Differences between minimally depressed patients who do and do not consider themselves to be in remission

OBJECTIVE: We recently derived a cutoff on a self-report scale corresponding to the most commonly used definition of remission in depression treatment studies (i.e., Hamilton Rating Scale for Depression [HAM-D] score < or = 7). However, recent research has suggested that use of this cutoff on the HAM-D to define remission is overinclusive. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to examine how many depressed patients in ongoing treatment who are considered to be in remission by a self-report equivalent of the HAM-D definition of remission nonetheless do not consider themselves to be in remission. METHOD: Five hundred thirty-five psychiatric outpatients treated for a DSM-IV major depressive episode were asked whether they considered themselves to be in remission and completed the Clinically Useful Depression Outcome Scale (CUDOS), a measure of the severity of the DSM-IV symptoms of depression. The study was conducted from August 2003 until July 2004. RESULTS: Nearly one quarter of the patients who met the remission threshold on the CUDOS (55/249) did not consider themselves to be in remission. Among the CUDOS remitters, the total score on the CUDOS was significantly lower (p < .001) in patients who considered themselves to be in remission than in patients who did not indicate that they were in remission. Examination of specific symptoms revealed greater appetite disturbance and hypersomnia in the patients who did not think they were in remission. CONCLUSIONS: Our results suggest that heterogeneity of clinical status exists even among patients who are minimally depressed and considered to be in remission according to contemporary definitions on symptom severity scales.     

Determining remission from depression on two self-report symptom scales: a comparison of the Quick Inventory of Depressive Symptomatology and the Clinically Useful Depression Outcome Scale

To answer fundamental questions regarding the effectiveness of treatments for depression in real-world clinical practice, it is necessary to incorporate the measurement of outcome. Self-report questionnaires are a cost-effective option to systematically, reliably, and validly evaluate clinical status because they are inexpensive in terms of professional time needed for administration, and do not require special training for administration. While there are many self-administered depression scales, only a limited number cover all of the diagnostic criteria for major depressive disorder (MDD) and have had cutoff scores derived corresponding to the Hamilton Depression Rating Scale (HAM-D) definition of remission. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared 2 scales in their respective ability to identify remission as defined by the HAM-D. We administered the 17-item HAM-D to 274 depressed outpatients in ongoing treatment. The patients completed the Quick Inventory of Depressive Symptomatology (QIDS) and the Clinically Useful Depression Outcome Scale (CUDOS). Based on the cutoffs recommended by the developers of the scales to identify remission, the 2 scales performed similarly overall though the sensitivity was higher for the QIDS than the CUDOS (95.5% vs. 78.7%), whereas specificity was higher for the CUDOS than the QIDS (73.0% vs. 50.0%). On the CUDOS, the cutoff that maximized the sum of sensitivity and specificity was similar to cutoff initially derived for this purpose; however, for the QIDS, the optimal cutoff was higher than the cutoff originally derived for this purpose. In conclusion, the CUDOS and the QIDS were equally highly related to the HAM-D definition of remission. The CUDOS takes less time to complete than the QIDS and, therefore, may be preferable to use in routine clinical practice.     

Validity of a self-report depression symptom scale for identifying remission in depressed outpatients

In treatment studies of depression, remission is usually defined by scoring less than a threshold value on an interview-based measure of depression severity such as the Hamilton Rating Scale for Depression (HRSD). Although it has been recommended that measures such as the HRSD be used by clinicians in clinical practice to evaluate remission status, the time demands of clinical practice limit the feasibility of this suggestion. Self-report questionnaires are a cost-effective option to thoroughly, systematically, reliably, and validly evaluate clinical status because they are inexpensive in terms of professional time needed for administration and do not require special training for administration. In a previous report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we derived a cutoff on a self-report depression questionnaire corresponding to the widely used definition of remission on the HRSD (ie, < or = 7). In the present report, we examined the validity of this questionnaire as an indicator of remission among patients who responded to antidepressant treatment. Specifically, we examined psychosocial functioning in treatment responders who were and were not in remission according to the self-report symptom scale. In a sample of 371 depressed outpatients who were judged by their treating psychiatrists as having responded to treatment, 250 scored in the remission range on the symptom scale. Compared with treatment responders whose depression was not in remission, the patients who were in remission reported significantly less psychosocial impairment and significantly better quality of life and were significantly more likely to assert that they are in remission from their depression. These findings support the validity of a self-report depression questionnaire as an index of remission status among treatment responders.     

