a brief self-rating questionnaire for depression (srq-d)
TRANSCRIPT
A Brief Self-Rating Questionnaire for Depression (SRQ-D)BURTON W. ROCKLlFF, M.D.
• The concept that the diagnosis of psychiat-ric disorders can be greatly aided by
evaluating the response of patients to a standardized set of questions or statements is amost attractive proposition, and has led tothe development of a number of self-administered scales, including the much-used andburdensome Minnesota Multiphasic Personality Inventory (MMPI). With respect tothe use of such scales in depressed patients,Zung has recently described' the constructionand testing of a Self-Rating Depression Scale(SDS) of 20 items, and subsequently reported" that this scale compared favorablywith MMPI in differentiating between diagnostic groups of out-patients. While the Zungscale thus demonstrates that brevity and adegree of sensitivity can co-exist in such aninstrument, the scale has several featureswhich limit its usefulness and reliability.
Briefly, the SDS does not provide the subject with the opportunity to respond to anyitem with a simple negative (such as "never");scoring can be done quickly only by use of aspecial over-lay; and, most importantly, several of the items are either ambiguous or nonspecific, and provide poor separation of meanitem scores as between depressed and nondepressed subjects'. This last point will bediscussed in detail in a later section, but wasthe stimulus to devise a questionnaire in whicheach item would contribute strongly andequally to high total scores in depressed patients while eliciting low scores in normal individuals.
METHOD
A systematic scheme for the constructionof the questionnaire was purposely avoided.Seven statements in the SDS which showed
From the Medical Department. Western Section. Geigy Pharmaceuticals, San Bernardino,California.
236
good separation of scores as between normalsand depressives1 were converted to questions.The thrust of the question was changed insome instances. For example, the statement"My mind is as clear as it used to be" waschanged to "Do you find it difficult to thinkclearly?" These questions constitute items 1,3, 7, 13, 14, 16 and 17 of the SRQ-D (TableI). An SDS statement on which normal subjects scored rather high (with reversed scoring) "Morning is when I feel the best", wasmade more specific for depression as "Do youfeel particularly discouraged in the mornings?" (item 5). Four additional questionsconcerning early-morning awakening, appetite, social participation and feelings of worthlessness were devised (items 9, 11, 15 and18), and these 12 questions constitute therelevant items of the SRQ-D.
All of the relevant questions are orientedsymptomatically- positive; that is, the moreaffirmative the answer the greater the indication of abnormality or illness. The Zung scalecorrectly avoids this sameness by reversingthe orientation of half the statements, although at the expense of specificity in someinstances. It was decided that the same general result would be achieved by interspersingsix non-relevant questions, some of which arenegatively oriented. An additional advantageof these questions is that they provide useful contrast data for both within-group andacross-group comparisons against the scoresof the relevant questions. In this respect, theyact as controls, and are considered controlitems. These items (2,4,6,8,10 and 12) werescored separately, and used in the validationof the scale.
The subjects tested have a choice of fouranswers to each question: seldom or never,some of the time, quite often or almost always. For anyone question, these answersare scored 0, 1, 2 and 3 respectively. Thus,
Volume X
A Brief Self-Rating Questionnaire for Depression (SRQ-D)BURTON W. ROCKLlFF, M.D.
• The concept that the diagnosis of psychiat-ric disorders can be greatly aided by
evaluating the response of patients to a standardized set of questions or statements is amost attractive proposition, and has led tothe development of a number of self-administered scales, including the much-used andburdensome Minnesota Multiphasic Personality Inventory (MMPI). With respect tothe use of such scales in depressed patients,Zung has recently described' the constructionand testing of a Self-Rating Depression Scale(SDS) of 20 items, and subsequently reported" that this scale compared favorablywith MMPI in differentiating between diagnostic groups of out-patients. While the Zungscale thus demonstrates that brevity and adegree of sensitivity can co-exist in such aninstrument, the scale has several featureswhich limit its usefulness and reliability.
Briefly, the SDS does not provide the subject with the opportunity to respond to anyitem with a simple negative (such as "never");scoring can be done quickly only by use of aspecial over-lay; and, most importantly, several of the items are either ambiguous or nonspecific, and provide poor separation of meanitem scores as between depressed and nondepressed subjects'. This last point will bediscussed in detail in a later section, but wasthe stimulus to devise a questionnaire in whicheach item would contribute strongly andequally to high total scores in depressed patients while eliciting low scores in normal individuals.
METHOD
A systematic scheme for the constructionof the questionnaire was purposely avoided.Seven statements in the SDS which showed
From the Medical Department. Western Section. Geigy Pharmaceuticals, San Bernardino,California.
