Emotion Thermometers Tool ©

    A rapid modular screening tool for detection and monitoring of emotional disorders in clinical practice



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The Emotion Thermometers tool is a simple rapid modular screening tool for detection and monitoring of emotional disorders in clinical practice. 

It was created by Prof Alex J Mitchell with a visual-analogue design which is easy for most patients (including older people and children) to understand, quick  to administer and simple to score. 

It is currently royalty free for (departmental) clinical use and for unfunded research (but please request permission via this link). 

It has been validated in over 1000 patients in Leicester and over 30 published studies worldwide and more than 200 clinical centers.


New App! (https://etscale.glideapp.io/)

Our new app will take care of data entry, scoring and interpretation


What's New?

...................New translations available in Swedish, Persian, Malay, Turkish, Czechoslovakian, Greek, Romanian and Hungarian! (see below)

...................Mini printed booklets by mail now available! (email me ajm80@le.ac.uk)

Permission Requests: New Form for 2019/2020!

Simply fill this form for unfunded research and clinical use and you will automatically get permission to use it immediately!!



Simple Data entry Form!

Use this link for a local data collection form using google forms. We don't keep any of your data.



Scoring Now Simplified with Our App!


Scoring / Interpretation: When looking for a specific emotion complication:

Method A. Use our app: https://etscale.glideapp.io/

Method B. Use fixed cut-offs of 0-3 (low) and 4-10 (high) on ANY thermometer. A high score should be followed-up by further enquiry / assessment esp when "help" is requested.

Method D. Use specific individual cut-offs of 4-10 (high) on DT; 5-10 (high) on DepT; 6-10 (high) on AnxT; 4-10 (high) on Help T or calculate these locally (using an appropriate gold standard).




Visual-analogue scales have been successfully used for decades in pain services. In 1998 the American Distress Thermometer (DT) was developed and validated for evaluation of distress in cancer [Roth et al, 1998]. It was adopted into recommendations by the US National Comprehensive Cancer Network. If you require the DT permission request is here. The DT is a simple, self-report, pencil and paper measure consisting of a line or thermometer image with a 0-10 scale anchored at the zero point with ‘No Distress’ and at scale point ten with ‘Extreme Distress’. Patients are given the instruction “How distressed have you been during the past week on a scale of 0 to 10?” The recommended cut-off was 4v5, but in 2007 was revised to 3v4. In a comprehensive review of the accuracy of the DT, it was found to have a sensitivity of 80.9% and a specificity of 60.2%, (positive predictive value (PPV) of 32.8 and negative predictive value (NPV) of 92.9%) for depression, a sensitivity of 77.3% and specificity 56.6% (PPV of 55.2% and NPV of 80.25%) for anxiety it and a sensitivity of 77.1% and specificity 66.1% (PPV 55.6% and NPV 84.0%) for broadly defined distress [Mitchell, 2007 J Clin Oncol 2007; 25:4670-4681].


In 2007 we locally piloted and validated a new multidomain extension and adaptation of the DT called the Emotion Thermometers tool. This is a new dimensional tool retaining the convenience of the innovative DT but with superior accuracy. It comprises five visual analogue scales in the form of four predictor domains (distress, anxiety, depression, anger) and one non-emotion domain (need for help). Each domain is rated on an 11 point (0 to 10) Likert scale in a visual thermometer, namely the Distress Thermometer (DT), Depression Thermometer (DepT), Anxiety Thermometer (AnxT) and Anger Thermometer (AngT). In a pilot evaluation in the Leicester Cancer Centre (UK), we found that the tool takes about 55 seconds (compared to about 30 seconds for the DT) for most patients for complete and is no less acceptable than the DT alone.


ET Versions

The original 207 version (ET5) comprised four emotion domains: DepT AnXT  AngT  DT  and a help thermometer

The 2009 ET7 added duration of illness and burden to the core thermometers above

The 2010 palliative ET7 added pain in place or duration of illness (burden retained) to the core thermometers above

In 2012 we launched the DepT as a stand alone tool go here for the DepT


We currently have pilot versions adding domains of function (work, social, family), pain, and QoL

We also have pilot versions including descriptive text anchors for the thermometers of help and pain.

