SCID Baseline/Lifetime Data Entry Form
Study of Women’s Health Across the Nation
SECTION A. GENERAL INFORMATION
A1. RESPONDENT ID: AFFIX ID LABEL HERE
A2. SWAN STUDY VISIT#: 12 A3. SCID INTERVIEW FORM VERSION: ___ ___/ ___ ___/ ___ ___ ___ ___ M M D D Y Y Y Y A4. DATA ENTRY FORM VERSION: 07/01/2010 A5. DATE INTERVIEW COMPLETED: ___ ___ / ___ ___ / ___ ___ ___ ___ M M D D Y Y Y Y
A6. INTERVIEWER’S INITIALS: ___ ___ ___ A7. TRANSCRIBER’S INITIALS: ___ ___ ___ A8. RESPONDENT’S DOB: ___ ___ /___ ___ / ___ ___ ___ ___ M M D D Y Y Y Y VERIFY WITH RESPONDENT ___________________________________________________________________ A9. INTERVIEW COMPLETED IN: RESPONDENT'S HOME.......................................1 CLINIC/OFFICE.....................................................2 RESPONDENT'S HOME BY PROXY....................3 CLINIC/OFFICE BY PROXY..................................4 TELEPHONE..........................................................5 TELEPHONE BY PROXY......................................6 Begin transcription with SCID page SWAN-12.
SCID Version 2.0 07/01/2010 Annual Follow-up 12
SCID Baseline/Lifetime Data Entry Form
SWAN Core Lifetime Data Entry Form 1 07/01/2010
SCID SUMMARY SCORE SHEET SWAN-3 Diagnosis Lifetime Meets Symptomatic Prevalence DX Criteria Past Month (DX Inade- Sub- Code) quate Ab- thresh- Thresh- Info. sent old old Absent Present MOOD DISORDERS (01) Bipolar I ? 1 2 3 - - - - - - - - - -> 1 3 Disorder Current Episode
Single manic episode 1 Manic 1
Recurrent episode 2 Mixed 2
Hypomanic 3
Major depressive 4 Unspecified 5
Not post-partum (4 not circled) 0
Post-partum (4 circled) 1
(only if not current) In partial remission 6
In full remission 7
NP9
NP11
NP8
NP10
NP8_A
NP15
SWAN Core Lifetime Data Entry Form 2 07/01/2010
SWAN-4 Diagnosis Lifetime Meets Symptomatic Prevalence DX Criteria Past Month MOOD DISORDERS (continued) (DX Inade- Sub- Code) quate Ab- thresh- Thresh- Info. sent old old Absent Present (02) Bipolar II ? 1 2 3 - - - - - - - - - -> 1 3 Disorder Current Episode
Hypomanic 1
Major 2 depressive
Not post-partum (4 not circled) 0
Post-partum (4 circled) 1
(only if not current)
In partial remission 6
In full remission 7
--------------------------------------------------------------------------------------------------------------------------
(03) Other Bipolar ? 1 2 3 - - - - - - - - - -> 1 3 Disorder
Cyclothymic disorder 1
Intermittent hypomanic episodes 2
Manic or hypomanic episode 3 superimposed on psychotic disorder
Other 4
NP17 NP18
NP19
NP17_A
NP23
NP25 NP26
NP27
SWAN Core Lifetime Data Entry Form 3 07/01/2010
SWAN-5 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month MOOD DISORDERS (continued) (Dx Inade- Code) quate Ab- Thresh- Info. sent old Absent Present (04) Major Depres- ? 1 3 - - - - - - - - - -> 1 3 sive Disorder Current Episode
Single episode 1 Neither melan- 0
cholic, atypical,
Recurrent 2 or catatonic
Melancholic 1
Atypical 2
Not post-partum (4 not circled) 0
Post-partum (4 circled) 1
(only if not current)
In partial remission 6
In full remission 7
Subthreshold recurrence 8
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Subthreshold (05) Dysthymic ? 1 2 3 Disorder (current only) Early onset 1
Late onset 2
--------------------------------------------------------------------------------------------------------------------------
NP28 NP29
NP30 NP31
NP28_A
NP33
NP35
NP36
SWAN Core Lifetime Data Entry Form 4 07/01/2010
SWAN-6 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month MOOD DISORDERS (continued) Dx Inade- Code quate Ab- Thresh- Info sent old Absent Present (06) Depressive ? 1 3 - - - - - - - - - -> 1 3 Disorder Not Otherwise Spec. 0 Not Postpartum 0
1 Postpartum 1
3a Possible premenstrual dysphoric disorder 3b
4a Minor Depressive disorder 4b
6a Other 6b
------------------------------------------------------------------------------------------------------------------------
