Table 1.

Screening Instruments for Depression and Anxiety

Instrument Name	Items; Scoring Criteria	Example Items
1. Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (Prime-MD PHQ)a,b	2-and 9-item versions depression sub-scale; 0 = not at all to 3=nearly every day; 5-item anxiety subscale; Yes or No.	Over the last 2 weeks, how often have you… Had little interest or pleasure in doing things. Been feeling down, depressed, or hopeless. Had trouble concentrating on things such as reading the newspaper or watching television. In the last 4 weeks, have you had… An anxiety attack---suddenly feeling fear or panic? Has this ever happened before? Do these attacks bother you a lot or are you worried about having another attack?
2. Center for Epidemiological Study of Depression Scale (CES-D)c	10-and 20-item versions; 0 = rarely or none of the time to 3 = most or all of the time	During past week, how often have you experienced… I was bothered by things that usually don’t bother me. I felt that everything I did was an effort. I talked less than usual.
3. Beck Depression Inventory-Revisedd	21 groups of statements; choose one of each group	Pick the one statement of each group that best describes how you have been feeling during the past 2 weeks, including today. Group 1 I do not feel sad. I feel sad much of the time. I am sad all the time. I am so sad or unhappy that I can’t stand it.
4. Depression Anxiety Stress Scales (DASS)e	21-and 42-item versions; 0 = not at all to 3 = very much or most of the time	How much has each statement applied to you over the past week? I felt downhearted and blue. I felt that life was meaningless. I felt I was pretty worthless. I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat). I was aware of dryness of my mouth. I was worried about situations in which I might panic or make a fool of myself.
5. Beck Anxiety Inventory (BAI)f	21 items; 0 = not at all to 3 = severely-it bothered me a lot	Rate how much you have been bothered by each of the following in the last week. Numbness or tingling Terrified or afraid Fear of losing control
6. Spielberger State and Trait Anxietyg	40 items; 0 = almost never to 3 = almost always	Rate how often the statement is true about you. I am tense. I am worried. I feel calm. I worry too much over something that really doesn’t matter. I am content; I am a steady person.

Adapted with permission from Hall, Steinberg and Marcus. In Cwiak and Allen (Eds), Contraception for the Medically Challenging Patient. Springer, 2014.

^aKroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: validity of a two-item depression screener. Med Care .2003; 41:1284-92.

^bSpitzer RL, Kroenke K, Williams JBW, and the Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study. JAMA. 1999; 282 (18): 1737-1744.

^cRadloff, L.S. The CES-D scale: A self-report depression scale for research in the general population. Applied Psych Meas. 1977;1:385-401.

^dRichter P, Werner J, Heerlein A, Kraus A, Sauer H. On the validity of the Beck Depression Inventory: A review. Psychopathology. 1998; 31(3): 160-168.

^eLovibond PF & Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with The Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3): 335-343.

^fFydrich T, Dowdall D, Chambless DL. Reliability and validity of the Beck Anxiety Inventory. J Anxiety Dis. 1992; 6(1): 55-61.

^gSpielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. State-trait anxiety inventory for adults: Manual, Test Booklet and Scoring Key 1983; Palo Alto, CA: Consulting Psychologist Press, Inc.