Chapter Rating Scales for Depression Cristina Cusin Huaiyu Yang Albert Yeung and Maurizio - PDF document

Chapter2 RatingScalesforDepression CristinaCusin,HuaiyuYang,AlbertYeung, andMaurizioFava Abstract Overthepastfewdecades,anumberofclinician-ratedandpatient-rated toselectprimaryefÞcacymeasuresthatarereliable,valid,andthatÞtwellwithin theaimsofdepressionclinicaltrials.Thisarticlewillreviewthemainconsidera- tionsthatinvestigatorsneedtomakewhenchoosingaprimaryefÞcacymeasurefor themethodologicalissuesconcerningtheuseofthesescales,assuggestedalsoby DemyttenaereandDeFruytinarecentreview[1],becauseclinicaltrialsresearchers indepressioncontinuetostrugglewiththeabilitytodetectsignalsoftheefÞcacyof antidepressantagents. Keywords B ) DepartmentofPsychiatry,MassachusettsGeneralHospitalandHarvardMedicalSchool,Wang AmbulatoryCareCenter812,15ParkmanStreet,Boston,MA02114,USA e-mail:ccusin@partners.org 7 8 C.Cusinetal. HamiltonRatingScaleforDepression(HAM-DorHRSD) Thisisoneoftheearliestscalestobedevelopedfordepression,andisaclinician- ratedscaleaimedatassessingdepressionseverityamongpatients.Theoriginal HAM-Dincluded21items,butHamiltonpointedoutthatthelastfouritems(diur- nalvariation,depersonalization/derealization,paranoidsymptoms,andobsessive- compulsivesymptoms)shouldnotbecountedtowardthetotalscorebecausethese symptomsareeitheruncommonordonotreßectdepressionseverity[2]. Therefore,the17-itemversionoftheHAM-D(reproducedintheappendixto thischapter)hasbecomethestandardforclinicaltrialsand,overtheyears,themost widelyusedscaleforcontrolledclinicaltrialsindepression(wefoundinarecent Medlinesearchthatmorethan500studieshaveusedtheHAM-DasprimaryefÞ- cacymeasure).Itswidespreaduse,however,hasnotpreventedinvestigatorsfrom recognizingthelimitationsofthisinstrumentandfromtryingtoimproveit.The mainlimitationsoftheoriginal17-itemversionoftheHAM-Dwererecognized tobe(1)thefailuretoincludeallsymptomdomainsofmajordepressivedisorder (MDD),inparticular,reverseneur ovegetativesymptoms,(2)thepresenceofitems measuringdifferentconstructs(e.g.,irritabilityandanxiety,lossofinterestand hopelessness),and(3)theunevenweightattributedtodifferentsymptomdomains (e.g.,insomniamayberatedupto6points,whilefatigueonlyupto2). ApplicationofScale MethodofAdministration Thescaleiswidelyusedinclinicaltrialsandinclinicalpractice,andingeneral isadministeredweekly.Toimproveinter-raterreliability,astructuredinterview guidefortheHAM-Dwasdevelopedin1988byJanetWilliams(SIGH-D)[3, 4]andherguidesoonbecamethegoldstandardfortrainingandforclini- calstudies(seeforexample:http://www.ids-qids.org/translations/english/SIGHD- IDSCEnglish-USA.pdf.).Werecommendusingtheinterviewguidetoimprove inter-raterreliability. TimingofAdministration Consideringthebusyscheduleofbothpatientsandhealthprofessionals,thetime neededtoadministerascalecouldrepresentasigniÞcantburden.Ourresearchhas foundthattheaveragedurationoftheHAM-Dinterviewswas12minutes.However, ourestimationsofthelengthofthoseinterviewsareunderestimatesandfeaturesof depressionsuchaspsychomotorretardationmaysigniÞcantlyincreasetheirdura- tion.Itisnoteworthythatinoursimulation,usingastructuredinterviewdidnot seemtoconsiderablyincreasethedurationoftheadministrationofthescale. Becauseofitswidespreaduseoverthecourseofdecades,theHAM-Disthe mostpopulardepressionseveritymeasureinthehistoryofMDDtrials,andisvery familiartomostclinicalresearchersintheareaofdepression. 2RatingScalesforDepression9 ReliabilityandInternalConsistency TheHAM-Disamultidimensionalscale,andthisimpliesthatthescoreofaspe- ciÞcitemcannotbeconsideredagoodpredictorofthetotalscore[5].Italsomeans thatidenticaltotalscoresfromtwodifferentpatientsmayhavedifferentclinical meanings(i.e.,averyhighratingonfewitemscanyieldthesamescoreasa moderateratingonmanyitems)[6].Anumberofstudieshaveshowntheinter- nalconsistencyofdifferentversionsofHAM-Dtorangewidelyfrom0.48to0.92. HighercoefÞcientalphavalueswerereachedwiththeuseofastructuredinterview (see[7]formoredetails).ArecentstudyreportedinternalconsistencycoefÞcients of0.83forHAM-D-17and0.88forHAM-D-24[8].Acompletereviewofthe psychometricpropertiesoftheHAM-Dhasbeenpublishedrecently.Inthispaper, theauthorsreviewed70studiesonpsychometricpropertiesoftheHAM-D,pub- lishedsince1979,andshowedthatthemajorityofHAM-Ditemshaveadequate reliability[9]. Inter-raterReliability Inter-raterreliabilityhasbeenreportedtobeveryhighforHAM-Dtotalscores (0.80Ð0.98),evenifitispoorforsomeofitsitems.Allitemsshowedadequate reliabilitywhenthescalewasadministeredwithinterviewguidelines[10].AsufÞ- cientlyhighinter-raterreliability�(0.60)wasreportedformostoftheHAM-Ditems andthetotalscore(0.57Ð0.73)inastudyoninter-raterreliabilityin21psychiatric noviceswhohadnegligiblepreviousexperiencewiththeHAM-D[11].Thisscore appearstobeimprovedgreatlywiththeuseofappropriatetrainingandstructured interview[12]. TestÐRetestReliability TestÐretestreliabilityfortheHAM-DusingtheStructuredInterviewGuidehasbeen reportedtobeashighas0.81,evenamongminimallytrainedratersfrommultiple disciplines[4,13,14] . Validity ValidityoftheHAM-Dhasbeenreportedtorangefrom0.65to0.90withglobal measuresofdepressionseverity,andtobehighlycorrelatedwithclinician-rated measuressuchasMADRSandIDS-C[7]. ScoringKey Thetotalscoreisobtainedbysummingthescoreofeachitem,0Ð4(symptomis absent,mild,moderate,orsevere)or0Ð2(absent,slightortrivial,clearlypresent). Forthe17-itemversion,scorescanrangefrom0to54. 