(07) Mood Disorder ? 1 3 - - - - - - - - - -> 1 3 due to a General Medical Condition Specify GMC _____________________
With major depressive-like episode 1
With depressive features 2
With manic features 3
With mixed features 4
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(08) Substance-In- ? 1 3 - - - - - - - - -> 1 3 duced Mood Disorder Specify Substance _________________
With depressive-like episode 1
With manic features 2
With mixed features 3
------------------------------------------------------------------------------------------------------------------------
(9) Psychotic ? 1 3 - - - - - - - - -> 1 3 Symptoms
Primary Psychotic Symptoms (not part of Mood Disorder)
NP37 NP38
NP38-A NP38_B
NP39 NP39_A
NP40 NP41
NP42
NP43 NP44
NP45
NP40A
NP43A
NP46 NP47
SWAN Core Lifetime Data Entry Form 5 07/01/2010
SWAN-7
Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month ANXIETY DISORDERS Dx Inade- Panic Code quate Ab- Panic Thresh- Attacks Info sent Attacks old Absent Disorder Present (26) Panic ? 1 2 3 - - - - - -> 1 2 3 Disorder/Attacks without Agoraphobia 1 with Agoraphobia 2 ------------------------------------------------------------------------------------------------------------------------ (28) Social Phobia ? 1 3 - - - - - -> 1 3 ------------------------------------------------------------------------------------------------------------------------ Refused Sub-threshold
(31) Posttraumatic -7 ? 1 2 3 - - - - - -> 1 3 Stress ------------------------------------------------------------------------------------------------------------------------ (32) Generalized ? 1 3 Anxiety (current only) ------------------------------------------------------------------------------------------------------------------------ (33) Anxiety ? 1 3 - - - - - -> 1 3 Disorder Due To a General Medical Condition Specify GMC: _______________ with Panic Attacks 1
with Generalized Anxiety 2
Social Phobia 3
Anxiety NOS 6
------------------------------------------------------------------------------------------------------------------------
NP66
NP68
NP67
NP71 NP72
NP79
NP77 NP78
NP80A
NP80 NP81
NP82
SWAN Core Lifetime Data Entry Form 6 07/01/2010
SWAN-8 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month
ANXIETY DISORDERS (Continued) Dx Inade- Code quate Ab- Thresh- Info sent old Absent Present ---------------------------------------------------------------------------------------------------------------------------- (35) Anxiety- ? 1 3 - - - - - -> 1 3 Disorder NOS ----------------------------------------------------------------------------------------------------------------------------
NP86 NP87
SWAN Core Lifetime Data Entry Form 7 07/01/2010
SWAN-9 Diagnosis Lifetime Meets Symptomatic Prevalence Dx Criteria Past Month (Dx Inade- Sub- Code) quate Ab- thresh- Thresh- Info. sent old old Absent Present (44)ADJUSTMENT 1 3
DISORDER (current only)
CODE SUBTYPE BASED ON PREDOMINANT SYMPTOMS 1 WITH DEPRESSED MOOD (e.g., depressed mood, tearful- ness, feelings of hopelessness) 2 WITH ANXIETY (e.g., nervousness, worry, jitteriness, or in children, fears of separation from major attachment figures) 3 WITH MIXED ANXIETY AND DEPRESSED MOOD (e.g., a combination of depression and anxiety) ------------------------------------------------------------------------------------------------------------------------ 45) OTHER SELF- ? 1 2 3 - - - - - - - - - -> 1 3
REPORTED DSM IV AXIS I DISORDER:
Specify: ____________________ ------------------------------------------------------------------------------------------------------------------------ (46) OTHER NON- ? 1 2 3 - - - - - - - - - -> 1 3 DMS IV AXIS I DISORDER: ------------------------------------------------------------------------------------------------------------------------
NP99_A
NP99
NP101_A NP101_B
NP100 NP101
NP100A
SWAN Core Lifetime Data Entry Form 8 07/01/2010
SWAN-10
DSM-IV Axis V: Global Assessment of Functioning (GAF) Scale
Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations.
