Depression, Anxiety, & Stress Scale

Last Updated

April 21, 2026

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Purpose

The DASS is a 21- or 42-item measure designed to assess the fundamental symptoms of depression, anxiety and tension/stress.

Link to Instrument

Acronym DASS

Area of Assessment

Activities & Participation

Assessment Type

Patient Reported Outcomes

Cost

Free

Cost Description

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

CDE Status

Not a CDE--last searched 4/21/2026

Diagnosis/Conditions

Brain Injury Recovery
Pain Management

Mixed Conditions

Chronic Pain

Brain Injury

Non-Patient

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.
Maximum score: 63 for the 21-item DASS; 126 for the 42-item DASS.
A higher score on the DASS indicates greater severity or frequency of these negative emotional symptoms.

Number of Items

42 or 21

5-10 minutes

Required Training

No Training

Required Training Description

Paper & writing instrument

Adult

18 - 64

years

Older Adult

65 +

years

Instrument Reviewers

Initially reviewed in 2013 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. Updated 4/21/2026 by Illinois Institute of Technology psychology students Felicia Diprizio, Brandon Dixon, and Teija Mitchell under the direction of Nicole Ditchman, PhD, LCPC, CRC, CVE.

ICF Domain

Body Function

Measurement Domain

Emotion

Professional Association Recommendation

(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)

The DASS should not be used as a diagnostic instrument, but rather to assess the severity of symptoms relating to depression, anxiety, and stress.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

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

Cut-Off Scores

Depression, Anxiety, or Comorbid Depression & Anxiety: (Tran et al., 2013; n = 221, mean age = 27.7 (5.5) years, age range = 20-44 years, 19.5% met diagnostic criteria for at least one of the mental disorders of depression, anxiety, or comorbid depression and anxiety; Rural North Vietnamese women; DASS21 translated and culturally adapted into Vietnamese (DASS21-V)

�� 10 on DASS21-D predicts depression better than anxiety with a higher cut-off (sensitivity 80.8%, specificity 77.4%)
�� 14 on DASS21-S predicts anxiety better than depression (sensitivity 79.2%, specificity 66.0%).
�� 10 on DASS21-A predicts depression and anxiety with the same cut-off score (sensitivity 80.8% for depression and 79.2% for anxiety, specificity 67.7% for depression and 67.0% for anxiety)

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 �C 54 years )

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

Psychiatric Patients: (Davies et al., 2015; n = 2,542; mean age = 41.47 (13.94) years; age range = 15.38-89.17 years; diagnoses include: depressive episode (n = 793), adjustment disorders (n = 330), substance abuse (n = 204), anxiety disorders (n = 144), PTSD (n = 136), somatoform pain disorders (n = 98), and schizophrenia (n = 91); referrals to private psychiatrist in Australia from 2000 to 2011)

Depression scale (D)

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��ǰ��&�Բ��;�Ǵ�&�Բ��;11&�Բ��;(52�Ի�&�Բ��;��Գپ��)&�Բ��;(95%&�Բ��;��:&�Բ��;49.7�C55.0)
��ǰ��&�Բ��;�Ǵ�&�Բ��;16&�Բ��;(74�ٳ�&�Բ��;��Գپ��)&�Բ��;(95%&�Բ��;��:&�Բ��;71.0�C77.2)

Anxiety scale (A)

Score of = 3 (24^th ��Գپ��)&�Բ��;(95%&�Բ��;��:&�Բ��;21.1�C27.4)
Score of = 9 (53^rd ��Գپ��)&�Բ��;(95%&�Բ��;��:&�Բ��;49.3�C55.7)
Score of = 14 (76^th ��Գپ��)&�Բ��;(95%&�Բ��;��:&�Բ��;73.4�C78.7)

Stress scale (S)

Score of = 7 (27^th percentile) (95% CI: 23.9�C29.9)
Score of = 12 (51^st percentile) (95% CI: 47.7�C64.8)
Score of = 16 (74^th ��Գپ��)&�Բ��;(95%&�Բ��;��:&�Բ��;70.5�C76.9)

