Iwona Chelminski

Severity classification on the Hamilton depression rating scale

BACKGROUND Symptom severity as a moderator of treatment response has been the subject of debate over the past 20 years. Each of the meta- and mega-analyses examining the treatment significance of depression severity used the Hamilton Depression Rating Scale (HAMD), wholly, or in part, to define severity, though the cutoff used to define severe depression varied. There is limited empirical research establishing cutoff scores for bands of severity on the HAMD. The goal of the study is to empirically establish cutoff scores on the HAMD in their allocation of patients to severity groups. METHODS Six hundred twenty-seven outpatients with current major depressive disorder were evaluated with a semi-structured diagnostic interview. Scores on the 17-item HAMD were derived from ratings according to the conversion method described by Endicott et al. (1981). The patients were also rated on the Clinical Global Index of Severity (CGI). Receiver operating curves were computed to identify the cutoff that optimally discriminated between patients with mild vs. moderate and moderate vs. severe depression. RESULTS HAMD scores were significantly lower in patients with mild depression than patients with moderate depression, and patients with moderate depression scored significantly lower than patients with severe depression. The cutoff score on the HAMD that maximized the sum of sensitivity and specificity was 17 for the comparison of mild vs. moderate depression and 24 for the comparison of moderate vs. severe depression. LIMITATIONS The present study was conducted in a single outpatient practice in which the majority of patients were white, female, and had health insurance. Although the study was limited to a single site, a strength of the recruitment procedure was that the sample was not selected for participation in a treatment study, and exclusion and inclusion criteria did not reduce the representativeness of the patient groups. The analyses were based on HAMD scores extracted from ratings on the SADS. However, we used Endicott et al.s (1981) empirically established formula for deriving a HAMD score from SADS ratings, and our results concurred with other small studies of the mean and median HAMD scores in severity groups. CONCLUSIONS Based on this large study of psychiatric outpatients with major depressive disorder we recommend the following severity ranges for the HAMD: no depression (0-7); mild depression (8-16); moderate depression (17-23); and severe depression (≥24).

A review of studies of the Hamilton depression rating scale in healthy controls: implications for the definition of remission in treatment studies of depression.

The Hamilton Rating Scale for Depression (HRSD) is the most commonly used symptom severity scale to evaluate the efficacy of antidepressant treatment. On the basis of an expert consensus panel, an HRSD score of ≤7 was recommended as a cutoff to define remission. Since that recommendation, little empirical work has been conducted to confirm the validity of this threshold. One approach toward determining a cutoff score for defining remission is to establish the range of values for healthy controls. We therefore conducted a literature review of studies of the HRSD in healthy controls to determine the normal range of values. Studies of the HRSD in healthy control groups were identified in two ways. First, a MEDLINE search for the years 1966 to 2002 was conducted using the key words Hamilton, depression, and controls, and articles were reviewed. Second, the 69 studies included in two review articles written by the authors were examined. We identified 27 studies that included data on the HRSD for 1014 healthy controls. Across all studies, the weighted mean (SD) HRSD score, adjusting for sample size, was 3.2 (3.2; 95% CI, 3.0 to 3.4). HRSD scores were similar in geriatric and nongeriatric samples, and in men and women. Because HRSD scores in healthy controls are more likely to follow a skewed than a normal distribution, based on a mean of 3.2 and a SD of 3.2, at least 84% of healthy controls scored 7 or less on the HRSD, and 97.5% scored 10 or less. Thus, these results can be taken as support for the recommended cutoff of 7 on the HRSD to define remission. The results can also be used for normative comparisons in which posttreatment group mean scores are compared with mean scores from normative samples.

The frequency of personality disorders in psychiatric patients.

Community-based epidemiological studies of psychiatric disorders provide important information about the public health burden of these problems; however, because seeking treatment is related to a number of clinical and demographic factors, studies of the frequency and correlates of psychiatric disorders in the general population should be replicated in clinical populations to provide the practicing clinician with information that might have more direct clinical utility. Diagnosing co-occuring personality disorders in psychiatric patients with an Axis I disorder is clinically important because of their association with the duration, recurrence, and outcome of Axis I disorders. This article reviews clinical epidemiological studies of personality disorders and finds that in studies using semi-structured diagnostic interviews, approximately half of the patients interviewed have a personality disorder. Thus, as a group, personality disorders are among the most frequent disorders treated by psychiatrists.

