Form VA Form 10-21085a, VA Form 10-21085a, Prevalence and Clinical Course of Depression Among Patie

OMB Number 2900-XXXX
Estimated burden: 22 minutes
VA Form 10-21085a,b,c,d,e(NR)

PREVALENCE & CLINICAL COURSE OF DEPRESSION AMONG PATIENTS WITH
HEART FAILURE, VA HSR&D, NURSING RESEARCH INITIATIVE # 05-209-3
INSTRUCTIONS FOR COMPLETING THIS QUESTIONNAIRE PACKET
The time that you will take to complete the questionnaire packet is greatly appreciated. By completing the
questionnaires, you are making a vital contribution to this research study. Your answers will help
determine how to provide necessary information in the most effective manner.
Please try to answer every question. People with a variety of experiences will be filling out these important
questionnaires. Some of the questions may not seem relevant you, however, we need you to answer every
question as honestly as you can. There are no right or wrong answers. We are interested in your opinions
and feelings.
This questionnaire packet consists of several different forms. Excluding the last 2 sets of questionnaires,
most of the questionnaires will be administered by a research assistant asking the questions. The last 2 sets
of questionnaires have instructions at the top of the first page of the form.
Please be assured that the answers you give are strictly confidential. You are identified by a code number
in this project. Only the project director and the principal investigator have access to the codes. Your
answers will remain private.
THANK YOU VERY MUCH FOR YOUR PARTICIPATION IN THIS IMPORTANT PROJECT
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for
this collection of information is estimated to average 22 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. This information is collected to fulfill the need
identified by the Department of Veteran Affairs, Health Services Research & Development (HSR&D),
Nursing Research Initiative to identify the prevalence and clinical course of depression as well as identify
the physiological and psychosocial measurements that may be associated with depression among Veterans
with heart failure. No person will be penalized for failing to furnish this information if it does not display
a currently valid OMB control number. Response to this survey is voluntary and failure to furnish this
information will have no impact on benefits to which you may be entitled.
Privacy Act: The execution of this form does not authorize the release of information other than that
specifically described below. The information requested on this form is solicited under Title 38, U.S.C.,
Part I, Chapter 5, Section 527. The form authorizes release of information in accordance with the Health
Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a, and 38 U.S.C.
5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary.
However, if the information including Social Security Number (SSN) (the SSN will be used to locate
records for release) is not furnished completely and accurately, the Department of Veterans Affairs will be
unable to comply with the request. The Veterans Health Administration may not condition treatment,
payment, enrollment or eligibility on signing the authorization.

VA Form 10-21085a (NR)

Study ID _______
Subject’s initials __ __ __
MINI-MENTAL STATUS EXAM
ORIENTATION:
1. DATE
2. YEAR
3. MONTH
4. DAY
5. SEASON
6. WARD (CLINIC, FLOOR)
7. HOSPITAL
8. CITY
9. COUNTY
10. STATE
REGISTRATION: REPEAT 3 NAMES OF OBJECTS
11. COOK
12. BLUE
13. HORSE
ATTENTION: SPELL “WORLD” BACKWARDS OR BACKWARDS 7’S
FROM 100
14. D
93
15. L
86
16. R
79
17. O
72
18. W
65
RECALL: REMEMBER 3 NAMES OF OBJECTS
19. COOK
20. BLUE
21. HORSE
LANGUAGE: NAMING AND REPEATING
22. WHAT IS THIS (WATCH)?
23. WHAT IS THIS (PEN OR PENCIL)?
24. REPEAT “NO IFS, ANDS OR BUTS”
25. FOLLOW 3-STEP INSTRUCTION:
TAKE THIS PAPER IN YOUR RIGHT HAND
26 FOLD IT IN HALF AND
27. PUT IT ON THE FLOOR
28. READ THIS SENTENCE AND DO WHAT IT SAYS (CLOSE YOUR
EYES)

CORRECT

INCORRECT

TOTAL (MAXIMUM = 28)

CLOSE YOUR EYES
Revision date 11/26/06
Completed by:_____________
Date:____________________

VA F'orm 10-21085b (NR)

Functional Class Instruments: New York Heart Association Functional
Classification (NYHA)

3

‰

Classification

CLASS I(1)

Description
Patients with cardiac disease but without resulting limitations of
physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, dyspnea, or anginal pain.
(no limitations)

‰

CLASS II(2)

Patients with cardiac disease resulting in slight limitation of physical
activity. They are comfortable at rest. Ordinary physical activity
results in fatigue, palpation, dyspnea, or anginal pain.
(ordinary physical activity causes symptoms)

‰

CLASS III(3)

Patients with cardiac disease resulting in marked limitation of physical
activity. They are comfortable at rest. Less than ordinary physical
activity causes fatigue, palpitation, dyspnea, or anginal pain.
(< ordinary physical activity causes symptoms)

‰

CLASS IV(4)

Patients with cardiac disease resulting in inability to carry on any
physical activity without discomfort. Symptoms of cardiac
insufficiency or of the anginal syndrome may be present even at rest.
If any physical activity is undertaken, discomfort is increased.
(symptoms at rest)

Functional Class Instruments:

Specific Activity Scale (SAS)

Criteria for Determination of the Specific Activity Scale Functional Class
Any Yes

No

1. Can you walk down a flight of steps without stopping? (4.5–5.2 mets)

Go to #2

Go to #4

2. Can you carry anything up a flight of 8 steps without stopping (5–5.5
mets), or can you:
a) have sexual intercourse without stopping (5-5.5 mets)?
b) garden, rake, weed (5.6 mets)?
c) roller skate, dance fox-trot (5-6 mets)?
d) walk at a 4 miles-per-hour rate?

Go to #3

Class III

3. Can you carry at least 24 pounds up 8 steps (10 mets), or can you:
a) carry objects that are at least 80 pounds (8 mets)?
b) do outdoor work – shovel snow, spade soil (7 mets)?
c) do recreational activities such as skiing, basketball, touch football,
squash, handball 1 (7-10 mets)?
d) jog/walk 5 miles per hour (mets)?

Class I

Class II

Class III

Go to #5

Class III

Class IV

4. Can you shower without stopping (3.6-4.2), or can you:
a) strip and make bed (3.9-5 mets)?
b) mop floors (4.2 mets)?
c) hang washed clothes (4.4 mets)?
d) clean windows (3.7 mets)?
e) walk 2.5 miles per hour (3-3.5 mets)?
f) bowl (3-4.4 mets)?
g) play golf (walk and carry clubs) (4.5 mets)?
h) push a power lawn mower (4 mets)?
5. Can you dress without stopping because of symptoms? (2 – 2.3 mets)
‰ Class I(1)

‰ Class II(2)

‰ Class III(3)

‰ Class IV(4)

VA Form 10-21085c (NR)

DSM-IV DEPRESSION INTERVIEW AND STRUCTURED HAMILTON

(Dish, Version 2d, Revised 3/31/98)

Patient ID:

Patient Initials:

VISIT:

Interview Date: _______/ _______/ ________
Month
Day
Year

INTERVIEW LOCATION: If interview was initiated while
the patient was still hospitalized but completed after
discharge, circle both “inpatient” and the location at
completion
ASSESSMENT PHASE: Circle the applicable box

Interview Initials: __________________

INPATIENT

OUTPATIENT

(I)

(O)

INITIAL
EVALUATION

RELIABILITY CHECK: If you are a secondary
interviewer conducting a reliability check on the “real”
interview, circle the method you’re using to watch and/or
listen to the interview.

IN-PERSON
(I)

AUDIOTAPE
(A)

#

VIDEOTAPED INTERVIEWS: Complete this section if you are coding a videotaped interview,
and staple the DSF or DFU to the DISH

1

PURPOSE:

2

SUBJECT INITIALS:

3

TAPED INTERVIEWER NUMBER

4

DATE OF INTERVIEW

(mmddyy)

5

Dx FORM TO ATTACH

1=DSF

1 = Training
2 = Certification
3 = Coding Test
AGE:

4 = Clinical Judge
5 = Clinical Consensus
6 = Primary Interviewer
GENDER:

PATIENT’S
RESIDENCE
(R)

TELEPHONE

FOLLOW-UP

OTHER

VIDEOTAPE
(V)

TELEPHONE
(T)

(T)

7 = Other

INTERVIEWER:

2=DFU

ACKNOWLEDGEMENTS: This interview was designed for use in the National heart, Lung, and Blood Institute’s Enhancing Recovery in Coronary Heart
Disease (ENRICHD) Project and related studies. Its purpose is to obtain the information needed to (1) diagnose current major and minor depressive
episodes and dysthymia according to the DSM-IV criteria (American Psychiatric Association, 1994); (2) assess the past history and longitudinal course
of depressive disorders, including partial and full remissions, relapses, and recurrences; (3) determine the 17-item Hamilton Rating Scale for Depression
severity score for the past week; and (4) perform preliminary screening for other neuropsychiatric disorders. The form integrates material from several
different sources including the Hamilton Rating Scale for Depression (Hamilton, 1960); the standardized version of the Hamilton scale developed by
NIMH for use in the Early Clinical Drug Evaluation (ECDEU) program (Guy, 1976) and the Treatment of Depression Collaborative Research Program
(Eikin et al, 1985, 1989); the Structured Interview Guide for the Hamilton Depression Rating Scales (Williams, 1988, 1992); the National Institute of
Mental Health Diagnostic Interview Schedule (Robins, Helzer, Croughan, and Ratcliff, 1981; Robins, Cottler, Buchotz, and Compton, 1995); a modified
version of the NIMH Diagnostic Interview Schedule (Carney and Freedland, 1988) that has been used primarily in research on depression in patients
with coronary heart disease, and the DSM-IV manual. Most of the Hamilton items were adapted from, or taken verbatim from, the SIGH-D (Wiiliams,
1988, 1992). Finally, numerous ENRICHD investigators, staff, and consultants contributed to this version of the DISH.