Indicate appropriate code for the LOWEST level of functioning during the week of POOREST functioning in past month. (Use intermediate level when appropriate, e.g., 45, 68, 72.)
Note: Make a rating of 0 (zero) if inadequate information _____ _____ _____ NP104
100 Superior functioning in a wide range of activities, life’s problems never seem to get out of 91 hand, is sought out by others because of his or her many positive qualities. No symptoms.
90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all
areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional
81 argument with family members).
80 If symptoms are present, they are transient and expectable reactions to psychosocial stress-ors (e.g., difficulty concentrating after family argument), no more than slight impairment in
71 social, occupational, or school functioning (e.g., temporarily falling behind in school or work).
70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or absences from work), but
61 generally functioning pretty well, has some meaningful interpersonal relationships.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends,
51 conflicts with co-workers).
50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends,
41 unable to keep a job).
40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is
31 failing at school).
30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job,
21 home, or friends).
20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death, frequently violent, manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication
11 (e.g., largely incoherent or mute).
10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicide act with clear expectations
1 of death.
SWAN Core Lifetime Data Entry Form 9 07/01/2010
SWAN-11 Baseline Core Assessment Date: ____________________________ 1. SCID Interview conducted more than 1 month after the Baseline Core Assessment: 1 = No (STOP) 2 = Yes (go to #2) 2. Is there a current episode or disorder in partial remission? 1 = No (go to #3) 2 = Yes, and episode onset after baseline core (go to #3) 3 = Yes, and episode onset before baseline core (STOP) 3. Was there another episode in year prior to SCID? 1 = No (STOP) 2 = Yes (go to #4) 4. At Baseline Core Assessment, episode was 1 = full remission 2 = Current or in partial remission (go to #5) 5. List diagnosis and diagnostic code(s) of episode(s): Code Diagnosis a. ______________________ ______________________ b. ______________________ ______________________ c. ______________________ ______________________
SWAN Core Lifetime Data Entry Form 10 07/01/2010
SWAN-12 OVERVIEW DEMOGRAPHIC DATA Age: _____ _____ Marital Status: 1 married or living with someone as if married
2 widowed
3 divorced or annulled
4 separated
5 never married
Any children? (What are their ages?) How many?: _____ _____ Age of youngest child?: _____ _____ Age of oldest child?: _____ _____ Education Level: 1 grade 6 or less
2 grade 7 to 12 (without graduating high school)
3 graduated high school or high school equivalent
4 part college
5 graduated 2 year college
6. graduated 4 year college
7 part graduate/professional school
8 completed graduate/professional school
SWAN-13 Are you working now? 1 No 2 Yes
NP106
NP108_A
NP108_B