10 C.Cusinetal. Cut-OffScores Itisacceptedbymostcliniciansthatscoresbetween0and6donotindicatethe presenceofdepression,scoresbetween7and17indicatemilddepression,scores between18and24indicatemoderatedepression,andscoresover24indicatesevere depression.AtotalHAM-Dscoreof7orlessaftertreatmentisformostratersa typicalindicatorofremission[15].Adecreaseof50%ormorefrombaselineduring thecourseofthetreatmentisconsideredindicatorofclinicalresponse,orinother words,aclinicallysigniÞcantchange. BeckDepressionInventory(BDI) Thegoldstandardofself-ratingscalesistheBeckDepressionInventory (BDI)[16],whichwasinitiallydevelopedtoassesstheefÞcacyofpsycho- analyticallyorientedpsychotherapyindepressedsubjects.TheBDIiscopy- rightedbyHarcourtAssessment,Inc.,andsoisnotreproducedinthischap- ter.Informationaboutpurchaseofthisscaleandmanualareavailablefrom theirwebsiteat:http://harcourtassessment.com/haiweb/cultures/en-us/productdetail. htm?pid = 015-8018-370. Thisscalewasdesignedtomeasuretheseverityofdepressivesymptomsthatthe testtakerisexperiencingÒatthatmoment.ÓTheoriginalBDIincluded21items concerningdifferentsymptomdomains,withfourpossibleanswersdescribing symptomsofincreasingseverityassociatedwithascorefrom0to3.Itwas lateramendedtoBDI-IA[17],andafterthepublicationoftheDSM-IV,tothe BDI-secondedition(BDI-II)[18].Fournewitems(agitation,worthlessness,con- centrationdifÞculty,andlossofenergy)wereaddedtomaketheBDI-IImore reßectiveofDSM-IVcriteriaofMDD,andsomeBDI-IAitems(i.e.,weightloss, bodyimagechange,workdifÞculty,andsomaticpreoccupation)wereeliminated becausetheywereconsideredlessindicativeoftheoverallseverityofdepression. BeckandcolleaguesalsorewrotealmostallotherBDI-IIitemsforclarity,andthe timeframeforratingswasextendedfrom1to2weeks[19,20]. Self-ratingscales,suchastheBDI,offersomeadvantagesoverclinician-rated scales,astheymaytakelesstime,donotrequiretrainedpersonnel,andtheiradmin- istrationandscoringprocessappearmorestandardized[21].Self-ratingscalesalso requirethatindividualsareabletoreadataminimalreadinglevel,andthatthey speakthelanguageusedinatleastonetranslationofthescale. ReliabilityandValidity Reliability InternalConsistency Beckandcolleaguesin1988publishedameta-analysisofallthepsychometricstud- iesontheBDIfrom1961toJune1986andfoundameancoefÞcientalphaof0.86 forpsychiatricsubjects[22].In1996,afterthepublicationoftheBDI-II,Beckand 2RatingScalesforDepression11 coworkerscomparedtheBDI-IIandBDI-IAscalesinasampleof140psychiatric outpatientswithvariouspsychiatricdisordersandfoundcoefÞcientalphaforthe BDI-IIandtheBDI-IAof0.91and0.89,respectively[19].TheBDIandtheBDI-II werealsotestedonalargersample( n = 500),wheretheBDI-IIshowedimproved clinicalsensitivity,withreliability(alpha = 0.92)higherthantheBDI(alpha = 0.86) (PsychologicalCorporationWebsite,2003). Test–RetestReliability Withself-administeredmeasures,assessingtestÐretestreliabilitymaybecompli- catedbythefactthatthecorrelationcoefÞcientmayincreasespuriouslybecause ofpracticeorbecauseofmemoryeffects.However,inaSpanishstudy,testÐretest reliabilityfortheBDIwasbetween0.65and0.72[23]. Validity TheconvergentvaliditywiththeBDIhasbeenreportedtobeextremelyvariable, rangingbetween0.27and0.89[24].Beckandcolleaguesshowedthatinpsychiatric patients,themeancorrelationsoftheBDIwere0.72withclinicalratingsand0.73 withtheHAM-D[22]and0.57Ð0.83withtheZungSDS[25]. InventoryofDepressiveSymptomatology Inthe1980s,JohnRushandcolleagues[35]developedandpublishedtheclinician- ratedInventoryofDepressiveSymptomatology(IDS)(reproducedintheappendix tothischapter),whichwasintendedtoÒremedythedeÞcitsoftheHAM-Dandthe MADRSÓbyincludingallthesymptomdomainsoftheDSM-basedMDD,aswell asbothmelancholicandatypical(e.g.,reversedneur ovegetative)features,byscaling eachitemtoallowforthemeasurementofmilderformsofMDD,providingclearer itemsdeÞnition(forexample,irritabilityandanxietywereratedseparately)and equivalentweightforeachsymptomdomain.TheoriginalIDShad28items[35], whileanadditionaltwoitems(leadenparalysis;interpersonalrejectionsensitivity) wereaddedlatertobettercaptureatypicalMDDfeatures[36].Subsequently,Rush andcolleaguesselected16itemsfromtheIDS-30,assessingtheDSM-IVdiagnos- ticcriteriaforMDD,andassembledthemintheshortversionoftheIDS,namely theQuickInventoryofDepressiveSymptomatology(QIDS)[8].Dr.RushandCol- leaguescreatedaself-ratedversionofthe28-itemIDS-Cinthe1980s,calledthe IDS-SR-28[35,37],thenaddedthetwoitemsofatypicalMDDfeaturestoobtain the30-itemversion[36],andshortenedittothe16itemsoftheDSM-IVdiagnostic criteriafortheQIDS-SR[8](reproducedintheappendixtothischapter). ScoringKey Foralltheversions,addthescoresoftheitemstoobtainthetotalscore,exceptfor items11Ð12(increasedordecreasedappetite)and13Ð14(increasedordecreased 12 C.Cusinetal. weight)forwhichthehighestofthetwohastobeincluded.Adescriptionofcut- offsformoderateandseveredepressionforthedifferentversionsisavailableatthe websitehttp://www.ids-qids.org/index2.html#table2. Reliability InternalConsistency InternalconsistencyoftheIDSishigh.Inastudypublishedin1999on68 patientsassessedatadmission,after5,10,and28daysofantidepressanttreat- ment,theCronbachÕsalphacoefÞcientsreportedwere0.75fortheIDS-Cand 0.79fortheIDS-SR[38].Alphavalueswerereportedtovaryfrom0.67to 0.82forsubjectswithcurrentdepressioninaverylargesample[36].Inanother studyon544outpatientswithMDDand402outpatientswithbipolardisorder, theCronbachÕsalpharangedfrom0.81to0.94forallfourscales(QIDS-C16, QIDS-SR16,IDS-C30,andIDS-SR30)[39].CronbachÕsalpharangedfrom0.81 