A clinically useful depression outcome scale

If the optimal delivery of mental health treatment ultimately depends on examining outcome, then precise, reliable, valid, informative, and user-friendly measurement is the key to evaluating the quality and efficiency of care in clinical practice. Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the reliability and validity of the Clinically Useful Depression Outcome Scale (CUDOS). The CUDOS was designed to be brief (completed in less than 3 minutes), quickly scored (in less than 15 seconds), clinically useful (fully covering the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of major depressive disorder and dysthymic disorder), reliable, valid, and sensitive to change. We studied the CUDOS in more than 1400 psychiatric outpatients and found that the scale had high internal consistency and test-retest reliability. The CUDOS was more highly correlated with another self-report measure of depression than with measures of anxiety, substance use problems, eating disorders, and somatization, thereby supporting the convergent and discriminant validity of the scale. The CUDOS was also highly correlated with interviewer ratings of the severity of depression, and CUDOS scores were significantly different in depressed patients with mild, moderate, and severe levels of depression. The CUDOS was a valid measure of symptom change. Finally, the CUDOS was significantly associated with a diagnosis of major depressive disorder. Thus, the results of this large validation study of the CUDOS shows that it is a reliable and valid measure of depression that is feasible to incorporate into routine clinical practice.     

The impact of medical comorbidity on acute treatment in major depressive disorder

OBJECTIVE: The authors investigated the impact of medical comorbidity on the acute phase of antidepressant treatment in subjects with major depressive disorder. METHOD: A total of 384 outpatients meeting DSM-III-R criteria for major depressive disorder enrolled in 8-week open treatment with fluoxetine, 20 mg/day. The authors used the Cumulative Illness Rating Scale to measure the burden of medical comorbidity and the 17-item Hamilton Rating Scale for Depression to assess changes in depressive symptoms. The outcome measures were response to treatment (>/=50% reduction in score) and clinical remission (score 相似文献   

Standardizing the Hamilton Depression Rating Scale: past,present, and future

The Hamilton Depression Rating Scale (HAM-D) has become the most widely used depression severity rating scale in the world. It was originally published by Max Hamilton in 1960 to measure severity of depression in previously diagnosed depressed inpatients. Since that time, multiple versions of the scale have been created, although authors are rarely clear about which version they used. In addition, structured interview guides, self-report forms, and computerized versions have been developed in an effort to standardize administration of the scale and improve the psychometric characteristics of the individual items. The history of the development of these features is discussed, and the various versions of the scale are summarized in tables. This article is a fitting tribute to Per Bech, who has contributed so much to the assessment of depression severity.

     

Standardizing the Hamilton Depression Rating Scale: past, present, and future

The Hamilton Depression Rating Scale (HAM-D) has become the most widely used depression severity rating scale in the world. It was originally published by Max Hamilton in 1960 to measure severity of depression in previously diagnosed depressed inpatients. Since that time, multiple versions of the scale have been created, although authors are rarely clear about which version they used. In addition, structured interview guides, self-report forms, and computerized versions have been developed in an effort to standardize administration of the scale and improve the psychometric characteristics of the individual items. The history of the development of these features is discussed, and the various versions of the scale are summarized in tables. This article is a fitting tribute to Per Bech, who has contributed so much to the assessment of depression severity.     