A version for older people was developed with "forgetfullness" 


ET Modular Versions

Choose your own set of thermometers, start with the core set DepT AnXT  AngT  DT 

........then choose any of

HelpT, BurdenT, DurationT, QoL-T, FunctionT, PainT


2012 version


2013 version (with more explicit help)

Download PDF Original Version   Download 2013 PDF Version

Download JPG Original Version

Download PDF Version in checklist format

Download Word Version (by request only)



Download PDF Version in Spanish (thanks Angelica DeSantiago!)

Download PDF Version in Portuguese (thanks Margarid Branco!)

Download PDF Version in Dutch (thanks Joke Fleer!)

Download PDF Version in German (thanks Cord Spilker!)

Download PDF Version in French (thanks Sylvie Lambert!)

Download PDF Version in Hindi (thanks Priya Kanna and Abhijit Dam!)

Download PDF Version in Italian (thanks Chiara Acquati!)

Download PDF Version in Polish (thanks Karolina  Kujawska-Debiec!)

Download PDF Version in Chinese (thanks Chen Chen!)

Download PDF Version in Greek (thanks Asimina Kiropoulou)

Download PDF Version in Romanian (thanks Csaba Dégi)

Download PDF Version in Hungarian (thanks Csaba Dégi)

Download PDF Version in Czechoslovakian (thanks Alena Javurkova)

Download PDF Version in Turkish (thanks Ozan Bahcivan)

Download PDF Version in Malay (thanks Nur Haidzat Abd Wahid)

Download PDF Version in Persian (thanks neda farahani )

Download PDF Version in Swedish (thanks Fia Hobbs; see Fia's new book here)


ET with a Comprehensive Problem list

There are many versions of a problem list but we prefer this open access "Concerns and Help Identifier for Medical Patients (CHIMP)" scale

CHIMP Problem list in cancer

CHIMP Problem list in cardiology

CHIMP Problem list in neurology

 (The CHIMP scale can be used freely and without restriction at the current time)


ET as part of an implementation screener

We trialed this form of the ET embedded into a short problem list and action plan in this form

ET screen and action

results were presented in the MD thesis of Mitchell (2012)


Scientific Papers (Try this link)











Validation:  systemic review 



A new systematic review of 17 studies using the ET in cancer has just been published in September 2019........


Objective Physiological and psychological sequelae are frequent after a cancer diagnosis and also on the long term. Screening could help detect psychological distress early and thus enable timely provision of adequate treatment. The emotion thermometer (ET) is a validated screening tool including five dimensions (distress, anxiety, depression, anger, and need-for-help). Reviewing the literature, we aimed to describe (a) the validity and (b) the application of the ET.

Methods Six databases were systematically searched for studies using the ET in individuals diagnosed with cancer. Included studies were critically appraised for methodological quality. ET validity and application were narratively synthesized.

Results We identified 580 records eligible for title-abstract screening. Seventeen studies based on 13 different populations were included. Validation studies (5 of 17) concluded that the ET is sensitive to distress detection, delivering prompt and accurate results with no negative impact on clinic visit time. Furthermore, its use is accepted in patients and clinicians. The remaining 12 exploratory studies applied the ET for screening purposes (3 of 12), as outcome measure (6 of 12), or as predictor variable measure (3 of 12). Most studies were conducted in Europe (11 of 17), and 7 of the 12 exploratory studies used the recommended cutoff (greater than or equal to 4). Study populations were mostly female (9 of 13) with a mean age greater than 50 years (12 of 13) at study.

ConclusionsPublications on distress screening with the ET are scarce, especially among young populations. However, research and studies' recommendations support the ET's utility as a valid and feasible tool for distress screening including anxiety and depression and suggest its implementation as part of a structured program for early screening in cancer care.