NP108_C
NP109
NP108
NP109_A
SWAN Core Lifetime Data Entry Form 11 07/01/2010
SWAN-13 PAST PERIODS OF PSYCHOPATHOLOGY LIFETIME Treatment for emotional problems with 1 No a physician or mental health professional 2 Yes Treated with psychotherapy? 1 No 2 Yes Treated with medication? 1 No 2 Yes If Yes, what drug code number (s)? _____, _____, _____, _____, _____. (May code up to 5 drugs) CURRENT Treated with psychotherapy? 1 No 2 Yes Treated with medication? 1 No 2 Yes If Yes, what drug code number (s)? _____, _____, _____, _____, _____. (May code up to 5 drugs) LIFETIME Treatment for drugs/alcohol? 1 No 2 Yes SWAN-14 Have you ever been a patient in a psychiatric hospital? If Yes: How many times? 0 1 2 3 4 5 (or more) Have you ever been hospitalized for drugs or alcohol? 1 No 2 Yes
NP111_A
NP110
NP110_A
NP110_B
NP110_C
NP111
NP110_D
NP110_E
NP110_F
NP110_G
SWAN-18 A. MOOD EPISODES - CURRENT MAJOR DEPRESSIVE EPISODE A1 Depressed mood ? 1 2 3 A1 A2 Markedly diminished interest or pleasure ? 1 2 3 A2 if either A1 or A2 above is coded “2” or“3”, continue; otherwise go to SWAN-28 (Q.A52)
SWAN-19 A3 Weight/appetite change ? 1 2 3 A3
A4 Weight loss or decreased appetite (1) Checked (2) Not Checked A4 A5 Weight gain or increased appetite (1) Checked (2) Not Checked A5
A6 Insomnia or hypersomnia ? 1 2 3 A6
A7 Insomnia (1) Checked (2) Not Checked A7 A8 Hypersomnia (1) Checked (2) Not Checked A8
A9 Psychomotor agitation or retardation ? 1 2 3 A9
A10 Psychomotor retardation (1) Checked (2) Not Checked A10 A11 Psychomotor agitation (1) Checked (2) Not Checked A11
A12 Fatigue or loss of energy ? 1 2 3 A12 SWAN-20 A13 Feelings of worthlessness or excessive ? 1 2 3 A13 or inappropriate guilt
A14 Worthlessness (1) Checked (2) Not Checked A14 A15 Inappropriate guilt (1) Checked (2) Not Checked A15
A16 Diminished ability to think or concentrate, or indecisiveness ? 1 2 3 A16
A17 Diminished ability to think (1) Checked (2) Not Checked A17 A18 Indecisiveness (1) Checked (2) Not Checked A18
A19 Recurrent thoughts of death, recurrent suicidal ? 1 2 3 A19
A20 Thoughts of own death (1) Checked (2) Not Checked A20 A21 Suicidal ideation (1) Checked (2) Not Checked A21 A22 Specific plan (1) Checked (2) Not Checked A22 A23 Suicide attempt (1) Checked (2) Not Checked A23
If not current MDE, go to SWAN-28 (Q.A52); otherwise, continue
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 12
SWAN-22 (if Current MDE D criterion is coded “1”, go to SWAN-28, Q.A52; otherwise, continue) A28_A Change in your life? A28_A 0=NO 1=YES 2=UNSURE
A28_B If yes, event # _____, _____, _____, _____, _____ A28_B A28_B1 If “9”, Specify: ______________________________ A28_B1 A28_C (Events) had anything to do with your becoming sick, depressed, etc.? A28_C 0=NO 1=YES 2=UNSURE 3=NA A28_D Treatment for this episode? A28_D 0=NO 1=YES 2=UNSURE A29 Number of Major Depressive Episodes ____ ____ A29 A29_A Episodes since SWAN started 1 3 A29_A SWAN-24 MELANCHOLIC FEATURES A38 Lack of reactivity ? 1 2 3 A38 (if either criterion A(1) or A(2) are coded “3”, continue; otherwise, go to SWAN-26, Q.A46)
A39 Distinct quality of depressed mood ? 1 2 3 A39 A40 Depression is regularly worse in the morning ? 1 2 3 A40
