Daniela A. Boerescu

Why do some depressed outpatients who are in remission according to the Hamilton Depression Rating Scale not consider themselves to be in remission

OBJECTIVE In treatment studies of depression, remission is typically defined narrowly, based on scores on symptom severity scales. Patients treated in clinical practice, however, define the concept of remission more broadly and consider functional status, coping ability, and life satisfaction as important indicators of remission status. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined how many depressed patients in ongoing treatment who scored in the remission range on the 17-item Hamilton Depression Rating scale (HDRS) did not consider themselves to be in remission from their depression. Among the HDRS remitters, we compared the demographic and clinical characteristics of patients who did and did not consider themselves to be in remission. METHOD From March 2009 to July 2010, we interviewed 274 psychiatric outpatients diagnosed with DSM-IV major depressive disorder who were in ongoing treatment. The patients completed measures of depressive and anxious symptoms, psychosocial functioning, and quality of life. RESULTS Approximately one-half of the patients scoring 7 and below on the HDRS (77 of 140 patients for whom self-reported remission status was available) did not consider themselves to be in remission. The self-described remitters had significantly lower levels of depression and anxiety than the patients who did not consider themselves to be in remission (P < .001). Compared to patients who did not consider themselves to be in remission, the remitters reported significantly better quality of life (P < .001) and less functional impairment due to depression (P < .001). Remitters were significantly less likely to report dissatisfaction in their mental health (P < .01), had higher positive mental health scores (P < .001), and reported better coping ability (P < .001). CONCLUSIONS Some patients who meet symptom-based definitions of remission nonetheless experience low levels of symptoms or functional impairment or deficits in coping ability, thereby warranting a modification in treatment. The findings raise caution in relying exclusively on symptom-based definitions of remission to guide treatment decision-making in clinical practice.

Further evidence that the cutoff to define remission on the 17-item Hamilton Depression Rating Scale should be lowered

In 1991, the recommendations of a consensus conference were that a cutoff of 7 on the 17‐item Hamilton Depression Rating Scale (HAM‐D) be used to define remission from depression, and since then this has been the most commonly used definition of remission. The cutoff was not derived from empirical study. In the present report from the MIDAS project, we examined the level of current psychosocial morbidity in depressed patients identified as being in remission according to different thresholds on the 17‐item HAM‐D.

How should residual symptoms be defined in depressed patients who have remitted

Symptomatic remission has been defined as a complete or near-complete absence of symptoms. Just as the distinction between remitters and nonremitters among treatment responders has clinical significance, the distinction between a complete and near-complete absence of symptoms itself might be important. Recent studies have reported a high frequency of residual symptoms in patients who are presumably in remission, and this raises questions about how residual symptoms are defined. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared the prevalence of residual symptoms based on different cutoff scores on 2 self-report measures of depression and then determined the association between residual symptoms and indices of psychosocial morbidity. We administered the 17-item Hamilton Rating Scale for Depression to 274 psychiatric outpatients diagnosed as having DSM-IV major depressive disorder who were in ongoing treatment. The patients completed the Clinically Useful Depression Outcome Scale (CUDOS) and Quick Inventory of Depressive Symptomatology (QIDS) and measures of psychosocial functioning and quality of life. We examined the frequency of residual symptoms in the 142 patients scoring in the remission range on the Hamilton Rating Scale for Depression. For both the CUDOS and QIDS, the threshold to define symptom presence strongly impacted on the prevalence of residual symptoms. The association between residual symptoms, psychosocial functioning, and quality of life varied according to the threshold used to define the symptoms. On the QIDS, a cutoff of 1 was a more valid indicator of the presence of residual symptoms than a cutoff of 2, whereas on the CUDOS, we recommend a cutoff of 2 be used to indicate the presence of residual symptoms. Examination of the frequency of specific symptoms suggests that the choice of scale might impact on which residual symptoms are considered the most frequent in treatment remitters.

Determining severity subtypes of depression with a self-report questionnaire

The American Psychiatric Associations recently revised guidelines for the treatment of major depressive disorder indicated that it is important to consider symptom severity in initial treatment selection. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we conducted two studies of psychiatric outpatients examining the correlates of severity classification based on a self-report depression scale. The first sample consisted of 470 depressed outpatients who completed the Clinically Useful Depression Outcome Scale (CUDOS) and measures of psychosocial morbidity at the time of presentation. The second sample consisted of 112 depressed outpatients who completed the CUDOS and were evaluated with the Hamilton Depression Rating Scale at baseline and after 3 months of treatment. Compared to mildly depressed patients, moderately depressed patients reported significantly more psychosocial morbidity across all functional domains. The same differences were found between moderately and severely depressed patients. Greater severity of depression was associated with lower rates of response and remission. The results of the present studies suggest that a self-report depression questionnaire can validly subtype depressed patients according to gradations of severity.

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.

Scoring rules and rating formats of Self-report Depression Questionnaires: A comparison of approaches

Self-report measures of depression differ in their construction and scoring rules. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we tested the hypothesis that the loss of information due to scoring rules or rating formats reduces the validity of depression severity assessment. One hundred fifty-three outpatients with DSM-IV major depressive disorder (MDD) who presented for treatment or who were in ongoing treatment and had their medication changed due to lack of efficacy completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology (QIDS) and Remission from Depression Questionnaire (RDQ) at the initiation of treatment and 4 month follow-up. The patients were evaluated with the 17-item Hamilton Depression scale (HAMD). The CUDOS and RDQ were equally highly correlated with the HAMD at baseline and follow-up. There was no significant difference in the correlations between the modified and original scoring algorithms of the QIDS with the HAMD at baseline and the follow-up. On each scale, the patients showed significant levels of improvement from baseline to 4 months, and the effect sizes were similar. These findings suggest that the loss of information due to the scoring rules of the QIDS or the rating format of the RDQ did not reduce the validity of depression severity assessment.

Are self-report scales as effective as clinician rating scales in measuring treatment response in routine clinical practice?

OBJECTIVE Recent treatment guidelines have suggested that outcome should be measured in routine clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared three self-report scales of depressive symptoms and the two most widely used clinician administered scales in treatment studies in their sensitivity to change and evaluation of treatment response in depressed patients treated in routine practice. METHODS At baseline and 4-month follow-up 153 depressed outpatients with DSM-IV MDD completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology-Self-report version (QIDS-SR), and Patient Health Questionnaire (PHQ-9). The patients were rated on the 17-item Hamilton Depression Rating Scale (HAMD) and the Montgomery-Asberg Depression Rating Scale (MADRS). On each scale treatment response was defined as a 50% or greater reduction in scores from baseline. RESULTS While there were some differences in the percentage of patients considered to be responders on the different scales, a large effect size was found for each scale, with little variability amongst the scales. The level of agreement between the three self-report scales and the clinician rating scales was approximately the same LIMITATIONS: The present study was conducted in a single clinical practice in which the majority of the patients were white, female, and had health insurance. DISCUSSION When measuring outcome in clinical practice the magnitude of change in depressive symptoms is as great on self-report scales as on clinician rating scales.