The issues regarding the HRSD include its behavioral and somatic content that are greater than those of other scales (33, p361); it has been criticized for omitting affective symptoms (e.g., non-reactivity of mood, reduction of concentration, anhedonia) (26, p18). This criticism should be considered carefully, however: the HRSD is a severity scale and not a diagnostic instrument, so it may not need to cover every aspect of depression (10, p81). But the criticism is important if the emphasis on somatic items, which are indicators of more severe depression, means that the scale cannot distinguish milder levels of depression (24). It may also mean that the HRSD exaggerates depression in patients with physical illness and intercurrent depression (59). Hamilton argued that anxiety is an important symptom of depression (60), but the inclusion of items on anxiety will clearly reduce the ability of the HRSD to discriminate between anxiety and depression.