SWAN-25 A41 Early morning awakening ? 1 2 3 A41 SWAN-26 ATYPICAL FEATURES (if not checked, continue; if checked go to SWAN-35, CME) A46 Mood reactivity ? 1 2 3 A46 Go to SWAN-35
(if coded “1”, go to SWAN-35 CME; otherwise, continue)
A49 Leaden paralysis ? 1 2 3 A49
A50 Long-standing pattern of interpersonal ? 1 2 3 A50 rejection sensitivity
SWAN-28 PAST MAJOR DEPRESSIVE EPISODE
A52 Depressed mood ? 1 2 3 A52
A53 Markedly diminished interest/pleasure ? 1 2 3 A53
(if either A52 or A53 above are coded “2” or“3”, continue; otherwise, go to SWAN-35, CME)
SWAN-29 A54 Weight/appetite change ? 1 2 3 A54
A55 Weight loss or decreased appetite (1) Checked (2) Not checked A55 A56 Weight gain or increased appetite (1) Checked (2) Not checked A56
A57 Insomnia or hypersomnia ? 1 2 3 A57
A58 Insomnia (1) Checked (2) Not checked A58 A59 Hypersomnia (1) Checked (2) Not checked A59
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 13
SWAN-29 A60 Psychomotor agitation or retardation ? 1 2 3 A60
A61 Psychomotor agitation (1) Checked (2) Not checked A61 A62 Psychomotor retardation (1) Checked (2) Not checked A62
A63 Fatigue or loss of energy ? 1 2 3 A63
SWAN-30 A64 Feelings of worthlessness or excessive ? 1 2 3 A64 or inappropriate guilt
A65 Worthlessness (1) Checked (2) Not checked A65 A66 Inappropriate guilt (1) Checked (2) Not checked A66
A67 Diminished ability to think or concentrate, ? 1 2 3 A67 or indecisiveness
A68 Diminished ability to think (1) Checked (2) Not checked A68 A69 Indecisiveness (1) Checked (2) Not checked A69
A70 Recurrent thoughts of death, recurrent suicidal ? 1 2 3 A70 A71 Thoughts of own death (1) Checked (2) Not checked A71 A72 Suicidal ideation (1) Checked (2) Not checked A72 A73 Specific plan (1) Checked (2) Not checked A73 A74 Suicide attempt (1) Checked (2) Not checked A74
SWAN-31 (if at least 5 sx are coded “3”, continue; otherwise, go to SWAN-35, CME) SWAN-32 (if Criterion D coded “3”, continue; otherwise, go to SWAN-35, CME) SWAN-33 A79_A Change in your life A79_A 0=NO 1=YES 2=UNSURE A79_B If yes, event # _____, _____, _____, _____, _____. A79_B A79_B1 If “9”, Specify: ______________________________________________. A79_B1 A79_C (Events) had anything to do with your becoming sick, depressed, etc.? A79_C 0=NO 1=YES 2=UNSURE 3=NA A79_D Treatment for this episode? A79_D 0=NO 1=YES 2=UNSURE SWAN-34 A80 Age at onset of Past Major Depressive Episode ___ ___ A80
A81 Total number of Major Depressive Episodes ___ ___ A81 A81_A Episodes since SWAN started 1 3 A81_A
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 14
SWAN-35 CURRENT MANIC (if checked, go to SWAN-44; if not checked and criterion A, ‘irritable/expansive mood’ is coded “1”, go to SWAN-44; if criterion A, ‘lasting at least 1 week’ is coded “1” or “2”, go to SWAN-40; otherwise, continue) SWAN-39 A100 Number of Manic Episodes, including current ___ ___ A100 SWAN-40 CURRENT HYPOMANIC EPISODE (if checked, go to SWAN-62; otherwise, continue)
A108 Period of persistently elevated expansive, ? 1 2 3 A108 or irritable mood go SWAN-44
A109 Elevated, expansive mood (1) Checked (2) Not checked A109 A110 Irritable mood (1) Checked (2) Not checked A110
A111 Inflated self-esteem or grandiosity ? 1 2 3 A111
A112 Decreased need for sleep ? 1 2 3 A112