Examples of Validation Papers (Try this link)

Mitchell et al. Psycho-oncology 2010 Feb;19(2):125-33 and 2010 Feb;19(2):134-140 and http://onlinelibrary.wiley.com/doi/10.1111/ajco.12180/abstract)

In our study in the Leicester Cancer Centre, 11.5% of people scored three or below on all ET domains and 69.3% scored four or above on at least one domain. Of low scorers on the DT about 50% recorded emotional difficulties on the new Emotion Thermometers (ET) tool, suggesting added value beyond the Distress thermometer (DT) alone. Using a cut-off of 3v4 on all thermometers against the total HADS score (cut-off 14v15), the optimal thermometer was the AngT (sensitivity 89% specificity 46%). Against HADS Anxiety scale (cut-off 7v8), and judging by the Predictive Summary Index, the optimal thermometer was AnxT (sensitivity 92% specificity 61%). Against the HADS depression scale, the optimal thermometer was the depression thermometer (sensitivity 60% specificity 78%). Finally, against the DSM-IV diagnosis of major depression the optimal thermometer was the depression thermometer sensitivity 80% specificity 79%) but no single method had good positive predictive value (PPV). Further improvements can be made by adjusting the cut-offs particularly for detection of anxiety (AnxT ROC = 0.867 at a cut-off of 5v6) and detection of depression (DepT ROC = 0.751 at a cut-off 4v5).


Independent Validation: Beck KR, Tan SM, Lum SS, Lim LE, Krishna LK. Validation of the emotion thermometers and hospital anxiety and depression scales in Singapore: Screening cancer patients for distress, anxiety and depression. Asia Pac J Clin Oncol. 2014 Mar 27. doi: 10.1111/ajco.12180. 

Aim To validate the emotion thermometer (ET) and hospital anxiety and depression scales (HADS) in Singapore, screening cancer patients for distress, anxiety and depression. Methods Three hundred fifteen cancer patients from National Cancer Centre and Singapore General Hospital participated in the study. Interviews and assessments were conducted in English, assessing patients' sociodemographic data and screening for emotional symptoms using the ET, HADS and Mini-International Neuropsychiatric Interview (MINI) tools. 

Results Fifty-three patients (16.83%) fulfilled the MINI criteria for major depressive disorder and 30 patients (12.77%) for generalized anxiety disorder. The ET depression thermometer correlated positively with HADS depression subscale, r?=?0.645 (P?<?0.01), with area under curve (AUC) value being 0.76, when cutoff score is 3. The ET anxiety thermometer correlated positively with HADS anxiety subscale, r?=?0.632 (P?<?0.01), with an AUC value of 0.76, when cutoff score is 4. The ET distress thermometer correlated positively with HADS depression subscale, r?=?0.506 (P?<?0.01), with AUC value being 0.72, when cutoff score is 2, the ET distress thermometer also correlated positively with HADS anxiety subscale, r?=?0.652 (P?<?0.01), with the AUC value being 0.77, when cutoff score is 4. Using MINI diagnoses for anxiety and depression as the gold standard, cutoff score for HADS depression scale is 7, which yielded an AUC of 0.826. The cutoff score for HADS anxiety scale is 5, yielding an AUC of 0.779. 

Conclusion Results from the study support the use of both ET and HADS as valid and reliable instruments assessing for distress, anxiety and depression in cancer patients.


Screening for Psychological Distress in Surgical Breast Cancer Patients Jane R. Schubart PhD, MS, MBA, Matthew Emerich BS, Michelle Farnan RN, MSN, OCN, J. Stanley Smith MD, Gordon L. Kauffman MD, Rena B. Kass MD Breast Oncology Volume 21, Issue 10 / October , 2014

Background This pilot study assessed the levels of patient emotional distress and impact on clinic throughput time.

Methods From April through August 2012, 149 breast cancer patients at the Penn State Hershey Breast Center were screened with the emotions thermometer (ET), a patient-rated visual 0–10 scale that measures distress, anxiety, depression, anger, burden, and need for help. Also, patients indicated their most pressing cancer-related concerns. Clinic visit time was computed and compared with a control group.