Means (SD) for subscores and total score on DASS by age group

Age

Group

Depression

Anxiety

Stress

Total

DASS

15-24

19.01

(13.64)

14.14

(11.17)

20.85

(12.86)

54.00

(35.00)

25-34

20.16

(13.61)

16.62

(11.90)

22.71

(12.29)

59.49

(35.05)

35-44

20.81

(13.09)

17.05

(11.70)

23.48

(12.12)

61.34

(34.29)

45-54

21.21

(13.10)

17.33

(11.67)

22.93

(11.90)

61.47

(34.10)

55-60

21.87

(13.41)

17.53

(11.06)

23.52

(11.87)

62.92

(33.43)

70+

15.95

(11.82)

16.61

(11.57)

22.69

(12.18)

59.81

(34.40)

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.

Internal Consistency

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 �C 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

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 �C 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)

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

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*)

Depression, Anxiety, or Comorbid Depression & Anxiety: (Tran et al., 2013; n = 221)

Adequate for Depression subscale: (Cronbach's alpha = 0.72)
Adequate for Anxiety subscale: (Cronbach's alpha = 0.77)
Adequate for Stress subscale: (Cronbach's alpha = 0.70)
Excellent for Total DASS21 scale: (Cronbach's alpha = 0.88)

Patients Visiting Outpatient Clinic: (Vignola and Tucci, 2013; n = 242, mean age = 39.9 (12.4) years, age range = 18-75 years, female = 62%, Brazilian Portuguese translation of DASS-21)

Excellent internal consistency for all subscales:
- �ٱ��ǲ�&�Բ��;��ܲ��:&�Բ��;(��ǲԲ��󡯲�&�Բ��;��&�Բ��;=&�Բ��;0.92*)
- Anxiety subscale: (Cronbach's alpha = 0.86)
- Stress subscale: (Cronbach��s alpha = 0.90)

Psychiatric disorders and general population: (Ali et al., 2021; Psychiatric patients: n = 168, female = 70.8%, age groups (years): 18-30 (51.8%), 31-40 (22.6%), 41-50 (16.1%), 51-60 (7.7%), >60 (1.8%); General population: n = 992, female = 62.7%, age groups (years): 18-30 (45.6%), 31-40 (23.4%), 41-50 (17.4%), 51-60 (10.7%), >60 (3.3%); standard Arabic version of DASS-21 in Saudi Arabia (during COVID-19 lockdown)

Excellent for DASS Total Score (Cronbach��s alpha = 0.96* for psychiatric patients and 0.94* for general population sample)
Excellent for Depression subscale (Cronbach��s alpha = 0.90 for psychiatric patients and 0.85 for general population sample)
Excellent for Anxiety subscale for psychiatric patients (�� = 0.87) and Adequate for General Population (�� = 0.79)
Excellent for Stress subscale (Cronbach��s alpha = 0.91* for psychiatric patients and 0.89 for general population sample)

Psychiatric Patients: (Davies et al., 2015; n = 2,542)

Excellent for subscales and total scale:
- Depression Scale (�� = 0.94*)
- Anxiety Scale (�� = 0.87)
- Stress Scale (�� = 0.91*)
- Total DASS-21 (�� = 0.96*)

*Scores higher than 0.9 may indicate redundancy in the scale questions.

Criterion Validity (Predictive/Concurrent)

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)

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)

Construct Validity

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)

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

Standard Error of Measurement (SEM)

Chronic Pain: (M?ckel et al., 2021; n = 774; mean age = 33.03 (0.37); female = 23.77%; Pre-hospital EMS workers; validated German version of the DASS-21)

SEM for depression (n = 695): 0.36
SEM for anxiety (n = 695): 0.25
SEM for stress (n = 695): 0.34

Cut-Off Scores

Chronic Back Pain: (Kanaan et al., 2023a; n = 54; mean age = 46.75 (11.11) years; age range = 18-65 years; female = 80%; chronic low back pain of >3 months duration; Arabic version of DASS-21)

The cut-off points are 9 for depression, 7 for anxiety, and 14 for stress, with higher scores indicating mild to extremely severe symptoms