236
good separation of scores as between normalsand depressives1 were converted to questions.The thrust of the question was changed insome instances. For example, the statement"My mind is as clear as it used to be" waschanged to "Do you find it difficult to thinkclearly?" These questions constitute items 1,3, 7, 13, 14, 16 and 17 of the SRQ-D (TableI). An SDS statement on which normal subjects scored rather high (with reversed scoring) "Morning is when I feel the best", wasmade more specific for depression as "Do youfeel particularly discouraged in the mornings?" (item 5). Four additional questionsconcerning early-morning awakening, appetite, social participation and feelings of worthlessness were devised (items 9, 11, 15 and18), and these 12 questions constitute therelevant items of the SRQ-D.
All of the relevant questions are orientedsymptomatically- positive; that is, the moreaffirmative the answer the greater the indication of abnormality or illness. The Zung scalecorrectly avoids this sameness by reversingthe orientation of half the statements, although at the expense of specificity in someinstances. It was decided that the same general result would be achieved by interspersingsix non-relevant questions, some of which arenegatively oriented. An additional advantageof these questions is that they provide useful contrast data for both within-group andacross-group comparisons against the scoresof the relevant questions. In this respect, theyact as controls, and are considered controlitems. These items (2,4,6,8,10 and 12) werescored separately, and used in the validationof the scale.
The subjects tested have a choice of fouranswers to each question: seldom or never,some of the time, quite often or almost always. For anyone question, these answersare scored 0, 1, 2 and 3 respectively. Thus,
Volume X
TABLE I
Self-Rating Questionnaire for Depression (SRQ-D) **
CHECK ONE ANSWER FOR EACH QUESTIONSeldom Some of Quite Almost 1/or Never the Time Often Always
l. Do you get tired for no reason? X 2
2. Do you get annoyed by noisl''! ~': X '.,3. Do you fcc 1 down-hearted and
X )blue?
-<. Do you enjoy music? .. X '.,5. Do you feel particularly dis- X 2
couraged in the mornings?
6. Do you get involved inX '.,arguments? *
7. Do you have crying spe lls orX 2
fee 1 like crying?
8. Do you su f fe r from headaches? .. X '.,
9. Do you awaken very early andhave difficulty falling back X 1to sleep?
10. Do you tend to have accidents /
and minor injuries? ,'. X ...,
ll. Do you have a poor a ppe tit,'X 3
for food?
12. Do you find te levis ionX L.,enjoyable? ....
13. Do you fce 1 your lif" is ~ll1pty? X 2
14. Do you find it d ifficu 1t toX 1think clear ly?
15. Do you avoid other people andsoc ia 1 activities? X 3
16. Do you f"e 1 that others would be X 0be t te r off if you were dead?
17. Do you find you no longer enjoyX 2
the th ings you used to do?
18. Do you fee 1 you are not worthX 2much as a pel son?
23
** Completed and scored as an example.
* Control question; not scored.
JUly-August 1969 237
TABLE I
Self-Rating Questionnaire for Depression (SRQ-D) **
CHECK ONE ANSWER FOR EACH QUESTIONSeldom Some of Quite Almost 1/or Never the Time Often Always
l. Do you get tired for no reason? X 2
2. Do you get annoyed by noisl''! ~': X '.,3. Do you fcc 1 down-hearted and
X )blue?
-<. Do you enjoy music? .. X '.,5. Do you feel particularly dis- X 2
couraged in the mornings?
6. Do you get involved inX '.,arguments? *
7. Do you have crying spe lls orX 2
fee 1 like crying?
8. Do you su f fe r from headaches? .. X '.,
9. Do you awaken very early andhave difficulty falling back X 1to sleep?
10. Do you tend to have accidents /
and minor injuries? ,'. X ...,
ll. Do you have a poor a ppe tit,'X 3
for food?
12. Do you find te levis ionX L.,enjoyable? ....
13. Do you fce 1 your lif" is ~ll1pty? X 2
14. Do you find it d ifficu 1t toX 1think clear ly?
15. Do you avoid other people andsoc ia 1 activities? X 3
16. Do you f"e 1 that others would be X 0be t te r off if you were dead?
17. Do you find you no longer enjoyX 2
the th ings you used to do?
18. Do you fee 1 you are not worthX 2much as a pel son?
23
** Completed and scored as an example.
* Control question; not scored.
JUly-August 1969 237
PSYCHOSOMATICS
for the 12 relevant items, the total score mayrange from 0 to 36. Similarly, the total scorefor the six control items may range from 0
to 18.In scoring a completed questionnaire, as
illustrated in Table I, the squares in the righthand tally column opposite the control items2, 4, 6, 8, 10 and 12 are crossed out. Theremaining items are scored on sight and the12 item scores are added for the total score.The control items may be scored and addedseparately if desired.
The questionnaire was given to 100 normal individuals consisting of office, administrative and sales personnel of a businessconcern. All were apparently well and attested to having no recent history of psychiatric illness.