A review of studies of the Montgomery-Asberg Depression Rating Scale in controls: implications for the definition of remission in treatment studies of depression.

The Montgomery–Asberg Depression Rating Scale (MADRS) is one of the most commonly used symptom severity scales to evaluate the efficacy of antidepressant treatment. Various cut-offs have been employed in antidepressant efficacy trials to define remission, although little empirical work has been carried out to determine the validity of various thresholds. One approach towards deriving a valid cut-off score for defining remission is to determine whether a patients level of symptoms falls within the normal range of values after treatment. We therefore conducted a literature review of studies of the MADRS in healthy controls to determine the normal range of values. We identified 10 studies of 14 samples that included data on the MADRS for 569 controls. Across all studies, the mean (±SD) weighted MADRS score, adjusting for sample size, was 4.0 (5.8) (95% confidence interval 3.5–4.5). These results are consistent with the findings of our study of the validity of different cut-offs to define remission on the MADRS—based on a narrow definition of remission, which required a complete absence of clinically significant symptoms of depression, the optimal MADRS cut-off was ≤4 whereas based on a broader definition, the optimal cut-off was ≤9. The findings can be used for normative comparisons in which post-treatment group mean scores are compared to mean scores from normative samples. A limitation of the review is that none of the studies was based on a randomly selected sample from the general population. In addition, the rigor of the screening used to exclude individuals with psychopathology in most studies is unknown; thus, some of the controls may have had diagnosable depression, thereby elevating the mean scores in the presumptively healthy control group.

Psychiatric diagnoses in patients previously overdiagnosed with bipolar disorder.

OBJECTIVE In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question not examined in that article was what diagnoses were given to the patients who had been overdiagnosed with bipolar disorder. In the present report from the MIDAS project, we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis. METHOD Eighty-two psychiatric outpatients reported having been previously diagnosed with bipolar disorder that was not confirmed when they were interviewed with the Structured Clinical Interview for DSM-IV (SCID). Psychiatric diagnoses were compared in these 82 patients and in 528 patients who were not previously diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered a modified version of the SCID for DSM-IV Axis I disorders and the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders. This study was conducted from May 2001 to March 2005. RESULTS The most frequent lifetime diagnosis in the 82 patients previously diagnosed with bipolar disorder was major depressive disorder (82.9%, n = 68). The patients overdiagnosed with bipolar disorder were significantly more likely to be diagnosed with borderline personality disorder compared to patients who were not diagnosed with bipolar disorder (24.4% vs 6.1%; P < .001). A previous diagnosis of bipolar disorder was also associated with significantly higher lifetime rates of major depressive disorder (P < .01), posttraumatic stress disorder (P < .05), impulse control disorders (P < .05), and eating disorders (P < .05), although only the association with impulse control disorders remained significant after controlling for the presence of borderline personality disorder. CONCLUSIONS Psychiatric outpatients overdiagnosed with bipolar disorder were characterized by more Axis I and Axis II diagnostic comorbidity in general, and borderline personality disorder in particular.

Borderline Personality Disorder and the Misdiagnosis of Bipolar Disorder

Recent reports suggest bipolar disorder is not only under-diagnosed but may at times be over-diagnosed. Little is known about factors that increase the odds of such mistakes. The present work explores whether symptoms of borderline personality disorder increase the odds of a bipolar misdiagnosis. Psychiatric outpatients (n=610) presenting for treatment were administered the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for DSM-IV Personality for DSM-IV axis II disorders (SIDP-IV), as well as a questionnaire asking if they had ever been diagnosed with bipolar disorder by a mental health care professional. Eighty-two patients who reported having been previously diagnosed with bipolar disorder but who did not have it according to the SCID were compared to 528 patients who had never been diagnosed with bipolar disorder. Patients with borderline personality disorder had significantly greater odds of a previous bipolar misdiagnosis, but no specific borderline criterion was unique in predicting this outcome. Patients with borderline personality disorder, regardless of how they meet criteria, may be at increased risk of being misdiagnosed with bipolar disorder.