A113 More talkative ? 1 2 3 A113 A114 Flight of ideas, thoughts are racing ? 1 2 3 A114
SWAN-41 A115 Distractibility ? 1 2 3 A115
A116 Increased in goal-directed activity or psychomotor ? 1 2 3 A116 agitation
A117 Increase in activity (1) Checked (2) Not checked A117
A118 Psychomotor agitation (1) Checked (2) Not checked A118
A119 Excessive involvement, a high potential for ? 1 2 3 A119
painful consequences SWAN-44 (if criterion A, ‘irritable/expansive mood’ is coded “1”, go to SWAN-54; if criterion A, ‘lasting at least 1 week’, is coded “1” or “2”, go to SWAN-49; otherwise, continue) SWAN-46 (if at least three “B” symptoms are coded “3” continue, otherwise, go to SWAN-54) SWAN-48 (if MANIC EPISODE is coded “1”, go to SWAN-54 - Q.A163; otherwise, continue) A143 Age at onset - Past Manic Episode ___ ___ A143
A144 Number of Manic Episodes ___ ___ A144 (go to SWAN-66)
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 15
SWAN-49 PAST HYPOMANIC EPISODE A145 Period of sustained elevated, expansive, ? 1 2 3 A145 or irritable mood go to SWAN-54
A146 Elevated, expansive mood (1) Checked (2) Not checked A146 A147 Irritable mood (1) Checked (2) Not checked A147
A148 Inflated self esteem or grandiosity ? 1 2 3 A148 A149 Decreased need for sleep ? 1 2 3 A149 A150 More talkative ? 1 2 3 A150 A151 Flight of ideas, thoughts racing ? 1 2 3 A151
SWAN-50 A152 Distractibility ? 1 2 3 A152
A153 Increase in goal-directed activity or psychomotor ? 1 2 3 A153 agitation
A153_A Increase in activity (1) Checked (2) Not checked A153_A A153_B Psychomotor agitation (1) Checked (2) Not checked A153_B
A154 Excessive involvement, painful consequences ? 1 2 3 A154
SWAN-53 (if past hypomanic episode criteria coded “3”, continue; otherwise, go to SWAN-54) A161 Age at onset of Past Hypomanic Episode ___ ___ A161
A162 Total number of Hypomanic Episodes ___ ___ ___ A162 SWAN-54 DYSTHYMIC DISORDER (if checked, go to SWAN-66; otherwise, continue)
A163 Depressed mood ? 1 2 3 A163 go to SWAN-66
SWAN-55 A164 Poor appetite or overeating ? 1 2 3 A164
A165 Insomnia or hypersomnia ? 1 2 3 A165 A166 Low energy or fatigue ? 1 2 3 A166 A167 Low self-esteem ? 1 2 3 A167 A168 Poor concentration or difficulty making decisions ? 1 2 3 A168 A169 Feelings of hopelessness ? 1 2 3 A169
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 16
SWAN-56 (if criterion D is coded “3”, continue; otherwise, go to SWAN-66) A173 Age at onset of current Dysthymic Disorder ___ ___ A173 SWAN-57 (if DYSTHYMIC DISORDER coded “3”, continue: otherwise, go to SWAN-66) A179 1 - Early Onset: Onset before age 21 A179 2 - Late Onset: Onset age 21 or older SWAN-66 MOOD DISORDERS (if checked, go to SWAN-76, F. Anxiety Disorders; otherwise, continue) SWAN-68 OTHER BIPOLAR DISORDERS (If diagnosis made, code D20 and then go to SWAN-76; if diagnosis not made, go to SWAN-72) SWAN-69 D20 Age at onset of disorder ____ ____ D20 SWAN-71 DEPRESSIVE DISORDER NOS (If diagnosis is made, continue; otherwise, go to SWAN-74) SWAN-72 D31_A Change in your life D31_A
0=NO 1=YES 2=UNSURE D31_B If yes, list event # _____, _____, _____, _____, _____ D31_B D31_B1 If “9”, Specify: _____________________________________________ D31_B1 D31_C (Events) had anything to do with your becoming sick, depressed, etc.? D31_C 0=NO 1=YES 2=UNSURE 3=NA D31_D Treatment for this episode? D31_D 0=NO 1=YES 2=UNSURE