to0.90fortheQIDS-Candwasreportedtobe0.86fortheQIDS-SR(http://www. ids-qids.org/IDS_Website_Document.pdf). Inter-raterReliability Inter-raterreliabilityfortheIDS-Cwasreportedtobeveryhigh(0.96). (http://www.ids-qids.org/IDS_Website_Document.pdf). Validity IDS-SRcorrelationwiththeHAM-D-24andBDIhavebeeninvestigatedina sampleof289patientswithmixeddiagnosesandreportedtoberespectively 0.67and0.78,whiletheIDS-CwashighlycorrelatedwiththeHAM-D( r = 0.92)andlesswiththeBDI( r = 0.61)inasampleof82outpatients[35].In anotherverylargesample( n = 596)ofpatientstreatedforchronicnon-psychotic MDD,theQIDS-SRtotalscoreswerehighlycorrelatedwithIDS-SR-30(0.96) andwiththeHAM-D-24(0.86)totalscores[8].TheQIDS-CandQIDS-SRscores havebeenreportedtobecorrelated(0.72ormore)withthoseoftheHAM-D-17 (http://www.ids-qids.org/IDS_Website_Document.pdf)andHAM-D-24[40]. OtherScalesAvailableforRatingDepression Montgomery–AsbergDepressionRatingScale Theclinician-ratedMontgomeryandAsbergDepressionRatingScale(MADRS) [reproducedintheAppendixtothischapter]wasdevelopedinthelate1970s[26] andthis10-itemscalewasdesignedtobesensitivetotheeffectsofantidepressant medications,primarilytricyclicantidepressants(TCAs)[26].Becausethisscalewas 2RatingScalesforDepression13 neverupdatedormodiÞed,itdoesnottargetreverseneur ovegetativesymptoms.It iscommonlyusedinclinicalstudiesandinclinicalpractice,administeredweekly. StructuredinterviewguidesfortheMADRShavebeendevelopedbyanumberof investigators[13,27Ð29] . Reliability InternalConsistency TheMADRSappearstobeaunidimensionalscale,morefocusedtowardpsycho- logical,asopposedtosomaticaspectsofdepression[30].Theinternalconsistency oftheMADRSisconsideredveryhigh,giventhehighcorrelationbetweenall items( r = 0.95)[31].Inarecentpsychometricre-analysisofprimaryefÞcacymea- suresderivedfromatrialoncitalopramefÞcacyinmaintenancetherapyofelderly depressedpatients,theinternalconsistencyoftheMADRS,wasfoundtobesuperior tothatoftheHAM-D-17[6]. Inter-raterReliability OneoftheoriginalgoalsoftheMADRSwastoobtainaninstrumentthatcould beusedbybothpsychiatristsandprofessionalswithoutaspeciÞcorwithmini- malpsychiatrictraining.FromtheoriginalreportoftheMADRS,theinter-rater reliabilityrangedfrom0.89to0.97[26].However,inaGermanstudy,signiÞcant differencesresultedwhenthesamepatientwasratedbyvariousgroupsofcaregivers (psychiatrists,psychologists,students,andpsychiatricnurses)[32]. Validity CorrelationofMADRShasbeenshowntobegenerallyhighorveryhigh withtheHAM-D(between0.80and0.90)[7,33],RDC(0.70)[34],andwith IDS-C(0.81)[34]. Cut-OffScores Ascoregreaterthan30or35ontheMADRSindicatesseveredepression,whilea scoreof10orbelowindicatesremission. ZungSelf-ReportDepressionScale TheZungSelf-ReportDepressionScale(ZungSDS)[41](reproducedinthe appendixtothischapter)waspublishedafewyearslaterthantheBDI.Itisa20-item self-reportindexthatcovers,invaryingdegree,abroaderspectrumofsymptoms thantheBDI,includingpsychological,affective,cognitive,behavioral,andsomatic aspectsofdepression. 14 C.Cusinetal. ScoringKey Respondentsareinstructedtorateeachitemonascalerangingfrom0to4interms ofÒhowfrequentlyÓtheyhaveexperiencedeachsymptom,insteadofÒhowsevere.Ó ThetimeframewasoriginallyÒatthepresent,Óbutinsubsequentversionthetime framewasextendedtooneweek,thereforerecommendingweeklyadministration. Atotalscoreisderivedbysummingtheindividualitemscores(1Ð4),andranges from20to80.Theitemsarescoredasfollows:1 = alittleofthetime,through4 = mostofthetime, except foritems2,5,6,11,12,14,16,17,18,and20whichare scoredinversely(4 = alittleofthetime). Cut-OffScores Mostpeoplewithdepressionscorebetween50and69,whileascoreof70andabove indicatesseveredepression.Norevisionofthescalewasmadeaftertheoriginal publicationandisnowadayslessusedinclinicalpractice. Validity ThecorrelationbetweenZungSDSandHAM-Dwasreportedtorangebetween 0.68and0.76,beinglowerwithHAM-Datbaseline[21].Thebestresults wereobservedatmildormoderateseveritylevels,whilethegreatestdisagree- mentbetweenZungandHAM-Dwasobservedforpatientswithnon-endogenous symptompatterns[42]. OtherIssuesinAssessingDepression AbilityofDepressionRatingScalestoDetectClinicalChanges withTreatment Theabilityofpsychometricinstrumentstodetectchangesrelatedtotreatmentisa conceptthathasbeenextensivelydiscussedbyRobertKellner[43].Inhisreviewof theliterature,heindicatedtheimportanceforameasureofcapturingchangesover time,particularlyinthosesymptomscharacterizingMDD[43].AsKellnerstated, ascalemaybevalidbuthavelowsensitivitytodetectchangeinthestateofthe patient.Forexample,ascalemaycontainitemsrelativelyinsensitivetochangeand thereforemaybehighlystableandunderestimatetheeffectsofatreatment.TheBDI measuresattitudesandcognitionswhicharefairlystableovertimeamongdepressed patients,andthereforemayunderestimatethedegreeofimprovementduringacute pharmacologicaltreatments.Inaddition,ascalemighthaveitemsaccuratelymea- suringmilddepression,butmaybelesssensitivetomoderateorseveredepression, leadingtoapoorsensitivitytodetectimprovementsinpatientswithmoresevere depressionatbaseline.Thescalesactuallyusedinclinicaltrialstypicallyarecon- sideredtohavearelativelygoodsensitivitytochange,withtheexceptionofthe Zungscale,whichisconsideredmoresensitivetodifferencesacrosssubgroupsof patients,thantochangeovertime[44]. 