Results Using a previously validated cut point ≥4 for any thermometer, we found emotional difficulty in the following proportions: distress 22 %, anxiety 28 %, depression 18 %, anger 14 %, burden 16 %, and need for help 10 %; 35 % scored above the cut point on at least 1 thermometer. We found higher levels of distress in all domains associated with younger age at diagnosis. More extensive surgery (bilateral mastectomy vs unilateral mastectomy vs. lumpectomy) was correlated with higher levels of psychosocial distress. Most often cited concerns, experienced by >20 %, included eating/weight, worry about cancer, sleep problems, fatigue, anxiety, and pain. Mean clinic visit time for evaluable patients screened using the ET (n = 109) was 43.9 min (SD 18.6), compared with 42.6 min (SD 16.2) for the control group (n = 50).

Conclusions Utilizing the ET, more than one-third of women screened met criteria for psychological distress. Younger age at diagnosis and more extensive surgery were risk factors. The ET is a simple validated screening tool that identifies patients in need of further psychological evaluation without impacting clinic throughput time.



Normative values for the distress thermometer (DT) and the emotion thermometers (ET), derived from a German general population sample

Quality of Life Research January 2019, Volume 28, Issue 1, pp 277–282 

Purpose The distress thermometer (DT) and the emotion thermometers (ET) are short screening instruments for use in oncological practice. The aim of this study was to provide normative values and to analyze the correlational structure of the ET.

Methods A representative sample of the adult German general population (N = 2437) completed the ET, the PHQ-4, the FACIT-fatigue scale, and the demoralization scale.

Results The percentages of people above the cutoff (≥ 4) and the mean scores of the five ET scales were as follows: distress: 39.0%, M = 3.15 ± 2.62, anxiety: 12.3%, M = 1.36 ± 1.93, depression: 16.1%, M = 1.65 ± 2.11, anger: 24.5%, M = 2.33 ± 2.16, and need for help: 10.7%, M = 1.18 ± 1.90. Women reported significantly higher levels of burden than men, with effect sizes between 0.07 (anger) and 0.36 (anxiety). All ET dimensions were interrelated (r between 0.44 and 0.69) and significantly correlated with the other scales (r between 0.36 and 0.68).

Conclusions The normative scores can help qualify assessments of groups of patients. The new four dimensions of the ET provide relevant additional information that is not already covered by the DT.


Validation Posters

We have published a series of posters on the ET at the IPOS and APOS conferences 2010-2014.

  IPOS2010 Poster 130 (defining ET thresholds)

  IPOS2010 Poster 131 (defining ET reliability)

  IPOS2010 Poster 131 (ET re-validation)

  APOS2011 Poster 153 (ET validation vs depression)

  IPOS2014 Poster 605 (ET large validation vs distress)

  IPOS2016 Poster 450 (ET validation vs anxiety disorder)

  IPOS2016 Talk 416 (ET correlation with unmet needs  



The tool is subject to copyright (c) Alex J Mitchell but freely available (royalty free) for non-commercial and clinical use.

If this (or related) tools are useful please consider donating to help with our research and always cite your sources.


Recent  Research on the ET

We welcome collaborations with other groups who are interested in using the ET for research. Here are some examples of groups that have sought permission to study the ET in various settings. Most of these studies are ongoing.





Rampling J et al St George's Hospital London

Efficient Screening for Depression in Epilepsy - Preliminary Comparison of Four Simple Methods


In-Fun Li, Supervisor of Nursing Department, Taiwan

Clinical application in Taiwan


Dalia Kamel,  Drogheda and Beaumont Hospital, Dublin

The effect of chemotherapy on the ovarian reserve of pre-menopausal women with breast cancer


Joana Gomes, Porto, Portugal

Emotional Intelligence, Quality of Life and its Correlates in Cancer Patients on Chemotherapy in Porto Healthcare Centre


Kathryn Taylor, St Georges Cancer Care Centre, NZ

Screening for psychosocial distress in patients attending the cancer care centre, St George’s hospital


Nancy J. Ames, Bethesda, Maryland 20892

The effect of music listening on the amount of opioids used in surgical intensive care patients


