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Depression screening tools don't just give your doctor an idea of whether you're depressed, but also how severely. What are the most commonly used rating scales for depression, and what do you need to know about them?

"I'd been feeling really down for about a year, and had actually considered making an appointment with my doctor," Terri, a 43-year old mother of three, shared. "Something stopped me, though — the feeling that I was making a fuss over nothing and that I shouldn't be a drama queen." Only when her friends staged a mini-intervention, coming together to let her know they were worried, did Terri take the plunge. 

A diagnosis of depression is, in many places, based on the diagnostic criteria found in the DSM-5, the fifth edition of the Diagnostic and Statistical Manual fo Mental Disorders, and the process is designed to rule other options out as well. Seeing your doctor about depression doesn't have to be daunting, though — Terri explains: "It started off with a chat about how I'd been feeling, and then my doctor asked me to fill in a form." 

These forms or questionnaires, commonly used screening tools, help doctors get a good initial idea of whether a person is clinically depressed. Beyond that, they also serve another incredibly important purpose — figuring out how severe your symptoms are.

Mild, moderate, or severe depression — why the distinction matters

Mild depression may not get better without treatment, but it can often effectively managed with:

  • Lifestyle changes — exercise is well-known to be a potent mood lifter for mild depression, alongside mind-body disciplines like yoga and Tai Chi. Sticking to a comforting routine that includes a regular bedtime and motivating daily activities can also really help. 
  • Alternative treatments, particularly melatonin and St John's Wort. Because these can interact with other medications to become less effective or induce side effects, it is important to run these by your doctor, too. 
  • Antidepressants, like serotonin reuptake inhibitors (SSRIs) are sometimes prescribed for mild depression, but they aren't the first point of call. 
  • Talk therapy, like cognitive behavioral therapy, is an effective treatment for mild depression. 

Moderate to severe depression is, meanwhile, more effectively managed with a combination of talk therapy and an antidepressant — to give you the best chance of recovering as soon as possible, your doctor should offer you both, with the therapy portion consisting of cognitive behavioral therapy or interpersonal therapy. You should also be monitored more closely if you have moderate to severe depression, and should be seen by a specialist if your symptoms don't improve with treatment. 

So, how is the distinction made? People with mild depression meet the diagnostic criteria, but fewer of them, less severely, and often less often as well — while someone with mild depression may feel down about life, for instance, they'll still be able to go out and engage in daily responsibilities, whereas someone with severe depression may feel totally unable to do anything, including getting out of bed.

Screening tests allow your doctor to understand what you are going through, and the most commonly used ones are:

  1. The Patient Health Questionnaire
  2. The Beck Depression Inventory
  3. The Zung Self-Rating Depression Scale
  4. The Center for Epidemiologic Studies-Depression Scale
  5. The Hamilton Rating Scale for Depression
Whatever scale your doctor offers you, Terri warns others to avoid the temptation to "downplay" the severity of their symptoms, as this may rob you of the correct diagnosis — and the chance to feel better. 

The Patient Health Questionnaire-9 (PHQ-9)

Based on the diagnostic criteria for depression, the PHQ-9 is a form your doctor will ask you to fill in yourself. A short and simple but effective tool, it offers nine questions that seek to determine how you've been feeling over the last two weeks. 

All the questions have four possible answers:

  • Zero is "not at all". 
  • A one means you have experienced the symptom you're asked about on some days.
  • A two indicates you have experienced the symptom on more than half of the days in the last fortnight.
  • A three means you've had the the symptom on most days. 

Worded quite clinically, the PHQ-9 asks to what extent you have been affected by:

  • Little interest or pleasure in activities, including those that used to be meaningful
  • Feeling down, depressed, or hopeless
  • Difficulty falling asleep or staying asleep (insomnia), or rather sleeping too much
  • Being fatigued or low on energy
  • Lack of appetite or overeating (comfort eating)
  • Feeling bad about yourself, or feeling excessively guilty
  • Trouble concentrating
  • Moving slowly or being fidgety and hyperactive
  • Thoughts about death or suicide

The Beck Depression Inventory

The Beck Depression Inventory (BDI) is a longer multiple choice questionnaire. To assess how severely you're affected by each possible depression symptom, the BDI offers four statements of which you circle one.

Examples of questions that differ from those you'll encounter on the PHQ-9 include:

  • I get as much satisfaction out of things as I used to, I don't enjoy things the way I used to, I don't get real satisfaction out of anything anymore, or I am dissatisfied or bored with everything.
  • I don't feel I am being punished, I feel I may be punished, I expect to be punished, or I feel I am being punished.
  • I can work about as well as before, it takes extra effort to get started at doing something, I have to push myself very hard to do anything, or I can't do any work at all.

After circling the items that apply to you, the score is then added up, with a score under 10 being considered normal (not depressed), a score over 17 indicating depression, a score between 21 and 30 suggesting moderate depression, and a score of 31 or higher pointing to severe depression. 

The Zung Self-Rating Depression Scale

The Zung Self-Rating Depression Scale features 20 items that you can answer on a scale from one to four. It targets your mood, physical symptoms, and ability to carry out daily activities, making statements such as:

  • I feel hopeful about the future
  • My heart beats faster than usual
  • I notice that I am losing weight
  • I get tired for no reason

While this is a useful screening tool — relevant because depression is so common and so often missed in a primary care setting that some studies recommend every primary care physician routinely screens all patients for depression — the Zung Self-Rating Depression Scale cannot be used as a stand-alone diagnostic method. 

The Center for Epidemiologic Studies-Depression Scale

The Center for Epidemiologic Studies-Depression Scale, originally developed for research purposes, has been criticized because it doesn't line up with up-to-date diagnostic criteria for depression. Its wording may also lead to the false impression that some people who aren't depressed are — older adults, for instance, are more likely to struggle with daily tasks for physical rather than mental reasons — and has been shown to lead to an overdiagnosis of depression in women, while having the opposite effect in men. It isn't, therefore, the best tool your doctor has available. 

It asks 20 questions relating to how you have felt in the past week — including things like "I was bothered by things that usually don’t bother me", "I felt that everything I did was an effort", "I felt fearful", and "people were unfriendly". Like the previous rating scales we have looked at, it offers the chance to offer four different answers, from "not at all" to "most or all of the time". 

The Hamilton Rating Scale for Depression (HRSD)

The widely-used Hamilton Rating Scale for Depression (HRSD) is a 17-item questionnaire that also contains four questions meant to figure out what subtype of depression you are suffer from.

While it asks some of the same questions found in the PHQ-9 and other screening forms for depression, it goes into more detail on the possible physical symptoms of depression, addressing things like:

  • Gastrointestinal problems
  • Headaches
  • Back pain
  • A feeling of physical "heaviness"
  • Insomnia — not just if you have it, but also when

Can I use these tests to self-screen for depression?

You could — but we wouldn't necessarily recommend it. If you're inclined to use a screening test for depression, it's fairly safe to say something is probably up. Remember that these screening tools are just one of many tools at your doctor's disposal, and that the full diagnostic process is more involved. Keep in mind, too, that a diagnosis is just the first step — and you'll still need your doctor to access the best available treatment. 

Terri decided to start with antidepressants after her diagnosis of moderate depression, and began attending therapy once she'd been taking them for a while. She's now happy to say she has been off the meds for two years, and has never felt better. What started with a chat and a screening test set the wheels that led Terri to get the help she needed in motion, and the same can be true for you, too.

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