 1995)
• Profile analysis: Baseline patterns inform treatment selection (Antony et al., 1998)

Research Applications

Epidemiological studies:

• Prevalence research: Used in large-scale mental health surveys (Henry & Crawford, 2005)
• Population screening: Community mental health assessments (Norton, 2007)

Clinical trials research:

Comparative effectiveness: Evaluates relative impact across emotional distress dimensions (Brown et al., 1997)

Outcome measure: Primary or secondary endpoint in intervention studies (Antony et al., 1998)

Usage Guidelines and Applications

Primary Clinical Applications

• Initial screening for depression, anxiety, and stress in clinical settings
• Comprehensive assessment of emotional distress profile
• Progress monitoring during psychological or pharmacological treatment
• Treatment outcome evaluation at therapy conclusion or follow-up
• Case conceptualization to understand presenting problems

Clinical Decision Support

Severity-based recommendations:

• Normal scores (all subscales): Psychoeducation about maintaining mental health
• Mild scores: Self-help resources, bibliotherapy, online interventions
• Moderate scores: Consider professional counseling or therapy referral
• Severe scores: Immediate clinical attention strongly recommended
• Extremely severe scores: Urgent mental health evaluation and referral

Profile-based treatment planning:

• Elevated depression only: Target anhedonia, negative thinking, behavioral activation
• Elevated anxiety only: Address arousal, worry, exposure to feared situations
• Elevated stress only: Focus on relaxation, time management, stress reduction
• Multiple elevations: Comprehensive treatment addressing all affected domains
• Comorbid presentations: Prioritize most severe or impairing symptoms first

Healthcare Settings Applications

Primary care:

• Brief screening during routine appointments for mental health concerns
• Mental health triage to inform referral decisions

Specialized mental health:

• Intake assessment for comprehensive evaluation at treatment onset
• Outcome documentation for clinical records and quality assurance

Hospital and medical settings:

• Consultation-liaison psychiatry assessments for medical patients
• Pre-surgical mental health evaluation when indicated

Workplace and Organizational Uses

• Employee wellbeing assessments for workplace mental health programs
• Stress management program evaluation and needs assessment
• Return-to-work readiness evaluation after mental health leave

Educational Settings Applications

• University counseling centers for student mental health screening
• Academic support services to identify students needing assistance

Research Considerations

Study design applications:

• Baseline assessment: Characterize participant emotional distress levels
• Outcome measure: Primary or secondary endpoint in intervention trials
• Screening tool: Include/exclude participants based on distress criteria

Cultural Considerations

• Cross-cultural validity: Established in diverse populations worldwide (Norton, 2007; Osman et al., 2012)
• Language translations: Available in multiple validated translations
• Cultural expression: Emotional distress manifestation may vary across cultures
• Interpretation caution: Consider cultural context when applying cutoff scores

Limitations and Cautions

Cutoff guidelines: Severity ranges should inform, not replace, clinical judgment

Self-report measure: Relies on accurate self-awareness and honest reporting

One-week timeframe: Captures recent symptoms but may miss important variations

Clinical diagnosis: Does not replace comprehensive diagnostic evaluation by trained professionals

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Legal and Copyright Information

Copyright and Usage Responsibility: Check that you have the proper rights and permissions to use this assessment tool in your research. This may include purchasing appropriate licenses, obtaining permissions from authors/copyright holders, or ensuring your usage falls within fair use guidelines.

The DASS-21 is free for clinical and research use. Commercial applications may require permission from the Psychology Foundation of Australia. Users should check the official DASS website for current usage policies and any required permissions.

Proper Attribution: When using or referencing this scale, cite the original development:

Lovibond, P. F., & 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. Behaviour Research and Therapy, 33(3), 335-343.

External Links and Resources

Official DASS Website – Psychology Foundation of Australia

Depression – Wikipedia

Anxiety – Wikipedia

Psychological Stress – Wikipedia

References

Primary Development Citation:

• Lovibond, P. F., & 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. Behaviour Research and Therapy, 33(3), 335-343.

Key Validation Studies:

• Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176-181.
• 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.

Factor Structure Research:

• Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D. H. (1997). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behaviour Research and Therapy, 35(1), 79-89.

Cross-Cultural Validation:

• Osman, A., Wong, J. L., Bagge, C. L., Freedenthal, S., Gutierrez, P. M., & Lozano, G. (2012). The Depression Anxiety Stress Scales-21 (DASS-21): Further examination of dimensions, scale reliability, and correlates. Journal of Clinical Psychology, 68(12), 1322-1338.
• Norton, P. J. (2007). Depression Anxiety and Stress Scales (DASS-21): Psychometric analysis across four racial groups. Anxiety, Stress & Coping, 20(3), 253-265.