Multiple screening tools are now available that are potentially easy to use in primary care settings.  The following tools are reproduced for consideration in local settings; they are arranged from shortest to longest.  Information on sensitivity and specificity of each screener are provided:

1. PRIME MD Primary Care Evaluations of Mental Disorders – Depression questions (2 items).
2. CES-D Center for Epidemiological Studies – Depression scale - (5 items)
3. Zung Depression Rating Scale (21 items)
4. MOS Medical Outcomes Study - depression questions (4 items)
5. Ham-D Hamilton Depression Scale (21 items)

1. Primary Care Evaluation of Mental Disorders: PRIME MD - depression questions (2 questions)
   
   

   Question	Yes or No
   1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?
   2. During the past month, have you often been bothered by little interest or pleasure in doing things?



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2. Center for Epidemiological Studies – Depression Scale (CES-D)

   5-item brief version developed as screening instrument for patients of all ages and 60 or over:

   For each of the following, please indicate how often you felt that way during the past week, using the following ratings (Total score of 4 or more is a positive depression screen):

   Score for questions 1 - 4 only Rarely or none of the time (less than one day) 0 Some or a little of the time (1 to 2 days) 1 Moderately or much of the time (3 to 4 days) 2 Most or almost all the time (5 to 7 days) 3 Item # Question Score 1. I felt that I could not shake off the blues even with help from my family or friends 0   1   2   3 2. I felt depressed 0   1   2   3 3. I felt fearful 0   1   2   3 4. My sleep was restless 0   1   2   3 Score for question 5 only Most of the time 0 Moderately or much of the time 1 Some of the time 2 Rarely 3 5. I felt hopeful about the future. 0   1   2   3

   This screening instrument is derived from the CES-D (Lewinsohn, et al., 1997). 

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3. Zung Self-Rating Depression Scale (21 items)

   Patient Name_________________________________Age_________Sex_________ Date______________
   
   
   INSTRUCTIONS:
   
   
   Read each sentence carefully.  For each statement, check the bubble in the column that best corresponds to how often you have felt that way during the past two weeks.  For statement 5 and 7, if you are on a diet, answer as if you were not.
   
   

   Please check a response for each of the 20 items.	None OR a Little of the Time	Some of the Time	Good Part of the Time	Most OR All of the Time
   1.   I feel downhearted, blue, and sad	[   ]	[   ]	[   ]	[   ]
   2.   Morning is when I feel the best	[   ]	[   ]	[   ]	[   ]
   3.   I have crying spells or feel like it	[   ]	[   ]	[   ]	[   ]
   4.   I have trouble sleeping through the night	[   ]	[   ]	[   ]	[   ]
   5.   I eat as much as I used to	[   ]	[   ]	[   ]	[   ]
   6.   I enjoy looking at, talking to, and being with attractive women/men	[   ]	[   ]	[   ]	[   ]
   7.   I notice that I am losing weight	[   ]	[   ]	[   ]	[   ]
   8.   I have trouble with constipation	[   ]	[   ]	[   ]	[   ]
   9.   My heart beats faster than usual	[   ]	[   ]	[   ]	[   ]
   10.   I get tired for no reason	[   ]	[   ]	[   ]	[   ]
   11.   My mind is as clear as it used to be	[   ]	[   ]	[   ]	[   ]
   12.   I find it easy to do the things I used to do	[   ]	[   ]	[   ]	[   ]
   13.   I am restless and can’t keep still	[   ]	[   ]	[   ]	[   ]
   14.   I feel hopeful about the future	[   ]	[   ]	[   ]	[   ]
   15.   I am more irritable than usual	[   ]	[   ]	[   ]	[   ]
   16.   I find it easy to make decisions	[   ]	[   ]	[   ]	[   ]
   17.   I feel that I am useful and needed	[   ]	[   ]	[   ]	[   ]
   18.   My life is pretty full	[   ]	[   ]	[   ]	[   ]
   19.   I feel that others would be better off if I were dead	[   ]	[   ]	[   ]	[   ]
   20.   I still enjoy the things I used to do	[   ]	[   ]	[   ]	[   ]

   W.W.K. Zung, 1965, 1974, 1989, 1991. Al Rights Reserved
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4. Medical Outcomes Study Depression Questionnaire

   Recommended screening instrument for patients age under age 60:

   This four-item screener recommended is also part of the evaluation package and has empirical support demonstrating its specificity and sensitivity (Rost, Burnam, Smith, 1993).  It may be administered as a paper and pencil measure, as a computer assessment package, or assessed by the clinician.