Penelope Schofield, Peter MacCallum Cancer Centre, AUZ

Use of the emotion thermometers tool for use in a remote monitoring system for haematological cancer patients receiving chemotherapy


Sara Moreira, Porto, Portugal

Distress in Oncologic Patients: Experience of Patients with Coetaneous Lymphoma


Sylvie Lambert, Newcastle, Australia

Clinical application of the ET on the website Care Search Palliative Care Knowledge Network


Lorraine Webster, The Beatson West of Scotland Cancer Centre, Glasgow

Clinical application of the ET in Scotland


Robbert Sanderman, University of Groningen, the Netherlands

Rapid Screening for Emotional Complications of Cardiovascular disease


Joshua Morgan, Loma Linda University Medical Center, Loma Linda, CA

Validation of Simple Visual-Analogue Thermometer Screen for Mood Complications of Cardiovascular Disease


Clare Carolan, Stirling University

The experience of distress and help-seeking for distress in palliative care families”.


Suzy  Hudson, The Royal National Orthopaedic Hospital Trust

Provision for Primary Malignant Bone Sarcoma Patients following Surgery” across 5 centres in England


Karen, Kayser PhD University of Louisville

Psychosocial Distress, Quality of Life and Rest/Activity in Head and Neck Cancer” at University of Louisville


Elaine Youngman, WakeMed Health and Hospital

Use of Healing Touch, a complementary energy therapy at WakeMed Health and Hospital


Dalia Kamel    Drogheda and Beaumont Hospital, Dublin

The effect of chemotherapy on the ovarian reserve of premenopausal women with breast cancer


Kent Hoskins, MD Department of Medicine, University of Illinois

How Do Underserved Minority Women Think About Breast Cancer Risk?


Sharon Fabbri, Loma Linda University Center                     

Evaluation and implementation in clinical practice


Hohee Nam, South Korea

Relationships of depression, anxiety and QoL in ACS (acute coronay syndrome) patients"


Nicole Champagne, Naval Medical Center San Diego           

Evaluation and implementation in clinical practice


Simon Parrett, Dorothy House Hospice Care

Dorothy House Hospice Care


Jessica Coyer, Psy.D. South Nassau Communities Hospital

Evaluation and implementation in clinical practice


Linda McLellan Cleveland Clinic   R32

Evaluation and implementation in clinical practice


Dr Tracey Bullen Australian Catholic University

Does full warm water immersion in spa bath positively impact on symptom scores/experience for people with pain/anxiety?


Josefa C. Alquisada, Research Institure Philippines

Factors Affecting the Coping Mechanism of Cancer Patient


Gregory D. Garber, Kimmel Cancer Center

 Evaluation and implementation in clinical practice


Tânia Brandão, University of Porto, Portugal

Clinical application of the ET


Ruth Fleming, Royal Brompton. London 

Clinical application of the ET


Robert Beecher, Temple University Hospital

Clinical application of the ET


Michael Green Penn State College of Medicine

Clinical application of the ET


Courtney Cook Baptist Hospital - Cancer Support Services

Clinical application of the ET


Maureen Evans Azusa Pacific University; Los Angeles.

grandparents providing support to their family


Karen Kayser, University of Louisville

Couples Coping with Impaired Sexual Function during and after Treatment for Rectal Cancer


Dégi L. Csaba Cluj Napoca

Babes Bolyai University  project


Prof. Emanuela Saita  Catholic University Milan

Clinical application of the ET












ET in Other Settings

The ET7 has been validated in a neurological setting (epilepsy) see this poster ...and paper in epilepsia

The ET5 has been validated in cardiovascular settings (link)



Roth AJ, Kornblith AB, Batel-Copel L, et al. Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 82:1904 –1908, 1998

NCCN Clinical Practice Guidelines in Oncology™ Distress  Management V.1.2007 http://www.nccn.org/professionals/physician_gls/PDF/distress.pdf (accessed 25 March 2007)

Mitchell AJ. Pooled results from 38 analyses of the accuracy of distress thermometer and other ultra-short methods of detecting cancer-related mood disorder. J Clin Oncol 2007; 25:4670-4681.