1

OPTIONAL OPENING QUESTIONS
#
1

[OPT]

I’D LIKE TO START BY ASKING YOU ABOUT YOUR FAMILY. {ARE YOU MARRIED? CHILDREN? GRANDCHILDREN? HOW
OLD? ETC.}

[OPT]

WOULD YOU MIND TELLING ME ABOUT HOW YOU FOUND ABOUT YOUR HEART DISEASE (I.E. HEART FAILURE? {DID
YOU HAVE CHEST PAIN? SHORTNESS OF BREATH? EXTREME FATIGUE? HEART ATTACK? GO TO THE ER? HAVE A
REGULAR CHECKUP?}

[OPT]

BEFORE THIS HAPPENED, DID YOU ALREADY KNOW THAT YOU HAD HEART DISEASE, OR DID KNOWING ABOUT
HAVING A HEART FAILURE COME AS A COMPLETE SURPRISE?

[OPT]

WHAT’S IT BEEN LIKE FOR YOU HAVING THIS PROBLEM OF HEART FAILURE? HAS IT BEEN HARD TO COPE WITH ALL
OF THIS? HAS IT BEEN HARD FOR YOUR {SPOUSE, FAMILY}?

[OPT]

HAVE YOU HAD MANY VISITORS? WHO’S BEEN ABLE TO COME AND VISIT? IS THREE ANYONE WHO’S TOO FAR AWAY
OR WHO CAN’T BE HERE FOR SOME REASON? HOW DO YOU FEEL ABOUT THAT?

[OPT]

ARE YOU WORRIED ABOUT HOW LIFE IS GOING TO BE FOR YOU {AND YOUR SPOUSE, FAMILY} AFTER YOU GET OUT
OF THE HOSPITAL? WHAT KINDS OF PROBLEMS DO YOU THINK YOU MIGHT HAVE TO FACE?

[OPT]

WHAT KIND OF WORK {DO, DID} YOU DO? ARE YOU RETIRED OR ON LEAVE?

[OPT]

[IF NOT WORKING]: HOW LONG HAVE YOU BEEN {RETIRED, ON LEAVE, ETC.}? DID YOU {RETIRE, STOP WORKING,
ETC.} BECAUSE OF YOUR AGE, YOUR HEALTH, OR SOME OTHER REASON?

[OPT]

[IF STILL WORKING]: HAS YOUR DOCTOR TOLD YOU ANYTHING YET ABOUTY WHEN YOU MIGHT BE ABLE TO GO BACK
TO WORK? ARE YOU CONCERNED ABOUT WHAT WILL HAPPEN {IF, WHEN} YOU GO BACK?

2

CURRENT DEPRESSION SYMPTOMS
#
2

ANHEDONIA AND ACTIVITY
[REQ]

[IF INPATIENT OR < 1 WEEK POST-DISCHARGE]: WHAT HAVE YOU BEEN DOING
TO PASS THE TIME OVER THE PAST FEW DAYS?

[REQ]

[IF > 1 WEEK POST DISCHARGE]: HAVE YOU BEEN WORKING THIS WEEK?

[OPT]

[IF YES]: HAVE YOU BEEN WORKING AS MANY HOURS AS USUAL? HAVE YOU
BEEN ABLE TO GET AS MUCH DONE AS YOU USUALLY DO (WHEN
YOU’RE FEELING OKAY)?

[OPT]

[IF NO]: WHAT ARE THE REASONS WHY YOU AREN’T WORKING?

[REQ]

[IF > 1 WEEK POST-DISCHARGE]: HOW HAVE YOU BEEN SPENDING YOUR FREE
TIME THIS PAST TWO WEEKS (WHEN YOU ARE NOT AT WORK)?

[OPT]

HAVE YOU BEEN DOING ANYTHING FOR FUN OR RECREATION?

[OPT]

HAVE YOU REALLY FELT INTRESTED IN DOING {THOSE THING}, OR HAVE YOU
HAD TO PUSH YOURSELF TO DO THEM?

[OPT]

HAVE YOU STOPPED DOING ANYTHING YOU USED TO ENJOY DOING? [IF YES]:
WHY?

[OPT]

IF/WHEN YOU ARE ABLE TO RESUME [YOUR FAVORITE ACTIVITES]; DO YOU
THINK THAT YOU WOULD STILL ENJOY THEM, OR HAVE YOU LOST INTEREST IN
[THESE ACTIVITIES]?

[REQ]

HAVE YOU BEEN FEELING LIKE YOU’VE LOST INTEREST IN MOST THINGS, OR
LIKE YOU’RE NOT GETTING MUCH PLEASURE FROM THINGS YOU USED TO
ENJOY?

CODE

HRDS

DSM-IV

DURATION

[IF YES]: HAVE YOU BEEN FEELING LIKE THAT MOST OF THE TIME OR SOME OF
THE TIME? HOW LONG HAVE YOU BEEN FEELING THAT WAY? SINCE YOUR
HOSPITALIZATION? OR EVEN BEFORE YOUR HOSPITALIZATION?
[OPT]

[REQ]

IS THERE ANYTHING YOU ARE LOOKING FORWARD TO DOING?

[RATE WORK & ACTIVITES LAST TWO WEEKS AND RECORD ON HRDS TALLY
SHEET

HRSD

0 --- NO DIFFICULTY
1 --- THOUGHTS & FEELINGS OF INCAPACITY, FATIGUE, OR WEAKNESS RELATED
TO ACTIVITIES, WORK OR HOBBIES
2 --- LOSS OF INTEREST IN ACTIVITIES, HOBBIES, OR WORK, OR PT. FEELS S/HE
HAS TO PUSH SELF TO DO WORK OR ACTIVITIES
3 --- DECREASE IN ACTUAL TIME SPENT IN ACTIVITIES OR DECREASE IN
PRODUCTIVITY. [IN HOSPITAL]: PT SPENDS < APPROX 25% OF FREE TIME
WHILE AWAKE & ALERT ON RECREATIONAL ACTIVITIES (EG., READING,
VISITNG, WATCHING TV)
4 --- PT HAS DISCONTINUED WORK AND/OR RECREATINAL ACTIVITIES (ABOVE &
BEYOND ANY PHYSICAL LIMITATIONS IMPOSED BY ILLNESS OR
HOSPITALIZATION)

3

CURRENT DEPRESSION SYMPTOMS
#
3

Anhedonia and Activity
[REQ]

LATELY HAVE YOU LOST INTEREST IN SPENDING TIME WITH OTHER PEOPLE,
OR HAVE YOU FELT LIKE AVOIDING PEOPLE YOU USUALLY LIKE TO VISITS? [IF
YES, PROBE FOR FREQUENCY]: HAVE YOU BEEN FEELING LIKE THAT MOST OF
THE TIME? SOME OF THE TIME?

[REQ]

[RATE SOCIAL WITHDRAWAL]

CODE

HSSRD

DSM-IV

DURATION

DSM-IV

DURATION

CODE

0 --- NO LOSS OF INTEREST IN OR AVOIDANCE OF SOCIAL CONTACT
1 --- SOCIALLY WITHDRAWN SOME DAYS
2 --- SOCIALLY WITHDRAWN MOST DAYS
M --- MEDICAL SX ONLY
R --- REFUSED
U --- UNABLE TO ASSESS

4

[REQ]

[RATE ANHEDONIA BASED ON ITEMS 1-3 AND TRANSFER TO DIAGNOSIS
GUIDE]
0 --- NO SIGNIFICANT LOSS OF INTEREST OR PLEASURE IN ACTIVITIES
(DURATION = N/A)
1 --- LOSS OF INTEREST OR PLEASURE IN MOST ACTIVITIES PRESENT SOME
DAYS (DURATION = ______WEEKS)
2 --- LOSS OF INTEREST OR PLEASURE IN MOST ACTIVITIES PRESENT MOST
DAYS (DURATION = ______WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________

4

CURRENT DEPRESSION SYMPTOMS
#
5

DYSPHORIC MOOD
[REQ]

WHAT’S YOUR MOOD BEEN LIKE OVER THE LAST TWO WEEKS?

[OPT]

HAVE YOU BEEN FEELING {SAD, DOWN, DEPRESSED, UNHAPPY, ETC.}

[OPT]

HAVE YOU FELT LIKE CRYING, OR HAVE YOU ACTUALLY BEEN CRYING OR HAD
CRYING SPELLSSOMETIME IN THE LAST WEEK?

[REQ]

[RATE MOOD PAST TWO WEEKS, BASED ON PT’S ANSWERS TO THIS ITEM AND
YOUR OBSERVATIONS

CODE

HRDS

DSM-IV

DURATION

DSM-IV

DURATION

HRSD

0 --- MOOD IS NOT DYSPHORIC
1 --- MOOD IS DYSPHORIC, BUT THIS IS APPARENT ONLY IN PT’S ANSWERS TO
QUESTIONS
2 --- MOOD IS DYSPHORIC, AND IS SEVERE ENOUGH THAT PT TALKS
SPONTANEOUSLY ABOUT IT
3 --- MOOD IS DYSPHORIC, AND IS SEVERE ENOUGH THAT YOU CAN TELL NOT
ONLY FROM PT’S ANSWERS BUT ALSO FROM FACIAL EXPRESSIONS, VOICE,
POSTURE, CRYING, ETC.
6

[REQ]

[RATE CURRENT MOOD, BASED ON ITEM #5, PROBES FOR FREQUENCY &
DURATION, AND YOUR OBSERVATIONS. IF MOOD IS DYSPHORIC ASK]: HAVE
YOU BEEN FEELING (SAD, DEPRESSED, EMPTY, ETC.) MOST OF THE TIME? HOW
LONG HAVE YOU BEEN FEELING LIKE THAT?
0 --- NOT DYSPHSORIC (DURATION = N/Q)

MAJOR: 2
MINOR: 2
DYSTH: 2

1 --- DYSPHORIC SOMEDAYS (DURATION = _____ WEEKS)
2 --- DYSPHORIC MOST DAYS (DURATION = _____ WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________

5

CURRENT DEPRESSION SYMPTOMS
#
7

DYSPHORIC MOOD
[REQ]

CODE

HRDS

DSM-IV

DURATION

A POSITIVE SCREEN FOR DEPRESSION REQUIRES EITHER:
A RATING OF “2” ON ITEM #4 WITH A DURATION ≥ 7 DAYS, OR
A RATING OF “2” ON ITEM #6 WITH A DURATION ≥ 7 DAYS
IF THESE CRITERIA ARE ABSENT, CONTINUE HRSD CRITERIA ONLY AND
COMPLETE HRDS TALLY SHEET.