Normative Data

Low Back Pain: (Asrar et al., 2021; n = 871; mean age = 33 (11) years; age range = 18-65 years)

Mean (SD) scores by DASS-21 scale (n = 698):
- Depression: 11.87 (4.05)
- Anxiety: 8.32 (4.48)
- Stress: 13.77 (5.98)

Chronic Back Pain: (Kanaan et al., 2023a; n = 54; Arabic version of DASS-21)

Baseline

DASS-21 Component	Intervention Mean (SD) (n = 27)	Control Mean (SD) (n = 27)	p
Depression	6.81 (3.77)	6.44 (3.95)	0.726
Anxiety	6.85 (5.04)	5.37 (3.89)	0.232
Stress	9.15 (4.83)	8.89 (4.48)	0.839

Four Weeks

DASS-21 Component	Intervention Mean (SD) (n = 25)	Control Mean (SD) (n = 27)	p
Depression	2.32 (2.16)	6.26 (3.71)	< 0.001
Anxiety	2.64 (3.09)	6.26 (4.74)	0.002
Stress	3.40 (3.02)	8.67 (5.14)	< 0.001

Three Months

DASS-21 Component	Intervention Mean (SD) (n = 24)	Control Mean (SD) (n = 26)	p
Depression	2.63 (4.18)	7.08 (4.41)	0.001
Anxiety	2.63 (3.80)	5.73 (4.44)	0.011
Stress	3.21 (3.22)	7.12 (4.36)	0.001

Low Back Pain: (Kanaan et al., 2023b; n = 271; mean age = 39.86 (11.27); female = 153 (56.5%); low back pain chronicity median = 18 (IQR = 44) months; Arabic version of DASS-21)

Mean DASS-21 scores by component: DASS-Depression 6.8 (4.9), DASS-Anxiety 6.6 (5.2), DASS-Stress 8.6 (5.6))

Internal Consistency

Low Back Pain: (Kanaan et al., 2023b; n = 271; Arabic version of DASS-21)

Excellent internal consistency for Depression subscale (Cronbach��s alpha = 0.94)
Excellent internal consistency for Anxiety subscale (Cronbach's alpha = 0.87)
Excellent internal consistency for Stress subscale (Cronbach��s alpha = 0.91)

Construct Validity

Discriminant Validity:

Low Back Pain: (Asrar et al., 2021; n = 871)

Significant ability of DASS-21 scores to discriminate between males and females with mild depression (p < 0.05) and moderate anxiety (p < 0.05) and stress (p < 0.05), with females exhibiting higher scores than males in each case.

Chronic Back Pain: (Kanaan et al., 2023a; n = 54; Note��see data table under ��Normative Data�� above)

Significant ability of DASS-21 scores to discriminate between intervention and control groups at 4 weeks for DASS-Depression (p < 0.001); DASS-Anxiety (p < 0.002), and DASS-Stress (p < 0.001)
Significant ability of DASS-21 scores to discriminate between intervention and control groups at 3 months for DASS-Depression (p < 0.001); DASS-Anxiety (p < 0.011), and DASS-Stress (p < 0.001)

Responsiveness

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

Non-Specific Low Back Pain (NSLBP): (Freigang et al., 2021; n = 34; mean age = 54 (11) years; inclusion criteria: age between 18-80 years; previous neurosurgical patients or regular pain clinic patients; assessed at baseline, after the 4th week, and after the 36^th week of stimulation)

Significant main effect of the factor session on the anxiety score (F ( 43.19) = 6.90, p = 0.003, d = 0.433).
- Significant (p < 0.001) decrease in anxiety score at the end of the 4^th week (4.09) of stimulation compared to baseline (6.47) (i.e., from ��moderate�� to ��mild��) shown by Bonferroni corrected post hoc t-test.
Significant main effect of the factor session on the stress score (F ( 40.91) = 12.19, p �� 0.001, d = 0.315).
- Significant decrease in stress score on the 4th week (6.84, p = 0.001) and 36th week (7.51, p = 0.018) of stimulation compared to baseline (10.17) (from ��moderate�� to ��normal�� for each) shown by Bonferroni corrected post hoc t-test.