2RatingScalesforDepression15 MinimizingBiasesintheAssessmentofDepressionSymptom Domains Apossiblebiasinmeasurementofdepressivesymptomsmayberelatedtothevari- ableemphasisonsomaticversuspsychologicalsymptoms.Forexample,since3of the17itemsoftheHAM-Dconcernsleepdisturbances(insomnia)andcontribute upto11.5%ofthetotalscore,ithasbeenhypothesizedthattheHAM-Dmayfavor sedatingantidepressantdrugs(i.e.,someTCAsortrazodone),whichmayimprove sleep,regardlessofÒtrueÓantidepressanteffects.Similarly,drugsassociatedwith sideeffectssuchassleepdisturbances,gastrointestinal(GI)symptoms,agitation, andnervousness,suchastheSSRIsandtheSNRIs,couldbeassociatedwithanarti- ÞciallyelevatedHAM-Dscoreatendpoint,therebyunderestimatingimprovement. Whenconsideringsomaticsymptoms,theconventionisoftenthatsuchsymp- tomsshouldberatedatfacevalue,withouttryingtodistinguishsideeffectsfrom symptoms.Thisapproachmayaffectallmeasuresofdepressionseverity,assleep andappetitedisturbancesmaybesideeffectsand/orsymptomsofMDD.However, inthecaseoftheHAM-D,psychological,andsomaticsymptoms/sideeffectssuch asanxiety/agitation,sexualdysfunction,drymouth,anddiarrheamaybeaffecting thescoretoagreaterdegreethanotherscales[45].TheBDI,MADRS,HAM-D-6, IDS,andQIDSareconsideredtoberelativelyinsensitivetothiswell-knownbiasof theHAM-D[46]. AbilityofDepressionRatingScalestoMeasureSymptomsAcross DepressiveSubtypes Sincemajordepressivedisorderisnotahomogeneousclinicalentity,avalidscale mustmeasuresymptomsacrossallsubtypes,allowingclinicianstocomparetreat- mentefÞcacyinvariousdepressivepopulations.Infact,inaccurateassessments acrosssubtypeshavebeenhypothesizedtobeoneoftheculpritsforthehighfailure rateofmanyMDDclinicaltrials[46,47].Duetothedifferencesinhistoricalback- groundandrationalebehindeachratingscale,theHAM-D,theMADRS,andthe IDS/QIDShavedifferentlevelsofabilitytoreßecttheheterogeneityofMDDandto capturesymptomscharacteristicofdepressivesubtypes.TheHAM-D-28,theIDS, andtheBDI-IIcoversymptomsofbothatypicalandmelancholicdepression,while atypicalsymptomsarefarlessrelevantintheBDIandtheZungscale,wherethey representonly5%ofthetotalscore,andintheMADRSwherethesesymptomsare notincludedatall. Self-VersusClinician-AdministeredDepressionRatingScales Thedilemmabetweenself-administeredandclinician-ratedscaleshasledtoanum- berofstudiesinvestigatingdifferencesandsimilaritiesbetweenthosetwoways ofassessingdepressivesymptoms.Althoughconcordanceratesbetweenselfrat- ingsandobserverratingsaregenerallyacceptable,signiÞcantlydiscordantratings 16 C.Cusinetal. havebeenobtainedinmanystudiesshowingthatcliniciansandpatientsratethe depressivesymptomsdifferently[48Ð50].Cliniciansarethoughttomeasuredepres- siveseveritymoreaccurately[37,51].Infact,inastudyofthetwoversionsof IDS(IDS-CandIDS-SR),wherethesetwoscaleswereadministeredto64inpa- tientswithMDDonday1,10,andday28afterantidepressanttreatment,the self-ratedversionofIDSshowedalessersensitivitytochangeovertimecom- paredtotheclinician-ratedversion[38].Ontheotherhand,self-ratedscalesmay bemoresensitivetodetectchangesthanclinician-ratedscalesinmilderforms ofdepression.Infact,astudycomparedthescoresfromthreedifferentscales, HAM-D,IDS-C,andIDS-SR,acrossseveritysubgroupsinpatientswithdys- thymicdepression,non-endogenousMDD,andendogenousMDD.Moresymptoms wereself-reportedbythedysthymicpatientsandthenon-endogenouspatients thanrecordedbytheclinician,butfortheendogenouslydepressedpatientsself- reportedandclinician-ratedsymptomswerecomparable[37].Similarly,astudy publishedin2000showedthatthediscrepanciesbetweenBDIandHAM-D-21 scoreswereincreasedinpatientswithyoungerage,highereducationallevel,atyp- icaldepressivesubtype,andneuroticpersonalityfeatures,allthosefactorsbeing associatedwithhigherBDIscores[52].Sayeretal.[53]investigatedthecorre- lationbetweentheHAM-D-24andtheBDIin114severelydepressedinpatients, treatedwithelectroconvulsivetherapy.Theirstudyshowedarelativelypoorcorre- lationbetweentheinstrumentsatbaseline,duetoaspeciÞcsubgroupofdepressive patientswhowereevaluatedbytheobserverasseverelydepressed,butratedthem- selvesaslesssymptomatic.Someclinicalfeaturesofthesubgroupwereadvanced age,lesseducation,presenceofpsychosis,lackofinsight,andseverehypochon- driasis.ThissamesubgroupshowedthegreatestimprovementinHAM-Dscore andcontributedlargelytothediscrepancyineffectsizebetweenHDRSandBDI ratings. Whentheeffectsizes(calculatedasthedifferencebetweentheproportionsof responderstakingdrugandthosetakingplacebo)derivedfrompatientself-ratings andfromclinicianratingswerecomparedbyPetkovaandcolleagues,theresult wasthattheself-ratingscaleswereassociatedwithsmallereffectsizes,therefore supportingthehypothesisthattheyarelesslikelytodifferentiateactivedrugfrom placebo[54].However,theself-ratingscalesinthePetkovastudydidnotinclude scales,suchastheIDS-SRorQIDS-SR,whicharereportedtoshowmorerobust performanceinclinicaltrialscomparedtotheolderself-ratingscales. Inclinicalpractice,differentclinicianschoosewhatscaletoadministeraccord- ingtotheirlevelofcomfortwithascaleandtothetimeavailable.Somechoose topresentself-ratingscales(mostoftenusedaretheBDI,IDS-SRorQIDS-SR) topatientsinthewaitingroomandhavethemÞlloutthequestionnaires.Other clinicianspreferaskingpatientsdirectlyaboutsymptomsandadministerthescale themselvesduringthevisit(HAM-D,MADRSorIDS-C),inparticularwithcom- plicatedpatientsorpatientswithcomorbiditiesforwhichanswersaboutphysical symptomsmayneedclariÞcation.Theclinicianshouldbeawareofstrengthsand limitationsofatleastfewofthemostcommonlyusedscales,andshouldbeableto choosethemostappropriateinstrumentforthepatient. 