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This review was authored by Jill Cyranowski, Ph.D.

Construct Definition
Clinical depression represents the most common mood disorder experienced by adults in the
United States and around the globe.  Epidemiologic studies conducted in the United States
indicate that 6.6% of adults will suffer from a major depressive episode over a given 12-month
period, and that 16.2% will experience a lifetime episode of major depression (Kessler et al.,
2003), with relative lifetime prevalence rates being higher in women as compared with men.
Major depression was rated as the fourth most important cause of global disease burden in
1990, and projections for the year 2020 rank unipolar major depression as second only to

The symptoms of depression included DSM do not represent the only symptoms or
manifestations of depressive syndromes.  Somatic symptoms related to depression may
include not only fatigue, sleep disturbance, and changes in appetite and weight
(see Table 1), but also:
decreased sexual desire and function, and
an increased experience of - and preoccupation with - bodily complaints.
Cognitive symptoms may include:
difficulties thinking,
concentrating and problem-solving,
difficulties making decisions, and
recurrent thoughts of death or suicide.
Specific negative cognitions associated with depression may also include those related to
the Beck’s negative cognitive triad, including negative thoughts about oneself (which may
engender feelings of guilt, worthlessness and low self-esteem), others (which may engender
feelings irritability or hostility toward others), and the future (which may engender feelings of
helplessness and hopelessness).
Behavioral symptoms of depression may include:
psychomotor retardation or agitation,
social withdrawal and avoidance,
decreased occupational function, and
self-harming or suicidal behaviors.
Additional mood-related symptoms associated with depression can include feelings of
anxiety, worry, irritability, anger and hostility.  The above description should provide the
reader with a notion of the heterogeneity within both diagnostic and dimensional
assessments of clinical depression. 
In terms of the psychiatric classification system (i.e., DSM-IV), the mood disorders are
generally divided between unipolar and bipolar subtypes.  While unipolar depression is
characterized by periods of depressed mood (with the recurrently depressed patient cycling
between depressed versus euthymic states), bipolar disorder is characterized by a lifetime
cycling between (or mixing of) depression and mania (defined as an elevated, expansive or
irritable mood and associated characteristics such as decreased need for sleep, inflated
self-esteem or grandiosity, significant increases in goal-directed and pleasurable activities,
and increased risk-taking behaviors).  Within the DSM-IV, symptoms of major depressive
episodes do not differ between those with unipolar versus bipolar disorder.  Instead,
diagnosis of bipolar disorder is made by history, i.e., patients reporting any lifetime history
of manic or hypomanic episodes will receive a bipolar diagnosis.  Because diagnosis of
bipolar disorder is relatively rare as compared with that of unipolar depression, the current
assessment review will focus on the syndrome of unipolar depression and the associated
symptoms of major depressive episodes.

Depression in Mind-Body Science
Recent years have witnessed an increasing interest in understanding the potential role of
depressive symptoms and syndromes within mind-body science.  From the psychological
side of the mind-body model, the fields of psychology and psychiatry have long recognized
the bidirectional relationship between depression and life stress.  Life stress precipitates
depressive episodes, and can influence the severity and course of major depressive disorder
over time. Depression, in turn, impairs instrumental coping responses, decreases one’s
sense of mastery or self-efficacy, strains interpersonal relationships, and undermines social
support.  From the physical side of the mind-body model, depressed patients have been
shown to display elevated rates of multiple medical disorders including hypertension, pain,
diabetes and heart disease.  Depressed individuals report significantly more physical
symptoms, incur significantly higher medical costs, display poorer health behaviors and
poorer adherence to medical treatment, and, in some cases, show poorer treatment
prognosis and higher mortality rates.

