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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 he 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 three 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 | |
