Initial assessments of depressive symptoms can help determine possible treatment options, and periodic assessment throughout care can guide treatment.

What Is Depression?Depression may be described as feeling sad, blue, unhappy, miserable or down in the dumps. Most of us feel this way at one time or another for short periods. But true clinical depression is a mood disorder in which feelings of sadness, loss, anger or frustration interfere with everyday life for an extended time.Depression is a common condition. The National Institute of Mental Health (NIMH) estimates that about 10 percent of American adults experience some form of depression. For people with chronic illnesses, the number can be higher.

For example, NIMH estimates that about 25 percent of people with cancer have depression, and one study of people with found that 41.8 percent had significant symptoms of depression.The symptoms of depression can be mild, moderate or severe. But even when symptoms are mild, the condition is not the same as temporarily having the blues. People cannot snap out of depression by force of their will. And while practicing healthy habits may help, getting regular exercise, eating right or taking a vacation may not completely alleviate depression.Depression is more common in women than men and is especially common during the teen years. Men seem to seek help for feelings of depression less often than women.

Therefore, women may only have more documented cases of depression. What Causes Depression?Depression often runs in families and may be due to heredity, learned behavior or both. Even with a genetic predisposition, it is usually a stressful or unhappy life event that triggers the onset of a depressive episode. While the exact causes of depression are unknown, several factors appear to affect its onset. Biochemistry: Nerve cells in the brain send and receive messages that control your emotions and feelings, with the help of chemicals called neurotransmitters. Scientists believe that depression symptoms occur when some of these neurotransmitters, including and norepinephrene, are not delivered correctly, causing a chemical imbalance. Genetics: A family history of depressive disorder puts people at greater risk, but depression also strikes people who have no family members with the illness.

Depression that results from a person's biology or genetic inheritance is sometimes referred to as endogenous depression. Personality: People who are pessimistic or have low self-esteem or low tolerance for stress are more likely to develop depression. Difficult life situations: Depression may be more likely in people who are facing serious problems in their lives, such as abuse, violence or poverty.

Difficult times, such as divorce, the death of a loved one, financial problems or moving from your home can also contribute to depression. This type of depression is sometimes referred to as reactive depression. Other illnesses: People who have certain other medical conditions – such as cancer, heart disease, stroke, diabetes, Parkinson's disease and hormonal disorders – are more likely to develop depression.Depression may also be brought on by:. Disappointment at home, work, or school (in teens, this may be breaking up with a boyfriend or girlfriend, failing a class or parents divorcing). Drugs such as sedatives and high blood pressure medications. Alcohol or drug abuse. Chronic stress.

Childhood events like abuse or neglect. Social isolation (common in the elderly). Nutritional deficiencies (such as folate and omega-3 fatty acids). Sleeping problemsWhat Are the Symptoms of Depression?Not everyone who is diagnosed with depression has the same symptoms.

Some experience only a few symptoms, others have most of them. How severe the symptoms are and how long they last also varies from person to person. Seasonal affective disorder (SAD) occurs during the fall-winter season and disappears during the spring-summer season. It's likely due to lack of sunlight.How Do I Get Help for Depression?Without treatment, depression can be extremely serious, and even life-threatening if a person has thoughts of suicide, so it's extremely important to seek help if you are having depression symptoms. How Is Depression Diagnosed?Because some medicines and medical conditions can cause the same symptoms as depression, the first step in diagnosis is a complete medical history and a thorough physical examination. The exam may include an interview and laboratory tests to rule out other causes for the symptoms. What Other Treatments Are Available for Depression?Depression is treated in a variety of ways.PsychotherapyPeople with mild depression may only need psychotherapy (talk) to improve their symptoms, though doctors often advise therapy in conjunction with medication.

Psychotherapy attempts to help people work through their problems by talking regularly with a therapist. Depending on the situation, a person may undergo psychotherapy one-on-one with a therapist, take part with a spouse or family or try group therapy with people who have similar problems.Research has shown that some one-on-one short-term therapies, lasting 10 to 20 weeks, can help with depression. Herbal treatmentsOne such herbal remedy is St. John's wort (Hypericum perforatum). In Germany, St. John's wort has long been used to treat mild to moderate depression.

