Depressed Mood (Sadness, Hopeless, Helpless, Worthless)

Absent

These feeling states indicated only on questioning

These feeling states spontaneously reported verbally

Communicates feeling states non-verbally, ie through facial expression, posture, voice and tendency to weep

Patient reports virtually only these feeling states in his/her spontaneous verbal and non-verbal communication

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Feelings of Guilt

Absent

Self reproach, feels he/she has let people down

Ideas of guilt or rumination over past errors or sinful deeds

Present illness is a punishment Delusions of guilt

Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations

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Suicide

Absent

Feels life is not worth living

Wishes he/she were dead or any thoughts of possible death to self

Ideas or gestures of suicide

Attempts at suicide

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Insomnia: Early In The Night.

No difficulty falling asleep

Complains of occasional difficulty falling asleep, ie more than 1 ⁄2 hour

Complains of nightly difficulty falling asleep

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Insomnia: Middle Of The Night

No difficulty

Patient complains of being restless and disturbed during the night

Waking during the night

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Insomnia: Early Hours Of The Morning

No difficulty

Waking in early hours of the morning but goes back to sleep

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Work And Activities

No difficulty

Thoughts and feelings of incapacity, fatigue or weakness related to activities, work or hobbies

Loss of interest in activity, hobbies or work – either directly reported by the patient or indirect in listlessness, indecision and vacillation (feels he/she has to push self to work or activities)

Decrease in actual time spent in activities or decrease in productivity Rate 3 if the patient does not spend at least three hours a day in activities (job or hobbies) excluding routine chores

Stopped working because of present illness Rate 4 if patient engages in no activities except routine chores, or if patient fails to perform routine chores unassiste

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Retardation(Slowness Of Thought And Speech, Impaired Ability To Concentrate, Decreased Motor Activity)

Normal speech and thought

Interview difficult

Complete stupor

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Agitation

None

Fidgetiness

Playing with hands, hair, etc

Moving about, can’t sit still

Hand wringing, nail biting, hair-pulling, biting of lips

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Anxiety Psychic

No Difficulty

Subjective tension and irritabili

Worrying about minor matters

Apprehensive attitude apparent in face or speech

Fears expressed without questioning

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Anxiety Somatic (Physiological Concomitants Of Anxiety) Such As: Gastro-intestinal– Dry Mouth, Wind, Indigestion, Diarrhea, Cramps, Belching Cardio-vascular– Palpitations, Headaches Respiratory– Hyperventilation, Sighing Urinary Frequency Sweating

Absent

Mild

Moderate

Severe

Very Severe

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Somatic Symptoms Gastro-intestinal

None

Loss of appetite but eating without staff encouragement Heavy feelings in abdomen

Difficulty eating without staff urging Requests or requires laxatives or medication for bowels or medication for gastro-intestinal symptoms

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General Somatic Symptoms

None

Heaviness in limbs, back or head Backaches, headaches, muscle aches Loss of energy and fatigability

Any clear-cut symptom rates 2

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Genital Symptoms (Symptoms Such As Loss Of Libido, Menstrual Disturbances)

Absent

Mild

Severe

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Hypochondriasis

None

Self-absorption (bodily)

Preoccupation with health

Frequent complaints, requests for help, etc

Hypochondriacal delusions

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Loss of Weight

No Loss

Probable Loss

Definite

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Insight

Acknowledges being depressed and ill

Acknowledges illness but attributes cause to bad climate,overwork, viral infection, need for rest etc.

Denies being ill

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