IF YOU BELIEVE THAT PT MAY ACTUALLY BE DEPRESSED DESPITE ANSWERS TO
THE CONTRARY, TRY ASKING SOME (OR SOME MORE OF) THE OPTIONAL
QUESTIONS FROM ITEM #1, AND/OR OTHER ITEMS FROM OTHER PARTS OF THE
DISH, TO ENCOURAGE THE PATIENT TO OPEN UP TO YOU ABOUT HIS/HER
PROBLEMS AND FEELINGS. THEN, RE-ADMINISTER THE ANHEDONIA AND
DYSPHORIA ITEMS. IF THE PATIENT NOW ADMITS TO THESE SYMPTOMS, REVISE
THE CODES ON ITEMS 1-6 ACCORDINGLY, AND THEN CONTINUE THE INTERVIEW.
8

[REQ]

[IF MOOD IS DYSPHORIC, BASED ON ITEMS 5-6, ASK ONE OR BOTH OF THE
FOLLOWING QUESTIONS:
A.

DID SOMETHING HAPPEN THAT MADE YOU START TO FEEL {SAD,
DEPRESSED, ETC.}? WHAT SEEMS TO BE GETTING YOU DOWN?

B.

IS THERE ANYTHING ELSE BESIDES {E.G., YOUR HEART DISEASE (OR
FAILURE)} THAT’S {GETTING YOU DOWN, MAKING YOU SAD, ETC.}?

[DESCRIBE THE EVENT(S), IF ANY ARE IDENTIFIED, THAT MAY HAVE
PRECIPITATED OR WORSENED PT’S DEPRESSED MOOD, ALONG WITH DATE(S)
OR DURATION(S). DOCUMENT BEREAVEMENT IF PT SUFFERED SIGNIFICANT
LOSS]

9

[REQ]

DURING THE PAST 2 WEEKS, HAVE YOU FELT IRRITABLE OR ANGRY AT TIMES?
[IF YES}: HAVE YOU BEEN FEELING THAT WAY MOST OF THE TIME?

[OPT]

[REQ]

{IF YES}: HAVE YOU BEEN [IRRITABLE, ANGRY} BOUT ANYTHING IN PARTICULAR?
WHAT’S BEEN MAKING YOU {E.G., MAD}?

[RATE IRRITABILITY AND/OR ANGER LAST 2 WEEKS]:

CODE

0 --- NOT IRRITABLE OR ANGRY
1 --- IRRITABLE OR ANGRY SOME DAYS
2 --- IRRITABLE OR ANGRY MOST DAYS
M --- MEDICAL SX ONLY
R --- REFUSED
U --- UNABLE TO ASSESS

6

CURRENT DEPRESSION SYMPTOMS
APPETITE AND WEIGHT
10

[REQ]

HOW HAS YOUR APPETITE BEEN OVER THE PAST 2 WEEKS?

[OPT[

IS THAT {DIFFERENT, MORE, LESS} THAN YOUR USUAL APPETITE?

[OPT]

HAVE YOU HAD TO FORCE YOURSELF TO EAT?

[OPT]

HAVE OTHER PEOPLE HAD TO URGE YOU TO EAT?

[OPT]

HAVE YOU BEEN SKIPPING MEALS?

[OPT]

HAVE YOU BEEN HAVING ANY STOMACH OR INTESTINAL PROBLEMS THAT
ARE MAKING IT HARD FOR YOU TO EAT?

CODE

HRSD

DSM-IV

DURATION

DSM-IV

DURATION

[IT YES]: IS THAT SOMETHING YOUR DOCTOR IS TREATING YOU FOR, OR IS IT
JUST THAT YOU DON’T FEEL VERY GOOD?
[REQ]

[RATE APPETITE PAST 2 WEEKS & ANY GI SYMPTOMS ASSOCIATED WITH LOSS
OF APPETITE AND RECORD ON HRDS TALLY SHEET}

HRDS

0 --- NO LOSS OF APPETITE
1 --- LOSS OF APPETITE IS PRESENT BUT PT IS EATING WITHOUT URGING OR
ENCOURAGEMENT FROM OTHER PEOPLE
2 --- PT HAS DIFFICULTY EATING WITHOUT BEING URGED OR APPETITE LOSS IS
SO SEVERE THAT PT REPORTS GI SYMPTOMS SUCH AS NAUSEA
11

[REQ]

HAVE YOU LOST OR GAINED ANY WEIGHT LATELY?
[IF YES]: HOW MUCH?
HOW LONG DID IT TAKE?

[OPT]

[IF WEIGHT GAIN]: IS THAT ONLY BECAUSE OF SWELLING & WATER RETENTION?
OR, HAVE YOU ACTUALLY GAINED SOME WEIGHT?

[OPT[

[IF WEIGHT LOSS]: HAVE YOU BEEN DIETING TO LOSE WEIGHT?
HAVE YOU BEEN TAKING DIURETICS {WATER PILLS}?

[OPT]

_____LOST ______GAINED
USUAL WEIGHT: _______ LBS

[REQ]

_______LBS IN _____WEEKS
WEIGHT NOW: ______LBS

[RATE WEIGHT LOSS AND RECORD ON HRSD TALLY SHEET]:

HRSD

0 --- NO WEIGHT LOSS (OR LOSS DUE SOLELY TO ILLNESS OR DIET)
1 --- PROBABE WEIGHT LOSS DUE TO CURRENT DEPRESSION
2 --- DEFINITE WEIGHT LOSSDUE TO CURRENT DEPRESSION
12

[REQ]

[RATE CHANGE IN APPETITE AND/OR WEIGHT, BASED ON ITEMS 10-11 AND
PROBES FOR FREQUENCY & DURATION AND RECORD ON DIAGNOSIS GUIDE]:
[IF APPETITE HAS CHANGED]: HAS YOUR APPETITE BEEN LIKE THAT MOST OF
THE TIME? HOW LONG HAS IT BEEN THAT WAY?

MAJOR: 2
MINOR: 2
DYSTH: 2

0 --- NORMAL APPETITE & WEIGHT (DURATION = N)
1 --- APPETITE IS DECREASED OR INCREASED SOME DAYS, OR WEIGHT HAS
CHANGED BUT LESS THAN 5% IN THE LAST MONTH (DURATION = ____
WEEKS)
2 --- APPETITE IS DECREASED OR INCREASED MOST DAYS, OR WEIGHT HAS
CHANGED AT LEAST 5% IN LAST MONTH (DURATION = _____WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________

7

CURRENT DEPRESSION SYMPTOMS
#
13

14

SLEEP DISTUBANCE AND FATIGUE
[REQ[

HOW HAVE YOU BEEN SLEEPING OVER THE PAST WEEK? HAVE YOU BEEN
SLEEPING {LESS THAN, MORE THAN, THE SAME AS} USUAL?

[OPT]

[IF MORE OR LESS]: IS THAT MAKING YOU VERY SLEEPY DURING THE DAY, OR
INTERFERING WITH YOUR DAYTIME ACTIVITIES?

[OPT[

HAVE YOU BEEN TAKING ANY MEDICINE TO HELP YOU SLEEP?
[IF YES]: IS IT HELPING? IS IT MAKING YOU SLEEP TOO MUCH?

[REQ]

HAVE YOU HAD TROUBLE FALLING ASLEEP AT NIGHT THIS WEEK?

[OPT]

RIGHT AFTER YOU GOT TO BED, HOW LONG HAS IT BEEN TAKING YOU TO FALL
ASLEEP?

[OPT]

HOW MANY NIGHTS THIS WEEK HAVE YOU HAD TROUBLE?

[REQ]

[RATE SLEEP ONSET INSOMNIA THIS WEEK, BASED ON ITEMS 13-14] AND
RECORD ON HRSD TALLY SHEET]:

CODE

HRSD

DSM-IV

DURATION

HRSD

0 --- NO DIFFICULTY FALLING ASLEEP
1 --- OCCASIONAL DIFFICULTY FALLING ASLEEP (TAKES > ½ HOURS)
2 --- NIGHTLY DIFFICULTY FALLING ASLEEP (TAKES > ½ HOURS)
15

[REQ]

DURING THE PAST 2 WEEKS, HAVE YOU BEEN WAKING UP IN THE MIDDLE OF THE
NIGHT?[IF YES]: IS THAT USUALLY BECAUSE YOU HAVE TO GO TO THE
BATHROOM, OR SHORTNESS OF BREATH, OR FOR SOME OTHER REASON?

[OPT]

DO YOU GET OUT OF BED? WHEN YOU GET BACK INTO BED, ARE YOU ABLE TO
FALL RIGHT BACK ASLEEP?

[OPT]

HAVE YOU BEEN SLEEPING RESTLESSLY? TOSSING & TURNING?

[REQ[

[RATE MIDDLE INSOMNIA & RESTLESS SLEEP OVER PAST 2 WEEKS BASED ON
ITEMS 13 & 15) AND RECORD ON HRSD TALLY SHEET]:

HRSD

0 --- NO DIFFICULTY STAYING ASLEEP; SLEEP IS RESTFUL
1 --- SLEEP IS RESTLESS OR DISTURBED DURING THE NIGHT
2 --- PT HAS BEEN WAKING UP DURING THE NIGHT AND HAVING DIFFUCLTY
FALLING BACK ASLEEP. (DO NOT COUNT IF PT IS ONLY WAKING UP TO GO
TO BATHROOM).
16

[REQ]

WHAT TIME HAVE YOU BEEN WAKING UP IN THE MORNING OVER THE PAST 2
WEEKS?
[IF EARLY]: IS THAT EARLIER THAN YOU USUALLY WAKE UP? IS IT TOO EARLY,
OR IS THAT THE TIME YOU WANT TO WAKE UP?