2RatingScalesforDepression17 AssessingDepressionAcrossAgeGroups Depressionisverycommonamongelderlypatients,whosedepressivepsy- chopathologyhasbeenshowntobedifferentinsomeaspectsfromyounger individuals,i.e.,increasedprevalenceofsleepdisturbancesandhypochondriasis [55].Elderlydepressedaremorelikelytobeaffectedbymedicalconditionsthat complicatetheirevaluationandtheirtreatment.Forexample,thepresenceof somaticsymptomsduetoconcomitantmedicalillnessesmaybemisattributedto thedepressionorviceversa[56].Lindenetal.[57]reportedthatindepressed patientswhowere70yearsorolderandalsosufferedfromamedicalillness,eight itemsoftheHAM-Dmaybeelevatedbytheconcurrentsomaticdisorder(somatic anxiety,GIsymptoms,generalsomaticsymptoms,hypochondriasis,weightloss, middleinsomnia,andwork).Inothercases,olderpatientswithclinicallysigniÞcant depressionmayunderreporttheirsymptoms[58] . Inaddition,thepresenceofcog- nitivesymptomsmayimpairtheevaluationofdepression,astheymightberelated tonaturalcognitivefunctioningdecline,totheonsetofdementingdisorders,orto depressionitself.Nebesetal.[59]measuredtheworkingmemory,information- processingspeed,episodicmemory,andattentionovera12-weekrandomized, double-blindtrialwithnortriptylineandparoxetine.Comparedtotheelderlycon- trols,cognitivedysfunctionpersistedinolderdepressedpatients,evenaftertheir depressionhadrespondedtoantidepressantmedications.Cognitivesymptomsmay affectpatientsÕabilitytounderstandand/orrespondappropriatelytoquestionsabout theirdepressivesymptoms.Finally,itemsassessingthoughtsofdeath,pessimism, andreducedinterestoractivitymayhaveadifferentmeaninginageriatricpop- ulationcomparedtoyoungeradults.ScaleshavebeendevelopedwiththespeciÞc purposeofscreeningforMDDinthegeriatricpopulation,ofwhichthegoldstan- dardistheGeriatricDepressionScale(GDS),aself-reportscalewithdifferent versionscontaining30,15,and4items[60,61].OtherscalesaretheBriefAssess- mentScheduleDepressionCards(BASDEC),theCornellScaleforDepression inDementiaandtheGeriatricMentalStateSchedule(GMSS)(forareviewsee [62]).Despitethedifferencesinsymptomsbetweengeriatricandadultpatientswith MDD,theprimaryoutcomemeasuresusedfortheantidepressanttrialsintheelderly (age  65years)arestillthescalesdevelopedintheadultpopulationsuchasthe HAM-D,theBDIandtheMADRS[63Ð66].However,furtherstudiesarenecessary tocomparetheperformanceofdifferentscalesinthisspeciÞcpopulation. Similarly,depressivesymptomsmaybedifferentinchildrenandadolescents fromthoseofadults,challengingtheuseinchildrenofscalesaimedtoassess depressionamongadults.Inaddition,scalesusedforadultsoftenuseanchorpoints thatarebestsuitedtocapturesymptomsinadultpopulations,andmaybelessuseful forchildrenandadolescents.Furthermore,asPoznanskipointedout,themeasureof thenon-verbalbehaviorforchildrenandadolescentswasmoststronglyassociated withthediagnosisofdepressionandwasalsothebestpredictoroftheseverityof depression[67].Manyauthorshavetriedtodevelopinstrumentstomeasuredepres- sioninchildrenandadolescents.TheChildrenÕsDepressionRatingScale(CDRS) anditsrevisedversion(CDRS-R)areclinician-ratedinstrumentstomeasureseverity 18 C.Cusinetal. ofdepressioninchildren[67,68].TheCDRShasbeenvalidatedforuseinchildren andadolescents[68]andhasbeenusedasaprimaryoutcomemeasureinclinical trials[70,71]. Self-ratedscalesarealsocommonlyusedinchildrenandadolescents,suchasthe KutcherAdolescentDepressionScale(KADS),theChildrenÕsDepressionInventory (CDI)[72],theChildDepressionScale[73Ð75],andtheBeckYouthInventoriesof EmotionalandSocialImpairment[76].Brooksetal.suggestedthatthe11-item KADSisasensitivemeasureoftreatmentoutcomeinadolescentsdiagnosedwith MDD[77]. AssessingDepressionAcrossDifferentCultures Cross-culturalvariationsinpresentingsymptomsofdepressionhavebeenreported [78].Forexample,certainsymptoms,suchasself-blameandguilt,arenotcommon toallcultures[79,80].Inaddition,differenceshavebeenobservedinthesever- ityofdecision-makingimpairmentsindepressionacrosscultures[81].Researchers fromourgrouphavealsoobservedhigherratesofsuicidalideationamongAsian- Americans(24%),participantswhoreportethnicheritageasÒOtherÓ(19.5%) Caucasians(16.9%),andAsian-Indians(14%),comparedtoHispanics(7.3%)and African-Americans(6%)inasampleof707collegestudents[82].Psychoticsymp- tomshavealsobeenfoundtobemoreprevalentinHispanicpatientswithMDD seekingtreatment,comparedtoCaucasiansandPortuguesepatients,butnotwhen comparedtoAfrican-American[83]. ThemoststrikingandconsistentÞndingofcross-culturalstudiesondepression isthevariationinthesomatizationdomain.Afterscreeningapproximately26,000 patientsforMDDat15primarycarecentersin14countriesand5continents,Simon andcolleaguesfoundthattheprevalenceofsomaticsymptomsvariedacrosscen- tersfrom45%to95%[84].Moreover,notonlythefrequency,butalsothetype ofsomaticcomplaintsmaybesubjecttoculturalinßuences,asshowninastudy oninpatientsadmittedforMDDinGreece( N = 60)andinAustralia( N = 56) [85].HigherratesofsomatizationhavebeenalsoreportedindepressedJapanese, Chinese,andTurkishpatientscomparedtotheirwesterncounterpartsdiagnosed withMDD[86Ð88].Relevantdifferenceshavealsobeenobservedinself-reported scales.FugitaandcolleaguesanalyzedtheZungSDSscoresinstudentsfromfour differentcountries.KoreanandPhilippinestudentshadthehighestscores,Cau- casianAmericansthelowest[89].Therelativelygreaterdepressionseverityin Asian-AmericanpopulationswasconÞrmedinarecentstudycomparingBDIresults betweenasampleofAsian-American( n = 238)andCaucasian-Americanstudents ( n = 556)[90].Cross-culturalcomparisonstudieshavetypicallynotusedoutcome measuressuchastheHAM-D,theMADRS,theIDSandtheQIDS,eventhoughall havetranslatedversionsavailableinmorethan20languages.Becauseofcross- culturalandcross-ethnicdifferencesinpatientswithMDD,onemayarguethat