Studies on its use there, however, have been short-term and have not usually used uniform doses.The U.S. National Institutes of Health conducted a three-year study of St. John's wort and major depression of moderate severity. The study found no significant difference in rate of response for depression among groups receiving St.

John's wort, taking an SSRI anti-depressant or those getting a placebo. People who took the anti-depressant, however, reported better overall functioning than those who took either the St. John's wort or the placebo.If you are using herbal treatments for depression or other conditions, you should always tell your doctor what you are taking since the herbal treatments may interact with other medications. Can Depression Be Prevented?Healthy lifestyle habits can help prevent depression, or lessen the chances of it happening again.

Current measures for major depressive disorder focus primarily on the assessment of depressive symptoms, while often omitting other common features. However, the presence of comorbid features in the anxiety spectrum influences outcome and may effect treatment. More comprehensive measures of depression are needed that include the assessment of symptoms in the anxiety–depression spectrum. This study examines the reliability and validity of the Symptoms of Depression Questionnaire (SDQ), which assesses irritability, anger attacks, and anxiety symptoms together with the commonly considered symptoms of depression. Analysis of the factor structure of the SDQ identified 5 subscales, including one in the anxiety–depression spectrum, with adequate internal consistency and concurrent validity. The SDQ may be a valuable new tool to better characterize depression and identify and administer more targeted interventions.

IntroductionMajor depressive disorder (MDD) is one of the most common psychiatric disorders. The Centers for Disease Control has reported that on a national survey 9.1% of respondents met the criteria for current depression (significant symptoms for at least 2 weeks before the survey), including 4.1% who met the criteria for MDD. MDD is associated with significant economic burden and morbidity, and is expected to represent the leading cause of disability worldwide by 2030. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), in order to meet criteria for MDD, one would have to exhibit either depressed mood or anhedonia and 4 additional symptoms, including difficulty with sleep, appetite disturbances, fatigue or low energy, low self-esteem or inappropriate guilt, psychomotor retardation or agitation, cognitive impairment, or suicidal ideation, and report significant distress or impairment in functioning. However, as reflected in the latest edition of the DSM (DSM-5), additional symptoms are often present among individuals with MDD.

Specifically, the DSM-5 added a new MDD specifier, “with anxious distress,” indicating the presence of anxiety symptoms. This revision in the DSM-5 classification results from numerous studies showing that anxiety symptoms are often present among MDD patients, and that the co-occurrence of MDD and anxiety disorders has been observed in many settings. – Throughout paper, please condense more than two sequential reference numbers with an en dash (ie, 4–7, but 4,5). Moreover, additional anxiety symptoms that are not included in the “anxious distress” specifier are also common among patients with MDD, such as irritability. We previously observed that among 2307 outpatients who enrolled in the Sequenced Treatment Alternatives to Relieve Depression Study (STAR.D) on nonpsychotic major depression, significant irritability was present in 46% of the participants. Similarly, several authors have described the presence of discrete anger attacks among individuals with MDD.,Assessing the presence of anxiety symptoms among MDD patients is critical, as it has been associated with greater depression severity, slower remission and lower likelihood of remission on antidepressants, and increased suicidality.

– A recent review has also outlined neurobiological differences between MDD with and without anxiety symptoms, which may influence prognosis and treatment. However, current assessment measures of depression either do not assess anxiety symptoms or assess them in a limited fashion. Measures that capture the common clinical features of MDD, as well as anxiety symptoms, may aid in the identification of patients who will require more tailored or intensive treatment strategies and may also contribute to studies on the pathophysiology of depressive disorders and the development of targeted new treatments. Finally, they may better capture improvement or worsening of symptoms and therefore treatment response. An instrument that assesses all the features of MDD is critical, as it will lead to improved treatment and outcome.In light of the limitations of current depression measures, our group developed a more comprehensive scale for the assessment of MDD, the Symptoms of Depression Questionnaire (SDQ), which includes features that are often not assessed, such as irritability, anger attacks, and anxiety symptoms. Here we present its preliminary validation information. ParticipantsThe analyses reported below were conducted using 2 separate samples.Sample 1 included 335 college students who were administered study questionnaires in the context of mental health screening conducted as part of a larger project on suicide prevention.