   Medical Outcomes Study: MOS Depression Questionnaire

   Item	Question	Response/Score
   A.	In the past year, have you had two consecutive weeks or more during which you felt sad, blue, or depressed, or when you lost all interest or pleasure in things that you usually cared about or enjoyed?	YES NO
   B.	Have you had two years or more in your life when you felt depressed or sad most days even if you felt okay sometimes?	YES NO
   C.	Have you felt depressed or sad much the time in the past year?	YES NO
   D.	How much of the time in the past week did you feel depressed?	Score less than one day 0 one or two days 1 three or four days 2 more than four days 3
   		1, 2, OR 3 – positive screen

   Positive Screen: the patient must indicate yes on question A OR yes on both questions B AND C, AND score 1, 2, or 3 on question D to be positive.

   NOTE:  If the answers to both questions A and C are NO, then the patient does not meet screening criteria for MDD even question D scores one or more. (currently depressed).  Another diagnosis, such as dysthymia, may be appropriate but is outside the scope of this algorithm.  Similarly, if the answer to question D is “less than one day” then the patient does not meet the screening criteria for MDD even if one or more of the earlier answers are “yes.”

   If the patient screening criteria for MDD is positive, then move on to a more intensive assessment on the algorithm.  (Whooley, et al., 1997)

   Evidence supports the sensitivity and specificity of the MOS Depression questions as a screening instrument for MDD in community and medical settings. (Rost K, Burnam MA, Smith GR, 1993) QE = II-2, SR = B



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5. The Hamilton Rating Scale For Depression (clinician administered)

   Patient’s Name _______________________________________

   Date of Assessment ___________________________________

   To rate the severity of depression in patients who are already diagnosed as depressed, administer this questionnaire.  The higher the score, the more severe the depression.

   For each item, write the correct number on the line next to the item.  (Only one response per item)

   ---

   _____	1	DEPRESSED MOOD (Sadness, hopeless, helpless, worthless) 0= Absent 1= These feeling states indicated only on questioning 2= These feeling states spontaneously reported 3= Communicates feeling states non-verbally—i.e., through facial expression, posture,       voice, and tendency to weep 4= Patient reports VIRTUALLY ONLY these feeling states in his spontaneous verbal and       non-verbal communication
   _____	2	FEELINGS OF GUILT 0= Absent 1= Self reproach, feels he 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 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 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 0= No difficulty 1= patient 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 LATE 0= No difficulty 1= Waking in early hours of the morning but goes back to sleep 2= Unable to fall asleep again if he gets out of bed
   _____	7	WORK AND ACTIVITIES 0= No difficulty 1= Thoughts and feeling of incapacity, fatigue or weakness related to activities; work or       hobbies 2= Lost of interest in activity; hobbies or work—either directly reported by patient, or indirect       in listlessness, indecision and vacillation (feels he has to push self to work or       activities) 3= Decrease in actual time spent in activities or decrease in productivity 4= Stop working because of present illness
   _____	8	RETARDATION: PSYCHOMOTOR (Slowness of thought and speech; impaired ability to concentrate; decreased motor activity) 0= Normal speech and thought 1= Slight retardation at interview 2= Obvious retardation at 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 (PSYCHOLOGICAL) 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, (i.e., effects of autonomic overactivity, “butterflies,” indigestion, stomach cramps, belching, diarrhea, palpitations, hyperventilation, paresthesia, sweating, flushing, tremor, headache, urinary frequency). Avoid asking about possible medication side effects (i.e., dry mouth, constipation) 0= Absent 1= Mild 2= Moderate 3= Severe 4= Incapacitating
   _____	12	SOMATIC SYMPTOMS (GASTROINTESTINAL) 0= None 1= Loss of appetite but eating without encouragement from others. Food intake about       normal 2= Difficulty eating without urging from others. Marked reduction of appetite and food       intake
   _____	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 (Symptoms such as: 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, ect. 4= Hypochondriacal delusions
   _____	16	LOSS OF WEIGHT A. When rating by history: 0= No weight loss 1= Probably weight loss associated with present illness 2= Definite (according to patient) weight loss 3= Not assessed
   _____	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
   _____	18	DIURNAL VARIATION Note whether symptoms are worse in morning or evening. If NO diurnal variation, mark none 0= No Variation 1= Worse in A.M. 2= Worse in P.M B. When Present, mark the severity of the variation. Mark “None” if NO variation 0= None 1= Mild 2= Severe
   _____	19	DEPERSONALIZATION AND DEREALIZATION (Such as: Feelings of unreality; Nihilistic ideas) 0= Absent 1= Mild 2= Moderate 3= Severe 4= Incapacitating
   _____	20	PARANOID SYMPTOMS 0= None 1= Suspicious 2= Ideas of reference 3= Delusion of reference and persecution
   _____	21	OBSESSIONAL AND COMPULSIVE SYMPTOMS 0= Absent 1= Mild 2= Severe

   Total Score_________

   Adapted from Hedlung and Vieweg, (1979). The Hamilton rating scale for depression, Journal of Operational Psychiatry,10(2), 149-165.

   
   

Functional Status Measures