SWAN-73 D33_A Age at first onset of disorder ____ ____ D33_A go to SWAN-76 if only 1 episode, otherwise, continue D33_B Episodes since SWAN started 1 3 D33_B SWAN-74 MOOD CHRONOLOGY
(if past month is coded “3”, go to D37) D35 Number of months last had depressed, ____ ____ ____ or D35 euphoric or irritable mood (episode) D37 Age at onset of first Manic, Mixed, or Major ____ ____ or NA D37 Depressive Episode (for Bipolar Disorder) (if not Bi-polar Disorder)
D39 Age at onset of first Major Depressive Episode ____ ____ or NA D39
(for Major Depressive Disorder) (if not MDD)
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 17
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 18
SWAN-76 ANXIETY DISORDERS - PANIC DISORDER/ATTACKS (if criterion A1 is coded “1”, go to SWAN-82; otherwise, continue) SWAN-77 (if criterion B is coded “1”, go to SWAN-82; otherwise, continue) F4 Palpitations, pounding heart ? 1 2 3 F4
F5 Sweating ? 1 2 3 F5 F6 Trembling or shaking ? 1 2 3 F6 F7 Shortness of breath or smothering ? 1 2 3 F7 F8 Feeling of choking ? 1 2 3 F8 F9 Chest pain or discomfort ? 1 2 3 F9 F10 Nausea or abdominal distress ? 1 2 3 F10 F11 Dizzy, unsteady, light-headed or faint ? 1 2 3 F11 F12 Derealization ? 1 2 3 F12 F13 Fear of losing control/going crazy ? 1 2 3 F13 F14 Fear of dying ? 1 2 3 F14
SWAN-78 F15 Numbness or tingling ? 1 2 3 F15
F16 Chills or hot flushes ? 1 2 3 F16 (if Panic Disorder criterion D is coded “1”, go to SWAN-82; otherwise, continue)
SWAN-81 F26 4 - Partial Remission F26 5 - Full Remission 6 - Prior History NA - i.e., past month coded “3”; Go to F28
F27 Number of months ago last had a symptom ___ ___ ___ F27
of Panic Disorder/Attacks F28 Age at onset of Panic Disorder/Attacks ____ ____ F28
F28_A Episodes since SWAN started 1 3 F28_A
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 19
SWAN-82 SOCIAL PHOBIA (if criterion A is coded “3”, continue; otherwise, go to SWAN-88)
F48 Public speaking (1) Checked (2) Not checked F48
F49 Eating in front of others (1) Checked (2) Not checked F49
F50 Writing in front of others (1) Checked (2) Not checked F50
F51 Generalized (1) Checked (2) Not checked F51
F52 Other (1) Checked (2) Not checked F52
F52_1 Specify:________________________________ F52_1
SWAN-85 If Social Phobia criteria A-H are met (i.e., coded “3”), continue; otherwise, go to SWAN-88) SWAN-86 F64 4 - Partial Remission F64
5 - Full Remission 6 - Prior History NA - i.e., past month coded “3”; Go to F66
F65 Number of months last had a symptom ____ ____ ____ F65
of Social Phobia
F66 Age at onset of Social Phobia ____ ____ F66
SWAN-87 POSTTRAUMATIC STRESS DISORDER (if F103 is checked, go to SWAN-93, GAD; otherwise, continue) Event Age when first How long did this Event assessed Code event occurred last (# months) (y/n) _____ ____________ ______________ ________ F103b F103c F103d F103e _____ ____________ ______________ ________ F103g F103h F103i F103j _____ ____________ ______________ ________ F103l F103m F103n F103o _____ ____________ ______________ ________ F103q F103r F103s F103t _____ ____________ ______________ ________ F103v F103w F103x F103y (if F104 is checked, go to SWAN-93, GAD; otherwise, continue) SWAN-88 F105 Threatening event ? 1 2 3 F105
