Appendix 2B: Source of Assessment Tools
1. Questionnaire-based tools
These may be completed at interview or by self–report where the individual has sufficient verbal skills. The following information should to help physicians to access tools and use them appropriately.
1.1 The Hospital Anxiety and Depression Scale
Original Reference Zigmond, A.S., and Snaith, R.P. (1983). The Hospital Anxiety and
Depression Scale. Acta Psychiatrica Scandinavica 67, 361-370
Copyright: Protected. Permission to use the scale may be obtained from:
The National Foundation for Educational Research ( http://www.nfer-
The firm supplies the scale, the chart for recording of scores and the
manual with instructions for its use.
Contact details nferNelson.
The Chiswick Centre. 414 Chiswick High Rd, London W4 5TF
Tel: 020 8996 8444
1.2 The Beck Depression Inventory (BDI-II)
Original Reference Beck AT, Ward CH, Mendelssohn MJ, Erbaugh J. An inventory for
measuring depression Archives of General Psychiatry 1961; 4:561-571
2. Sheikh JI, Yesavage JA. Geriatric Depression Scale: recent evidence
and development of a shorter version. Clin Gerontol. 1986; 5:165-172
Copyright: Protected. Permission to use the scale may be obtained from:
Harcourt Assessment http://www.harcourt-uk.com/
The firm supplies the scale and the manual with instructions for its use.
Contact details Harcourt Assessment
Halley Court, Jordan Hill, Oxford, OX2 8EJ
Tel: 01865 888188 Fax: 01865 314348
1.3 The Geriatric Depression Scale (GDS)
Original Reference 1. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of
a geriatric depression rating scale: a preliminary report. J Psych Res.
Copyright: The Geriatric Depression Scale may be used freely for patient assessment
according to the authors.
The Geriatric Depression Scale (GDS)
Choose the best answer for how you felt this past week CIRCLE ONE
1. Are you basically satisfied with your life? Yes No 2. Have you dropped many of your activities and interests? Yes No 3. Do you feel that your life is empty? Yes No 4. Do you often get bored? Yes No 5. Are you hopeful about the future? Yes No 6. Are you bothered by thoughts you can't get out of your head? Yes No 7. Are you in good spirits most of the time? Yes No 8. Are you afraid that something bad is going to happen to you? Yes No 9. Do you feel happy most of the time? Yes No 10. Do you often feel helpless? Yes No 11. Do you often get restless and fidgety? Yes No 12. Do you prefer to stay at home, rather than going out and doing new things? Yes No 13. Do you frequently worry about the future? Yes No 14. Do you feel you have more problems with memory than most? Yes No 15. Do you think it is wonderful to be alive now? Yes No 16. Do you often feel downhearted and blue? Yes No 17. Do you feel pretty worthless the way you are now? Yes No 18. Do you worry a lot about the past? Yes No 19. Do you find life very exciting? Yes No 20. Is it hard for you to get started on new projects? Yes No 21. Do you feel full of energy? Yes No 22. Do you feel that your situation is hopeless? Yes No 23. Do you think that most people are better off than you are? Yes No 24. Do you frequently get upset over little things? Yes No 25. Do you frequently feel like crying? Yes No 26. Do you have trouble concentrating? Yes No 27. Do you enjoy getting up in the morning? Yes No 28. Do you prefer to avoid social gatherings? Yes No 29. Is it easy for you to make decisions? Yes No 30. Is your mind as clear as it used to be Yes No
Total bold (depressed) answers
Total score (No. of depressed answers)
Normal 5 +/- 4 Mildly depressed 15 +/- 6 Very depressed 23 +/- 5
2. Non-verbal rating tools
Tools such as visual analogue scales in different forms, may be useful where verbal communication is limited although facilitation will often be required.
2.1 Numeric Graphic Rating Scale
People with acquired brain injury, especially involving the right hemisphere, may have difficulty with visuo-spatial perception. For this reason, vertical visual analogue scales have been favoured over horizontal scales. For those with retained numeracy skills the addition of numbered increments may help to orientate patients to the whole scale.
