Appendix 2: Methods for assessment of mood in people with cognitive and/or communicative impairment
Cognitive/communication level Assessment method Some Suitable Instruments Minimally responsive (Formal assessment of mood involving patient’s
No meaningful communication/interaction Assessment of distress (nature, severity, participation is impossible)
Or acute confusional state frequency) using clinical judgement, including
Observation by staff. quantification
Extremely severe impairment
Unreliable yes/no response Observation or mood-related behaviour by staff Signs of Depression Scale (SDSS) Some interaction possible – but may be limited using systematic questionnaires Stroke Aphasic Depression Questionnaire (SADQ)
Very limited communication
Severe expressive dysphasia, unable to read - Simple questions or scales which do not rely on Yale question
but basic comprehension and reliable yes/no ability to speak or read, and Depression Intensity Scale Circles (DISCs) response through gesture or pointing. Observation as above Visual analogue scale e.g.
Numbered graphic rating scale (NGRS)
Moderately limited communication
Some social interaction through spoken word More complex questionnaires or scales requiring Hospital Anxiety and Depression Scale (HADS) Reasonable aural comprehension some facilitation or verbal administration Beck Depression Inventory (BDI-II) and/or limited ability to read. through structured interview and using large-Geriatric Depression Scale (GDS)
print version if required
No significant limitation in communication
Able to read simple sentences Any instrument may be used, determined by Any of the above
Good aural comprehension client group, trained staff time available for
with no significant impairment in communication or As above, but focussing on present mood state Any of the above
cognition and repeated administration, supplemented by
staff observation and recording
Complex or severe depression, .
Previous psychiatric condition or high risk of self-Formal psychiatric assessment Present State Examination to apply the DSM-IV harm, and reasonable cognitive skills Supported if necessary by SALT or carer if criteria(1)
patient has significant communication problems
Details of assessment instruments and their validation
Instrument Brief Description Comments and references
Beck Depression Inventory (BDI-II) Self report scale - 21 items Widely used and validated, including in stroke
May be used to form basis for an interview research(2, 3).
BDI Fastscreen Short-from of BDI-II – 7 items - Designed to pick Short form not yet validated for patients with stroke
up cognitive features of depression only or other ABI. Copyright protected
Hospital Anxiety and Depression Scale(HADS) Self report scale – 14 items Very widely used and validated for many
7 items on anxiety, and 7 items on depression conditions(4, 5), some validation in the context of
Designed to overcome the effects of stroke(6, 7) but not in other forms of ABI.
hospitalisation. Copyright protected
Geriatric Depression Scale (GDS) 30 items with yes/no answers Quite widely used, and some validation in stroke(8, 9)
Designed for older adults - excludes somatic items Short form not yet well validated with stroke patients GDS short form Short form: 15 items as above Freely available
Non-verbal rating scales
Visual analogue / numerical rating scales Assess mood on a visual or numeric rating scale – Good evidence for reliability in those patients who (See figure 3) usually scored 0 – 10 can complete them - Patients with visuo-spatial
Theoretically useful for dysphasic patients neglect may have difficulty with horizontal scales(10-
13). Pre-screening is recommended(10)
Depression Intensity Scale with Circles (DISCS) 6 point scale using vertical array of circles Validated in stroke and ABI(14)
(See figure 4) Designed as a simplified rating scale for use in ABI Freely available from authors
Visual Analogue Mood Scales (VAMS) Series of 8 vertical VAS scales for different aspects Normative validation and in stroke population(15-17)
of mood. Scored in mm on a 100 mm scale
Visual Analogue Self-Esteem Scale (VASES) 10 illustrations of bipolar constructs Often used by speech and language therapists, but
Scored 1 – 5 little formal validation(17, 18)
Scales based on observation of behaviour
Signs of Depression Scale (SDSS) 6 items, Yes/No answers Suitable as a crude screening tool(17, 19, 20)
Validity/reliability not yet established
Freely available from authors
Stroke Aphasic Depression Scale (SADQ) 21 items of mood-related behaviour Validated in stroke and multiple sclerosis (17, 21-24) Hospital Stroke Aphasic Depression Scale (SADQ-H) Hospital- and Community version Freely available from authors
Stroke Aphasic Depression Scale – 10 (SADQ-10) Short form: 10 items - from the SADQ Validity/reliability as yet uncertain(23)
(Hamilton Depression Rating Scale (HRDS)) 21-items of mood-related symptoms/ behaviour Has been widely used in stroke research, but not
Assessed by psychiatrically trained observer formally validated in this population(25)
Requires training to administer so probably not
suitable for more general settings
References for assessment tools and validation
1. APA. Diagnostic and statistical manual of mental disorders (DSM-IV). Fourth edition. Washington DC:
American Psychiatric Association; 1994.