This was a convenience sample of primarily female (62%) and Caucasian (78%) college students, with a mean age of 19.5 years (standard deviation SD 1.7 years). We used this sample to conduct the factor analysis and to examine concurrent validity.Sample 2 included 11 individuals enrolled in a study examining the effectiveness of open-label placebo. Briefly, this sample included 5 (45.6%) males and 6 (54.4%) females. Breath of fire 4 iso. Participants were on average 38.8 years old (SD 12.5). We used this sample to examine test–retest reliability of the SDQ.

Sample 1Data were collected at one mid-size Boston college. For a detailed description of recruitment procedures, please see Guidi et al. Briefly, during an on-campus mental health screening study, staff explained to interested students the details and aims of the project and provided a consent form approved by the Partners Human Research Committee (IRB) and college IRB along with a packet of screening questionnaires. The screening packet included several measures about mental health symptoms. For the current study, we considered information collected by the SDQ, the Beck Depression Inventory, the Beck Anxiety Inventory, and the Suicide Behavior Questionnaire–Revised (SBQ-R). Sample 2Participants in Sample 2 were enrolled in a randomized, controlled, pilot study to assess feasibility and effectiveness of an open-label placebo treatment for subjects with MDD. Eligible subjects were randomly assigned to 4 weeks of open-label placebo or to 2 weeks of wait-list/no-treatment followed by 4 weeks of open-label placebo.

Following informed consent, subjects underwent a screening visit to determine eligibility. Participants randomized to the immediate treatment group were given the placebo pills after the screen visit. Patients randomized to the wait-list group were given the placebo pills 2 weeks after the screen visit. The SDQ was administered at the screening visit and afterward every 2 weeks for the duration of the study. Symptoms of Depression Questionnaire (SDQ)The SDQ is a 44-item, self-report scale designed to measure the severity of symptoms across several subtypes of depression.

As such, the SDQ includes items that inquire about an extensive number of depressive symptoms. Items reflect a broad and heterogeneous collection of depression-related symptom features. Moreover, it includes several items that inquire about anxiety symptoms often present among depressed patients. The scale was developed by 2 of the authors (R.S. And M.F.) who chose the items on the basis of the most current knowledge of depressive symptoms and MDD subtypes. The 43 SDQ items are rated on a 6-point scale.

Each item is rated based on a subject's perception of what is normal for the individual (score = 2), what is better than normal (score = 1), and what is worse than normal (scores = 3–6). SDQ itemsF-1F-2F-3F-4F-5h 2SDQ 458SDQ 736SDQ 541SDQ 024SDQ 145SDQ 047SDQ 745SDQ 243SDQ 859SDQ 0672SDQ 0362SDQ 1047SDQ −0447SDQ −0667SDQ 1351SDQ −0948SDQ −0645SDQ 183819SDQ −1726SDQ −0956SDQ −0538SDQ 0050SDQ −0162SDQ 0461SDQ −0637SDQ 0954SDQ 0935SDQ 4939SDQ 6548SDQ − 5338SDQ 310902−03−00− 8166SDQ 0520SDQ −0335SDQ −1025SDQ 1048SDQ 30340SDQ 0225SDQ 0541SDQ 0952SDQ 0012SDQ 0249SDQ 0839SDQ 1146SDQ 1162% Variance31.04.933.443.322.29.

Factor loadings and commonalities (h 2) are presented without decimal points. Primary item loadings are presented in bold.A principal axis factor analysis (PAF) was employed to determine the internal structure of the 43 SDQ items. Prior to conducting the PAF, a parallel analysis (PA) was undertaken to help determine the number of meaningful factors that could be extracted from the PAF., The first 6 random eigenvalues generated by the PA were 1.83, 1.72, 1.66, 1.60, 1.55, and 1.50, while the first 6 real eigenvalues generated by the PAF were 14.17, 2.64, 2.05, 1.96, 1.55, and 1.46. Although the sixth eigenvalue generated by the PAF was greater than 1, it was also lower than the one generated by the PA, suggesting that 5 meaningful factors were present in the SDQ matrix. The 5 factors were extracted and varimax rotated to improve interpretability. These 5 factors contained meaningful (.35 or greater) loadings for 43 of the 44 items.