Two psychiatrists (see acknowledgements) gave the SRQ-D to patients whowere hospitalized with a primary diagnosisof depression. No patients with schizophreniawere included regardless of the presence ofsecondary depressive symptoms. A total of 60depressed patients completed the questionnaire.
The SRQ-D was also administered to agroup of 23 female office patients seen primarily for gynecologic complaints. Theywere considered by the gynecologist (seeacknowledgement) to have significant depressive symptoms. A few of these patients hada history of psychiatric illness and previouspsychotherapy. They were evaluated by thephysician without regard to their SRQ-D results, and were independently rated on a ver-
sion of the Lehmann rating scale" modifiedby the author4
• All of these patients were considered candidates for anti-depressant therapy.
RESULTS
Because of the large number of variablesto be examined, the data and analyses werehandled by computer. Differences in meanswere tested by t-test, while distributions werecompared by chi-square.
The age and sex distribution in the groupsof normals and hospitalized depressives issummarized in Table II. While the two groupswere comparable with respect to age, therewas a significantly greater proportion of females in the depressive group. Consequently,examination of the results by sex was includedin the total analysis to determine whether biaswas introduced by this distribution.
In Table III, the distribution of totalSRQ-D scores (relevant items) in the twogroups is shown, as well as the means (normals 2.80; depressives 18.38). Scores of thenormal subjects are tightly clustered at thelow end of the scale, with 95% having a valueof 7 or less. About 10% of the depressed patients had scores this low, the rest showinga fairly diffuse distribution extending to thehigh end of the scale. The difference betweenthe groups both in regard to means (t-test)and distribution (chi-square) was highly significant (p<O.OOOl).
With regard to the results by sex, thenormal males had a mean total score of 2.14as compared to 19.67 in the male depressives.
TABLE II
Age and Sex Distribution in Two Groups
~ !1!!!!. SexRange ~ Male Femal~
Numb('f (~) (Yea rs) (7)
t'orma Is 100 22-58 37.3 56 (';6) 44 (44)
D~pressives 60 16-69 40.9 15 (25) 45 (75)
D i f ft.· n·ne(.' N.S. p <'0. 0001
238Volume X
PSYCHOSOMATICS
for the 12 relevant items, the total score mayrange from 0 to 36. Similarly, the total scorefor the six control items may range from 0
to 18.In scoring a completed questionnaire, as
illustrated in Table I, the squares in the righthand tally column opposite the control items2, 4, 6, 8, 10 and 12 are crossed out. Theremaining items are scored on sight and the12 item scores are added for the total score.The control items may be scored and addedseparately if desired.
The questionnaire was given to 100 normal individuals consisting of office, administrative and sales personnel of a businessconcern. All were apparently well and attested to having no recent history of psychiatric illness.
Two psychiatrists (see acknowledgements) gave the SRQ-D to patients whowere hospitalized with a primary diagnosisof depression. No patients with schizophreniawere included regardless of the presence ofsecondary depressive symptoms. A total of 60depressed patients completed the questionnaire.
The SRQ-D was also administered to agroup of 23 female office patients seen primarily for gynecologic complaints. Theywere considered by the gynecologist (seeacknowledgement) to have significant depressive symptoms. A few of these patients hada history of psychiatric illness and previouspsychotherapy. They were evaluated by thephysician without regard to their SRQ-D results, and were independently rated on a ver-
sion of the Lehmann rating scale" modifiedby the author4
• All of these patients were considered candidates for anti-depressant therapy.
RESULTS
Because of the large number of variablesto be examined, the data and analyses werehandled by computer. Differences in meanswere tested by t-test, while distributions werecompared by chi-square.
The age and sex distribution in the groupsof normals and hospitalized depressives issummarized in Table II. While the two groupswere comparable with respect to age, therewas a significantly greater proportion of females in the depressive group. Consequently,examination of the results by sex was includedin the total analysis to determine whether biaswas introduced by this distribution.
In Table III, the distribution of totalSRQ-D scores (relevant items) in the twogroups is shown, as well as the means (normals 2.80; depressives 18.38). Scores of thenormal subjects are tightly clustered at thelow end of the scale, with 95% having a valueof 7 or less. About 10% of the depressed patients had scores this low, the rest showinga fairly diffuse distribution extending to thehigh end of the scale. The difference betweenthe groups both in regard to means (t-test)and distribution (chi-square) was highly significant (p<O.OOOl).
With regard to the results by sex, thenormal males had a mean total score of 2.14as compared to 19.67 in the male depressives.