scalesthatweredevelopedfortheassessmentofdepressionamongWesternEuro- peanandNorthAmericanCaucasiansmaynotbeculturallysensitiveinmeasuring 2RatingScalesforDepression19 symptomsacrossotherethnicandculturalgroups.However,thereisnogoodevi- dencethatthesescalesfailtoperformwellinclinicaltrialsconductedindifferent countries. AssessingDepressionAcrossDifferentEducationaland ComprehensionLevels Toeffectivelyassessseverityofdepressivesymptomsthroughaclinician- administeredquestionnaire,itisnecessarythatpatientsunderstandthemeaningof thequestionsasked.Althoughreadabilityiswidelyusedasaproxyforcompre- hension,itmightgiveafalsesenseofconÞdenceaboutcomprehensibility.Infact, whenrespondentslackednotonlythecognitivecapacitytofullyunderstandastan- dardizedquestion,butalsothemotivationtoansweritthoughtfully,patientsoften produceasuperÞciallyadequateanswer(i.e.,choosingtheÞrstorlastresponse, choosinganeutralresponse,choosingasociallydesirableresponseorrepeating thepreviousresponse)[91].FinallyinsituationsinwhichrespondentsÕmotiva- tionand/ortimearelimited,evenindividualswhocouldunderstandacomplex instrumentmaynotmaketheefforttoanswerquestionsthoughtfully[92]. AssessingDepressionwithPsychiatricComorbidities Littleisknownabouttheabilityofscalestomeasurechangesindepressivesymp- tomatologyacrosspopulationswithvaryingdegreesofpsychiatriccomorbidity.For example,itiswellknownthatcomorbidanxietydisordersareverycommonin MDDandthepresenceofacomorbidanxietydisordercaninßuencetheanxietyand somaticitemsandthereforeinßatethetotalscoreofamultidimensionalscalesuch astheHAM-D.Furthermore,coreobsessiveÐcompulsivedisorder(OCD)symptoms mayheavilyaffectratingsonitemscoveringguiltfeelings(becauseofaggres- sive/sexualobsessions),workandactivities(reducedifthepatientsareimmersed intheircompulsions),andanxiety[92].Whenacomorbideatingdisorderisnotan exclusioncriterion,therelativeinßuenceofitemsrelatedtoweightchange,irregular eatinghabits,guilt,andGIandsomaticsymptomshastobecarefullyconsidered. ForexampleintheHAM-D17,thesumofitemscoveringfeelingguilty,weight change,somaticanxiety,andgastrointestinalsymptoms,mayrepresent33.6%ofthe totalscore,butonly22.2%and20%oftheQIDSandMADRSscores,respectively. AssessingDepressionwithMedicalComorbidities Assessmentofdepressioninmedicallyillpopulationsiscomplicatedbythefactthat emotional,behavioral,orcognitivesymptomsmaybecausedbytheconcomitant 20 C.Cusinetal. medicalillnessand/orbythemedicationsusedtotreattheillness.Ideally,depres- sionassessmentsshouldberestrictedtovariablesanditemsthatavoidconfounding bymedicalillness.Twomeasureshavebeendesignedforassessingdepressionin themedicalpatientsbyexcludingsomaticitems:theHospitalAnxietyDepression Scale(HADS)[93]andtheBeckDepressionInventoryforPrimaryCare(BDI-PC); however,mostofthedepressionmeasuresdevelopedformedicallyillpopulations havenotbeenadequatelytestedasoutcomemeasureindepressiontrials. Acknowledgments ThisworkhasbeenfundedinwholeorinpartwithFederalfundsfromthe NationalInstituteofMentalHealth,NationalInstitutesofHealth,underContractN01MH90003 (STAR  D)andGMON01MH90003(NIMHDepressionTrialsNetwork).Thecontentofthis publicationdoesnotnecessarilyreßecttheviewsorpoliciesoftheDepartmentofHealthand HumanServices,nordoesmentionoftradenames,commercialproducts,ororganizationsimply endorsementbytheU.S.Government. TheauthorsthankDrJanetB.W.Williams,DrKennethKobak,andDrJohnRushfortheir contributionstothischapter. 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Foreachitem,circlethenumbernexttothecorrectitem(onlyoneresponseperitem). 1.DepressedMood (sadness,hopeless,helpless,worthless) 0-Absent 1-Thesefeelingstatesindicatedonlyonquestioning 2-Thesefeelingstatesspontaneouslyreportedverbally 3-Communicatesfeelingstatesnon-verballyÐi.e.,throughfacialexpression,posture,voice, andtendencytoweep 4-PatientreportsVIRTUALLYONLYthesefeelingstatesinhisspontaneousverbaland non-verbalcommunication 2.FeelingsofGuilt 0-Absent. 1-Selfreproach,feelshehasletpeopledown 2-Ideasofguiltorruminationoverpasterrorsorsinfuldeeds 3-Presentillnessisapunishment.Delusionsofguilt 4-Hearsaccusatoryordenunciatoryvoicesand/orexperiencesthreateningvisualhallucina- tions 3.Suicide 0-Absent 1-Feelslifeisnotworthliving 2-Wishesheweredeadoranythoughtsofpossibledeathtoself 3-Suicidalideasorgesture 4-Attemptsatsuicide(anyseriousattemptrates4) 4.InsomniaEarly 0-NodifÞcultyfallingasleep 1-ComplainsofoccasionaldifÞcultyfallingasleepÐi.e.,morethan1/2hour 2-ComplainsofnightlydifÞcultyfallingasleep 5.InsomniaMiddle 0-NodifÞculty 1-Patientcomplainsofbeingrestlessanddisturbedduringthenight 2-WakingduringthenightÐanygettingoutofbedrates2(exceptforpurposesofvoiding) 6.InsomniaLate 0-NodifÞculty 1-Wakinginearlyhoursofthemorningbutgoesbacktosleep 2-Unabletofallasleepagainifhegetsoutofbed 7.WorkandActivities 0-NodifÞculty 1-Thoughtsandfeelingsofincapacity,fatigueorweaknessrelatedtoactivities,workor hobbies 2-Lossofinterestinactivity,hobbiesorworkÐeitherdirectlyreportedbypatient,or indirectinlistlessness,indecisionandvacillation(feelshehastopushselftoworkor activities) 26 C.Cusinetal. 3-Decreaseinactualtimespentinactivitiesordecreaseinproductivity 4-Stoppedworkingbecauseofpresentillness 8.Retardation:Psychomotor (slownessofthoughtandspeech;impairedabilitytoconcentrate; decreasedmotoractivity) 0-Normalspeechandthought 1-Slightretardationatinterview 2-Obviousretardationatinterview 3-InterviewdifÞcult 4-Completestupor 9.Agitation 0-None 1-Fidgetiness 2-Playingwithhands,hair,etc. 3-Movingabout,canÕtsitstill. 