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 ≤7. This recommendation was accompanied by a call for research to validate this cutoff value; however, little research in this area has been performed since then. The goal of the present study was to compare the validity of different HRSD cutoffs for defining remission. Three hundred three depressed psychiatric outpatients were rated on the 17-item HRSD, the Global Assessment of Functioning (GAF) scale, and the Standardized Clinical Outcome Rating for Depression, an index of DSM-IV remission status. We examined the sensitivity, specificity, and overall classification rate of the HRSD for identifying a broad and narrow interpretation of the DSM-IV definition of remission, and the association between the breadth of the definition of remission on the HRSD and self-report ratings of global psychosocial functioning and quality of life. Based on a narrow definition of DSM-IV remission, which requires an absence of clinically significant symptoms of depression, the optimal 17-item HRSD cutoff was ≤2. Compared with patients scoring 3 through 7 on the HRSD, those who scored 0 to 2 reported significantly less psychosocial impairment and better quality of life. Our results thus support the use of a lower cutoff on the HRSD than has been traditionally used to define remission.

Screening for Bipolar Disorder and Finding Borderline Personality Disorder

OBJECTIVE Bipolar disorder and borderline personality disorder share some clinical features and have similar correlates. It is, therefore, not surprising that differential diagnosis is sometimes difficult. The Mood Disorder Questionnaire (MDQ) is the most widely used screening scale for bipolar disorder. Prior studies found a high false-positive rate on the MDQ in a heterogeneous sample of psychiatric patients and primary care patients with a history of trauma. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether psychiatric outpatients without bipolar disorder who screened positive on the MDQ would be significantly more often diagnosed with borderline personality disorder than patients who did not screen positive. METHOD The study was conducted from September 2005 to November 2008. Five hundred thirty-four psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and Structured Interview for DSM-IV Personality Disorders and asked to complete the MDQ. Missing data on the MDQ reduced the sample size to 480. Approximately 10% of the study sample were diagnosed with a lifetime history of bipolar disorder (n = 52) and excluded from the initial analyses. RESULTS Borderline personality disorder was 4 times more frequently diagnosed in the MDQ positive group than the MDQ negative group (21.5% vs 4.1%, P < .001). The results were essentially the same when the analysis was restricted to patients with a current diagnosis of major depressive disorder (27.6% vs 6.9%, P = .001). Of the 98 patients who screened positive on the MDQ in the entire sample of patients, including those diagnosed with bipolar disorder, 23.5% (n = 23) were diagnosed with bipolar disorder, and 27.6% (n = 27) were diagnosed with borderline personality disorder. CONCLUSIONS Positive results on the MDQ were as likely to indicate that a patient has borderline personality disorder as bipolar disorder. The clinical utility of the MDQ in routine clinical practice is uncertain.

Diagnosing Major Depressive Disorder I: A Psychometric Evaluation of the Dsm-iv Symptom Criteria

The diagnostic criteria for depression were developed on the basis of clinical experience rather than empirical study. Although they have been available and widely used for many years, few studies have examined the psychometric properties of the DSM criteria for major depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether criteria such as insomnia, fatigue, and impaired concentration that are also diagnostic criteria for other disorders are less specific than the other DSM-IV depression symptom criteria. We also conducted a regression analysis to determine whether all criteria are independently associated with the diagnosis of major depressive disorder. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. All of the DSM-IV symptom criteria for major depressive disorder were significantly associated with the diagnosis. Contrary to our prediction, symptoms such as insomnia, fatigue, and impaired concentration, which are also criteria of other disorders, generally performed as well as the criteria that are unique to depression such as suicidality, worthlessness, and guilt. The results of the regression analysis, which controlled for symptom covariation, indicated that five symptoms (increased weight, decreased weight, psychomotor retardation, indecisiveness, and suicidal thoughts) were not independently associated with the diagnosis of depression. The implications of these results for revising the diagnostic criteria for major depression are discussed.

The construct validity of depressive personality disorder.

This study examined the construct validity of depressive personality disorder (DPD: American Psychiatric Association, 1994). Adult psychiatric outpatients (N = 900) underwent comprehensive Axis I and II evaluations and provided data on 4,768 of their 1st-degree relatives. Despite modest overlap, DPD was not redundant with any Axis I or II disorder. Participants with DPD exhibited more Axis I and Axis II comorbidity, and greater psychosocial dysfunction, than participants without DPD. Relatives of participants with DPD had higher rates of mood disorders, alcohol abuse, and antisocial personality. Results are consistent with findings of several other similar investigations. The authors argue that DPD is a valid construct and should be conceptualized as a personality disorder as opposed to a mood disorder.