UT Austin Major Depressive Disorder (MDD) Research Study - Screening Questionnaire

UT Austin Major Depressive Disorder (MDD) Research Study - Screening Questionnaire

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Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1990)

What is your sex assigned at birth?

Male Female

City and State You Live In

Are you willing to be contacted about future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

What is your height?

What is your weight?

Have you ever been diagnosed with depression or major depressive disorder?

Yes No

Have you ever been treated for depression?

Yes No

Over the last 2 weeks, how often have you been bothered by any of the following?

For each of the following, please select the one response that best describes how often you have been bothered by this experience in the last 2 weeks. There are no right or wrong answers.

Little interest or pleasure in doing things

Not at all Several days More than half the days Nearly every day

Feeling down, depressed, or hopeless

Not at all Several days More than half the days Nearly every day

Trouble falling or staying asleep, or sleeping too much

Not at all Several days More than half the days Nearly every day

Feeling tired or having little energy

Not at all Several days More than half the days Nearly every day

Poor appetite or overeating

Not at all Several days More than half the days Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Not at all Several days More than half the days Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television

Not at all Several days More than half the days Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

Not at all Several days More than half the days Nearly every day

Did these problems impair your ability to do your work, take care of things at home, get along with other people, or in any other way?

Yes No

For how long have you had these problems?

Less than 3 months Between 3 months and 24 months More than 24 months

How long have you been feeling consistently low?

I have not been feeling low Less than 3 months 3 to 6 months 6 to 12 months 12 months or more

What percent improvement in your symptoms have you experienced on your current medication regimen?

Less than 25% 25–49% 50–74% More than 75%

Would you be willing to share your medical and pharmacy records so that study staff can understand the course of your diagnosis and treatment?

Yes No

Have you ever had periods where your mood was much higher than usual — feeling extremely energized, overly happy, or unusually irritable — to the point where it was noticeably different from your normal self?

Yes No

During these times when you experienced elevated or irritable mood, did you also experience things like needing much less sleep, talking very fast, having racing thoughts, or engaging in risky or impulsive behaviors?

Yes No

Have you ever been diagnosed with bipolar disorder or mania?

Yes No

Have you been diagnosed with schizophrenia, Parkinson's disease, Alzheimer's disease, dementia, multiple sclerosis, or epilepsy?

Yes No

Have you been diagnosed with a new medical condition in the past three months?

Yes No

Have you received electroconvulsive therapy (ECT), deep brain stimulation (DBS), or vagus nerve stimulation (VNS) during this current depressive episode?

Yes No

Have you received transcranial magnetic stimulation (TMS) during this current depressive episode?

Yes No

Have you received treatment with ketamine or esketamine during this current depressive episode?

Yes No

Below is a list of antidepressant medications. If you are taking an antidepressant medication (or more than one), please select which ones below. If none, please select that option. If you are on esketamine or ketamine, there will be a separate question on this.

Citalopram (Celexa) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta, Drizalma Sprinkle) Escitalopram (Lexapro) Fluoxetine (Prozac, Sarafem) Fluvoxamine (Luvox) Levomilnacipran (Fetzima) Paroxetine (Paxil, Pexeva, Brisdelle) Sertraline (Zoloft) Vortioxetine (Trintellix) Venlafaxine (Effexor XR) Amitriptyline (Elavil) Bupropion (Wellbutrin, Zyban) Desipramine (Norpramin) Dextromethorphan-Bupropion (Auvelity) Doxepin (Sinequan) Gepirone (Exxua) Imipramine (Tofranil) Mirtazapine (Remeron) Nortriptyline (Pamelor) Vilazodone (Viibryd) Trazodone (Desryl, Oleptro) None of the above

Below is a list of medications often given for depression, especially if you are not improving enough. Please select any you are currently taking. You can select more than one. If none, please select that option.

Aripiprazole (Abilify) Asenapine (Saphris) Brexpiprazole (Rexulti) Cariprazine (Vraylar) Clozapine (Clozaril) Iloperidone (Fanapt) Lumateperone (Caplyta) Lurasidone (Latuda) Olanzapine (Zyprexa) Paliperidone (Invega) Pimavanserin (Nuplazid) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) None of the above

Below is a list of mood stabilizer medications — medications to help keep your mood from going up and down. If you are taking one or more of these, please select which ones. If none, please select that option.

Lithium Divalproex / valproic acid (Depakote, Depakene, Stavzor) Carbamazepine (Tegretol, Equetro) Lamotrigine (Lamictal) Oxcarbazepine None of the above

Below is a list of ADHD or attention-related medications. If you are taking one or more of these, please select which ones. You can select more than one. If none, please select that option. You will be asked to indicate how many days per week you take the medication.

Amphetamine salts (Adderall) Dexmethylphenidate (Focalin) Dextroamphetamine (Dexetrine) Lisdexamfetamine (Vyvanse) Methylphenidate (Ritalin, Concerta, Methylin) None of the above

If you selected a stimulant medication above, how many days per week do you typically take it?

0 1 2 3 4 5 6 7

Below is a list of anxiety medications. If you are taking one or more of these, please select which ones. You can select more than one. If none, please select that option.

Alprazolam (Xanax) Clonazepam (Klonopin) Diazepam (Valium) Lorazepam (Ativan) None of the above

How many days per week do you typically use marijuana, THC, or CBD products?

0 1 2 3 4 5 6 7

Approximately how many alcoholic drinks do you typically have per week?

0–3 4–7 8–14 15–21 More than 21

Have you used cocaine, speed, mushrooms, opioids, or any illegal drugs not listed in the past 3 months?

Yes No

Have you participated in a clinical trial in the past 24 months?

Yes No

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