TABLE II
Age and Sex Distribution in Two Groups
~ !1!!!!. SexRange ~ Male Femal~
Numb('f (~) (Yea rs) (7)
t'orma Is 100 22-58 37.3 56 (';6) 44 (44)
D~pressives 60 16-69 40.9 15 (25) 45 (75)
D i f ft.· n·ne(.' N.S. p <'0. 0001
238Volume X
SELF-RATING QUESTIONAIRE-ROCKLIFF
The corresponding scores in the females were3.64 and 17.96 respectively. The inter-groupdifferences for each sex were highly significant(p<O.OOI).
When the scores of individual items wereaveraged, consistent separation of the meansfor each group by item was noted as illustrated in figure 1. The total SRQ-D scoredivided by 12 provides an index which canbe directly compared to the score for anysingle question. The means of these indices(TS/12) for each group are also shown infigure 1, and are 0.23 for the normals and1.53 for the depressives. This difference ishighly significant (t-test), as are the differences between groups for the scores of eachitem (chi-square, p<O.OOOI).
The total scores for the six control questions ranged from 2 to 12 in the normals, andfrom 1 to 13 in the depressed patients. Themean control scores were 6.34 and 5.93 respectively for the two groups, and the difference was not significant (p = 0.29). There
were significant differences between thegroups in the average scores of individualcontrol items, however, as shown in figure 2.The total score of the control items dividedby six (TS/6) provides an index for comparison with individual item scores, and themean of these indices shown in figure 2 isvirtually the same for both groups. It is obvious, however, that this is a result of thebalancing of real differences in both directions from item to item. Analysis by chi-squareof the distribution of scores by item in thetwo groups shows that there is a highly significant difference for questions 4, 10 and 12(p<O.OOI), and question 2 (p<O.OI), anda significant difference for questions 6 and 8(p<O.OS).
The SRQ-D scores of the 23 female officepatients ranged from 2 to 36 with a mean total score of 14.22 (as compared to 17.96 inthe hospitalized female depressives). Thephysician rated these patients on a modifiedLehmann scale consisting of 10 items con-
TABLE III
Distribution and Means of SRQ-D Scores (Relevant Items) inNormal Subjects (NS) and Hospitalized Depressed Patients (DH)
Score ~s Oil Score ~s Oil Score ~s 011
0 18 13 ~ l'
21 14 :?i
12 I'> 28
18 1h 29
10 17 JO
4 18 J1
h 9 19 1:
:0 J'\
s ,
I: I 34
9 ,. '3')
10 21 3,)
11 " 100 ,0
12 25 '<l·al' ~.~O l' ,'\'
JUly-AUgust 1969 239
SELF-RATING QUESTIONAIRE-ROCKLIFF
The corresponding scores in the females were3.64 and 17.96 respectively. The inter-groupdifferences for each sex were highly significant(p<O.OOI).
When the scores of individual items wereaveraged, consistent separation of the meansfor each group by item was noted as illustrated in figure 1. The total SRQ-D scoredivided by 12 provides an index which canbe directly compared to the score for anysingle question. The means of these indices(TS/12) for each group are also shown infigure 1, and are 0.23 for the normals and1.53 for the depressives. This difference ishighly significant (t-test), as are the differences between groups for the scores of eachitem (chi-square, p<O.OOOI).
The total scores for the six control questions ranged from 2 to 12 in the normals, andfrom 1 to 13 in the depressed patients. Themean control scores were 6.34 and 5.93 respectively for the two groups, and the difference was not significant (p = 0.29). There
were significant differences between thegroups in the average scores of individualcontrol items, however, as shown in figure 2.The total score of the control items dividedby six (TS/6) provides an index for comparison with individual item scores, and themean of these indices shown in figure 2 isvirtually the same for both groups. It is obvious, however, that this is a result of thebalancing of real differences in both directions from item to item. Analysis by chi-squareof the distribution of scores by item in thetwo groups shows that there is a highly significant difference for questions 4, 10 and 12(p<O.OOI), and question 2 (p<O.OI), anda significant difference for questions 6 and 8(p<O.OS).
The SRQ-D scores of the 23 female officepatients ranged from 2 to 36 with a mean total score of 14.22 (as compared to 17.96 inthe hospitalized female depressives). Thephysician rated these patients on a modifiedLehmann scale consisting of 10 items con-
TABLE III
Distribution and Means of SRQ-D Scores (Relevant Items) inNormal Subjects (NS) and Hospitalized Depressed Patients (DH)
Score ~s Oil Score ~s Oil Score ~s 011
0 18 13 ~ l'
21 14 :?i
12 I'> 28
18 1h 29
10 17 JO
4 18 J1
h 9 19 1:
:0 J'\
s ,
I: I 34
9 ,. '3')
10 21 3,)
11 " 100 ,0
12 25 '<l·al' ~.~O l' ,'\'
JUly-AUgust 1969 239
.:'.i.. .',:.;:1..::....,
T-I -
I}- -
t,'l
------ - ----(---.I
J :
, J- j _-- - --~-- ----->-J- - - ~11 1 ~ 1:~ 1 C; I') t ~ 1 '~ rs 112
Fig. 1: Mean scores of each relevant question for the hospitalized depressedpatients and normal subjects. Dashed lines represent the means of the averaged itemscores (total score +-) for each group. All inter-group differences are highly significant<p<O.OOOl).