Shows the factor loadings for the SDQ items. While a number of multiple loadings were observed, only 8 SDQ items failed to achieve a clear primary loading (primary factor loading of ≥.35 and ≥.10 greater than its secondary loading) on a factor. Each SDQ item was assigned to a subscale based on its strongest factor loading.As shows, the first factor was marked by SDQ item 20 (“How has your energy been over the past months?”) and item 7 (“How has your motivation/interest/enthusiasm been over the past month?”). This factor appears to tap a dimension of lassitude, mood, and cognitive and social functioning. The second factor was marked by item 23 (“How agitated have you felt over the past month?”) and item 24 (“How irritable have you felt over the past month?”). This factor appears to capture anxiety, agitation, irritability, and anger.

The third factor was marked by item 10 (“How has your outlook on life been over the past month?”), which measures the extent to which one wishes to be dead, and by item 11 (“How has your outlook on suicide been over the last month?”), which measures the extent to which one wishes to kill oneself. Therefore, it appears that factor 3 assesses suicidal ideation. The fourth factor was marked by item 14 (“How has your ability to fall asleep been over the past month?”), which assesses disruptions in sleep quality. The fifth factor was marked by item 31 (“Have you gained weight over the last month?”), which seems to capture changes in appetite and weight. Only one item, item 40 (“How has your sexual functioning been over the last month?”), failed to load (≥.35) onto a factor. This item had its highest loading (.298) and strongest correlation to factor 1, and was therefore assigned to that factor.

Scale and Item Level Analysespresents the basic scale and item-level analyses for the SDQ Full Scale and subscales along with the properties of the concurrent validity measures (BDI, BAI, and SBQ-R). The SDQ Full Scale had excellent internal consistency (.94), low mean inter-item correlation, and only 2 items with adjusted item-to-scale correlations below the boundary of.30. The SDQ subscales 1, 2, and 3 showed good internal consistency (.85–.91), while the SDQ subscales 4 and 5 had internal consistencies that were slightly below the acceptable level of.80 (.78 and.71, respectively), as recommended by Nunnally and Bornstein. The lower internal consistency of these 2 subscales likely results from the limited number of items assigned to each scale (3 and 4 items, respectively). Concurrent ValidityCorrelation analyses were used to evaluate the concurrent validity of the SDQ Full scale and subscales. Correlations were obtained to examine the relationships of the SDQ Full Scale and subscales with the BDI, BAI, and SBQ-R.

The SDQ Full Scale had strong significant correlations with all the concurrent validity scales, but was most strongly associated with depression, as measured by the BDI (.85). The SDQ Subscales were all strongly correlated with depression (BDI), but also revealed a meaningful pattern of secondary correlations. For example, SDQ Subscale 2 (anxiety, agitation, irritability, and anger) had the highest correlations with anxiety (BAI,.70), and SDQ Subscale 3 (suicide, self-harm, and worthlessness) had a high correlation with depression (.75) and suicide (SBQ-R,.57) and lower correlation with anxiety (.56). Sample size (Ns) range from 308 to 325. All correlations are statically significant at p. DiscussionThis study examined the validity and reliability of a novel scale, the SDQ, which was developed to more fully capture the heterogeneity of symptom presentations of depressive disorders than current, widely used scales for MDD. The SDQ Full Scale had excellent internal consistency, low mean inter-item correlation, and good temporal stability.

Moreover, the SDQ includes 5 meaningful factors, each with adequate reliability and concurrent validity. SDQ factors 1, 3, 4, and 5 assess psychological and physiological symptoms that are typically included in measures of depression. Factor 1 measures common dimensions of depressive symptoms including lassitude, energy, mood, and cognitive, and social functioning (subscale 1).

Factor 3 includes items on outlook on life, pessimism, suicide, self-harm, and worthlessness (subscale 3). The validity of these 2 factors is supported by their strong correlation with the BDI. Moreover, subscale 3, which captures suicide ideation and worthlessness, had a high association with a specific measure of suicide. Factors 4 and 5 measure physiological features of depression, namely sleep difficulties and changes in appetite/weight, respectively.

Given that these 2 factors focus on specific aspects of depression, they had a lower, though still significant, correlation with the total score of the BDI. The most innovative aspect of SDQ is its inclusion of a factor that measures anxiety, agitation, irritability, and anger.

Our findings indicate that subscale 2 has strong reliability, and a review of its items suggests that it also has good construct (face) validity. Moreover, concurrent validity was supported by the fact that SDQ factor 2 was the SDQ subscale with the highest correlation with the BAI.One of the strengths of the SDQ is that it includes several items that assess anxiety symptoms, which are often present among depressed patients.