[REQ]

[RATE EARLY MORNING WAKING THIS WEEK, BASED ON ITEMS 13 & 16 AND
RECORD ON HRSD TALLY SHEET]”

HRSD

0 --- NO DIFFICULTY; WAKES UP AT USUAL TIME
1 --- WAKES UP TOO EARLY, BUT GOES BACK TO SLEEP
2 --- WAKES UP TOO EARLY, AND CANNOT GO BACK TO SLEEP

8

CURRENT DEPRESSION SYMPTOMS
#
17

SLEEP DISTUBANCE AND FATIGUE
[REQ]

CODE

HRSD

[RATE SLEEP DISTURBANCE, BASED ON ITEMS 13-16, AND PROBES FOR
FEQUENCY AND DURATION AND RECORD ON DIAGNOSIS GUIDE]. IF SLEEP IS
DISTURBED ASK: HAVE YOU BEEN HAVING (E.G. TROUBLE SLEEPING, SLEEPING
TOO MUC, ETC.) ALMOST EVERYDAY? HOW LONG HAS THIS BEEN HAPPENING?

DSM-IV

DURATION

DSM-IV
MAJOR: 2
MINOR: 2
DYSTH: 2

DURATION

DSM-IV
MAJOR: 2
MINOR: 2
DYSTH: 2

DURATION

0 --- NO SIGNIFICANT SLEEP DISTURBANCE (DURATION = N/A)
1 --- INSOMNIA OR HYPERSOMNIA SOME DAYS, USUALLY NOT BAD ENOUGH TO
CAUSE DAYTIME SLEEPINESS OR TO AFFECT DAYTIME FUNCTIONING
(DURATION = ______ WEEKS)
2 --- INSOMNIA OR HYPERSOMNIA MOST DAYS, USUALLY BAD ENOUGH TO
CAUSE DAYTIME SLEEPINESS OR TO AFFECT DAYTIME FUNCTIONING
(DURATION = ______ WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________
18

[REQ]

HOW HAS YOUR ENERGY LEVEL BEEN THIS PAST WEEK? HAVE YOU BEEN
FEELING TIRED OR FATIGUED THIS WEEK?
[IF YES]: HOW BAD HAS IT BEEN?

[OPT]]

HOW WAS YOUR ENERGY LEVEL BEFORE HEART FAILURE?

[OPT]]

[IF TIRED, FATIGUED, OR LOW ON ENERGY]: AT THOSE TIMES WHEN YOU ARE
FEELING ESPECIALLY {TIRED, FATIGUED, etc.} HAVE YOU ALSO BEEN GETTING
ANY ACHES & PAINS {e.g. BACKACHES, HEADACHES, HEAVINESS IN LIMBS, etc.)

[REQ]

[RATE THE SEVERITY OF FATIGUE OR LOW ENERGY THIS PAST WEEK AND
RECORD ON HRSD TALLY SHEET]

HRSD

0 --- ONE (NORMAL ENERGY, NOT FATIGUED)
1 --- PT REPORTS MILD TO MODERATE LOSS OF ENERGY OR FATIGUE
2 --- PT REPORTS SEVERE LOSS OF ENERGY OR FATIGUE; MAY COMPLAIN OF
ASSOCIATED SYMPTOMS (EG. ACHES & PAINS
19

[REQ]

[RATE FATIGUE OR LOSS OF ENERGY, BASED ON ITEM #18 AND PROBES FOR
FREQUENCY & DURATION AND RECORD ON DIAGNOSIS GUIDE]. IF FATIGUE OR
LOSS OF ENERGY IS PRESENT, ASK]: HAVE YOU BEEN FEELING (E.G., FATIGUED,
LOW ON ENERGY) MOST OF THE TIME? HOW LONG HAVE YOU BEEN FEELING
LIKE THAT?
0 --- NO SIGNIFICANT FATIGUE OR LOS OF ENERGY (DURATION = N)
1 --- FATIGUE OR LOW ENERGY SOME DAYS (DURATION = ______WEEKS)
2 --- FATIGUE OR LOW ENERGY MOST DAYS (DURATION = ______WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________

9

CURRENT DEPRESSION SYMPTOMS
#
20

GUILT, WORTHLESSNESS, AND LOW SELF-ESTEEM
[REQ]

FOR THE PAST WEEK, HAVE YOU BEEN THINKING THAT YOU’VE DONE
SOMETHING BAD OR WRONG, OR THAT YOU’VE LET OTHER PEOPLE DOWN IN
SOME WAY

[REQ]

HAVE YOU BEEN FEELING GUILTY ABOUT ANYTHING?

[OPT]

HAVE YOU BEEN THINKING THAT YOU BROUGHT {e.g., YOUR PROBLEMS, YOUR
HEART FAILURE, YOUR HEART DISEASE, DEPRESSION, etc.} ON YOURSELF?
THAT IT’S YOUR FAULT? DOES IT SEEM LIKE YOU’RE BEING PUNISHED?

[REQ[

[IF YES]: HAVE YOU BEEN FEELING GUILTY MOST OF THE TIME?

CODE

HRSD

DSM-IV

DURATION

DSM-IV
DYSTH: 2

DURATION

HOW LONG HAVE YOU BEEN FEELING LIKE THAT?

[REQ]

[RATE SEVERITY OF GUILT THIS WEEKS AND RECORD ON HRSD TALLY SHEET]:

HRSD

0 --- ABSENT; PT DOES NOT FEEL GUILTY
1 --- PT FEELS SOMEWHAT GUILTY, EXPRESSES SELF-REPROACH, THINKS
S/HE HAS LET OTHER PEOPLE DOWN
2 --- PT FEELS VERY GUILTY OR IS RUMINATING ABOUT PAST ERRORS OR
SINFUL DEEDS
3 --- PT BELIEVES THAT S/HE IS ACTUALLY BEING PUNISHED IN SOME WAY(EG,
AS IF FEELING BAD OR BEING ILL IS PUNISHMENT FOR A SIN, MISTAKE,
ETC.); OR DELUSIONAL GUILT {EG, IRRATIONALLY BLAMESSELF FOR
PROBLEMS, REAL OR IMAGINED, THAT PROBABLY AREN’T HER FAULT).
4 --- PT HAS ACCUSATORY OR DENUNCIATORY HALLUCINATIONS
21

[REQ]

OVER THE LAST WEEK, HAVE YOU BEEN: {CRITICIZING, COMING DOWN PRETTY
HARD ON} YOURSELF? FEELING WORTHLESS AND INADEQUATE?

[OPT]

HAVE YOU BEEN PUTTING YOURSELF DOWN? THINKING THAT YOU DON’T LIKE
YOURSELF VERY MUCH?

[REQ]

[IF YES]: HAVE YOU BEEN FEELING GUILTY MOST OF THE TIME?
HOW LONG HAVE YOU BEEN FEELING LIKE THAT?

[REQ]

[RATE PT’S SELF-ESTEEM,BASED ON RESPONSES TO THIS ITEM, PROBES FOR
SEVERITY & DURATION, & YOUR OBSERVATIONS THROUGHT THE INTERVIEW
AND RECORD ON DIAGNOSIS GUIDE]:
0 --- PT HAS GOOD SELF-ESTEEM; MAY OCCASIONALLY HAVE NEGATIVE
THOUGHTS ABOUT SELF, BUT GENERALLY LIKE AND ACCEPTSSELF
(DURATION = N)
1 --- PT HAS FAIR SELF-ESTEEM; SOMETIMES DISLIKES, DISAPPROVES OF, IS
DISAPPOINTED IN, OR IS CRITICAL OF SELF (DURATION = _____YEARS)
2 --- PT HAS LOW SELF-ESTEEM; FREQUENTLY OR STRONGY DISLIKES,
DISAPPROVES OF, IS DISAPPOINTED IN, OR IS CRITICAL OF SELF
(DURATION = _____YEARS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)

10

CURRENT DEPRESSION SYMPTOMS
#
22

GUILT, WORTHLESSNESS, AND LOW SELF-ESTEEM
[REQ
]

[RATE EXCESSIVE OR INAPPROPRIATE GUILT OR FEELINGS OF
WORTHLESSNESS, BASED ON ITEMS 20-21 AND PROBES FOR FREQUENCY &
DURATION AND RECORD ON DIAGNOSIS GUIDE]. IF PRESENT, ASK: HAVE YOU
BEEN FEELING (E.G., GUILTY, WORTHLESS, ETC.) MOST OF THE TIME? HOW LONG
HAVE YOU BEEN FEELINGLIKE THAT?

CODE

HRSD

DSM-IV

DURATION

DSM-IV
MAJOR: 2
MINOR: 2

DURATION

0 --- DOES NOT FEEL WORTHLESS OR EXCESSIVELY OR INAPPROPRIATELY
GUILTY (DURATION = N)
1 --- FEELS WORTHLESS OR EXCESSIVELY OR INAPPROPRIATELY GUILTY SOME
DAYS (DURATION = ______WEEKS)
2 --- FEELS WORTHLESS OR EXCESSIVELY OR INAPPROPRIATELY GUILTY MOST
DAYS (DURATION = ______WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________

11

CURRENT DEPRESSION SYMPTOMS
HOPELESSNESS AND SUICIDAL FEATURES
23

[REQ]

OVER THE LAST 2 WEEKS, HAVE YOU BEEN FEELING DISCOURAGED OR
PESSIMISTIC ABOUT THE FUTURE? HAVE YOU FELT HOPELESS?

[OPT]

[IFYES]: WHAT ARE YOU FEELING {e.g., DISCOURAGED, HOPELESS, ETC.}
ABOUT? HOW SURE ARE YOU THAT THINGS WON’T GET BETTER?

[REQ[

[RATE FEELINGS OF HOPELESSNESS BASED ON THIS ITEM AND PROBES FOR
FREQUENCY & DURATION AND RECORD ON DIAGNOSIS GUIDE]. IF FEELING
HOPELESS, ASK: HAVE YOU BEEN FEELING HOPELESS MOST OF THE TIME?
HOW LONG HAVE YOU BEEN FEELING THAT WAY?