Fig. 2: Mean scores of each control question for the hospitalized depressed patients and normal subjects. Dashed lines represent the means of the averaged item scores(total score +- 6) for each group. The difference between these two values is notsignificant, but inter-group difference of the mean item scores are significant at varying levels (p<O.05 to p<O.OOl).
240 Volume X
.:'.i.. .',:.;:1..::....,
T-I -
I}- -
t,'l
------ - ----(---.I
J :
, J- j _-- - --~-- ----->-J- - - ~11 1 ~ 1:~ 1 C; I') t ~ 1 '~ rs 112
Fig. 1: Mean scores of each relevant question for the hospitalized depressedpatients and normal subjects. Dashed lines represent the means of the averaged itemscores (total score +-) for each group. All inter-group differences are highly significant<p<O.OOOl).
Fig. 2: Mean scores of each control question for the hospitalized depressed patients and normal subjects. Dashed lines represent the means of the averaged item scores(total score +- 6) for each group. The difference between these two values is notsignificant, but inter-group difference of the mean item scores are significant at varying levels (p<O.05 to p<O.OOl).
240 Volume X
SELF-RATING QUESTIONAIRE-ROCKLIFF
cerned with mood, appearance, retardation,suicidal tendencies, impairment of work,agitation, feelings of guilt, insomnia, somaticcomplaints and appetite>'. Since each itemwas rated 0 to 3, a maximum total score of30 was possible. A score of 10 or more is consistent with clinically significant depression.The mean score was 18.8 in this group, andFigure 3 shows how each patient's SRQ-Dscore compared with the physician's rating.The correlation is fairly good except for atendency of the moderately depressed patients to under-rate their illness as comparedto the physician's judgment. This confirmsthe commonly observed phenomenon of"denial" in some depressed patients, which isone of the factors limiting the usefulness ofany self-rating instrument.
COMMENT
Devising a self-administered scale thatwill differentiate statistically between groups
• :"r :,,~:-.,.! "r::;
o ~t ~~~l~ .~lrn
1 r
i;::~ :. '.- ." _- "J"" ~
> - •
I I
~ l
I1'" 1 _~ ~:;,' •
Fig. 3: Scattergram of SRQ-D and physicianrated (on modified Lehmann depression scale)scores in the same 23 female office patients withdepressive symptoms. High correlation is indicated by proximity to diagonal dashed line.
July-August 1969
of depressed and non-depressed subjects is aridiculously easy matter. Such a scale mayvery well be useless as a diagnostic aid forthe individual patient, however, if the tailsof the distributions of scores in the two groupsoverlap greatly.
In general, a questionnaire for depressioncan be designed for one of two possible setsof results: 1) through devious and non-specific wording, it may be aimed at eliciting highscores from patients with any degree of depression, including those with "denied" or"masked" symptoms, or 2) by using directand unambiguous questions, it may be constructed to produce very low scores from normal subjects while eliciting high scores frommost depresEed patients. A scale devised according to the first formula tends to producescores in a proportion of normals which fallin the depressive range, while a scale prepared by the second method tends to permitsome depressed patients to score in the low,normal range. Since both of these goals cannot be attained in the same instrument, achoice must be made.
The questions in the SRQ-D were wordedso as to promote consistently low scores innormal subjects. The close grouping of scoresin the normals at the low end of the scaleshows that this goal was achieved, and thatthere is little risk that any single normal individual will be suspect as a "depressive" onthe basis of this questionnaire. This wouldseem to be a more desirable and necessaryobjective than to attempt to detect minimal
or covert depression in some patients at the
expense of "false positive" scores in normals.
Aside from this general consideration, andthe obvious desirability of brevity, the contribution of each item to the differentiation
between groups should be demonstrated em
pirically by the results. While it may be
academically interesting to base the itemsinitially on some theoretical scheme or concept, if the performance of any item is poorin the light of the actual data, that item shouldbe deleted or replaced.
241
SELF-RATING QUESTIONAIRE-ROCKLIFF
cerned with mood, appearance, retardation,suicidal tendencies, impairment of work,agitation, feelings of guilt, insomnia, somaticcomplaints and appetite>'. Since each itemwas rated 0 to 3, a maximum total score of30 was possible. A score of 10 or more is consistent with clinically significant depression.The mean score was 18.8 in this group, andFigure 3 shows how each patient's SRQ-Dscore compared with the physician's rating.The correlation is fairly good except for atendency of the moderately depressed patients to under-rate their illness as comparedto the physician's judgment. This confirmsthe commonly observed phenomenon of"denial" in some depressed patients, which isone of the factors limiting the usefulness ofany self-rating instrument.