To date, in order to evaluate anxiety symptoms among depressed patients, some clinicians would administer a measure of depressive symptoms as well as a separate measure of anxiety. However, the administration of 2 separate measures does not allow accurate determination of a patient's response to treatment. For example, it would be difficult to determine whether a person is responding to treatment in the case where the depression measure would indicate improvement while the anxiety measure would indicate worsening.Thus, the administration of 1 measure that assesses depressive symptoms as well as anxiety symptoms would best guide treatment. Although scales of depression that include items measuring anxiety and tension exist, the number of items addressing these areas is low, and the scales tend to omit other important features of depression.

For example, the Hamilton Depression Rating Scale (HAM-D) is a 17-item scale that includes only 3 items measuring anxiety, and it does not inquire separately about other important aspects of depression that are included in the SDQ, such as hypersensitivity to criticism and irritability. Similarly, the Quick Inventory of Depressive Symptomatology (QIDS), another very common 16-item measure of depression, includes only Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptoms of depression. To our knowledge, the SDQ is the most comprehensive measure of depression available, as it includes items on depression as well as on anxiety and irritability. Given that anxious depression features are associated with greater severity of illness, and lower response and remission rates to standard treatments, and that depression with irritability and anger attacks is characterized by distinctive psychological and neurobiological features, the SDQ and its subscales may provide a more complete characterization of depressed patients along clinically and biologically meaningful dimensions. Thus, the SDQ provides information on symptom severity on a more comprehensive level than previous scales and may be able to better inform treatment.A limitation of the study is that the measure was developed primarily on the bases of a theoretical conceptualization of what symptoms constitute depression. The SDQ was not developed based on a method of identification of relevant items. Moreover, items were developed by 2 of the authors on the bases of their extensive clinical and research knowledge.

Patients were not consulted on the level of comprehension of the items. However, many items include clarification in parentheses of terms that respondents may not be familiar with (items 3, 8, and 10), and the options of answers provide further clarification.

Nonetheless, future studies are needed to further evaluate the level of understanding of the items and their content validity. An additional limitation is the fact that the factor analysis was conducted among young, generally healthy, college students with low levels of depressive symptoms. Future studies are needed to determine whether our results are generalizable to diverse, clinical populations. Despite these limitations, the SDQ appears to have face validity, concurrent validity, and high reliability. ConclusionIn summary, we found that the SDQ is a valid measure of depression. It encompasses 5 subscales, with good convergent validity, as shown by a high correlation with other measures of depression, anxiety, and suicide ideation.

Given that symptoms of anxiety and anger are common among depressed patients, the SDQ represents a valid and novel measure that assesses a more complete spectrum of physical and cognitive depressive symptoms than previous scales, and will be a valuable new tool in efforts to better characterize depression and identify and administer more targeted interventions. Disclosures: Paola Pedrelli, Mark A. Blais, Jonathan E. Alpert, and Rosemary S. Walker do not have anything to disclose. Shelton has the following disclosures: Bristol-Myers Squibb, Co., consultant, consulting fees; Cerecor, Inc., consultant, research support; Janssen Pharmaceutica, consultant, research support; Naurex, Inc., consultant, research support; Pamlab, Inc., consultant, consulting fees; Ridge Diagnostics, consultant, consulting fees; Shire Pic, consultant, consulting fees; Takada Pharmaceuticals, consultant, research support; Cerecor, Inc., consultant, research support; Novartis Pharmaceuticals, research, grant; Otsuka America, research, grant.

Symptoms of Depression Questionnaire (SDQ)Please answer all questions by circling the correct answer or the answer which seems the most appropriate to you.Instructions: Please read each item and circle the number above the statement that you think applies to you. Some questions use the words “minimally,” “moderately,” “markedly,” and “extremely.” Minimally means that this item happens to you only rarely or that it is mild when it happens. Moderately means that this item bothers you some of the time but that it does not interfere with your life in any way.

Markedly means that this item bothers you quite a bit and that it causes you some problems in your life. That is, it interferes with your ability to do certain things that are important to you such as working, taking care of your family, or enjoying time with friends. Extremely means that this problem troubles you a lot and that it interferes with your ability to do a lot of things.