4-Handwringing,nailbiting,hair-pulling,bitingoflips. 10.Anxiety(psychological) 0-NodifÞculty 1-Subjectivetensionandirritability 2-Worryingaboutminormatters 3-Apprehensiveattitudeapparentinfaceorspeech 4-Fearsexpressedwithoutquestioning 11.AnxietySomatic: Physiologicalconcomitantsofanxiety(i.e.,effectsofautonomicoverac- tivity,Òbutterßies,Óindigestion,stomachcramps,belching,diarrhea,palpitations,hyperven- tilation,paresthesia,sweating,ßushing,tremor,headache,urinaryfrequency).Avoidasking aboutpossiblemedicationsideeffects(i.e.,drymouth,constipation) 0-Absent 1-Mild 2-Moderate 3-Severe 4-Incapacitating 12.SomaticSymptoms(gastrointestinal) 0-None. 1-Lossofappetitebuteatingwithoutencouragementfromothers.Foodintakeaboutnormal 2-DifÞcultyeatingwithouturgingfromothers.Markedreductionofappetiteandfood intake. 13.SomaticSymptomsGeneral 0-None 1-Heavinessinlimbs,backorhead.Backaches,headacheormuscleaches.Lossofenergy andfatigability. 2-Anyclear-cutsymptomratesÒ2Ó 14.GenitalSymptoms (symptomssuchaslossoflibido;impairedsexualperformance;menstrual disturbances) 0-Absent 1-Mild 2-Severe 2RatingScalesforDepression27 15.Hypochondriasis 0-Notpresent 1-Self-absorption(bodily) 2-Preoccupationwithhealth 3-Frequentcomplaints,requestsforhelp,etc. 4-Hypochondriacaldelusions 16.LossofWeight 0-Noweightloss 1-Probableweightlossassociatedwithpresentillness 2-DeÞnite(accordingtopatient)weightloss 3-Notassessed 17.Insight 0-Acknowledgesbeingdepressedandill 1-Acknowledgesillnessbutattributescausetobadfood,climate,overwork,virus,needfor rest,etc. 2-Deniesbeingillatall TotalScore(totalofcircledresponses):________ 28 C.Cusinetal. MontgomeryAsbergDepressionRatingScale 1.ApparentSadness Representingdespondency,gloomanddespair(morethanjustordinarytransientlowspirits) reßectedinspeech,facialexpression,andposture.Ratebydepthandinabilitytobrightenup. 0-Nosadness. 2-LooksdispiritedbutdoesbrightenupwithoutdifÞculty. 4-Appearssadandunhappymostofthetime. 6-Looksmiserableallthetime.Extremelydespondent. 2.ReportedSadness Representingreportsofdepressedmood,regardlessofwhetheritisreßectedinappearanceor not.Includeslowspirits,despondencyorthefeelingofbeingbeyondhelpandwithouthope. 0-Occasionalsadnessinkeepingwiththecircumstances. 2-SadorlowbutbrightensupwithoutdifÞculty. 4-Pervasivefeelingsofsadnessorgloominess.Themoodisstillinßuencedbyexternal circumstances. 6-Continuousorunvaryingsadness,miseryordespondency. 3.InnerTension Representingfeelingsofill-deÞneddiscomfort,edginess,innerturmoil,mentaltension mountingtoeitherpanic,dreadoranguish.Rateaccordingtointensity,frequency,duration andtheextentofreassurancecalledfor. 0-Placid.Onlyßeetinginnertension. 2-Occasionalfeelingsofedginessandill-deÞneddiscomfort. 4-Continuousfeelingsofinnertensionorintermittentpanicwhichthepatientcanonly masterwithsomedifÞculty. 6-Unrelentingdreadoranguish.Overwhelmingpanic. 4.ReducedSleep RepresentingtheexperienceofreduceddurationordepthofsleepcomparedtothesubjectÕs ownnormalpatternwhenwell. 0-Sleepsasnormal. 2-SlightdifÞcultydroppingofftosleeporslightlyreduced,lightorÞtfulsleep. 4-Moderatestiffnessandresistance. 6-Sleepreducedorbrokenbyatleast2hours. 5.ReducedAppetite Representingthefeelingofalossofappetitecomparedwithwhenwell.Ratebylossofdesire forfoodortheneedtoforceoneselftoeat. 0-Normalorincreasedappetite. 2-Slightlyreducedappetite. 4-Noappetite.Foodistasteless. 6-Needspersuasiontoeatatall. 6.ConcentrationDifÞculties RepresentingdifÞcultiesincollectingoneÕsthoughtsmountingtoanincapacitatinglackof concentration. 0-NodifÞcultiesinconcentrating. 2-OccasionaldifÞcultiesincollectingoneÕsthoughts. 2RatingScalesforDepression29 4-DifÞcultiesinconcentratingandsustainingthoughtwhichreducedabilitytoreadorhold aconversation. 6-UnabletoreadorconversewithoutgreatdifÞculty. 7.Lassitude RepresentingdifÞcultyingettingstartedorslownessininitiatingandperformingeveryday activities. 0-HardlyanydifÞcultyingettingstarted.Nosluggishness. 2-DifÞcultiesinstartingactivities. 4-DifÞcultiesinstartingsimpleroutineactivitieswhicharecarriedoutwitheffort. 6-Completelassitude.Unabletodoanythingwithouthelp. 8.InabilitytoFeel Representingthesubjectiveexperienceofreducedinterestinthesurroundingsoractivities thatnormallygivepleasure.Theabilitytoreactwithadequateemotiontocircumstancesor peopleisreduced. 0-Normalinterestinthesurroundingsandinotherpeople. 2-Reducedabilitytoenjoyusualinterests. 4-Lossofinterestinthesurroundings.Lossoffeelingsforfriendsandacquaintances. 6-Theexperienceofbeingemotionallyparalyzed,inabilitytofeelanger,grieforpleasure andacompleteorevenpainfulfailuretofeelforcloserelativesandfriends. 9.PessimisticThoughts Representingthoughtsofguilt,inferiority,self-reproach,sinfulness,remorse,andruin. 0-Nopessimisticthoughts. 2-Fluctuatingideasoffailure,self-reproachorself-depreciation. 4-Persistentself-accusationsordeÞnitebutstillrationalideasofguiltorsin.Increasingly pessimisticaboutthefuture. 6-Delusionsofruin,remorseorirredeemablesin.Self-accusationswhichareabsurdand unshakable. 10.SuicidalThoughts Representingthefeelingthatlifeisnotworthliving,thatanaturaldeathwouldbewelcome, suicidalthoughts,andpreparationsforsuicide.Suicideattemptsshouldnotinthemselves inßuencetherating. 0-Enjoyslifeortakesitasitcomes. 2-Wearyoflife.Onlyßeetingsuicidalthoughts. 4-Probablybetteroffdead.Suicidalthoughtsarecommon,andsuicideisconsideredasa possiblesolution,butwithoutspeciÞcplansorintentions. 