COMMENT
Devising a self-administered scale thatwill differentiate statistically between groups
• :"r :,,~:-.,.! "r::;
o ~t ~~~l~ .~lrn
1 r
i;::~ :. '.- ." _- "J"" ~
> - •
I I
~ l
I1'" 1 _~ ~:;,' •
Fig. 3: Scattergram of SRQ-D and physicianrated (on modified Lehmann depression scale)scores in the same 23 female office patients withdepressive symptoms. High correlation is indicated by proximity to diagonal dashed line.
July-August 1969
of depressed and non-depressed subjects is aridiculously easy matter. Such a scale mayvery well be useless as a diagnostic aid forthe individual patient, however, if the tailsof the distributions of scores in the two groupsoverlap greatly.
In general, a questionnaire for depressioncan be designed for one of two possible setsof results: 1) through devious and non-specific wording, it may be aimed at eliciting highscores from patients with any degree of depression, including those with "denied" or"masked" symptoms, or 2) by using directand unambiguous questions, it may be constructed to produce very low scores from normal subjects while eliciting high scores frommost depresEed patients. A scale devised according to the first formula tends to producescores in a proportion of normals which fallin the depressive range, while a scale prepared by the second method tends to permitsome depressed patients to score in the low,normal range. Since both of these goals cannot be attained in the same instrument, achoice must be made.
The questions in the SRQ-D were wordedso as to promote consistently low scores innormal subjects. The close grouping of scoresin the normals at the low end of the scaleshows that this goal was achieved, and thatthere is little risk that any single normal individual will be suspect as a "depressive" onthe basis of this questionnaire. This wouldseem to be a more desirable and necessaryobjective than to attempt to detect minimal
or covert depression in some patients at the
expense of "false positive" scores in normals.
Aside from this general consideration, andthe obvious desirability of brevity, the contribution of each item to the differentiation
between groups should be demonstrated em
pirically by the results. While it may be
academically interesting to base the itemsinitially on some theoretical scheme or concept, if the performance of any item is poorin the light of the actual data, that item shouldbe deleted or replaced.
241
PSYCHOSOMA'pes
Actually, it is difficult to devise questionswhich will be answered in the same quantitative fa£hion by both depressed and normalsubjects. This becomes evident in examiningthe scores of the control items, which werenot expected to show good separation betweengroups. From figure 2, however, it can be seenthat question number 4 (Do you enjoymusic?), as an example, was scored quite differently by the two groups. Since depressedpatients tend to lack enjoyment of mostthings, this is not too surprising, and one mayask whether this should not be considereda relevant item. Analysis of the answers toquestion number 4 reveals that 95% of normals had scores of 2 or 3; but so did 53%of the depressives. While this difference isstatistically highly significant, there is toomuch overlap to consider this a clinically useful item for differentiation.
In comparison, examination of the answers to (relevant) question number 13 (Doyou feel your life is empty?) shows that noneof the normals scored 2 or 3, while 60% of thedepressives did. This difference is not onlystatistically highly significant, but also demonstrates that the question elicits a very consistent response from normals which differsfrom that of most depressives.
Changing the wording of an item may increase its usefulness greatly. The SDS itemwhich produced the least separation betweengroups1 was the statement: "Morning is whenI feel the best". As question number 5 (Doyou feel particularly discouraged in the mornings?) in the SRQ-D, the separation of meanscores was one of the best (figure 1). Analysisof the answers shows that only 1% of normalsubjects scored 2 or 3 on this question as compared with 57% of the depressed patients.
While these results show that the SRQ-Dsatisfactorily differentiates between depressedpatients and normal subjects, scores fromother diagnostic groups are not presentlyavailable. Additional data from non-depressedneurotic patients, for instance, would be helpful in further evaluating the specificity of thescale.
242
Finally, it should be emphasized that noself-administered questionnaire should be relied upon uncritically as the basis for makinga diagnosis. In the case of SRQ-D, one canonly state with confidence that a score of12 or higher indicates an abnormal affectivestate, and depression should be suspected. Alow score, on the other hand, does not necessarily exclude depression because of the phenomenon of denial previously mentioned. Inany case, the response to individual questionscan serve as the basis for further investigation by the physician, and, together with thetotal score, may serve to facilitate the diagnosis of depression in many patients. The implication that any self-rating scale provides"do-it-yourself diagnosis", however, must beconsidered deplorably naive and misleading.
