What to Know About the DASS-21 Depression Anxiety Scale

According to the World Health Organization, approximately 280 million people worldwide have depression, and 301 million people have anxiety. Additionally, the American Institute of Stress found that approximately 1 in 3 Americans experiences “extreme” amounts of stress. But how do we determine what level of stress is actually "extreme" versus "normal"?

Many mental health professionals use scale questionnaires to gather information about client symptoms and get further insight into the client’s specific concerns if the client struggles to articulate them. Scale questionnaires can indicate how severe symptoms are at present.

The Depression, Anxiety, and Stress Scale, 21 (DASS-21) is one such assessment. It contains 21 questions about an individual’s level of depressive symptoms, anxious distress, and current stress levels to help inform their mental health needs. It uses a four-point rating scale to determine severity and identifies if an individual’s experience is “normal,” mild, moderate, severe, or extremely severe.

The DASS-21: An Overview

The DASS-21 was developed in 1995 by Lovibond and Lovibond through the Psychology Foundation of Australia. Their aim was to create a brief but comprehensive screening tool that could identify clients struggling with anxiety, depression, or stress. It asks about the client’s experience over the past week.

Clients complete the DASS-21 by responding to 21 statements using the following 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 a considerable degree or a good part of the time
• 3: Applied to me very much or most of the time

Mental health screening measures like the DASS-21 can be useful in determining which clients might need to be referred for further support, assessment, or treatment for their mental health symptoms. It can ensure that the client answers important questions and reduces the likelihood that the provider will forget to ask. Additionally, some clients might be more forthcoming about their symptoms in writing rather than face-to-face with the provider.

Chris Dabbs, PhD, professor of psychology, and licensed counselor, uses the DASS-21 in research and practice. He shared, “It's got great psychometric properties, particularly internal reliability scores, and discriminant validity with other measures of depression and anxiety.”

Understanding Depression

The DASS-21 measures depression using the Depression subscale. It assesses dysphoric mood, feelings of hopelessness, reduced interest in life, negative self-talk, and outlook on life. The seven depression questions determine how severe a client’s depressive symptoms are at the present time, though it does not gather information about depressive episodes or how long the client has been experiencing the symptoms.

Understanding Anxiety

The Anxiety subscale of the DASS-21 has seven questions to assess the individual’s current level of anxious distress. Again, it does not ask about length of symptoms or specific details about what triggers these symptoms, so the measure would provide general information about anxiety rather than a specific anxiety disorder diagnosis. The anxiety questions include anxiety related to specific situations, muscle tension, and anxious distress.

Understanding Stress

Like the other subscales, the Stress subscale on the DASS-21 contains seven questions. Again, the client does not provide personal details about their life stressors or how long they have been experiencing this level of stress. The stress scale queries for difficulty relaxing, nervousness, irritability, and impatience.

Administration of the DASS-21

The DASS-21 is a self-report scale, meaning that the client fills it out and answers the questions based on how they are feeling. Due to the length, it can be completed in five to 10 minutes.

If you are completing the DASS-21, try to answer with your gut. It can be easy to overthink the questions, but your first instinct is often the most reflective of your experience. There are no right or wrong answers, and you are encouraged to answer honestly so that the provider can best interpret your results and support you.

Interpretation of the DASS-21

After administering the DASS-21, the provider will score the three subscales and interpret the results based on the recommended cutoff scores for severity. Scores in the “normal” range suggest that the individual is not struggling with depression, anxiety, or stress. Higher scores can indicate if the client’s current symptoms are mild, moderate, severe, or extremely severe.

Clients with a mild elevation might simply be having a bad day when they completed the form, or they could have a mental health issue with symptoms that are somewhat managed at this time. Moderate or severe symptoms mean that an individual is likely experiencing a mental health issue or extreme stress. Extremely severe symptoms indicate that the client likely needs support right away, and the provider should intervene immediately to further assess their symptoms and provide resources.

Although the DASS-21 provides subscale scores, Dr. Dabbs noted that the total score can also be useful. He shared: “I believe it conceptually works best to use the total score. In that way, I find giving the DASS-21 comparable to giving a combination of PHQ-9/GAD-7/MDQ [other mental health screening measures], but the DASS-21 is only one tool which makes scoring and interpretation much simpler.”

Limitations and Other Considerations

Brief screeners like the DASS-21 gather a small amount of information snapshotting the individual’s mental state at the time when they completed the measure. While this can be useful in a primary care setting when there is not time to complete extensive testing, this means that providers who administer the DASS-21 only gather a small amount of information about the client. It might reflect that further intervention or assessment is needed, but the DASS-21 alone is unlikely to provide comprehensive information about an individual’s diagnosis or treatment needs, and clients who obtain elevated scores may need a more comprehensive psychological evaluation.

The DASS-21 also only looks at symptoms of anxiety, depression, and stress, and so it might not reflect other mental health concerns including (but not limited to) obsessive compulsive-type disorders, trauma, or psychosis.

Dr. Dabbs noted that this measure is less in-depth than some other screening measures: “The major limitation is that it doesn't give you as much data as a more extensive individual measure of the sub-scales would (e.g., a BDI or a BAI).”

Additionally, because the DASS-21 assesses how the person is doing when they complete the measure, it does not show trends or changes in symptoms unless it is given repeatedly, and the provider tracks the scores. For instance, an individual experiencing a stressful week due to a work project might obtain a higher DASS-21 score, which could lower on its own when that project is complete.

No piece of data is useful in isolation. Any provider who uses the DASS-21 still needs to directly communicate with clients about mental health and potential symptoms. The DASS-21 (and any other mental health screener) is not a substitute for an open conversation between the provider and patient.

Finally, the DASS-21 does not ask about suicidal ideation or thoughts of self-harm. Research shows that it is important for healthcare providers to assess for thoughts of suicide in all clients, in addition to asking about mental health in general. In order to comply with this standard for best practice, providers would have to assess for suicide in addition to administering the DASS-21.

Conclusion

Screening measures like the DASS-21 can be useful in determining if a client might need more support for their mental health, though they are not all-encompassing. It is unlikely that a provider will be able to determine a specific diagnosis from the DASS-21, though it could yield insight into what further support would be appropriate.

The DASS-21 is brief but provides specific and comprehensive cutoff scores about an individual’s current levels of anxiety, depression, and stress. It can open up the conversation about an individual’s current mental health and can ensure that the provider thoroughly screens for these concerns. It can normalize discussion of the difficulties an individual is experiencing and help de-stigmatize the conversation around mental health.

If you have concerns about your mental health, help is available. Your primary doctor can help you figure out what support you need and how to access it. You can also use a directory to find a therapist. Remember, there is no minimum amount of difficulty that you have to reach. You deserve support.