A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents

CONTEXT: Adolescent depression is highly prevalent and has substantial morbidity, including suicide attempts, school dropout, and substance abuse, but many depressed adolescents are untreated. The school-based health clinic offers the potential for accessible and efficient treatment, although it is unknown whether school-based clinicians can be trained to implement evidence-based psychotherapies for depression in routine care. OBJECTIVE: To assess the effectiveness of interpersonal psychotherapy modified for depressed adolescents (IPT-A) compared with treatment as usual (TAU) in school-based mental health clinics. DESIGN: A 16-week randomized clinical trial was conducted from April 1, 1999, through July 31, 2002. SETTING: Five school-based mental health clinics in New York City, NY.Patients Sixty-three adolescents referred for a mental health intake visit who met eligibility criteria. Eligible patients had a mean Hamilton Depression Rating Scale score of 18.6 (SD, 5.5) and a mean Children's Global Assessment Scale score of 52.6 (SD, 5.5) and met DSM-IV criteria for major depressive disorder, dysthymia, depression disorder not otherwise specified, or adjustment disorder with depressed mood. Mean age was 15.1 years (SD, 1.9 years). The sample was predominantly female (n = 53 [84%]), Hispanic (n = 45 [71%]), and of low socioeconomic status.Intervention Patients were randomly assigned to receive IPT-A (n = 34) or TAU (n = 29) from school-based health clinic clinicians. MAIN OUTCOME MEASURES: The Hamilton Depression Rating Scale, Beck Depression Inventory, Children's Global Assessment Scale, Clinical Global Impressions scale, and the Social Adjustment Scale-Self-Report. RESULTS: Adolescents treated with IPT-A compared with TAU showed greater symptom reduction and improvement in overall functioning. Analysis of covariance showed that compared with the TAU group, the IPT-A group showed significantly fewer clinician-reported depression symptoms on the Hamilton Depression Rating Scale (P =.04), significantly better functioning on the Children's Global Assessment Scale (P =.04), significantly better overall social functioning on the Social Adjustment Scale-Self-Report (P =.01), significantly greater clinical improvement (P =.03), and significantly greater decrease in clinical severity (P =.03) on the Clinical Global Impressions scale. CONCLUSIONS: Interpersonal psychotherapy delivered in school-based health clinics is an effective therapy for adolescent depression. This effort is a significant step toward closing the gap between treatment conducted in the laboratory and community clinic.     

Antidepressant side effects in depression patients treated in a naturalistic setting: a study of bupropion, moclobemide, paroxetine, sertraline, and venlafaxine.

OBJECTIVE: There is no commonly accepted standard for comparing antidepressant-induced side effects. This study evaluates a clinician-administered scale, the Toronto Side Effect Scale (TSES), in a natural practice clinic. METHOD: We used the TSES to assess side effects in 193 depression patients who completed 8 weeks of treatment with either bupropion, moclobemide, paroxetine, sertraline, or venlafaxine. RESULTS: Rates of remission (Hamilton Rating Scale for Depression [HRSD] < 7) did not differ across drugs after 8 weeks of treatment. Paired drug comparisons yielded significant differences in 16 of the 32 side effects. We present differences between pairs of the 5 antidepressants in Central Nervous System (CNS), gastrointestinal (GI), and sexual side effects. A measure of side-effect intensity distinguished paroxetine from the other antidepressants on a measure of sexual dysfunction. CONCLUSIONS: These results confirm the clinical utility of the TSES as a simple, clinician-administered antidepressant side-effect scale.     

Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate

OBJECTIVE: Depressed men commonly have erectile dysfunction, and men with erectile dysfunction are frequently depressed. Since the etiologic and modulatory relationships between depression and erectile dysfunction have been poorly characterized, a 12-week, randomized, double-blind, placebo-controlled trial was conducted at 20 urologic clinics to evaluate the effects of sildenafil treatment in men with erectile dysfunction and mild-to-moderate comorbid depressive illness. METHOD: Men (N=152, mean age=56 years) with erectile dysfunction for > or =6 months (mean=5.7 years), a DSM-IV diagnosis of depressive disorder not otherwise specified, and a Hamilton Depression Rating Scale score > or =12 (mean at baseline=16.9) were randomly assigned to flexible-dose treatment with sildenafil citrate or matching placebo. Interviewer-rated and self-report instruments were used to assess changes in sexual function, depressive symptoms, and quality of life. Conservative criteria were used to classify erectile dysfunction treatment response and nonresponse. RESULTS: Sildenafil was strongly associated with erectile dysfunction treatment response. Fifty-eight men met the conservative criteria for response (48 given sildenafil, 10 given placebo), and 78 men did not respond (18 given sildenafil, 60 given placebo). Mean decreases of 10.6 and 2.3 in Hamilton depression scale scores were seen in treatment responders and nonresponders, respectively; 76% of treatment responders showed a > or =50% decline in Hamilton depression scale score versus 14% of nonresponders. Quality of life was similarly improved in treatment responders. CONCLUSIONS: Sildenafil is efficacious for erectile dysfunction in men with mild-to-moderate depressive illness. Improvement of erectile dysfunction is associated with marked improvement in depressive symptoms and quality of life.     

Severity of depression and response to cognitive behavior therapy

OBJECTIVE: The authors studied the relationship between clinical severity of depression and response to cognitive behavior therapy. METHOD: Fifty-nine outpatients with major depression with endogenous features, according to Research Diagnostic Criteria, were stratified into more severe (score of 20 or more on the Hamilton Rating Scale for Depression; N = 38) or less severe (Hamilton score of 19 or less; N = 21) subgroups. Patients were treated with a 16-week, 20-session cognitive behavior therapy protocol. Outcome was assessed with the Hamilton scale, the Global Adjustment Scale, and the Beck Depression Inventory. RESULTS: The more severe group was significantly more symptomatic across the 16-week protocol and had a significantly lower response rate on the Beck inventory (50% versus 81%). However, the groups did not significantly differ at end point on any of the three measures, and they showed comparable rates of symptomatic improvement (i.e., percent change in scores and interactions between severity classification and time). CONCLUSIONS: These results partially replicate the National Institute of Mental Health's Treatment of Depression Collaborative Research Program's findings of poorer response to cognitive behavior therapy in patients with Hamilton scale scores of 20 or more. However, both groups experienced robust and clinically significant reductions in depressive symptoms, and the response of the more severe patients in the current study could hardly be considered poor. While these findings do not support the view that a Hamilton scale score of 20 or more is a relative contraindication for cognitive behavior therapy, the symptoms of the more severely depressed patients did tend to remit less completely (particularly on the Beck inventory) and thus these patients may benefit from a more intensive or extended course of therapy.     

Social inequalities in response to antidepressant treatment in older adults

CONTEXT: We examined the relationship between socioeconomic status and response to treatment for depression among older adults. METHODS: Secondary analysis of pooled data from the open-label phase of 2 National Institute of Mental Health-funded clinical trials of nortriptyline hydrochloride or paroxetine combined with interpersonal psychotherapy (N = 248). We used Cox proportional hazards regression analyses to examine the association between socioeconomic status, indexed by census tract median annual household income and the subject's educational attainment, and treatment response and remission according to the Hamilton Depression Rating Scale. The association between socioeconomic status and suicidality or depressed mood reported at each week of treatment was examined using repeated-measures generalized logit models. RESULTS: Subjects residing in middle-income census tracts were significantly more likely to respond to antidepressant treatment than subjects residing in low-income census tracts (adjusted hazard ratio, 1.80; 95% confidence interval [CI], 1.18-2.75]). Throughout the course of antidepressant treatment, subjects in the middle- and high-income census tracts were significantly less likely to report suicidal ideation (adjusted odds ratios, 0.48 [95% CI, 0.27-0.94] and 0.39 [95% CI, 0.16-0.94], respectively). No association was found between socioeconomic status and remission. CONCLUSION: Residence in a low-income census tract is associated with a less favorable course of depression among older adults receiving a combination of pharmacologic and psychosocial treatment.     