SUMMARY
A self-rating questionnaire for depression(SRQ-D) consisting of 12 relevant and 6 control questions was administered to 100 normalsubjects and 60 hospitalized depressed patients. Answers to each question were scoredo to 3, so that the total scores of the 12relevant questions ranged from 0 to 36. Themean total score for the normal subjects was2.80 as compared to 18.38 for the depressives.This difference and the inter-group differencesin scoring for each individual relevant itemwere all statistically highly significant (p<0.0001). The mean total scores of the control items did not differ significantly for thetwo groups, although scores of the individualcontrol items did differ at various levels ofsignificance.
The SRQ-D was also given to 23 femaleout-patients presenting with symptoms of depression. These patients were rated independently by the physician on a modified Lehmann~epression rating scale. The scores of the twoscales showed good correlation except for atendency of the moderately depressed patients to show lower self-rated scores than indicated by the physician's ratings.
Each relevant item in the SRQ-D wasshown to contribute strongly to the differen-
Volume X
PSYCHOSOMA'pes
Actually, it is difficult to devise questionswhich will be answered in the same quantitative fa£hion by both depressed and normalsubjects. This becomes evident in examiningthe scores of the control items, which werenot expected to show good separation betweengroups. From figure 2, however, it can be seenthat question number 4 (Do you enjoymusic?), as an example, was scored quite differently by the two groups. Since depressedpatients tend to lack enjoyment of mostthings, this is not too surprising, and one mayask whether this should not be considereda relevant item. Analysis of the answers toquestion number 4 reveals that 95% of normals had scores of 2 or 3; but so did 53%of the depressives. While this difference isstatistically highly significant, there is toomuch overlap to consider this a clinically useful item for differentiation.
In comparison, examination of the answers to (relevant) question number 13 (Doyou feel your life is empty?) shows that noneof the normals scored 2 or 3, while 60% of thedepressives did. This difference is not onlystatistically highly significant, but also demonstrates that the question elicits a very consistent response from normals which differsfrom that of most depressives.
Changing the wording of an item may increase its usefulness greatly. The SDS itemwhich produced the least separation betweengroups1 was the statement: "Morning is whenI feel the best". As question number 5 (Doyou feel particularly discouraged in the mornings?) in the SRQ-D, the separation of meanscores was one of the best (figure 1). Analysisof the answers shows that only 1% of normalsubjects scored 2 or 3 on this question as compared with 57% of the depressed patients.
While these results show that the SRQ-Dsatisfactorily differentiates between depressedpatients and normal subjects, scores fromother diagnostic groups are not presentlyavailable. Additional data from non-depressedneurotic patients, for instance, would be helpful in further evaluating the specificity of thescale.
242
Finally, it should be emphasized that noself-administered questionnaire should be relied upon uncritically as the basis for makinga diagnosis. In the case of SRQ-D, one canonly state with confidence that a score of12 or higher indicates an abnormal affectivestate, and depression should be suspected. Alow score, on the other hand, does not necessarily exclude depression because of the phenomenon of denial previously mentioned. Inany case, the response to individual questionscan serve as the basis for further investigation by the physician, and, together with thetotal score, may serve to facilitate the diagnosis of depression in many patients. The implication that any self-rating scale provides"do-it-yourself diagnosis", however, must beconsidered deplorably naive and misleading.
SUMMARY
A self-rating questionnaire for depression(SRQ-D) consisting of 12 relevant and 6 control questions was administered to 100 normalsubjects and 60 hospitalized depressed patients. Answers to each question were scoredo to 3, so that the total scores of the 12relevant questions ranged from 0 to 36. Themean total score for the normal subjects was2.80 as compared to 18.38 for the depressives.This difference and the inter-group differencesin scoring for each individual relevant itemwere all statistically highly significant (p<0.0001). The mean total scores of the control items did not differ significantly for thetwo groups, although scores of the individualcontrol items did differ at various levels ofsignificance.
The SRQ-D was also given to 23 femaleout-patients presenting with symptoms of depression. These patients were rated independently by the physician on a modified Lehmann~epression rating scale. The scores of the twoscales showed good correlation except for atendency of the moderately depressed patients to show lower self-rated scores than indicated by the physician's ratings.
Each relevant item in the SRQ-D wasshown to contribute strongly to the differen-
Volume X
SELF-RATING QUESTIONAIRE-ROCKLIFF
tiation between normal and depressed subjects. Total scores of the normals were allclustered at the low end of the scale, so thatany individual with a score of 12 or highershould be suspect for some degree of depression. A low score does not necessarily rule outthis disorder, however, because of the tendency of some patients to deny symptoms.
The limitations of self-rating instrumentsare emphasized. Within these limitations, it issuggested that the SRQ-D may be a usefulaid in making the diagnosis of depression.
Ackllowledgement: The contributions of Dr.Anthony Lapolla, Camarillo State Hospital, Camarillo, California and Dr. T. P. S. Watts, presentlyMedical DIrector, The Donwood Foundation, Toronto, who selected and tested the depressed hospitalized patients, are gratefully acknowledged.