Related Constructs
Clinical depression, defined in both diagnostic and dimensional terms, shares significant
conceptual and methodological overlap with a number of associated psychological constructs.
Most notably, the constructs of depression and anxiety share significant variance at both the
syndromal and dimensional levels of assessment.  At the diagnostic or syndromal level,
recent data indicate that 59.2% of individuals who report a lifetime history of major depressive
disorder will also meet criteria for one or more lifetime anxiety disorders (Kessler et al., 2003).
Similarly, self-report measures of depression and anxiety display a high level of shared
variance, with correlations of twin depression and anxiety scales (such as the Beck
Depression and Anxiety Inventories) or depression and anxiety subscales of the same
instrument (such as the SCL-90) showing correlations in the range of .66-.70 within both
patient and non-patient populations (Clark & Watson, 1991). 
These findings have generated considerable debate regarding the nature of the relationship
between these constructs, including arguments that both depression and anxiety represent
specific facets of a more general construct alternately labeled as neuroticism or general
distress.  Clinical depression also displays a significant, if lesser, degree of construct overlap
with measures of anger and hostility (see also Assessment of Hostility section; add web link).
In addition, depression is conceptually related to a number of other constructs encountered
within the health psychology literature, such as burn-out and vital exhaustion. 
Finally, diagnostic and dimensional scales of depression as a clinical condition are related
to, yet should be differentiated from, acute measures of current mood state.  The most
common of these mood state measures include the Profile of Mood States (POMS; McNair,
Lorr & Droppleman, 1971), the Positive and Negative Affect Schedule (PANAS; Watson &
Clark, 1990), and the Multiple Affect Adjective Check List (MAACL; Zuckerman & Lubin, 1965).

Major Measurement Methods
Assessment scales for measuring depression as a clinical disorder can be divided into two
broad categories: those developed to produce a categorical diagnosis of major depressive
disorder (such as those defined by the DSM-IV or ICD-9) and those developed to provide a
dimensional assessment of the experience and/or severity of depressive symptoms (which
may or may not represent a clinically-diagnosable disorder).  Choice of depression
assessment instrument for use in mind-body research should be guided by a number of
psychometric, research and pragmatic factors, including: the specific hypotheses or
research goals for evaluating depression; practical constraints of assessment time and
study personnel; psychometric properties of available assessment scales; and the specific
setting or population in which depression is being evaluated.
The following review is divided into three sections.  In the first section we briefly review the
most commonly used diagnostic interviews for the assessment of the diagnosis of major
depressive disorder, including the SCID-IV, DIS, and CIDI.  In the second section we review
commonly used dimensional assessments of depressive symptomatology, including the BDI,
CESD and HRSD.  Finally, in the last section we discuss population-specific measures of
depression, including the PRIME-MD, Edinburgh Postnatal Depression Scale, and Geriatric
Depression Scale.  This overview is in no way meant to be comprehensive.  For further detail
regarding the psychometric properties of these and other depression-relevant psychiatric
scales, the reader is referred to recent detailed reviews by Dew et al (in press), Skodol &
Bender (2000), and Yonkers & Samson (2000).
Diagnostic Assessment of Major Depressive Disorder
Dimensional Assessment of Depressive Symptoms
Assessing Depression in Special Populations

References
Clark LA, Watson D:  Tripartite model of anxiety and depression: Psychometric evidence
and taxonomic implications.  J Abnormal Psychol 100:316-336, 1991.
Dew MA, Switzer GE, Myaskovsky L, DiMartini AF, Tovt-Korshynski MI:  Rating scales
for mood disorders.  In DJ Stein, DJ Kupfer, AF Schatzberg (eds). The American Psychiatric
Publishing Textbook of Mood Disorders.  Washington, DC: American Psychiatric
Publishing, Inc.
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE,
Wang PS.  The epidemiology of major depressive disorder: Results from the national
comorbidity survey replication (NCS-R). JAMA 289:3095-3105, 2003. 
McNair DM, Lorr M, Droppleman LF. Manual for the Profile of Mood States (POMS).
San Diego: Educational and Industrial Testing Service.
Murray CJ, Lopez AD:  Evidence-based health policy – lessons from the Global Burden of
Disease Study. Science 274:740-743, 1996.
Skodol AE, Bender DS: Diagnostic interviews for adults. In AJ Rush et al (eds). Handbook of
Psychiatric Measures, Washington, DC: American Psychiatric Association, 2000.
Watson D, Clark LA: The Positive and Negative Affect Schedule – Expanded Form.
Unpublished manuscript. Southern Methodist University, 1990.
Yonkers KA, Samson J: Mood disorders measures. In AJ Rush et al. (eds). Handbook of
Psychiatric Measures. Washington DC: American Psychiatric Association, 2000.
Zuckerman M, Lubin B: Manual for the Multiple Affect Adjective Check List – Revised. San
Diego, CA: Educational and Industrial Testing Service.

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