脑卒中合并抑郁治疗前后对比分析

目的　观察、分析脑卒中后抑郁症状的干预对患者康复的影响。方法　脑卒中合并抑郁患者 33例 ,常规脑血管病治疗同时予抗抑郁药物治疗或心理疏导 ,于治疗第 1、2、4、6周末分别进行HAMD抑郁量表评分和神经功能缺损、生活能力状态评定。结果　于 6周末HAMD评分明显降低 (P <0 0 1) ,神经功能缺损和生活能力状态评定明显减低 (P <0 0 1) ,神经功能缺损评定与HAMD评分减低有相关性 (r=0 4 4 5 ,P <0 0 1)。结论　对脑卒中后抑郁症状的干预治疗 ,不但能有效改善抑郁症状 ,而且有利于患者神经功能缺损的康复和生活能力的提高。     

The reliability and validity of the Chinese Polarity Inventory

For the simultaneous measurement of manic and depressive symptoms, the Chinese Polarity Inventory (CPI), a 20-item self-report scale, was developed. A total of 329 depressive and 356 manic/hypomanic patients were recruited in this scale developmental study in China. All patients completed the CPI and either the Chinese version of the Hamilton Depression Rating Scale (for depressed subjects) or the Chinese version of the Bech-Rafaelsen Mania Scale (for manic subjects). The CPI was found to have excellent reliability and satisfactory concurrent validity. Construct validity analysis was performed using principal component analysis, which yielded 4 clinically meaningful factors: activity, pleasurability, capability and irritability. The CPI was sensitive in differentiating different severities of depression and mania. However, its ability to differentiate mixed phase from other mood states and its sensitivity to changes during the treatment still need to be studied further.     

Assessment of mood: Guides for clinicians

Objective

This article is one of the series of review articles aiming to present a convenient guideline for practicing clinicians in their selection of scales for clinical and research purposes. This article focuses on assessment scales for mood (depression, mania).

Methods

After reviewing the basic principles of clinical psychometrics, we present a selective review of representative scales measuring depressed or manic mood.

Results

We reviewed and reported on reliability, validity, interpretability, and feasibility of the following rating scales: Patient Health Questionnaire-9 (PHQ-9), K6, Beck Depression Inventory II (BDI-II), and Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR) as self-report scales for depressed mood; Hamilton Rating Scale for Depression (HAM-D) and Montgomery–Asberg Depression Rating Scale (MADRS) as clinician-administered measure for depression; and Young Mania Rating Scale (YMRS) as a clinician-administered instrument for mania.

Conclusion

Although the rating scales for mood represent a well-trodden terrain, this brief review of the most frequently used scales in the literature revealed there is still some room for improvement and for further research, especially with regard to their clinical interpretability.     

A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) has been reported to be as effective as electroconvulsive therapy (ECT) for major depression. The authors conducted a multicenter randomized, controlled trial to test the equivalence of rTMS with ECT. METHOD: Forty-six patients with major depression referred for ECT were randomly assigned to either a 15-day course of rTMS of the left dorsolateral prefrontal cortex (N=24) or a standard course of ECT (N=22). The primary outcome measures were the score on the 17-item Hamilton Depression Rating Scale (HAM-D) and the proportion of patients with remissions (Hamilton score, 相似文献   

Use of the five-factory inventory in characterizing patients with major depressive disorder