I am also indebted to Dr. Robert S. Scott, LosAngeles, for providing the SRQ-D and LehmannRockliff rating scale data on office patients. Mrs.Bonnie Fraley supervised the computer analysis.
Reprint requests to 255 North D Street, SanBernardino, California 92401.
REFERENCES
1. Zung, W.W.K.: A Self-Rating DepressionScale, Arch. Gen. Psychiat. 12 :63-70, 1965.
2. Zung, W.W.K., Richards, C.B. and Short,M.J.: Self-Rating Depression Scale in an Outpatient Clinic; Further Validation of the SDS,Arch. Gen. Psychiat. 13 :508-515, 1965.
3. Lehmann, H.E., Cahn, C.H. and de Verteuil,R.L.: The Treatment of Depressive Conditions with Imipramine (G 22355), Canad.Psychiat. Assoc. J. 3 :155-164, 1958.
4. Rockliff, B.W.: Use of a Brief Rating Scalefor Depression, to be published.
16th Annual Meeting of the Academy of Psychosomatic Medicine
The 16th annual meeting of the Academy of Psychosomatic Medicine will takeplace in Scottsdale, Arizona, on November 19-23, 1969. The general theme will encompass the role of psychiatry in the daily practice of medicine.
Dr. Adam J. Krakowski of 202 Cornelia St., Plattsburgh, N.Y. 12902, is the program chairman. The following topics will be covered in genuine psychosomatic pattern;cardiac disease, respiratory disease, gastrointestinal disease, oral dsease (with dentalproblems), surgery and obstetrics (post-operative psychoses, plastic surgery and transplants, amputations), organic disease with emotional overlay, sexual problems, alcoholand drug abuse, recent advances in psychopharmacology, problems that children havewith their parents and the rehabilitation of the mentally ill.
Please note the dates, Nov. 19-23 on your calendar and plan to be at MountainShadows, Scottsdale, Arizona.
JUly-August 1969
SELF-RATING QUESTIONAIRE-ROCKLIFF
tiation between normal and depressed subjects. Total scores of the normals were allclustered at the low end of the scale, so thatany individual with a score of 12 or highershould be suspect for some degree of depression. A low score does not necessarily rule outthis disorder, however, because of the tendency of some patients to deny symptoms.
The limitations of self-rating instrumentsare emphasized. Within these limitations, it issuggested that the SRQ-D may be a usefulaid in making the diagnosis of depression.
Ackllowledgement: The contributions of Dr.Anthony Lapolla, Camarillo State Hospital, Camarillo, California and Dr. T. P. S. Watts, presentlyMedical DIrector, The Donwood Foundation, Toronto, who selected and tested the depressed hospitalized patients, are gratefully acknowledged.
I am also indebted to Dr. Robert S. Scott, LosAngeles, for providing the SRQ-D and LehmannRockliff rating scale data on office patients. Mrs.Bonnie Fraley supervised the computer analysis.
Reprint requests to 255 North D Street, SanBernardino, California 92401.
REFERENCES
1. Zung, W.W.K.: A Self-Rating DepressionScale, Arch. Gen. Psychiat. 12 :63-70, 1965.
2. Zung, W.W.K., Richards, C.B. and Short,M.J.: Self-Rating Depression Scale in an Outpatient Clinic; Further Validation of the SDS,Arch. Gen. Psychiat. 13 :508-515, 1965.
3. Lehmann, H.E., Cahn, C.H. and de Verteuil,R.L.: The Treatment of Depressive Conditions with Imipramine (G 22355), Canad.Psychiat. Assoc. J. 3 :155-164, 1958.
4. Rockliff, B.W.: Use of a Brief Rating Scalefor Depression, to be published.
16th Annual Meeting of the Academy of Psychosomatic Medicine
The 16th annual meeting of the Academy of Psychosomatic Medicine will takeplace in Scottsdale, Arizona, on November 19-23, 1969. The general theme will encompass the role of psychiatry in the daily practice of medicine.
Dr. Adam J. Krakowski of 202 Cornelia St., Plattsburgh, N.Y. 12902, is the program chairman. The following topics will be covered in genuine psychosomatic pattern;cardiac disease, respiratory disease, gastrointestinal disease, oral dsease (with dentalproblems), surgery and obstetrics (post-operative psychoses, plastic surgery and transplants, amputations), organic disease with emotional overlay, sexual problems, alcoholand drug abuse, recent advances in psychopharmacology, problems that children havewith their parents and the rehabilitation of the mentally ill.
Please note the dates, Nov. 19-23 on your calendar and plan to be at MountainShadows, Scottsdale, Arizona.
JUly-August 1969