F106 Intense fear, helplessness ? 1 2 3 F106
F107 Recurrent, intrusive recollections ? 1 2 3 F107
F108 Recurrent distressing dreams ? 1 2 3 F108
F109 Feel like event recurring, reliving experience ? 1 2 3 F109 F110 Intense psychological distress ? 1 2 3 F110
Go to “GAD” SWAN-93
Go to “GAD” SWAN-93
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true SWAN Lifetime Data Entry Form 07/01/2010 20
SWAN-89 F111 Physiological reactivity ? 1 2 3 F111 F112 AT LEAST ONE “B” SX IS CODED “3” ? 1 3 F112
F113 Avoid thoughts associated with trauma ? 1 2 3 F113 F114 Avoid activities that remind of trauma ? 1 2 3 F114 F115 Unable to recall aspects of trauma ? 1 2 3 F115 F116 Diminished interest in activities ? 1 2 3 F116 F117 Feeling detached from others ? 1 2 3 F117 F118 Restricted range of affect ? 1 2 3 F118 SWAN-90 F119 Foreshortened future ? 1 2 3 F119 F120 AT LEAST THREE “C” SXS ARE CODED “3” 1 3 F120 F121 Difficulty sleeping ? 1 2 3 F121 F122 Irritable or angry ? 1 2 3 F122 F123 Difficulty concentrating ? 1 2 3 F123 F124 Hypervigilance ? 1 2 3 F124 F125 Exaggerated startle response ? 1 2 3 F125
F126 AT LEAST TWO “D” SXS ARE CODED “3” 1 3 F126
If either criterion “C” or “D” = 3, continue.
SWAN-91 F127 Duration greater than 1 month ? 1 2 3 F127
F128 Disturbance causes clinically significant distress ? 1 2 3 F128
F129 PTSD CRITERIA A, B,C,D,E AND F ARE CODED “3”. 1 2 3 F129
SWAN-92 POSTTRAUMATIC STRESS DISORDER CHRONOLOGY F130 PTSD threshold/Subthreshold current in past month? ? 1 3 F130 (if past month is coded “3”, go to F134; otherwise continue)
F132 4 - In Partial Remission F132 5 - In Full Remission 6 - Prior History NA - i.e., past month coded “3”, Go to F134
F133 Number of months last had a symptom ____ ____ ____ F133 of Posttraumatic Stress Disorder F134 Age at onset of Posttraumatic Stress Disorder ____ ____ F134
Go to “GAD” SWAN-93
Go to “GAD” SWAN-93
Go to “GAD” SWAN-93
Go to “GAD” SWAN-93
? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true 21
SWAN-93 GENERALIZED ANXIETY DISORDER (GAD)
F135 Excessive anxiety or worry ? 1 2 3 F135
(if GAD criteria A, B, and F coded “2” or “3”, continue; otherwise, go to SWAN-102)
SWAN-94 F138 Restlessness or feeling keyed up or on edge ? 1 2 3 F138
F139 Being easily fatigued ? 1 2 3 F139 F140 Difficulty concentrating or mind going blank ? 1 2 3 F140 F141 Irritability ? 1 2 3 F141 F142 Muscle tension ? 1 2 3 F142 F143 Sleep disturbance ? 1 2 3 F143
SWAN-97 F149 Age at onset of Generalized Anxiety Disorder ____ ____ F149
SWAN-102 ANXIETY DISORDER NOS (If diagnosis made, i.e., coded “3”, continue; otherwise, go to SWAN-104)
SWAN-103 F158 Experienced a number of these symptoms (1) Checked (2) Not Checked F158
the past month
F158_A Age at first onset ____ ____ F158_A F159 1 Social Phobia Subthreshold F159 2 Panic Disorder/Attacks Subthreshold 3 Multiple Anxiety SX that didn’t meet criteria
for a specific diagnosis 4 GAD Subthreshold
SWAN-104 ADJUSTMENT DISORDER (if checked , end of interview) I2 Symptoms in response to an identifiable stressor ? 1 2 3 I2
NOTES:
Go to SWAN-102