Version May 2024
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| 0 – Absent. 1 – These feeling states indicated only on questioning. 2 – These feeling states spontaneously reported verbally. 3 – Communicates feeling states nonverbally (ie, through facial expression, posture, voice, and tendency to weep). 4 – Subject reports virtually only these feeling states in their spontaneous and nonverbal communication. | |
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| 0 – Absent. 1 – Self-reproach, feels they have 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. | |
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| 0 – Absent. 1 – Feels life is not worth living. 2 – Wishes they were dead or any thoughts of possible death to self. 3 – Suicide ideas or gestures. 4 – Attempts at suicide (any serious attempt rates 4). | |
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| 0 – No difficulty falling asleep. 1 – Complains of occasional difficulty falling asleep (eg, more than 30 minutes). 2 – Complains of nightly difficulty falling asleep. | |
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| 0 – No difficulty. 1 – Subject 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) | |
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| 0 – No difficulty. 1 – Waking in early hours of the morning but goes back to sleep. 2 – Unable to fall asleep again if they get out of bed. | |
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| 0 – No difficulty. 1 – Thoughts and feelings of incapacity, fatigue, or weakness related to activities, hobbies, or work. 2 – Loss of interest in activities, hobbies, or work, either directly reported by subject or indirect in listlessness, indecision, and vacillation (feels has to push self to work or activities). 3 – Decrease in actual time spent in activities or decrease in productivity. In hospital, rate 3 if subject does not spend at least 3 hours a day in activities (hospital job or hobbies) exclusive of ward chores. 4 – Stopped working because of present illness. In hospital, rate if subject engages in no activities except ward chores, or if subject fails to perform ward chores unassisted. | |
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| 0 – Normal speech and thought. 1 – Slight retardation at interview. 2 – Obvious retardation at interview. 3 – Interview difficult. 4 – Complete stupor. | |
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| 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. | |
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| 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. | |
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| 0 – Absent. 1 – Mild. 2 – Moderate. 3 – Severe. 4 – Incapacitating. | |
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| 0 – None. 1 – Loss of appetite but eating without staff encouragement. Heavy feelings in abdomen. 2 – Difficulty eating without staff urging. Requests or requires laxatives or medication for bowels or medication for GI symptoms. | |
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| 0 – None. 1 – Heaviness in limbs, back, or head. Backaches, headaches, or muscle aches. Loss of energy and fatigability. 2 – Any clear-cut symptoms rates 2. | |
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| 0 – Absent. 1 – Mild. 2 – Severe. | |
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| 0 – Not present. 1 – Self-absorption (bodily). 2 – Preoccupation with health. 3 – Frequent complaints, requests for help, etc. 4 – Hypochondriacal delusions. | |
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| 0 – No weight loss. 1 – Probable weight loss associated with present illness. 2 – Definite (according to subject) weight loss. | |
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| 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. | |
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