Chronic Pain: (M?ckel et al., 2021; n = 695; validated German version of DASS-21)

Significantly higher DASS-21 depression scores for those with chronic vs. no pain (p �� 0.001); chronic vs. recurrent pain (p = 0.002); and recurrent vs. no pain (p �� 0.001)

Internal Consistency

Brain Injury: (Randall et al., 2017; n = 504, male = 405 (80.4%), mean age = 33.10 (14.07) years, age range = 16-71 years, mean time since injury = 5.2 (5.7) months (range = 12 days to 2 years); moderate to severe TBI in acute to chronic sample at hospital rehabilitation unit in Australia)

Excellent for subscales and total scale:
- Depression Scale (�� = 0.90)
- Anxiety Scale (�� = 0.82)
- Stress Scale (�� = 0.89)
- Total General Distress (DASS-21) (�� = 0.95*)

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Brain Injury: (Dahm et al., 2013, n = 123, mean age = 37.94 (14.96) years, age range = 18-78 years, male = 95 (77.2%), mean time since injury = 716.35 (1,023.53) days, range = 64-9,324 days; patients in hospital TBI rehabilitation program)

Excellent correlations between DASS anxiety and depression scales and the corresponding scales on the Hospital Anxiety and Depression Scale (HADS) (both r = 0.76, p < 0.001)

Construct Validity

Construct validity:

Brain Injury: (Randall et al., 2017; n = 504)

Henry and Crawford's quadripartite model (Depression, Anxiety, Stress, General Distress) exhibited the lowest mean discrepancy and had a good model fit for the constructs as indicated by a Comparative Fit Index of 0.96.
Lovibond and Lovibond's original three factor model (Depression, Anxiety, and Stress) had the second lowest mean discrepancy and an adequate Comparative Fit Index of 0.94.

Standard Error of Measurement (SEM)

Adolescents: (Silva et al. 2016; n = 310, mean age = 14.16 (2.12) years, age range = 10-19 years, male = 179 (57.7%); adolescents recruited from schools and sports centers, validated Portuguese translation of DASS-21 for Brazil)

SEM for Depression subscale = 0.80
SEM for Anxiety subscale = 0.88
SEM for Stress subscale = 1.14

Minimal Detectable Change (MDC)

Adolescents: (Silva et al. 2016; n = 310; validated Portuguese translation of DASS-21 for Brazil)

MDC for Depression subscale = 2.22
MDC for Anxiety subscale = 2.44
MDC for Stress subscale = 3.16

Cut-Off Scores

Medical Students: (Coker et al., 2018; n = 240, mean age = 25 (4.5) years, age range = 25-34 years, female = 50%; Nigerian sample)

�� 10 for Depression, �� 8 for Anxiety, �� 15 for Stress

Normative Data

Medical Students: (Coker et al., 2018; n = 240)

Mean (SD) DASS21 scores:
- Depression: 5.12 (6.76)
- Anxiety: 6.0 (6.50)
- Stress: 8.70 (7.40)

Test/Retest Reliability

Adolescents: (Silva et al. 2016; n = 25; female = 14; median age (IQR) = 18 (4); test-retest interval = one week; validated Portuguese translation of DASS-21 for Brazil)

Acceptable test-retest reliability for all subscales (ICC (95%CI)):
- Depression (0.86 (0.68-0.94))
- Anxiety (0.80 (0.54-0.91))
- Depression (0.82 (0.57-0.92))

Internal Consistency

Medical students: (Coker et al, 2018; n = 240)

Excellent for the Depression (�� = 0.81) and Anxiety (�� = 0.89) subscales and for the Total Score (�� = 0.91*)
Adequate for the Stress subscale (�� = 0.78)

*Scores higher than 0.9 may indicate redundancy in the scale questions.

