Using the Depression Anxiety Stress Scales-21 (DASS-21) with Your Therapy Clients

In Brief

When a client is feeling emotionally distressed, it can be difficult for them to describe what they’re going through, let alone ask for the right kind of help. It is common for symptoms of depression, anxiety, and stress to all present together and in similar ways. Luckily, we have tools to help assess these symptoms to help plan targeted therapeutic interventions. The Depression Anxiety Stress Scales-21 (DASS-21) helps assess various categories of emotional distress in clients. Knowing how to administer, score, and interpret the DASS-21 plays a key role in effective treatment planning and progress monitoring. Let’s delve into the details of using the DASS-21 in your practice, including when to use it, what insights it provides, and how to interpret the results.

When do you use the Depression Anxiety Stress Scales-21 (DASS-21)?

‍The Depression Anxiety Stress Scales-21 (DASS-21) measures the presence and severity of symptoms of depression, anxiety, and stress. Each of these three topics have 7 items which also serve as subscales. These subscales measure various aspects of the categories they measure, including:

Depression: looks at dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia.
Anxiety: looks at autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect.
Stress: looks at difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.

The DASS-21 is validated for use only with adults aged 17 and older. Although there is a version available for youth.younger individuals. While not a diagnostic tool, the DASS-21 offers valuable insights for clients with depression, generalized anxiety disorder, panic disorder, and similar conditions. It also evaluates stress levels in clients without a specific diagnosis. Therapists typically administer the DASS-21 weekly or after each therapy session to track progress over time. This approach helps monitor symptom changes and adjust treatment as needed.

What Do You Learn from the Depression Anxiety Stress Scales-21 (DASS-21)?

‍The DASS-21 offers useful insights into a client's emotional state, helping you determine the intensity of their symptoms and guide treatment choices. Here's what you can learn from the DASS-21 scores:

Symptom severity: The total and subscale scores reveal the intensity of depression, anxiety, and stress symptoms. Higher scores suggest more severe symptoms, while lower scores indicate milder issues.
Specific areas of distress: The DASS-21 subscales assess the severity of symptoms related to depression, anxiety, and stress, providing insight into which area(s) of emotional distress may be most prominent for a client.This information allows you to customize interventions to meet their particular needs.

When administered regularly, the DASS-21 allows you to:

Track progress over time: Comparing DASS-21 scores across sessions helps you determine if a client's symptoms are improving, staying the same, or worsening. This information is important for assessing treatment effectiveness and making necessary adjustments.
Identify patterns and triggers: Regularly reviewing DASS-21 scores along with a client's experiences can help you spot patterns and potential triggers for their symptoms. This insight aids in developing coping strategies and preventing relapse.
Acknowledge successes: As clients progress in therapy, their DASS-21 scores will likely decrease. Highlighting these improvements can boost motivation and emphasize the benefits of treatment. If the scores are not decreasing, this information will be helpful as decisions are made about treatment plan changes.

Remember, while the DASS-21 is a valuable tool, it should always be used alongside clinical judgment and a comprehensive assessment of a client's unique situation.

Research and Evidence Behind the Depression Anxiety Stress Scales-21 (DASS-21)

Researchers at the University of New South Wales in Australia developed the DASS in 1995. The original version of the measure had 42-items. In 1998, the shorter 21-item version (DASS-21) was introduced for a more concise assessment.

Since its creation, extensive research has supported the DASS-21’s reliability, validity, and practical use:

Strong psychometric properties: Studies consistently show the DASS-21 has excellent internal consistency, test-retest reliability, and construct validity. It effectively measures depression, anxiety, and stress, with its factor structure confirmed in diverse populations, including with transgender and nonbinary populations.
Diagnostic accuracy: The DASS-21 demonstrates good sensitivity and specificity in identifying clinically significant depression and anxiety levels. It aligns well with structured clinical interviews and other established measures.
Cross-cultural applicability: The DASS-21 has been translated into nearly 60 languages and is used in research and clinical settings globally. Its psychometric properties hold in various cultural contexts, supporting its reliability and validity in measuring emotional distress across different groups.

