Activity |
Score |
Depressed mood
Sad, hopeless, helpless, worthless
0 = Absent
1 = Gloomy attitude, pessimism, hopelessness
2 = Occasional weeping
3 = Frequent weeping
4 = Patient reports highlight these feelings states
in his/her spontaneous verbal and
non-verbal communication.
|
___ |
Feelings of guilt
0 = Absent
1 = Self-reproach, feels he/she has let people down
2 = Ideas of guilt or rumination over past errors
or sinful deeds
3 = Present illness is punishment
4 = Hears accusatory or denunciatory voices and/or
experiences threatening visual
hallucinations. Delusions of guilt.
|
___ |
Suicide
0 = Absent
1 = Feels life is not worth living
2 = Wishes he/she were dead, or any thoughts of possible
death to self
3 = Suicide, ideas or half-hearted attempt
4 = Attempts at suicide (any serious attempt rates
4)
|
___ |
Insomnia, early
0 = No difficulty falling asleep
1 = Complaints of occasional difficulty in falling
asleep i.e. more than half-hour
2 = Complaints of nightly difficulty falling asleep
|
___ |
Insomnia, middle
0 = No difficulty
1 = Patient complains of being restless and disturbed
during the night
2 = Walking during the night – any getting out of
bed rates 2 (except voiding bladder)
|
___ |
Insomnia, late
0 = No difficulty
1 = Waking in the early hours of the morning but goes
back to sleep
2 = Unable to fall asleep again if he/she gets out
of bed
|
___ |
Work and activities
0 = No difficulty
1 = Thoughts and feelings of incapacity related to
activities: work or hobbies
2 = Loss of interest in activity – hobbies or work
– either directly reported by patient or
indirectly seen in listlessness, in decisions and
vacillation (feels he/she has to push
self to work or activities)
3 = Decrease in actual time spent in activities or
decrease in productivity. In hospital,
rate 3 if patient does not spend at leas three hours
a day in activities
4 = Stopped working because of present illness. In
hospital rate 4 if patient engages
in no activities except supervised ward chores
|
___ |
Retardation
Slowness of thought and speech; impaired ability to
concentrate; decreased motor activity
0 = Normal speech and thought
1 = Slight retardation at interview
2 = Obvious retardation at interview
3 = Interview difficult
4 = Interview impossible
|
___ |
Agitation
0 = None
1 = Fidgetiness
2 = Playing with hands, hair, obvious restlessness
3 = Moving about; can’t sit still
4 = Hand wringing, nail biting, hair pulling, biting
of lips, patient is on the run
|
___ |
Anxiety, psychic
Demonstrated by:
- subjective tension and irritability, loss of concentration
- worrying about minor matters
- apprehension
- fears expressed without questioning
- feelings of panic
- feeling jumpy
0 = Absent
1 = Mild
2 = Moderate
3 = Severe
4 = Incapacitating
|
|
Anxiety, somatic
Physiological concomitants of anxiety such as:
- gastrointestinal: dry mouth, wind, indigestion,
diarrhea, cramps, belching
- cardiovascular: palpations, headaches
- respiratory: hyperventilation, sighing
- urinary frequency
- sweating
- giddiness, blurred vision
- tinnitus
0 = Absent
1 = Mild
2 = Moderate
3 = Severe
4 = Incapacitating
|
|
| Somatic symptoms: general
0 = None
1 = Heaviness in limbs, back or head; backaches, headaches,
muscle aches, loss of energy, fatigability
2 = Any clear-cut symptom rates 2
|
|
General Symptoms
Symptoms such as: loss of libido, menstrual disturbances
0 = Absent
1 = Mild
2 = Severe
|
|
Hypochondriasis
0 = Not present
1 = Self-absorption (bodily)
2 = Preoccupation with health
3 = Strong conviction of some bodily illness
4 = Hypochondrial delusions
|
|
Loss of Weight
Rate either ‘A’ or ‘B’:
A When rating by history:
0 = No weight loss
1 = Probable weight loss associated with present illness
2 = Definite (according to patient) weight loss
B Actual weight changes (weekly):
0 = Less than 1 lb (0.5 kg) weigh loss in one week
1 = 1-2 lb (0.5 kg-1.0 kg) weight loss in week
2 = Greater than 2 lb (1 kg) weight loss in week
3 = Not assessed
|
|
Insight
0 = Acknowledges being depressed and ill
1 = Acknowledges illness but attributes cause to bad
food, overwork, virus, need for rest, etc.
2 = Denies being ill at all
|
|
TOTAL SCORE: |
|