Rampling J, Mitchell AJ, Von Oertzen T, Docker J, Jackson J, Cock H, Agrawal N. Screening for depression in epilepsy clinics. A comparison of conventional and visual-analog methods. Epilepsia. 2012 Oct;53(10):1713-1721. doi: 10.1111/j.1528-1167.2012.03571.x. Epub 2012 Jul 5.



FAQ on the ET

Q. Has the ET been validated?

A. Yes in cancer in around 17 studies (incl small palliative subsample), neurology (epilepsy) and cardiovascular disease

Q. Can the ET be used clinically without permission?

A. No, permission is required but don't worry it is royalty free for clinical use at the current time using https://bit.ly/etpersmission

Q. Can the ET be used for funded/unfunded research without permission?

A. Unfunded just use https://bit.ly/etpersmission; if funded please write to me with the title and duration and the number of applications of the ET that is intended for your proposed project. It is likely I will grant permission.

Q. Is the ET available with addition thermometer domains?

A. Yes there is a modular ET (ET_mod) which optionally adds customised assessments of QoL, function, pain.

Q. Is the ET sensitive to change?

A. Usually VAS are very sensitive to change, but this requires formal study

Q. What is the best cut off on the ET?

A. Please refer to the validation papers, generally we have used >3 on each scale but be aware fixed cut-offs are somewhat arbitrary, and may require study in your setting

Q. How long does the ET take to administer

A. Usually about 1 to 2 minutes

Q. Has the ET been translated into.....my language?

A. So far 17 languages eg Spanish, Portuguese, Polish, Dutch, German, French Italian and Hindi if you need another, please consider doing this and sending us your version

Q. Can the ET be read out by a caregiver or clinician for those with visual (or other) impairment?

A. Yes but this really requires separate validation

Q. Can the ET be applied by clinician

A. Yes but the patient must indicate their own score

Q. What should happen when someone scores above threshold?

A. We recommend a further assessment is made along with clarification of unmet needs, and treatment as appropriate, but this is a local decision

Q. How does the ET compare to  the HADS?

A. Please see above poster on ET vs HADS in n=801 cancer subjects.

Q. How easy is it to adopt the ET into a screening programme delivered by cancer clinicians?

A. Please feel free to use our screening programme form and see our new paper on here

Q. Can the ET be computerized to automated screening?

A. Certainly, but no one has done this yet

Q. Can the ET be separated in individual thermometers?

A. The original scale was 4 emotion domains and help, ideally the 4 emotion domains should be kept, but yes each one can be applied individually if essential.

Q. how does the ET differ from the NCCN's distress thermometer?

A. The ET is multi-domain, the ET is colour coded, the ET has half marks, the ET includes help, the ET is modular. The problem list on the DT is unique to the DT. An optional "problem list" is available on the ET embedded version.

Q. can the ET be applied with unmet needs, depression interview, anxiety interview etc?

A. Yes the ET can be used as part of other tools.

Q. how many ET have been applied to patients in Leicester?

A. To date about 1000

Q. Can we distribute the ET locally?

A. Only within the centre covered by your permission letter.

Q. Can we distribute the ET on our internet?

A. No! but you can on your intranet (firewalled etc) during your permission period.

Q. What is the best comparison tool to validate the ET?

A. Ideally a clinical interview, but many have used the PHQ, HADS. Anger has been tested against "hostility" rating scales.

Q. Can the ET be combined into a new scale with other questionnaires

A. Generally no, but discuss this with us.

Q. What is research use and what is clinical use?

A. Research use, is applied by a researcher in a research project (even if in a clinical centre); clinical use is use by a clinical member of staff who is not conducting research but doing their normal job. Clinical screening requires no permission; research screening usually is for a defined period / in a defined project and requires permission and/or funding license from us.



nccn distress thermometer in spanish national comprehensive cancer network distress thermometer national comprehensive cancer network distress thermometercut-off