While the DASS offers many strengths, consider its limitations:

Self-report nature: Like any self-report measure, the DASS depends on individuals accurately reporting their symptoms, which may be influenced by self-awareness, social desirability, and response bias.
Limited scope: The DASS focuses on specific aspects of emotional distress and may not capture the full range of symptoms experienced by individuals with more complex or comorbid mental health issues.

Frequently Asked Questions (FAQ)

How long does it take to complete each version of the DASS?
There are a number of DASS versions available. The time needed to finish the DASS depends on the version used:

DASS-42: The complete 42-item version usually takes 10-15 minutes.
DASS-21: The shorter 21-item version typically takes 5-8 minutes.
DASS-10: The brief 10-item version can be done in just 2-4 minutes.

Can the DASS be used for diagnostic purposes?
While the DASS offers useful insights into a client's emotional distress, it isn't meant to be used for diagnostic purposes. The DASS-21 is designed to measure psychological symptoms as levels or degrees instead of sorting them into specific categories of mental disorders. It is based on the idea (supported by research) that the depression, anxiety, and stress felt by people in everyday life and those in clinical settings differ in intensity rather than being completely different experiences. Because of this, the DASS-21 doesn’t classify people into official diagnoses

How often should I administer the DASS-21 to my clients?
The suggested frequency for administering the DASS-21 depends on the treatment context, client presentation, and goals:

Weekly or after each session: This helps in closely monitoring symptom changes and treatment progress.
Every 2-4 weeks: Suitable for clients with more stable symptoms or those in longer-term treatment.
At key milestones: Administering the DASS-21 at the beginning, middle, and end of treatment can provide a useful overview of progress.

How do I interpret the total score on the DASS-21?
A total composite score can be found by adding or averaging the three subscale scores together. However, scoring and interpreting the DASS-21 typically consists of relying on the three subscales—Depression, Anxiety, and Stress—each containing seven items. To interpret the scores:

Sum the scores for each subscale.
Multiply each subscale score by 2 to match the DASS-42 scoring.

Higher scores indicate more severe symptoms in each category. Here are the validated interpretation guidelines for each subscale:

Depression:

0-9: Normal
10-13: Mild
14-20: Moderate
21-27: Severe
28+: Extremely severe

Anxiety:

0-7: Normal
8-9: Mild
10-14: Moderate
15-19: Severe
20+: Extremely severe

Stress:

0-14: Normal
15-18: Mild
19-25: Moderate
26-33: Severe
34+: Extremely severe

By evaluating each subscale separately, you can identify specific areas where the client is experiencing difficulties and tailor interventions to address their unique needs.

Are there any limitations to using the DASS-21?
While the DASS-21 is a reliable and valid measure of emotional distress, it's important to consider its limitations:

Self-report bias: Like any self-report tool, the DASS relies on the client's accurate symptom reporting, which can be influenced by factors such as self-awareness and social desirability.
Cultural considerations: Developed in Australia, the DASS-21 has been validated in many countries, but cultural differences in expressing and reporting emotional distress may affect its interpretation in some contexts. Fortunately, the DASS-21 has been translated into nearly 60 languages which may be better at addressing cultural norms surrounding emotional expression than the English version.

Other Assessments Similar to Depression Anxiety Stress Scales (DASS) to Consider

When looking for tools to assess emotional distress, you might find several other options that complement or provide alternatives to the DASS. Consider these similar assessments:

Patient Health Questionnaire-9 (PHQ-9): This 9-item measure focuses specifically on depression symptoms and is widely used in clinical settings for screening and monitoring depression severity.
Generalized Anxiety Disorder-7 (GAD-7): A brief 7-item scale that assesses the presence and severity of generalized anxiety disorder symptoms, making it a useful tool for identifying and tracking anxiety concerns.
Perceived Stress Scale (PSS-10): A widely used 10-item measures the degree to which individuals perceive their life situations as stressful.

Each of these assessments offers unique benefits and focuses, allowing you to select based on your clients' specific needs and treatment goals. While the DASS provides a comprehensive assessment of depression, anxiety, and stress, these other measures may be more suitable when targeting specific symptoms or disorders.