CODE

HRSD

DSM-IV

DURATION

DSM-IV
DYSTH: 2

DURATION

0 --- NOT FEELING HOPELESS (DURATION = N)
1 --- FEELS HOPELESS SOME DAYS (DURATION = _____WEEKS)
2 --- FEELS HOPELESS MOST DAYS (DURATION = _____ WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
24

[REQ]

THIS PAST 2 WEEKS, HAVE YOU BEEN THINKING ABOUT DEATH OR DYING?

[OPT]

[IF YES]: ARE YOU AFRAID OF THAT? LOOKING FORWARD TO IT?

[REQ]

HAD ANY THOUGHTS THAT LIFE IS NOT WORTH LIVING ANYMORE?

[REQ]

ANY THOUGHTS THAT YOU’D BE BETTER OFF DEAD, OR THAT YOUR {SPOUSE,
FAMILY} WOULD BE BETTER OFF?

[REQ]

HAVE YOU HAD ANY THOUGHT OF HURTING OR KILLING YOURSELF?

REQ]

[IF YES]: WHAT HAVE YOU BEEN THINKING ABOUT DOING?

REQ]

[IF YES} DO YOU THINK YOU MIGHT ACTUALLY DO THAT?
HAVE YOU MADE ANY PLANS TO DO THIS? HOW SOON?
DO YOU ACTUALLY HAVE THE {e.g., PILLS, WEAPON} YOU’D NEED?

REQ]

[IF YES]: HAVE YOU ACTUALLYDONE ANYTHING TO HURT YOURSELF {OR TO
TRY TO KILL YOURSELF}?

12

CURRENT DEPRESSION SYMPTOMS
#
24

HOPELESSNESS AND SUICIDAL FEATURES
[REQ]

[RATE THE SEVERITY OF CURRENT SUICIDAL FEATURES AND RECORD ON HRSD
TALLY SHEET]:

CODE

HRSD

DSM-IV

DURATION

DSM-IV

DURATION

HRSD

0 --- ABSENT
1 --- PT FEELS LIFE IS NOT WORTH LIVING OR THAT SHE (OR FAMIY) WOULD BE
BETTER OFF IF S/HE WERE DEAD
2 --- PT. WISHES S/HE WERE DEAD
3 --- PT IS ACTIVELY THINKING ABOUT, PLANNING TO, OR PREPARING TO
ATTEMPT SUICIDE, OR HAS MADE A NON-LETHAL SUICIDAL GESTURE (e.g.,
TAKING A FEW PILLS) WITHIN THE PAST WEEK
4 --- PT HAS ACTUALLY ATTEMPTED SUICIDE THIS WEEK
25

[REQ]

[RATE CURRENT SUICIDAL FEATURES, BASED ON ITEM #24 AND PROBES FOR
FRQUENCY & DURATION AND RECORD ON DIAGNOSIS GUIDE]
0 --- NO SUICIDAL IDEATION OR BEHAVIOR. PATIENT MAY HAVE OCCASIONAL, NORMAL
(NON-MORBID) THOUGHTS ABOUT DEATH AND DYING (E.G., IS AFRAID OF DYING), BUT DOES
NOT DWELL ON THE SUBJECT. RISK OF A SUICIDE ATTEMPT APPEARS NEGLIGIBLE AT THIS
TIME (DURATION = N)
1 --- MINIMAL SUICIDAL IDEATION OR BEHAVIOR. PATIENT MAY HAVE OCCASIONAL
THOUGHT ABOUT “BEING BETTER OFF DEAD” OR PASSING THOUGHTS ABOUT SUICIDE, BUT
DENIES ANY DESIRE, INTENT, PLANS, OR MEANS TO ATTEMPTSUICIDE, AND DOES NOT DWELL
ON THOUGHTS OF DEATH, DYING, OR SUICIDE. RISK OF A SUICIDE ATTEMPT APPEARS MINIMAL
(DURATION = ____WEEKS)
2 --- SIGNIFICANT SUICIDAL IDEATION OR BEHAVIOR. PATIENT HAS ONE OR MORE OF
THE FOLLOWING: RECURRENT THOUGHTS OF DEATH (NOT JUST FEAR OF DYING), FREQUENT
THOUGHTS OF “BEING BETTTER OFF DEAD”, RECURRENT SUICIDAL IDEATION, A SPECIFIC
PLAN FOR COMMITTING SUICIDE, OR HAS RECENTLY ATTEMPTED SUICIDE. RISK OF A SUICIDE
ATTEMPT IS SIGNIFICANT (DURATION = ____WEEKS).
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________

26

[REQ]

SUICIDE RISK ASSESSMENT, ACTION PLAN & DOCUMENTATION
[IF PT HAS SIGNIFICANT SUICIDAL IDEATION OR BEHAVIOR (I.E., ITEM #25 = 2,
CIRCLE “A” OR “B”]:
A.
B.

[REQ]

PATIENT IS AT IMMINENT RISK OF ATTEMPTING SUICIDE WITHIN HOURS
OR DAYS
PATIENT IS AT ELEVATED RISK OF ATTEMPTING SUICIDE AT SOME POINT,
BUT PROBABLY NOT IMMEDIATELY.

NOTIFY THE PRINCIPAL INVESTIGATOR AND/OR PSYCHIATRIC LIAISON MD AND
DOCUMENT YOUR ACTIONS BELOW, INCLUDING DATE/TIME OF NOTIFICATION:
IF PATIENT IS AT IMMINENT RISK OF ATTEMPTING SUICIDE, FOLLOW YOUR
SITE’S IMMINENT SUICIDE RISK PLAN AND DOCUMENT YOUR ACTIONS IN THE
PATIENT’S RESEARCH FILE (NOT IN HIS/HER HOSPITAL CHART)
IF PATIENT IS AT INCREASED RISK OF ATTEMPTING SUICIDE SOMETIME IN THE
FUTURE, FOLLOW YOUR SITE’S NOTIFICATION PLAN FOR ACTIVE SUICIDAL
IDEATIONN AND DOCUMENT YOUR ACTIONS IN THE PATIENT’S RESEARCH FILE
(NOT IN HIS/HER HOSPITAL CHART

13

CURRENT DEPRESSION SYMPTOMS
COGNITIVE AND SOMATIC FEATURES
27

[REQ]

DURING THE PAST WEEK, HAVE YOU HAD TROUBLE CONCENTRATING?

[OPT]

HAVE YOU BEEN LOSING YOUR TRAIN OF THOUGHT, LIKE YOUR MIND IS OFF
SOMEWHERE ELSE?

[OPT]

HAVE YOU BEEN HAVING A HARD TIME {KEEPING YOUR MIND ON, PAYING
ATTENTION TO} CONVERSATIONS, TV PROGRAMS, THE BOOKS OR MAGAZINES
YOUR READING, ETC.?

[OPT]

HAS IT SEEMED AT TIMES LIKE YOUR THOUGHTS ARE MIXED UP OR
CONFUSED?

[REQ]

LATELY, HAS IT BEEN VERY HARD FOR YOU TO MAKE DECISIONS OR
CHOICES? EVEN SMALL ONES?

[REQ]

[RATE IMPAIRED CONCENTRATION AND/OR INDECISIVENESS, BASED ON THIS
ITEM, PROBES FOR FREQUENCY & DURATION, AND YOUR OBSERVATIONS
DURING THE INTERVIEW AND RECORD ON THE DIAGNOSIS GUIDE]: IF PRESENT,
ASK: HAVE YOU BEEN HAVING TROUBLE (E.G., CONCENTRATING, MAKING
DECISIONS) MOST OF THE TIME LATELY? HOW LONG HAS THAT BEEN
HAPPENING?

CODE

HRSD

DSM-IV

DURATION

DSM-IV
MAJOR: 2
MINOR: 2
DYSTH: 2

DURATION

0 --- NO SIGNIFICANT COGNITIVE IMPAIRMENT (DURATON = N)
1 --- DIMINISHED ABILITY TO CONCENTRATE OR MAKE DECISIONS SOME DAYS
(DURATION = ____WEEKS)
2 --- DIMINISHED ABILITY TO CONCENTRATE OR MAKE DECISIONS MOST DAYS
(DURATION = ____WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________
28

[REQ]

OVER THE PAST WEEK, HAVE YOU BEEN WORRYING A LOT? ABOUT BIG
PROBLEMS, OR ABOUT LITTLE THINGS THAT YOU DON’T ORDINARILY WORRY
MUCH ABOUT? [IF YES]: LIKE WHAT, FOR EXAMPLE?

[REQ]

[RATE SEVERITY OF COGNITIVE ANXIETY THIS WEEK]

HRSD

0 --- PT IS NOT WORRIED OR ANXIOUS
1 --- PT IS WORRIED, ANXIOUS, OR APPREHENSIVE, BUT THIS IS APPARENT ONLY
IN PT’S ANSWERS TO THIS ITEM
2 --- PT IS WORRIED, ANXIOUS OR APPREHENSIVE, AND THIS IS APPARENT NOT
ONLY IN ANSWERS TO THIS ITEM BUT IN SOME OF PT’S OTHER STATEMENTS
AS WELL.
3 --- PT IS WORRIED, ANXIOUS OR APPREHENSIVE, AND THIS IS APPARENT NOT
ONLY IN PT.’S VERBAL ANSWERS TO BUT ALSO IN HIS/HER FACIAL
EXPRESSIONS, VOICE, ETC.
4 --- PT IS SO SEVERELY WORRIED, ANXIOUS OR APPREHENSIVE THAT THIS IS
OBVIOUS, BOTH VERBALLY AND NONVERBALLY.

14

CURRENT DEPRESSION SYMPTOMS
COGNITIVE AND SOMATIC FEATURES
29

[REQ]

IN THE PAST 2 WEEKS, HAVE YOU BEEN FEELING PHYSICALLY TENSE OR
NERVIOUS? [IF YES]: HOW {TENSE, NERVOUS} HAVE YOU BEEN?

