Depression
(print this page and
circle your responses)
SLEEP
I. Falling asleep
0 I never take longer
than 30 minutes to fall asleep
1 I take at least 30 minutes to fall asleep, less than half the time
2 I take at least 30 minutes to fall asleep, more than half the time
3 I take more than 60 minutes to fall asleep, more than half the time
II. Sleep During the Night
0 I do not wake up at night
1 I have a restless, light sleep with a few brief awakenings each night
2 I
wake up at least once a night, but I go back to sleep easily
3
I awaken more than once a night
and stay awake for 20 minutes or more, more than half the time
III. Waking Up too Early
0 Most of the time, I awaken no more
than 30 minutes before I need to get up
1 More than half the time, I awaken more than 30 minutes before I need to get
up
2 I almost always awaken at least one hour or so before I need to, but I go
back to sleep eventually
3
I awaken at least one hour
before I need to, and can’t go back to sleep
IV. Sleeping too much
0 I sleep no longer than 7-8 hours per night, without napping during the day
1 I sleep no longer than 10 hours in a 24-hour period including naps
2 I sleep no longer than 12 hours in a 24 hour period including naps
3 I sleep longer than 12 hours in a 24-hour period including naps
A. Enter the highest score on any one
(1) of the four SLEEP items above: _____
MOOD
V. Feeling Sad
0 I do not feel sad
1 I feel sad less than half the time
2 I feel sad more than half the time
3 I feel sad nearly all the time
B. Enter your score on the mood item
(V) above: _________
APPETITE/WEIGHT
VI. Decreased Appetite
0 There is no change in my usual appetite
1 I eat somewhat less often or lesser amounts of food than usual
2 I eat much less than usual and only with personal effort
3 I rarely eat within a 24-hour period, and only with extreme personal effort
or when others persuade me to eat.
VII. Increased Appetite
0 There is no change in my usual
appetite
1 I feel a need to eat more frequently than usual
2 I regularly eat more often and/or greater amounts of food than usual 3 I
feel driven to overeat both at mealtime and between meals
VIII. Decreased Weight Within the
Last Two Weeks
0 I have not had a change in my weight
1 I feel as if I’ve had a slight weight loss
2 I have lost 2 pounds or more
3 I have lost five pounds or more
IX. Increased Weight With the Last
Two Weeks
0 I have not had a change in my weight
1 I feel as if I’ve had a slight weight gain
2 I have gained 2 pounds or more
3 I have gained 5 pounds or more
C. Enter the highest score on any 1
(one) of the 4 appetite/weight change items (VI - IX) above: ________
X. Concentration/Decision Making:
0 There is no change in my usual capacity to concentrate or make decisions
1 I occasionally feel indecisive or find that my attention wanders
2 Most of the time I struggle to focus my attention or make decisions
3 I cannot concentrate well enough to read or cannot make even minor decisions
D. Enter your score on the
Concentration/Decision Making item (X) above: ________
XI. View of Myself:
0 I see myself as equally worthwhile and deserving as other people
1 I am more self-blaming than usual
2 I largely believe that I cause problems for others
3 I think almost constantly about major and minor defects in myself
E. Enter your score on the View of
Myself item (XI)
above: _________
XII. Thoughts of Death or Suicide:
0 I do not think about death or suicide
1 I feel that life is empty or wonder if it’s worth living
2 I think of suicide or death several times a week for several minutes
3 I think of suicide or death several times a day in some detail or I have made
specific plans for suicide or have actually tried to take my life
F. Enter your score on the Thoughts of
Death or Suicide item (XII) above: _______
XIII. General Interest:
0 There is no change from usual in how interested I am in other people or
activities
1 I notice that I am less interested in people or activities
2 I find I have interest in only one or two of my formerly pursued activities
3 I have virtually no interest in formerly pursued activities
G. Enter your score on the General
Interest item (XIII)
above: ______
XIV. Energy Level:
0 There is no change in my usual level of energy
1 I get tired more easily than usual
2 I have to make a big effort to start or finish my usual daily activities (for
example shopping, cooking, homework or going to work)
3 I have I really cannot carry out most of my usual daily activities because I
just don’t have the energy
H. Enter your score on the Energy
Level item (XIV)
above: _________
PSYCHOMOTOR
XV. Feeling Slowed Down:
0 I think, speak, and move at my usual rate of speed
1 I find that my thinking is slowed down or my voice sounds dull or flat
2 It takes me several seconds to respond to most questions and I’m sure my
thinking is slowed
3 I am often unable to respond to questions without extreme effort
XVI. Feeling Restless:
0 I do not feel restless
1 I’m often fidgety, wringing my hands, or need to shift how I am sitting
2 I have impulses to move about and am quite restless
3 At times, I am unable to stay seated and need to pace around
I. Enter your highest score on either
of the psychomotor items (15 & 16) above: _____
Enter the sum of
A+B+C+D+E+F+G+H+I = ____ This is your
total score (range 0-27)
0-5 Normal
6-10 Mild Depression
11-15 Moderate Depression
16-20 Moderate to Severe Depression
21+ Severe Depression
