1. Depressed mood (sadness, hopelessness, helplessness, worthlessness)
1 : When it is doubtful whether the patient is more despondent or sad than usual.
2 : When the patient more clearly is concerned with unpleasant experiences, although he still is without helplessness or hopelessness.
3 : The patient shows clear non-verbal signs of depression and/or is at times overpowered by helplessness or hopelessness.
4 : The patient's remarks on despondency and helplessness, or the non-verbal ones, dominate the interview in which the patient cannot be distracted.
2. Feelings of guilt (self-depreciation and guilt feelings)
0 : No self-depreciation or guilt feelings.
1 : Doubtful whether guilt feelings are present, because the patient is only concerned with having been a burden to family or colleagues due to reduced work capacity.
2 : Self-depreciation or guilt feelings are more clearly present, concerned with incidents in the past prior to the actual episode (e.g. reproaches himself for small omissions or failures).
3 : The patient suffers from more severe guilt feelings, may express that the actual suffering is some sort of punishment, but can still intellectually see that this view is unfounded.
4 : The guilt feelings are firmly maintained and resist any counterargument, so that they have become paranoid ideas.
3. Suicide (suicidal impulses)
0 : No suicidal impulses.
1 : The patient feels that life is not worthwhile, but expresses no wish to die.
2 : The patient wishes to die, but has no plans of taking his own life.
3 : It is probable that the patient contemplates committing suicide.
4 : If during the days prior to the interview the patient has tried to commit suicide, or if the patient is under special observation due to suicidal risk.
4. Insomnia early (initial insomnia)
1 : The patient, 1-2 out of the last 3 nights, has had to lie in bed for more than 30 minutes before falling asleep.
2 : The patient, all 3 nights, has been in bed for more than 30 minutes before falling asleep.
5. Insomnia middle
1 : The patient complains of being restless and disturbed during the night, once or twice during the last 3 nights.
2 : Waking during the night, at least once every night (except for voiding purposes).
6. Insomnia late (delayed insomnia / premature awakening)
1 : Waking in early hours of the morning but goes back to sleep, less than 1 hour early.
2 : Unable to fall asleep again if he/she gets out of bed; constantly, or more than 1 hour too early.
7. Work and activities (interests)
0 : Normal work activity.
1 : Insufficiency due to lack of motivation and/or trouble carrying out the usual workload, which is nonetheless managed without reduction.
2 : More pronounced insufficiency, reduced work capacity, cannot keep normal speed, copes with less; may stay home some days or try to leave early.
3 : Sick-listed, or hospitalized (day-activities).
4 : Fully hospitalized and generally unoccupied without participation in ward activities.
8. Retardation (slowness of thought and speech; impaired ability to concentrate; decreased motor activity)
0 : Normal verbal and motor activity with adequate facial expression.
1 : Conversational speed doubtfully or slightly reduced; facial expression doubtfully or slightly stiffened.
2 : Conversational speed clearly reduced, with intermissions; reduced gestures and slow pace.
3 : The interview is clearly prolonged due to long latencies and brief answers; all movements slow.
4 : The interview cannot be completed; retardation approaches (and includes) stupor.
9. Agitation
0 : Normal motor activity with adequate facial expression.
1 : Doubtful or slight agitation, e.g. tendency to change position in chair or scratching head.
2 : Fidgeting, wringing hands, changing position in chair repeatedly; restless in ward, some pacing.
3 : Patient cannot stay in chair during interview and/or much pacing in ward.
4 : Interview has to be conducted “on the run”; almost continuous pacing, pulling off clothes, tearing hair.
10. Anxiety (psychic)
0 : The patient is neither more nor less insecure or irritable than usual.
1 : It is doubtful whether the patient is more insecure or irritable than usual.
2 : The patient more clearly expresses a state of anxiety, apprehension, or irritability that is difficult to control, but still only about minor matters.
3 : The anxiety or insecurity is at times more difficult to control, worrying about major injuries or harms that might occur; may be experienced as panic; has occasionally interfered with daily life.
4 : The feeling of dreadfulness is present so often that it markedly interferes with the patient's daily life.
11. Anxiety (somatic) – physiological concomitants of anxiety (gastrointestinal, cardiovascular, respiratory, urinary frequency, sweating)
0 : The patient is neither more nor less prone than usual to experience somatic concomitants of anxiety.
1 : Occasional slight manifestations (abdominal symptoms, sweating, or trembling), vague and doubtful.
2 : From time to time experiences abdominal symptoms, sweating, trembling, etc.; clearly described but not marked, still without influence on daily life.
3 : Physiological concomitants of anxious feelings are marked and sometimes very worrying; interfere occasionally with daily life.
4 : The feeling of dreadfulness is present so often that it markedly interferes with the patient's daily life.
12. Somatic symptoms, gastrointestinal
0 : No gastrointestinal complaints (or symptoms unchanged from before onset of depression).
1 : Eats without encouragement, food intake about normal but without relish; sometimes constipated.
2 : Food intake reduced, patient has to be urged to eat; as a rule clearly constipated.
13. Somatic symptoms, general (fatigue, exhaustion, loss of energy, diffuse muscular aches)
0 : The patient is neither more nor less tired or troubled by bodily discomfort than usual.
1 : Doubtful or very vague feelings of muscular fatigue or other somatic discomfort.
2 : Clearly or constantly tired and exhausted, and/or troubled by bodily discomfort, e.g. muscular headache.
14. Genital symptoms (loss of libido, menstrual disturbances)
1 : Doubtful or mild reduction in sexual interest and enjoyment.
2 : Clear loss of sexual appetite, often functional impotence in men and lack of arousal or plain disgust in women.
15. Hypochondriasis
0 : The patient pays no more interest than usual to the slight bodily sensations of everyday life.
1 : Slightly or doubtfully more occupied than usual with bodily symptoms and functions.
2 : Quite worried about physical health; expresses thoughts of organic disease with a tendency to “somatize.”
3 : Convinced of suffering from a physical illness that can explain all symptoms, but can be briefly reassured that this is not the case.
4 : The preoccupation with bodily dysfunction has clearly reached paranoid dimensions (nihilistic or guilt-related delusions), and is unaffected by counter-argument.
16. Loss of weight
1 : Probable weight loss associated with present illness (1-2.5 kg / about 1/2 kg per week).
2 : Definite (according to patient) weight loss (3 kg or more / 1 kg or more per week).
17. Insight
0 : The patient agrees to having depressive symptoms or a “nervous” illness.
1 : The patient agrees to being ill, but feels this to be secondary to non-illness related conditions (bad food, climate, overwork, virus, need for rest, etc.).
2 : Denies being ill at all.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.