[OPT]

DO YOU KNOW WHAT’S BEEN MAKING YOU FEEL THIS WAY?

OPT]

WHEN YOU’RE FEELING {TENSE, NERVOUS} DO YOU GET ANY OTHER
SYMPTOMS LIKE DRY MOUTH, INDIGESTION, HEART PALPITATIONS,
HYPERVENTILATION, SWEATING, FREQUENCY OF URINATION, ETC.?

[REQ]

[BASED ON THIS ITEM AND ON YOUR OWN OBSERVATIONS, RATE SEVERITY OF
SOMATIC ANXIETY THIS WEEK:

CODE

HRSD

DSM-IV

DURATION

HRSD

0 --- ABSENT
1 --- MINIMAL (ONLY APPARENT IN VERBAL ANSWERS TO THIS ITEM)
2 --- MODERATE (PT REPORTS BOTHERSOME SYMPTOMS, MAY LOOK TENSE OR
NERVOUS)
3 --- SEVERE (PT REPORTS SEVERE SYMPTOMS; LOOKS VERY TENSE OR
NERVOUS)
4 --- INCAPACITATING (PT IS DEBILITATED BY NERVOUSNESS)
30

[REQ]

IN THE WEEK, HOW MUCH HAVE YOUR THOUGHTS BEEN FOCUSED ON YOUR
PHYSICAL HEALTH OR HOW YOUR BODY IS WORKING?

[OPT]

HAVE YOU BEEN WORRYING A LOT ABOUT {BEING, BECOMING} ILL?

[OPT]

HAVE YOU BEEN COMPLAINING A LOT ABOUT YOUR HEALTH PROBLEMS OR
ABOUT HOW YOU FEEL PHYSICALLY?

[OPT]

HAVE YOU FOUND YOURSELF ASKING FOR HELP WITH THINGS YOU COULD
REALLY DO FOR YOURSELF? [IF YES:] LIKE WHAT, FOR EXAMPLE?
HOW OFTEN HAS THAT HAPPENED?

[REQ]

[RATE THE CURRENT SEVERITY OF HYPOCHONDRIACAL CONCERNS &
BEHAVIOR. FOR PTS WHO ARE CLEARLY MEDICALLY ILL, A RATING OF 1 OR 2 IS
NOT EXCEPTIONAL; A 3 OR 4 WOULD INDICATE HYPOCHONDRIACAL CONCERNS
OR BEHAVIORS THAT ARE EXCESSIVE EVEN FOR SOMEONE WHO IS MEDICALLY
ILL AND RECORD ON HRSD TALLY SHEET].

HRSD

0 --- PT IS NOT WORRIED ABOUT HEALTH
1 --- PT IS SOMEWHAT WORRIED OR CONCERNED ABOUT HEALTH
2 --- PT IS PREOCCUPIED WITH WORRIES OR CONCERNS ABOUT HEALTH,
ILLNESS, OR MEDICAL CARE
3 --- PT IS VERY WORRIED AND PREOCCUPIED WITH HEALTH-RELATED
CONCERNS, OR FREQUENTLY COMPLAINS ABOUT HEALTH, OR REQUESTS
HELP IN EXCESS OF NEED (GIVEN MEDICAL CONDITION), ETC.
4 --- PT HAS HYPOCHONDRIACAL DELUSIONS (E.G., IRRATIONALLY BELIEVES,
WITHOUT EVIDENCE, SHE HAS A SERIOUS DISEASE).

15

CURRENT DEPRESSION SYMPTOMS
COGNITIVE AND SOMATIC FEATURES
31

[REQ]

HOW HAS YOUR INTEREST IN SEX BEEN THIS WEEK?

[OPT]

I’M NOT ASKING ABOUT YOUR ACTUAL SEXUAL ACTIVITY, BUT ABOUT YOUR
INTEREST IN SEX – HOW MUCH YOU THIK ABOUT IT. HAVE YOU HAD LESS
INTEREST IN SEX LATELY THAN YOU USUALLY DO?

[OPT]

[IF PT HAS NO PARTNER, ADD IF APPROPRIATE]: DO YOU THINK YOU’D BE
INTERESTED IN SEX IF YOU MET SOMEONE SPECIAL?

[OPT

[IF FRIGHTENED ABOUT SEX DUE TO PHYSICAL HEALTH]: IF YOU WERE SURE
THAT IT WAS SAFE FOR YOUR TO HAVE SEX AGAIN, HOW MUCH INTEREST DO
YOU THINK YOU WOULD HAVE?

[REQ]

[RATE SEVERITY OF LOSS OF INTEREST IN SEX]

CODE

HRSD

DSM-IV

DURATION

HRSD

0 --- NO REAL LOSS OF INTEREST IN SEX COMPARED TO USUAL LEVEL
1 --- MILD LOSS OF INTEREST IN SEX
2 --- SEVERE LOSS OF INTEREST IN SEX

16

CURRENT DEPRESSION SYMPTOMS
#
32

[REQ]

OBSERVATONS DURING INTERVIEW
[OBSERVE PT’S PSYCHOMOTOR BEHAVIOR]

CODE

HRSD

DSM-IV

DURATION

DSM-IV
MAJOR: 2
MINOR: 2

DURATION

PSYCHOMOTOR RETARDATION IS PREENT IF PT TAKES A LONG TIME TO
RESPOND TO QUESTIONS, TALKS SLOWLY WITH NUMEROUS PAUSES OR
HESITATIONS, MOVES AS IF IN SLOW MOTION (MORE THAN PHYSICAL
CONDITION WARRANTS), ETC.
PSYCHOMOTOR AGITATION IS PRESENT IF PT IS RESTLESS, OVERACTIVE,
EDGY, FIDGETY, UNABLE TO SIT STILL.]
[REQ]

[IF TELEPHONE INTERVIEW]
DO YOU FEEL SLUGGISH? DOES IT SEEM LIKE YOU’RE TALKING & MOVING IN
SLOW MOTION? LIKE YOUR THOUGHTS ARE VERY SLOW IN COMING TO YOU?
ARE YOU FEELING RESTLESS OR HAVING TROUBLE SITTING STILL?
FIDGETING?

33

[REQ]

[RATE CURRENT PSYCHOMOTOR RETARDATION AND RECORD ON HRSD
TALLY SHEET]:
0 --1 --2 --3 --4 ---

34

[REQ]

35

[REQ]

NORMAL SPEECH, THOUGHT, SPEED OF BEAVHIOR, ETC.
SLIGHT RETARDATION AT INTERVIEW
OBVIOUS RETARDATION AT INTERVIEW
RETARDATION SO SEVERE THAT PT IS DIFFICULT TO INTERVIEW
PT IS STUPOROUS, UNRESPONSIVE TO MOST QUESTIONS

[RATE CURRENT PSYCHOMOTOR AGITATION AND RECORD ON HRSD TALLY
SHEET]:
0 --1 --2 --3 --4 ---

HRSD

HRSD

NOT AGITATED
PT IS EDGE OR MILDLY RESTLESS
PT IS FIDGETY OR UNCOMFORTABLY RESTLESS
PT IS OVERACTIVE, UNABLE TO SIT STILL
PT IS STRIKINGLY AGITATED, EG., RELENTLESSLY PACING, WRINGING
HAND, BITING NAILS OR LIPS, PULLING HAIR, ETC.

[RATE PT’S PSYCHOMOTOR BEHAVIOR AND RECORD ON DIAGNOSIS GUIDE]:
[IF AGITATION OR RETARDATION IS PRESENT, TRY(WITHIN THE LIMITS OF
FEASIBILITY), TO USE THE BEST AVAILABLE SOURCES OF INFORAMTION
(INCLUDING PT, CAREGIVERS, ETC.) TO ASSESS FREEQUNCY & DURATION. IF
YOU OBSERVE PSYCHOMOTOR SIGNS BUT ARE UNABLE TO ESTIMATE THE
FREQUENY OR DURATION, ENTER A ‘1” IN THE DSM-IV COLUMN AND A “U” IN
THE DURATION COLUMN.]
0 --- NO SIGNIFICANT PSYCHOMOTOR SIGNS OBSERVED (DURATION = N)
1 --- PSYCHOMOTOR RETARDATION OR AGITATION OBSERVED, BUT IT IS MILD
AND/OR HAS BEEN PRESENT ONLY SOME DAYS (DURATION =
_____WEEKS)
2 --- PSYCHOMOTOR RETARDATION OR AGITATION OBSERVED, AND IT HAS
BEEN PRESENT ON MOST OF THE DAYS PRECEDING THE INTERVIEW
(DURATION = ______WEEKS)
M --- MEDICAL SX ONLY (DURATION = WEEKS)
R --- REFUSED (DURATION = R)
U --- UNABLE TO ASSESS (DURATION = U)
DURATION IN DAYS IF < 2 WEEKS: ________

17

CURRENT DEPRESSION SYMPTOMS
#
36

OBSERVATONS DURING INTERVIEW
[REQ]

CODE

[RATE PT’S LEVEL OF INSIGHT (OR LACK OF INSIGHT) INTO HIS/HER
DEPRESSION. NOTE THAT THERE ARE TWO DIFFERENT WAYS TO SCORE A
ZERO ON THIS ITEM]: RECORD SCORE ON HRSD TALLY SHEET:

HRSD

DSM-IV

DURATION

HRSD

0 --- PT IS NOT DEPRESSED (IN INTERVIEWER’S JUGEMENT)
0 --- PT IS DEPRESSED (IN INTERVIEWER’S JUGEMENT), AND IS AWARE OF
(AND ACKNOWLEDGES) BEING DEPRESSED
1 --- PT IS DEPRESSED (IN INTERVIEWER’S JUGEMENT), AND ALTHOUGH THE
PT. ADMITS TO HAVING SOME DEPRESSIVE SYMPTOMS, S/HE DENIES
BEING DEPRESSED OR BLAMES THE SYMPTOMS ON UNLIKELY CAUSES
2 --- PT IS DEPRESSED (IN INTERVIEWER’S JUGEMENT), AND IS SO SEVERELY
DEPRESSED THAT S/HE BELIEVES HIS/HER CURRENT STATE IS
SOMETHING OTHER THAN (AND PERHAPS MUCH WORSE THAN)
DEPRESSION (E.G., PT BELIVES S/HE IS DOOMED, CURSED, OR NEAR
DEATH).

