A clinician rated scale to rate the severity of depression.
For each item, circle the number to select the one "cue" that best characterizes the patient.

1. Depressed Mood (sadness, hopeless, helpless, worthless)
• 0 = Absent.
• 1 = These feeling states indicated only on questioning.
• 2 = These feeling states spontaneously reported verbally.
• 3 = Communicates feeling states nonverbally, i.e., through facial expression, posture, voice, tendency to weep.
• 4 = Patient reports virtually only these feeling states in spontaneous verbal and nonverbal communication.
2. Feelings of Guilt
• 0 = Absent.
• 1 = Self reproach; feels he/she has let people down.
• 2 = Ideas of guilt or rumination over past errors or sinful deeds.
• 3 = Present illness is a punishment. Delusions of guilt.
• 4 = Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations.
3. Suicide
• 0 = Absent.
• 1 = Feels life is not worth living.
• 2 = Wishes he/she were dead or any thoughts of possible death to self.
• 3 = Suicidal ideas or gesture.
• 4 = Attempts at suicide (any serious attempt rates 4).
4. Insomnia: Early in the Night
• 0 = No difficulty falling asleep.
• 1 = Complains of occasional difficulty falling asleep, i.e., more than ½ hour.
• 2 = Complains of nightly difficulty falling asleep.
5. Insomnia: Middle of the Night
• 0 = No difficulty.
• 1 = Complains of being restless and disturbed during the night.
• 2 = Waking during the night—any getting out of bed rates 2 (except for purposes of voiding).
6. Insomnia: Early Hours of the Morning
• 0 = No difficulty.
• 1 = Waking in early hours of the morning, but goes back to sleep.
• 2 = Unable to fall asleep again if he/she gets out of bed.
7. Work and Activities
• 0 = No difficulty.
• 1 = Thoughts and feelings of incapacity, fatigue, or weakness related to activities, work, or hobbies.
• 2 = Loss of interest in activity, hobbies, or work—either directly reported by patient, or indirectly in listlessness, indecision, and vacillation (feels he/she has to push self to work or activities).
• 3 = Decrease in actual time spent in activities or decrease in productivity. Rate 3 if patient does not spend at least 3 hours a day in activities (job or hobbies), excluding routine chores.
• 4 = Stopped working because of present illness. Rate 4 if patient engages in no activities except routine chores, or if does not perform routine chores unassisted.
8. Psychomotor Retardation (slowness of thought and speech, impaired ability to concentrate, decreased motor activity)
• 0 = Normal speech and thought.
• 1 = Slight retardation during the interview.
• 2 = Obvious retardation during the interview.
• 3 = Interview difficult.
• 4 = Complete stupor.
9. Agitation
• 0 = None.
• 1 = Fidgetiness.
• 2 = Playing with hands, hair, etc.
• 3 = Moving about, can't sit still.
• 4 = Hand wringing, nail biting, hair pulling, biting of lips.
10. Anxiety (Psychic)
• 0 = No difficulty.
• 1 = Subjective tension and irritability.
• 2 = Worrying about minor matters.
• 3 = Apprehensive attitude apparent in face or speech.
• 4 = Fears expressed without questioning.
11. Anxiety (Somatic): Physiological concomitants of anxiety (e.g., dry mouth, indigestion, diarrhea, cramps, belching, palpitations, headache, tremor, hyperventilation, sighing, urinary frequency, sweating, flushing)
• 0 = Absent.
• 1 = Mild.
• 2 = Moderate.
• 3 = Severe.
• 4 = Incapacitating.
12. Somatic Symptoms (Gastrointestinal)
• 0 = None.
• 1 = Loss of appetite, but eating without encouragement. Heavy feelings in abdomen.
• 2 = Difficulty eating without urging from others. Requests or requires medication for constipation or gastrointestinal symptoms.
13. Somatic Symptoms (General)
• 0 = None.
• 1 = Heaviness in limbs, back, or head. Backaches, headache, muscle aches. Loss of energy and fatigability.
• 2 = Any clear-cut symptom rates 2.
14. Genital Symptoms (e.g., loss of libido, impaired sexual performance, menstrual disturbances)
• 0 = Absent.
• 1 = Mild.
• 2 = Severe.
15. Hypochondriasis
• 0 = Not present.
• 1 = Self-absorption (bodily).
• 2 = Preoccupation with health.
• 3 = Frequent complaints, requests for help, etc.
• 4 = Hypochondriacal delusions.
16. Loss of Weight (Rate either A or B)
1. According to subjective patient history:
• 0 = No weight loss.
• 1 = Probably weight loss associated with present illness.
• 2 = Definite weight loss associated with present illness.
2. According to objective weekly measurements:
• 0 = Less than 1 lb. weight loss in week.
• 1 = Greater than 1 lb. weight loss in week.
• 2 = Greater than 2 lb. weight loss in week.
17. Insight
• 0 = Acknowledges being depressed and ill.
• 1 = Acknowledges illness but attributes cause to bad food, climate, overwork, virus, need for rest, etc.
• 2 = Denies being ill at all.

TOTAL SCORE _________________

Scoring:

• 0–7 = Normal
• 8–13 = Mild Depression
• 14–18 = Moderate Depression
• 19–22 = Severe Depression
• ≥23 = Very Severe Depression