2. Leentjens AF, Verhey FR, Luijckx GJ, Troost J. The validity of the Beck Depression Inventory as a
screening and diagnostic instrument for depression in patients with Parkinson's disease. Movement
3. Aben I, Verhey F, Lousberg R, Lodder J, Honig A. Validity of the beck depression inventory, hospital
anxiety and depression scale, SCL-90, and hamilton depression rating scale as screening instruments for
depression in stroke patients. Psychosomatics. 2002;43(5):386-93.
4. Herrmann C. International experience with the Hospital Anxiety and Depression Scale A review of
validation data and clinical results. J Psychosom Res 1997;42:17-41.
5. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale;
an updated review. J Psychiat Res 2002;52:69-77.
6. Johnson G, Burvill PW, Anderson CS, Jamrozik K, Stewart-Wynne EG, Chakera TMH. Screening
instruments for depression and anxiety following stroke: Experience in the Perth community stroke
study. Acta Psychiatr Scand 1995;91(4):252-257.
7. O'Rourke S, MacHale S, Signorini D, Dennis M. Detecting psychiatric morbidity after stroke: comparison
of the GHQ and the HAD Scale. Stroke 1998;29(5):980-5.
8. Agrell B, Dehlin O. Comparison of six depression rating scales in geriatric stroke patients. Stroke
9. Lieberman D, Galinsky D, Fried V, Grinshpun Y, Mytlis N, Tylis R. Geriatric Depression Screening Scale
(GDS) in patients hospitalized for physical rehabilitation. Int J Geriatr Psychiatry 1999;14(7):549-55. 10. Turner-Stokes L, Rusconi S. Screening for ability to complete a questionnaire: a preliminary evaluation
of the AbilityQ and ShoulderQ for assessing shoulder pain in stroke patients. Clinical Rehabilitation.
11. Stephenson NL, Herman JA. Pain measurement: a comparison using horizontal and vertical visual
analogue scales. Applied Nursing Research. 2000;13(3):157-8.
12. Breivik EK, Skoglund LA. Comparison of present pain intensity assessments on horizontally and vertically
oriented visual analogue scales. Methods & Findings in Experimental & Clinical Pharmacology.
13. Price CIM, Curless RH, Rodgers H. Can stroke patients use visual analogue scales? Stroke
14. Turner-Stokes L, Kalmus M, Hirani D, Clegg F. The Depression Intensity Scale Circles: Initial evaluation
of a simple assessment tool for depression in the context of brain injury. JNNP. In press 2004. 15. Arruda JE, Stern RA, Somerville JA. Measurement of mood states in stroke patients: validation of the
visual analog mood scales. Archives of Physical Medicine & Rehabilitation. 1999;80(6):676-80. 16. Nyenhuis DL, Stern RA, Yamamoto C, Luchetta T, Arruda JE. Standardization and validation of the
Visual Analog Mood Scales. Clinical Neuropsychologist 1997;11(4):407-415.
17. Groom MJ, Lincoln NB, Francis VM, Stephan TF. Assessing mood in patients with multiple sclerosis.
Clinical Rehabilitation. 2003;17(8):847-57.
18. Brumfitt SM, Sheeran P. The development and validation of the Visual Analogue Self-Esteem Scale
(VASES). British Journal of Clinical Psychology. 1999;38(Pt 4):387-400.
19. Hammond MF, O'Keeffe ST, Barer DH. Development and validation of a brief observer-rated screening
scale for depression in elderly medical patients. Age Ageing 2000;29:511-515.
20. Watkins C, Leathley M, Daniels L, Dickinson H, Lightbody CE, van den Broek M, et al. The signs of
depression scale in stroke: how useful are nurses observations? Clin Rehabil 2001;15:447-457. 21. Sutcliffe LM, Lincoln NB. The assessment of depression in aphasic stroke patients: the development of
the Stroke Aphasic Depression Questionnaire. Clin Rehabil 1998;12(6):506-13.
22. Lincoln NB, Sutcliffe LM. Development of the Stroke Aphasic Depression Questionnaire. Clin Rehabil
23. Leeds L, Meara RJ, Hobson JP. The utility of the Stroke Aphasia Depression Questionnaire (SADQ) in a
stroke rehabilitation unit. Clin Rehabil 2004;18(2):228-31.
24. Lincoln NB, Sutcliffe LM, Unsworth G. Validation of the Stroke Aphasic depression Questionnaire (SADQ)
for use with patients in hospital. Neuropsychological Assessment 2000;1:88-96.
25. Hamilton M. Development of a rating scale for primary depressive illness. Brit J Soc Clin Psychol