37

[DSM-IV DISTRESS OR FUNCTIONAL IMPAIRMENT CRITERION]
[REQ]

CODE

[IF YOU BELIEVE THAT THE PT IS CURRENTLY DEPRESSED, DOES THE
DEPRESSION APPEAR TO BE CAUSING THE PATIENT ANY EMOTIONAL
DISTRESS OR IS IT HAVING ANY ADVERSE EFFECTS ON THE PATIENT’S DAYTO-DAY SOCIAL OR OCCUPATIONAL FUNCTIONING, ABILITY TO CARE FOR
SELF, ABILITY TO COPE WITH PROBLEMS, ETC.?}
0 --- NO
1 --- YES (DESCRIBE)
N --- NOT APPLICABLE (PT IS NOT DEPRESSED)
U --- UNABLE TO ASSESS

38

[REQ]

[NOTE WHETHER DURING THE INTERVIEW, YOU OBSERVED SIGNS OF ANY
MAJOR NEUROPSYCHIATRIC PROBLEMS
EXAMPLES OF EXCLUSIONARY NEUROPSYCHIATRIC PROBLEMS::
PARANOIA, DELUSIONS, HALLUCINATIONS, HYPOMANIA OR MANIA, BIZARRRE
BEHAVIOR, LANGUAGE DEFICITS, DEMENTIA, CONFUSION

18

SCREENING & BASELINE ASSESSMENT
ITEM
39

[REQ]

HAVE YOU EVER BEEN DEPRESSED BEFORE {OTHER THAN THIS TIME}?

CODE
CODE

0 --- NO
1 --- YES
R – REFUSED
U – UNABLE TO ASSESS
40

[REQ]

[IF YES TO ITEM #39: PROBE TO ESTIMATE PROBABLE NUMBER OF PRIOR MAJOR DEPRESSIVE EPISDOES. FOR
EACH REPORTED PERIOD OF DEPRESSION, BRIEFLY ASSESS WHETHER IT LASTED AT LEAST 2 WEEKS, AND
WHETHER IT WAS PROBABLY A MAJOR DEPRESSIVE EPISODE. COUNT IT AS A PROBABLE MAJOR DEPRESSIVE
EPISODE IF PT RECALLS NOT ONLY FEELING DEPRESSED BUT ALSO THAT 1) DEPRESSION WAS BAD ENOUGH TO
AFFECT FUNCTIONING IN SOME WAY (EG., MAKING IT HARDER TO HANDLE WORK OR INTERPERSONAL
RELATIONSHIPS), AND/OR 2) THAT SOME OTHER DEPRESSIVE SYMPTOMS WERE PROBABLY PRESENT AT THE
SAME TIME AS WELL, SUCH AS:
ANHEDONIA
APPETITE CHANGE
WEIGHT CHANGE

[REQ]

SLEEP DISTURBANCE,
AGITATION OR RETARDATION,
FATIGUE OR LOSS OF ENERGY

CODE

FEELING WORTHLESS OR GUILDY POOR
CONCENTRATION OR INDECISION
SUICIDAL IDEATION

RECORD THE PROBABLY NUMBER OF PRIOR MAJOR DEPRESSIVE EPISODES
0 --- NONE
# --- NUMBER OF PROBABLE MAJOR DEPRESSIV EPISODES
R--- REFUSED
U---UNABLE TO ASSESS

41

[REQ]

[IF ANY PRIOR EPISODES]: HOW OLD WERE YOU {THE FIRST TIME}?

CODE

# --- AGE AT ONSET OF FIRST (PRIOR) EPISODE OF MAJOR DEPRESSION
N --- NOT APPLICABLE (NO PRIOR EPISODES)
R --- REFUSED
U --- UNABLE TO ASSESS
42

[REQ]

IF MORE THAN ONE PRIOR EPISODE: HOW OLD WERE YOU THE LAST TIME {BEFORE THIS}?

CODE

# --- AGE AT ONSET OFLAST (PRIOR) EPISODE OF MAJOR DEPRESSION
N --- NOT APPLICABLE (<2 PRIOR EPISODE)
R --- REFUSED
U --- UNABLE TO ASSESS
43

[REQ]

[IF ANY PRIOR EPISODES]: WERE YOU EVER TREATED FOR DEPRESSION DURING ANY OF THESE TIMES?

CODE

YES

CODE

YES

IF YES, DETERMINE WHICH TREATMENT MODALITIES THE PT EVER RECEIVED FOR PAST DEPRESSIVE
EPISODES. WRITE “1” IN THE CORRESPONDING BOXES TO THE RIGHT (OR CODE ZERO, N, R, OR U).
A. PSYCHOTHERAPY OR COUNSELING
B. ANTIDEPRESSANT MEDICATION
C. ECT (ELECTROCONVULSIVE OR SHOCK THERAPY)
D. PSYCHIATRIC HOSPITALIZATION
44

REQ

ARE YOU CURRENTLY BEING TREATED FOR DEPRESSION {OR TAKING AN ANTIDEPRESSANT}? IF YES,
DETERMINE WHICH MODALITIES THE PT EVER RECEIVED. CHECK THE YES BOX IF YES ONLY. LEAVE BLANK IF
“NO”. USE ABOVE CODES (N,R,U) IF APPLICABLEA.

PSYCHOTHERAPY OR COUNSELING

B.

1.

ANTIDEPRESSANT MEDICATION ((Write Drug name here): _________________________________

2.

NUMBER OF WEEKS ON ANTIDEPRESSANT

3.

DATE ANTIDEPRESSANT STARED (IF < 2 WEEKS AGO):

19

SCREENING & BASELINE ASSESSMENT
ITEM
45

[REQ]

[IF PT HAS HAD 2 OR MORE PRIOR DEPRESSIVE EPISODES]:
HAVE YOU EVER BEEN TOLD BY A PSYCHIATRIST THAT YOU HAVE MANIC DEPRESSION?

CODE
CODE

0 --- NO
1 --- YES
N – NOT APPLIABLE
R – REFUSED
U – UNABLE TO ASSESS

[REQ]

HAS ANYONE IN YOUR IMMEDIATE FAMILY EVER BEEN DEPRESSED FOR TWO WEEKS OR LONGER? [IF YES,
PROBE FOR THE NEMBER OF AFFECTED 1ST DEGREE BIOLOGICAL RELATIVES (PARENTS, SIBLINGS, CHILDREN)
IN THE CODE COLUMN, RECORD THE NUMBER OF THOSE WITH UNIPOLAR DEPRESSION, AND IN THE SPACE
BELOW, WRITE A NOTE ABOUT ANY RELATIVE WHO REPORTEDLY HAS/HAD MANIC DEPRESSION (BIPOLAR
DISORDER).
0 –-- NONE
# --- NUMBER OF AFFECTED 1ST DEGREE RELATIVES WITH UNIPOLAR DEPRESSION
R --- REFUSED
U --- UNABLE TO ASSESS

46

47

[REQ]

HAVE YOU EVER BEEN TREATED FOR ANY OTHER PSYCHIATRIC DISORDER OR EMOTIONAL PROBLEM?

[REQ]

HAVE YOU HAD ANY PROBLEMS WITH DRUGS OR ALCOHOL?
[IF YES]: WHAT PROBLEMS? WHEN? ARE YOU STILL HAVING THESE PROBLEMS? ARE YOU BEING TEATED FOR
THEM?

[REQ]

[RATE PSYCHIATRIC HISTORY OTHER THAN UNIPOLAR DEPRESSION. IF THE PATIENT HAS MORE THAN ONE
PSYCHIATRIC PROBLEM, CHOOSE THE HIGHEST APPLICABLE RATING]
0 --- NO OTHER PSYCH PROBLEMS REPORTED
1 --- PT REPORTS OTHER PSYCHIATRIC PROBLEMS THAT ARE CLEARLY NOT GROUND FOR EXCLUSION FROM
THE TRIAL (e.g., ANXIETY, ORDINARY ADJUSTMENT PROBLEMS, POST-TRAUMATIC STRESS DISORDER, ETC.)
2 --- PT REPORTS OTHER PSYCH PROBLEMS THAT MIGHT REQUIRE EXCLUSION (e.g. PAST HISTORY OF DRUG
ADDICTION, PREVIOUS TREATMENT FOR PSYCHOSIS, etc.)
3 --- PT REPORTS OTHER PSYCH PROBLEMS THAT DEFINITELY WILL REQUIRE EXCLUSION FROM THE TRIAL (e.g.,
ACTIVE ALCOHOLISM OR DRUG ADDICTION, SCHIZOPHRENIA, BIPOLAR (MANIC) DEPRESSION, etc..)
R --- REFUSED
U --- UNABLE TO ASSESS

20

DSM-IV DIAGNOSIS GUIDE
CURRENT SX
[OPTIONAL]
COPY DSM-IV CODES
AND DURATIONS FROM
THE CURRENT
DEPRESSION SYMPTOM
ITEMS TO THE BOXES
BELOW, AS NEEDED TO
DETERMINE WHETHER
THE PT. CURRENTLY
MEETS THE CRITERIA
FOR A DEPRESSIVE
DISORDER

MAJOR DEPRESSION

MINOR DEPRESSION

DYSTHYMIA

AT LEAST 5 OF THE
SYMPTOMS LISTED
BELOW HAVE
SIMULTANEOUSLY BEEN
PRESENT DURING THE
SAME 2 – WEEK PERIOD
AT THE FREQUENCY OR
SEVERITY RATING
LISTED IN THIS COLUMN

AT LEAST 2 BUT LESS
THA N 5 OF THE
SYMPTOMS LISTED
BELOW HAVE
SIMULTANEOUSLY BEEN
PRESENT DURING THE
SAME 2-WEEK PERIOD
AT THE FREQUENCY OR
SEVERITY RATING
LISTED IN THIS COLUMN

DEPRESSED MOOD MUST
HAVE BEEN PRESENT
MOST OF THE DAY, MORE
DAYS THAN NOT, FOR AT
LEAST 2 YEARS.