Construct Validity

Medical students: (Coker et al, 2018; n = 240)

Excellent correlation between DASS-21 scores for depression and stress (r = 0.658)
Excellent correlation between scores for the depression subscale of DASS-21 and scores on the Self-Rating Depression Scale (SDS) (r = 0.701)
Adequate correlation between scores for the Anxiety subscale of the DASS-21 and those correlated State-Trait Anxiety Inventory (STAI-Y2) (r = 0.650)

Bibliography

Ali, A. M., Alkhamees, A. A., Hori, H., Kim, Y., & Kunugi, H. (2021). The Depression Anxiety Stress Scale 21: Development and Validation of the Depression Anxiety Stress Scale 8-Item in Psychiatric Patients and the General Public for Easier Mental Health Measurement in a Post COVID-19 World. International Journal of Environmental ��B�о�Ժ and Public Health, 18(19), 10142-.

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.

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.

Asrar, M. M., Ghai, B., Pushpendra, D., & Bansal, D. (2021). Psychosocial morbidity profile in a community based sample of low back pain patients. Scientific Reports, 11(1), 1�C9.

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.

Coker, A., Coker, O., & Sanni, D. (2018). Psychometric properties of the 21-item Depression Anxiety Stress Scale (DASS-21). African ��B�о�Ժ Review, 12(2), 135.

Dahm, J., Wong, D., & Ponsford, J. (2013). Validity of the Depression Anxiety Stress Scales in assessing depression and anxiety following traumatic brain injury. Journal of Affective Disorders, 151(1), 392�C396.

Davies, G., Caputi, P., Skarvelis, M., & Ronan, N. (2015). The D epression A nxiety and S tress S cales: Reference data from a large psychiatric outpatient sample. Australian Journal of Psychology, 67(2), 97-104.

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.

Freigang, S., Lehner, C., Fresnoza, S. M., Mahdy Ali, K., Hlavka, E., Eitler, A., Szilagyi, I., Bornemann-Cimenti, H., Deutschmann, H., Reishofer, G., Berlec, A., Kurschel-Lackner, S., Valentin, A., Sutter, B., Zaar, K., & Mokry, M. (2021). Comparing the Impact of Multi-Session Left Dorsolateral Prefrontal and Primary Motor Cortex Neuronavigated Repetitive Transcranial Magnetic Stimulation (nrTMS) on Chronic Pain Patients. Brain Sciences (2076-3425), 11(8), 961.

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.

Kanaan, S. F., Alhendi, Z. M., Almhdawi, K. A., Aldahamsheh, Z., Ismail, N., & Khalil, H. (2023a). Evaluating the effectiveness of a comprehensive education on low back pain treatment outcomes: A controlled clinical study. Clinical Rehabilitation, 37(1), 98�C108.

Kanaan, S. F., Alissa, H. M. K., Jaber, A. F., Almhdawi, K. A., Mansour, Z. M., & Alhanada, M. (2023b). Knowledge related to low back pain and its associated factors in patients with low back pain: A cross-sectional study. Journal of Back & Musculoskeletal Rehabilitation, 36(1), 217�C225.

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.

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.

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.

M?ckel, L., Gerhard, A., Mohr, M., Armbrust, C. I., & M?ckel, C. (2021). Prevalence of pain, analgesic self-medication and mental health in German pre-hospital emergency medical service personnel: a nationwide survey pilot-study. International Archives of Occupational & Environmental Health, 94(8), 1975�C1982.

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.

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.

Randall, D., Thomas, M., Whiting, D., & McGrath, A. (2017). Depression Anxiety Stress Scales (DASS-21): Factor structure in traumatic brain injury rehabilitation. The Journal of head trauma rehabilitation, 32(2), 134-144.

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

Silva, H. A. D., Passos, M. H. P. D., Oliveira, V. M. A. D., Palmeira, A. C., Pitangui, A. C. R., Ara��jo, R. C. D. (2016). Short version of the Depression Anxiety Stress Scale-21: Is it valid for Brazilian adolescents? Einstein (s?o Paulo), 14(4), 486�C493.

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.

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.

Tran, T. D., Tran, T., & Fisher, J. (2013). Validation of the depression anxiety stress scales (DASS) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern Vietnamese women. BMC Psychiatry, 13(1), 1�C7.

Vignola, R. C. B., & Tucci, A. M. (2013). Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. Journal of Affective Disorders, 155, 104�C109.

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