Research on personality traits has suggested an association between depression and certain personality traits, such as neuroticism and extraversion. Costa and McCrae's five-factor personality inventory (NEO) has been shown to measure personality traits in a nonclinical population, but its use has not been fully explored in clinical populations. This study aims to compare NEO results in a sample of depressed outpatients with published test norms, and determine if different levels of neuroticism and extraversion are associated with differences in certain psychosocial and clinical characteristics. Seventy-six depressed outpatients participating in antidepressant clinical trials completed this self-report questionnaire before beginning pharmacological treatment. Diagnosis of major depressive disorder (MDD) was made using the Structured Clinical Interview for DSM-III-R or DSM-IV and the severity of depression was measured with the 17-item Hamilton Depression Rating Scale (HAM-D). The three analyses conducted were as follows: (1) NEO factor scores were compared with published normative means; (2) three groups, based on level of neuroticism, were compared on certain psychosocial and clinical characteristics; and (3) three groups, based on level of extraversion, were compared on the same psychosocial and clinical characteristics. Both the males and females obtained T score values for the Neuroticism Scale 1.5 SD above the mean, for the Extraversion Scale 1.5 SD below the mean, and for the Conscientiousness Scale 1.5 SD below the mean. No significant differences were found between subjects with different levels of neuroticism and extraversion, although a trend did exist indicating a positive relationship between neuroticism and severity of depression. Depressed outpatients experience frequent negative affects, have irrational thought processes, cope with stress poorly, have difficulty controlling impulses, prefer to be alone, and have difficulty carrying out tasks. Future studies should examine how such personality factors affect response to treatment and course of illness.     

Integrated treatment of comorbid depression and substance use disorders.

OBJECTIVE: The goals of this 6-month prospective study were to evaluate the effect of a current diagnosis of depression on the course and outcome of addiction treatment and to determine whether patients with depression received or required additional treatment compared with those without depression. METHOD: On entering addiction treatment, 75 men and 45 women with substance use disorders were assessed by clinical and semistructured interviews, Global Assessment Scale, Hamilton Rating Scale for Depression, Beck Depression Inventory, and revised 90-item Symptom Checklist. RESULTS: Forty-three patients (35.8%) met DSM-IV criteria for a current depressive disorder at intake into addiction treatment. The depressed patients had significantly (p < .0001) higher levels of psychopathology at intake. However, contrary to previous studies, they fared as well as the nondepressed patients in terms of all addiction outcome measures and all indicators of psychiatric status at 6 months. During the 6-month follow-up period, the depressed patients received more treatment than the nondepressed patients. Specifically, they had more psychiatric appointments, and they were more likely to require inpatient detoxification and to be prescribed new antidepressant medication regimens. CONCLUSION: Depression comorbidity may not have had a negative impact on the course and outcome of addiction treatment because the dual disorder was identified at the initial assessment, and integrated psychiatric care was available. It may be that additional treatment compensated for greater psychopathology among dual-disorder patients.     

Bipolar depression: An underestimated treatment challenge

We sought to determine whether depressive and mixed/cycling episodes were as responsive to standardized pharmacotherapeutic interventions as were manic episodes in bipolar 1 patients. As part of the Maintenance Therapies in Bipolar Disorder (MH29618, E. Frank, PI) study, forty-two acutely ill bipolar 1 patients who had been randomly assigned to one of two preliminary phase non-pharmacologic treatment strategies (interpersonal and social rhythm therapy [IPSRT] or a standard medication clinic approach) were treated according to a standardized pharmacotherapeutic protocol. Symptom severity was measured weekly with the Hamilton Depression Rating Scale and the Bech-Rafaelsen Mania Scale in order to assess symptomatic remission. Survival analysis with the proportional hazards model was performed on time to remission. Manic patients were significantly more likely to achieve clinical remission than the depressed patients (100 vs. 59%) and did so significantly more rapidly. The difference in proportion remitting and time to remission between the depressed and mixed/cycling groups was not statistically significant. No significant effect for non-pharmacologic treatment assignment was found. These results point to the need to develop more effective treatments for bipolar depression. They also suggest that psychotherapy has a limited impact in the acute phase treatment of bipolar episodes. Depression and Anxiety 5:73–83, 1997. © 1997 Wiley-Liss, Inc     

Is the cutoff to define remission on the Hamilton Rating Scale for Depression too high?

The Hamilton Rating Scale for Depression (HRSD) is the most frequently used measure of outcome in antidepressant efficacy trials. More than a decade ago, a consensus panel recommended that remission be defined on the 17-item version of the HRSD as a cutoff 相似文献