THE SYMPTOMS MUST
REPRESENT A CHANGE
FROM PREVIOUS
FUNCTIONING
AT LEAST ONE OF THE
SUMPTOMS MUST BE
EITHER DEPRESSED
MOOD OR ANHEDONIA
THE SYMPTOMS MUST
CAUSE SIGNIFICANT
DISTRESS OR
IMPAIRMENT IN SOCIAL,
OCCUPATIONAL, OR
OTHER IMPORTANT
AREAS OF FUNCTIONING

---

FREQ/
SEVER.
CODE

DURATION
D = DAYS
W = WEEKS

THE SYMPTOMS MUST
REPRESENT A CHANGE
FROM PREVIOUS
FUNCTIONING
AT LEAST ONE OF THE
SYMPTOMS MUST BE
EITHER DEPRESSED
MOOD OR ANHEDONIA
THE SYMPTOMS MUST
CAUSE SIGNIFICANT
DISTRESS OR
IMPAIRMENT IN SOCIAL,
OCCUPATIONAL, OR
OTHER IMPORTANT
AREAS OF FUNCTIONING

AT LEAST 2 OF THE
OTHER SYMPTOMS MUST
HAVE BEEN
SIMULTANEOUSLY
PRESENT DURING THE
SAME 2-YEAR PERIOD AT
THE FREQUENCY OR
SEVERITY RATING LISTED
IN THIS COLUMN
DURING THIS PERIOD
LASTING AT LEAST TWO
YEARS, THE PATIENT HAS
NEVER BEEN WITHOUT
THE SYMPTOMS FOR
MORE THAN 2 MONTHS
AT A TIME.
THERE WERE NO MAJOR
DEPRESSIVE EPISODES
DURING THE TWO YEARS.

MAJOR DEPRESSION
COUNTS FOR
ELIGIBILITY AFTER AS
LITTLE AS ONE WEEK IF
THE PATIENT HAS A
PAST HISTORY OF
MAJOR DEPRESSION

MINOR DEPRESSION
COUNTS FOR
ELIGIBILITY ONLY IF THE
PATIENT HAS A PAST
HISTORY OF MAJOR
DEPRESSION

THE SYMPTOMS MUST
CAUSE SIGNIFICANT
DISTRESS OR
IMPAIRMENT IN SOCIAL,
OCCUPATIONAL, OR
OTHER IMPORTANT
AREAS OF FUNCTIONING

MINIMUM REQUIRED
FREQUENCY/SEVERITY
CODE

MINIMUM REQUIRED
FREQUENCY/SEVERITY
CODE

MINIMUM REQUIRED
FREQUENCY/SEVERITY
CODE

4.

ANHEDONIA

2

2

---

6.

DYSPHORIC MOOD

2

2

2

12. CHANGE IN APPETITE
OR WEIGHT

2

2

2

17. SLEEP DISTURBANCE

2

2

2

19. FATIGUE OR LOSS OF
ENERGY

2

2

2

21. POOR SELF-ESTEEM

---

---

2

22. GUILT OR
WORTHLESSNESS

2

2

---

23. HOPELESSNESS

---

---

2

25. SUICIDAL IDEATION

2

2

---

27. POOR CONCENTRATION
OR INDECISIVENESS

2

2

2

35. PSYCHOMOTOR
RETARDATION OR
AGITATION

2

2

---

40. PAST HX OF MAJOR
DEPRESSION

YES

NO

FINAL CLASSIFICATION AT THIS INTERVIEW:
NOT DEPRESSED: __________ MINOR DEPRESSION/DYSTHYMIA: ___________ MAJOR DEPRESSION ___________

21

HDRS TALLY SHEET

2

#

ITEM (DURING LAST 2 WEEKS)
WORK & ACTIVITIES

5

DEPRESSED MOOD

10

APPETITE – GI SOMATIC SYMPTOMS

11

WEIGHT LOSS

14

EARLY INSOMNIA

15

MIDDLE INSOMNIA

16

LATE INSOMNIA (EARLY AWAKENING)

18

FATIGUE OR LOW ENERGY

20

FEELINGS OF GUILT

24

SUICIDAL FEATURES

28

COGNITIVE ANXIETY

29

SOMATIC ANXIETY

30

HYPOCHONDRIASIS

31

LIBIDO

33

PSYCHOMOTOR RETARDATION

34

PSYCHOMOTOR AGITATION

36

INSIGHT

SCORE

TOTAL HRSD SCORE

22

VA Form 10-21085d (NR)

Name:

Marital Status:

Occupation:

Education:

Age:

Sex: -

Instructions: This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and
then pick out the one statement in each group that best describes the way you have been feeling during the past two
weeks, including today. Circle the number beside the statement you have picked. If several statements in the group
seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one
statement for any group, including Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).

1. Sadness
0
I do not feel sad.
1 I feel sad much of the time.
2
I am sad all the time.
3

I am so sad or unhappy that I can't stand it.

2. Pessimism
0
I am not discouraged about my future.
1 I feel more discouraged about my future than I
2
3

used to be.
1do not expect things to work out for me.
I feel my future is hopeless and will only get
worse.

3. Past Failure
0
I do not feel like a failure.
1
I have failed more than I should have.
2 As I look back, I see a lot of failures.
3
I feel I am a total failure as a person.

4. Loss of Pleasure
0
I get as much pleasure as I ever did from the
things I enjoy.
1
I don't enjoy things as much as I used to.
2 I get very little pleasure from the things I used
3

to enjoy.
I can't get any pleasure from the things I used
to enjoy.

5. Guilty Feelings
0
I don't feel particularly guilty.
1 I feel guilty over many things I have done or
2
3

6. Punishment Feelings
0
I don't feel I am being punished.
1
I feel I may be punished.
2 I expect to be punished.
3
I feel I am being punished.

7. Self-Dislike
0
I feel the same about myself as ever.
1

2
3

I have lost confidence in myself.
I am disappointed in myself.
I dislike myself.

8. Self-Criticalness
0
I don't criticize or blame myself more than usual.
1
I am more critical of myself than I used to be.
2
I criticize myself for all of my faults.
3
I blame myself for everything had that happens.
9. Suicidal Thoughts or Wishes
0
1

2
3

I don't have any thoughts of killing myself.
I have thoughts of killing myself, but I would
not carry them out.
I would like to kill myself.
I would kill myself if I had the chance.

10. Crying
0
I don't cry anymore than I used to.
1
I cry more than I used to.
2
3

I cry over every little thing.
I feel like crying, but I can't.

should have done.
I feel quite guilty most of the time.
I feel guilty all of the time.

-Subtotal Page 1
PSYCHOLOGICAL CORPORATIONN
@THE Hurcourt
Brace 6 Compa~zy

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.
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.ranworth .'romnto - ~ o n d a n .syduey

Copyright '996 by Aaron T. Beck
All rights reserved. Printed in the United States of America.

01 5401 8392

11. Agitation
0 I am no more restless or wound up thau usual.
1
2
3

I feel more restless or wound up than usual.
I am so restless or agitated that it's hard to stay
still.
I am so restless or agitated that I have to keep
moving or doing something.

12. Loss of Interest
0 I have not lost interest in other people or
1
2

3

activities.
I am less interested in other people or things
than before.
I have lost most of my interest in other people
or things.
It's hard to get interested in anything.

13. Indecisiveness
0
1
2

3

I make decisions about as well as ever.
I find it more difficult to make decisions than
usual.
I have much greater difficulty in making
decisions than I used to.
I have trouble making any decisions.

14. Worthlessness
I do not feel I am worthless
0
1 I don't consider myself as worthwhile and useful
2
3

as I used to.
I feel more worthless as compared to other
people.
I feel utterly worthless.

15. Loss of Energy
0
1
2

3

I have as much energy as ever.
I have less energy than I used to have.
I don't have enough energy to do very much.
I don't have enough energy to do anything.

17. Irritability
I am no more initable than usual.
0
1 I am more irritable thau usual.
I am much more imitable than usual.
2
3 I am imtable all the time.
18. Changes in Appetite
I have not experienced any change in my
0
la
1b
2a
2b
3a
3b

appetite.
My appetite is somewhat less than usual.
My appetite is somewhat greater than usual.
My appetite is much less than before.
My appetite is much greater than usual.
I have no appetite at all.
I crave food all the time.

19. Concentration Difficulty
I can concentrate as well as ever.
0
1 I can't concentrate as well as usual.
2

3

It's hard to keep my mind on anything for
very long.
I find I can't concentrate on anything.

20. Tiredness or Fatigue
I am no more tired or fatigued than usual.
0
1
2

3

I get more tired or fatigued more easily than
usual.
I am too tired or fatigued to do a lot of the things
I used to do.
I am too tired or fatigued to do most of the
things I used to do.

21. Loss of Interest in Sex
I have not noticed any recent change in my
0
1
2

3

interest in sex.
I am less interested in sex than I used to be.
I am much less interested in sex now,
I have lost interest in sex completely.

16. Changes in Sleeping Pattern
I have not experienced any change in my
0
sleeping pattern.
I sleep somewhat more than usual.
Ib I sleep somewhat less than usual.
2a I sleep a lot more than usual.
2b I sleep a lot less than usual.
3a I sleep most of the day.
3b I wake up 1-2 hours early and can't get back
to sleep.
la

N0TICE:This iorm is printed with both blue and black ink. If your
copy does not appear this way, it has been photocopied in
violation of coDvrioht IaQls.

-Subtotal Page 2
-Subtotal Page 1

VA Form 10-21085e (NR)

Peoplig sometimes look to others for companionship, assistance, Or Other types of support, W w v often
Is each ofme fallowing kinds sf support srvailabls to you if you need it?Circle me number on each line.