TheScale CDSS PDF

Interviewer: Ask the first question as written. Use follow up probes or qualifiers at your discretion.
Time frame
refers to last two weeks unless stipulated. N.B. The last item, #9, is based on observations of the entire interview.
1. DEPRESSION: How would you describe your mood over the last two 6. MORNING DEPRESSION: When you have felt depressed over the last
weeks? Do you keep reasonably cheerful or have you been very 2 weeks have you noticed the depression being worse at any
depressed or low spirited recently? In the last two weeks how often particular time of day?
have you (own words) every day? All day?
0. Absent No depression.
0. Absent 1. Mild Depression present but no diurnal variation.
1. Mild Expresses some sadness or discouragement on questioning. 2. Moderate Depression spontaneously mentioned to be worse in a.m.
2. Moderate Distinct depressed mood persisting up to half the time over last 3. Severe Depression markedly worse in a.m., with impaired functioning
2 weeks: present daily. which improves in p.m.
3. Severe Markedly depressed mood persisting daily over half the time
interfering with normal motor and social functioning.
2. HOPELESSNESS: How do you see the future for yourself? Can you 7. EARLY WAKENING: Do you wake earlier in the morning than is
see any future? - or has life seemed quite hopeless? Have you given normal for you? How many times a week does this happen?
up or does there still seem some reason for trying?
0. Absent No early wakening.
0. Absent 1. Mild Occasionally wakes (up to twice weekly) 1 hour or more before
1. Mild Has at times felt hopeless over the last two weeks but still has normal time to wake or alarm time.
some degree of hope for the future. 2. Moderate Often wakes early (up to 5 times weekly) 1 hour or more before
2. Moderate Persistent, moderate sense of hopelessness over last week. Can normal time to wake or alarm.
be persuaded to acknowledge possibility of things being better. 3. Severe Daily wakes 1 hour or more before normal time.
3. Severe Persisting and distressing sense of hopelessness.
3. SELF DEPRECIATION: What is your opinion of your self compared 8. SUICIDE: Have you felt that life wasn’t worth living? Did you ever
to other people? Do you feel better, not as good, or about the same feel like ending it all? What did you think you might do? Did you
as others? Do you feel inferior or even worthless? actually try?
0. Absent 0. Absent
1. Mild Some inferiority; not amounting to feeling of worthlessness. 1. Mild Frequent thoughts of being better off dead, or occasional
2. Moderate Subject feels worthless, but less than 50% of the time. thoughts of suicide.
3. Severe Subject feels worthless more than 50% of the time. May be 2. Moderate Deliberately considered suicide with a plan, but made no
challenged to acknowledge otherwise. attempt.
3. Severe Suicidal attempt apparently designed to end in death (i.e.:
accidental discovery or inefficient means).
4. GUILTY IDEAS OF REFERENCE: Do you have the feeling that you 9. OBSERVED DEPRESSION: Based on interviewer’s observations
are being blamed for something or even wrongly accused? What during the entire interview. The question “Do you feel like crying?”
about? (Do not include justifiable blame or accusation. Exclude used at appropriate points in the interview, may elicit information
delusions of guilt.) useful to this observation.
0. Absent 0. Absent
1. Mild Subject feels blamed but not accused less than 50% of the time. 1. Mild Subject appears sad and mournful even during parts of the
2. Moderate Persisting sense of being blamed, and/or occasional sense of interview, involving affectively neutral discussion.
being accused. 2. Moderate Subject appears sad and mournful throughout the interview, with
3. Severe Persistent sense of being accused. When challenged, gloomy monotonous voice and is tearful or close to tears at times.
acknowledges that it is not so. 3. Severe Subject chokes on distressing topics, frequently sighs deeply
and cries openly, or is persistently in a state of frozen misery if
5. PATHOLOGICAL GUILT: Do you tend to blame yourself for little examiner is sure that this is present.
things you may have done in the past? Do you think that you deserve
to be so concerned about this?
0. Absent
1. Mild Subject sometimes feels over guilty about some minor
peccadillo, but less than 50% of time.
2. Moderate Subject usually (over 50% of time) feels guilty about past
actions the significance of which he exaggerates.
3. Severe Subject usually feels s/he is to blame for everything that has
gone wrong, even when not his/her fault. © Dr. Donald Addington and Dr. Jean Addington.

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Interviewer: Ask the first question as written. Use follow up probes or qualifiers at your discretion.

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