6-Explicitplansforsuicidewhenthereisanopportunity.Activepreparationsforsuicide. TotalScore(totalofcircledresponses):________ 30 C.Cusinetal. QIDS-SR16 Instructions: Pleasecircleoneresponsetoeachitemthatbestdescribesyouforthepast7days. DuringthePast7Days ... 1.FallingAsleep 0-Inevertakelongerthan30mintofallasleep. 1-Itakeatleast30mintofallasleep,lessthanhalfthetime. 2-Itakeatleast30mintofallasleep,morethanhalfthetime. 3-Itakemorethan60mintofallasleep,morethanhalfthetime. 2.SleepDuringtheNight 0-Idonotwakeupatnight. 1-Ihavearestless,lightsleepwithafewbriefawakeningseachnight. 2-Iwakeupatleastonceanight,butIgobacktosleepeasily. 3-Iawakenmorethanonceanightandstayawakefor20minormore,morethanhalfthe time. 3.WakingUpTooEarly 0-Mostofthetime,Iawakennomorethan30minbeforeIneedtogetup. 1-Morethanhalfthetime,Iawakenmorethan30minbeforeIneedtogetup. 2-Ialmostalwaysawakenatleast1hourorsobeforeIneedto,butIgobacktosleep eventually. 3-Iawakenatleast1hourbeforeIneedto,andcanÕtgobacktosleep. 4.SleepingTooMuch 0-Isleepnolongerthan7Ð8hours/night,withoutnappingduringtheday. 1-Isleepnolongerthan10hoursina24-hourperiodincludingnaps. 2-Isleepnolongerthan12hoursina24-hourperiodincludingnaps. 3-Isleeplongerthan12hoursina24-hourperiodincludingnaps. 5.FeelingSad 0-Idonotfeelsad. 1-Ifeelsadlessthanhalfthetime. 2-Ifeelsadmorethanhalfthetime. 3-Ifeelsadnearlyallofthetime. PleaseCompleteEither6or7(NotBoth) 6.DecreasedAppetite 0-Thereisnochangeinmyusualappetite. 1-Ieatsomewhatlessoftenorlesseramountsoffoodthanusual. 2-Ieatmuchlessthanusualandonlywithpersonaleffort. 3-Irarelyeatwithina24-hourperiod,andonlywithextremepersonaleffortorwhenothers persuademetoeat. 2RatingScalesforDepression31 -Or- 7.IncreasedAppetite 0-Thereisnochangefrommyusualappetite. 1-Ifeelaneedtoeatmorefrequentlythanusual. 2-Iregularlyeatmoreoftenand/orgreateramountsoffoodthanusual. 3-Ifeeldriventoovereatbothatmealtimeandbetweenmeals. PleaseCompleteEither8or9(NotBoth) 8.DecreasedWeight(WithintheLast2Weeks) 0-Ihavenothadachangeinmyweight. 1-IfeelasifIÕvehadaslightweightloss. 2-Ihavelost2poundsormore. 3-Ihavelost5poundsormore. -Or- 9.IncreasedWeight(WithintheLast2Weeks) 0-Ihavenothadachangeinmyweight. 1-IfeelasifIÕvehadaslightweightgain. 2-Ihavegained2poundsormore. 3-Ihavegained5poundsormore. 10.Concentration/DecisionMaking 0-Thereisnochangeinmyusualcapacitytoconcentrateormakedecisions. 1-IoccasionallyfeelindecisiveorÞndthatmyattentionwanders. 2-Mostofthetime,Istruggletofocusmyattentionortomakedecisions. 3-Icannotconcentratewellenoughtoreadorcannotmakeevenminordecisions. 11.ViewofMyself 0-Iseemyselfasequallyworthwhileanddeservingasotherpeople. 1-Iammoreself-blamingthanusual. 2-IlargelybelievethatIcauseproblemsforothers. 3-Ithinkalmostconstantlyaboutmajorandminordefectsinmyself. 12.ThoughtsofDeathorSuicide 0-Idonotthinkofsuicideordeath. 1-IfeelthatlifeisemptyorwonderifitÕsworthliving. 2-Ithinkofsuicideordeathseveraltimesaweekforseveralminutes. 3-Ithinkofsuicideordeathseveraltimesadayinsomedetail,orIhavemadespeciÞcplans forsuicideorhaveactuallytriedtotakemylife. 13.GeneralInterest 0-ThereisnochangefromusualinhowinterestedIaminotherpeopleoractivities. 1-InoticethatIamlessinterestedinpeopleoractivities. 2-IÞndIhaveinterestinonlyoneortwoofmyformerlypursuedactivities. 3-Ihavevirtuallynointerestinformerlypursuedactivities. 14.EnergyLevel 0-Thereisnochangeinmyusuallevelofenergy. 1-Igettiredmoreeasilythanusual. 32 C.Cusinetal. 2-IhavetomakeabigefforttostartorÞnishmyusualdailyactivities(forexample, shopping,homework,cookingorgoingtowork). 3-IreallycannotcarryoutmostofmyusualdailyactivitiesbecauseIjustdonÕthavethe energy. 15.FeelingSlowedDown 0-Ithink,speak,andmoveatmyusualrateofspeed. 1-IÞndthatmythinkingissloweddownormyvoicesoundsdullorßat. 2-IttakesmeseveralsecondstorespondtomostquestionsandIÕmsuremythinkingis slowed. 3-Iamoftenunabletorespondtoquestionswithoutextremeeffort. 16.FeelingRestless 0-Idonotfeelrestless. 1-IÕmoftenÞdgety,wringmyhands,orneedtoshifthowIamsitting. 2-Ihaveimpulsestomoveaboutandamquiterestless. 3-Attimes,Iamunabletostayseatedandneedtopacearound. TotalScore  :_________  Totalofcircleditemsincluding either 6or7,butnotboth,and either 8or9butnotboth 2RatingScalesforDepression33 ZungSelf-RatingDepressionScale Instructions: Pleasereadeachstatementanddecidehowmuchofthetimethestatementdescribes howyouhavebeenfeelingduringthepastseveraldays.Makeacheckmark(  )intheappropriate column. 34 C.Cusinetal. Alittleof thetime Someof thetime Goodpart ofthetime Mostof thetime 1.Ifeeldown-heartedandblue 2.MorningiswhenIfeelthebest 3.Ihavecryingspellsorfeellikeit 4.Ihavetroublesleepingatnight 5.IeatasmuchasIusedto 6.Istillenjoysex 7.InoticethatIamlosingweight 8.Ihavetroublewithconstipation 9.Myheartbeatsfasterthanusual 10.Igettiredfornoreason 11.Mymindisasclearasitusedtobe 12.IÞnditeasytodothethingsIusedto 13.IamrestlessandcanÕtkeepstill 14.Ifeelhopefulaboutthefuture 15.Iammoreirritablethanusual 16.IÞnditeasytomakedecisions 17.IfeelthatIamusefulandneeded 18.Mylifeisprettyfull 19.Ifeelthatotherswouldbebetteroffif Iweredead 20.IstillenjoythethingsIusedtodo TotalScore  :______  refertoscoringkey 2RatingScalesforDepression35 ZungSelf-RatingDepressionScaleScoringKey  Atotalscoreisderivedbysummingtheindividualitemscores(1Ð4)andrangesfrom20to80. Theitemsarescored:1 = alittleofthetime,through4 = mostofthetime, except foritems2,5, 6,11,12,14,16,17,18,and20whicharescoredinversely(4 = alittleofthetime)