The Numbered Graphic Rating Scale provides a simple vertical visual analogue scale with numbered ;cues. Pre-screening for ability to perceive the whole scale is recommended prior to use
An example of the NGRS together with instructions for administration is given in Figure 3.
2.2 The Depression Intensity Scale Circles (DISCs)
This visual analogue scale has been developed as a simple intuitive scale, especially for people with cognitive and communicative problems following brain injury. The DISCs, together with instructions for administration, is given in Figure 4.
Original Reference 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.
Copyright: Freely available from authors
Contact details Prof Lynne Turner-Stokes
RRU, Northwick Park Hospital, Watford Road,Harrow, Middlesex.HA1 3UJ
Tel: 020-8869-2800 Fax: 020-8869-2803
; 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. 2003;17(2):150-7.
3. Scales based on observation of behaviour
For patients unable to communicate their feelings even as a basic level, scales which record
observation by staff of mood related behaviour such as crying, withdrawal, apathy may be the only
3.1 The Signs of Depression Scale (SDSS)
Original Reference 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 Nov;29(6):511-5
Copyright: British Geriatrics Society The scale is freely available with permission from the
Contact details Margaret F Hammond
Department of Primary Care, University of Liverpool
Whelan Building. The Quadrangle. Brownlow Hill. Liverpool L69 3GB. UK
Fax: +44 (0) 151 794 5604
Signs of Depression Scale (SDSS)
1. Does the patient sometimes look sad, miserable or depressed? Yes / no
2. Does the patient ever cry or seem weepy? Yes / no
3. Does the patient seem agitated, restless or anxious? Yes / no
4. Is the patient lethargic or reluctant to mobilise? Yes / no
5. Does the patient need a lot of encouragement to do things for him/herself? Yes / no
6. Does the patient seem withdrawn, showing little interest in the surroundings? Yes / no
(Score 1 for ‘yes’ and 0 for ‘no’) Total Score
3.2 The Stroke Aphasic Depression Questionnaire (SADQ)
Original Reference SADQ-H (Hospital version): 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
SAD-Q-10 (Shorter version): Sutcliffe LM, Lincoln NB. The assessment of
depression in aphasic stroke patients: the development of the Stroke Aphasic
Depression Questionnaire. Clinical Rehabilitation 1998;12(6):506-13.
Copyright: The scale is freely available with permission from the authors
Prof. Nadina Lincoln Contact details
School of Psychology, University of Nottingham, University Park. Nottingham.
NG7 2RD. UKTel. Tel: +44 115 951 5315. Fax: +44 115 951 5324
The Stroke Aphasic Depression Questionnaire – Hospital version:
Please indicate on how many out of the last 7 the patients has shown the following behaviours:
Days this week
Every 4-6 1-4 Not Behaviour day at all
3 2 1 0 1. Did his/her waking cause a disturbance in sleep patterns?
3 2 1 0 2. Did he/she have weeping spells?*
3 2 1 0 3. Did he//she have restless disturbed nights?*
0 1 2 3 4. Did he/she initiate activities?
3 2 1 0 5. Did he/she avoid eye contact when you spoke to him/her?*
3 2 1 0 6. Did he/she burst into tears?*
0 1 2 3 7. Did he/she smile when you spoke to him/her?
0 1 2 3 8. Did he/she complain of aches and pains?*
3 2 1 0 9. Did he/she refuse to eat meals?
3 2 1 0 10. Did he/she get angry?*
3 2 1 0 11. Did he/she refuse to participate in social activities?*
0 1 2 3 12. Did he/she laugh at a joke?
3 2 1 0 13. Is he/she restless and fidgety?*
3 2 1 0 14. Did he/she sit without doing anything?*
0 1 2 3 15. Did he/she concentrate on activities?
0 1 2 3 16. Did he/she take care of his/her appearance to the best of their ability?
0 1 2 3 17. Did he/she seem to enjoy social activities or outings?
0 1 2 3 18. Did he/she keep him/herself occupied during the day?*
3 2 1 0 19. Did he/she take sleeping tablets
0 1 2 3 20. Did he/she take interest in events around him/her?
0 1 2 3 21. Did he/she look at you when you approached him/her?
Questions marked with a * are the 10 items included in the short SADQ-10