William H. Norman

The modified Hamilton rating scale for depression: Reliability and validity

While the Hamilton Rating Scale for Depression (HRSD) has been the standard instrument for the assessment of the severity of depression for many years, this scale has a number of limitations. We developed the Modified Hamilton Rating Scale for Depression (MHRSD) to overcome some of these limitations and to enable paraprofessional research assistants to make reliable and valid assessments of depressive symptoms. The present study investigates the reliability and validity of the MHRSD. Interrater reliability among paraprofessional research assistants was excellent. The relationship between the MHRSD and expert clinician ratings on the MHRSD and the original HRSD was also high. Thus, the MHRSD appears to be a useful addition to the clinical researchers assessment battery.

Cognitive-behavioral treatment of depressed inpatients

Forty-seven depressed inpatients were randomly assigned to one of three treatment conditions: 1) standard treatment (hospital milieu, pharmacotherapy, medication and management sessions), 2) cognitive therapy (cognitive therapy + standard treatment), or 3) social skills training (social skills training + standard treatment). All treatments began while the patients were in the hospital and continued for 4 months on an outpatient basis after discharge. The results from analyses of measures of psychiatric symptoms administered at discharge from the hospital and at the end of outpatient treatment are reported in this paper. All treatment groups evidenced significant improvement at discharge and end of outpatient treatment relative to pretreatment levels of symptoms. While there were no significant differences between the treatment groups at discharge from the hospital, the patients assigned to the cognitive therapy and the social skills training groups manifested lower levels of symptoms at the end of outpatient treatment than did the Standard Treatment group.

The dexamethasone suppression test and completed suicide

The present study was undertaken to further explore the relationship between the dexamethasone suppression test (DST) and suicide. Depressed inpatients who had undergone the DST at index admission and later committed suicide (n= 13) were matched for age, gender, diagnosis, and type of DST (1 mg, 2 mg) with depressed inpatients from the same hospital and study time period to form 2 groups: a suicide attempter group (n= 25) and a nonattempter group (n= 28). The suicide completers group had significantly higher 1600 postdexamethasone cortisol levels than the suicide attempters group and a significantly higher 1600 rate of DST nonsuppression compared with the suicide attempter + nonattempter combined group. Although the rate of DST nonsuppression did not differ between the suicide attempter and nonattempter groups, serious attempters had significantly higher 1600 cortisol levels and a statistically higher proportion of patients who completed suicide than nonserious attempters. Comparing suicide completers with and without DST nonsuppression revealed a marginal difference concerning the time of the DST to suicide, with the nonsuppressor group time to suicide being less than the suppressor group (4.3 months vs 11.7 months).

Characteristics of depressed patients with elevated levels of dysfunctional cognitions.

The characteristics of subjects with elevated scores on both the Dysfunctional Attitudes Scale and Cognitive Bias Questionnaire were studied in a sample of 72 depressed inpatients. In comparison with low cognitive dysfunctional subjects (n =48), subjects with elevated dysfunctional cognitions (n =24) revealed greater severity of depression, more hopelessness, higher frequencies of automatic thoughts, less social support, and overall poorer social adjustment. Furthermore, the data suggest that age of depression onset, duration of current depressive episode, and number of previous depressive episodes are associated with elevated levels of dysfunctional cognitions. There were no differences between high and low dysfunctional cognitive groups with respect to DSM-III melancholic diagnosis or response on the dexamethasone suppression test.

Assessment of cognitive distortion in a clinically depressed population

The Cognitive Bias Questionnaire, the Present State Examination, the Beck Depression Inventory, and an expectancy of success measure were administered to depressed and nondepressed psychiatric inpatients. The depressed subjects selected significantly more depressed distortions on the Cognitive Bias Questionnaire than did the nondepressed subjects. Results also revealed that depressed distortion scores from the Cognitive Bias Questionnaire correlated significantly with measures of cognitive distortion obtained from the Beck Depression Inventory, the Present State Examination, and an experimental task. Although primary and secondary depressed groups did not differ significantly in their responses to the Cognitive Bias Questionnaire, depressed subjects who endorsed high levels of depressed distortion revealed significantly more cognitive symptoms of depression on the Beck Depression Inventory and the Present State Examination, and evidenced a nonsignificant trend to expect less success prior to an experimental task. Implications of these results for future research in this area are discussed.

Persistence of depressive cognitions within a subgroup of depressed inpatients

The persistence of depressive cognitions was investigated in two studies of psychiatric inpatients. In Study 1, depressed and nondepressed inpatients were given the Cognitive Bias Questionnaire (CBQ) immediately after admission to the hospital and after clinical improvement prior to discharge. A nondepressed, nonpsychiatric control group was also assessed. In Study 2, depressed and nondepressed individuals were administered the CBQ immediately following admission and 9 months following discharge from the hospital. Analysis of both samples indicated that following clinical improvement, depressed, nondepressed, and control subjects did not differ significantly in the proportions of individuals who manifested significant levels of depressive cognitions on the CBQ. However, when the depressive samples in both studies were subdivided according to their initial level of depressive cognitions, a significantly higher percentage of the high distorting group than of the nondepressed or control subjects manifested elevated levels of depressive cognitions after clinical improvement.

Hopelessness depression in depressed inpatients: Symptomatology, patient characteristics, and outcome

This exploratory study examined the association between level of hopelessness and specific depression symptomatology, patient characteristics, and treatment outcome. Results from 80 unipolar depressed inpatients suggested that high-hopelessness patients could be discriminated from low-hopelessness patients on hypothesized symptoms of depression, characterized by retarded initiation of voluntary responses (a motivational symptom) and sad affect (an emotional symptom). Moreover, high-hopelessness patients could be discriminated from patients low in hopelessness on the patient characteristics of greater suicidal ideation, social dysfunction, and cognitive dysfunction. Finally, compared to low-hopelessness patients, depressed inpatients high in hopelessness exhibited a poorer outcome to pharmacological and cognitive-behavioral treatment interventions.

Treatment response of high cognitive dysfunction depressed inpatients

A sample of depressed inpatients was subdivided according to their initial levels of cognitive dysfunction. These high cognitive dysfunction (HCD) patients and low cognitive dysfunction (LCD) patients received either pharmacotherapy or combined pharmacotherapy plus cognitive-behavioral psychotherapy. Treatments began in the hospital and continued for 20 weeks on an outpatient basis. Results indicated that HCD patients had significantly better treatment response to the combined treatment than pharmacotherapy alone, while LCD patients responded equally to pharmacotherapy alone and combined treatment.

Personality and family functioning in families of depressed patients

In this cross-sectional study, the authors attempted to identify correlates of family functioning in 86 couples with a depressed member during the acute phase of the patients depression. Demographic variables, psychiatric status, and personality traits of both the patient and spouse were investigated as potential predictors of family functioning. Regression analyses indicated that lower levels of personality pathology in the patient, higher levels of patient conscientiousness, and less psychological distress in the spouse were associated with healthier family functioning. Future research implications and clinical importance of these findings are discussed.

Family functioning and suicidal behavior in psychiatric inpatients with major depression

Family functioning was compared between suicide-attempting and nonsuicidal depressed inpatients in order to further understand psychosocial determinants of suicidal behavior. Suicidal behavior was strongly associated with a discrepancy between the patients perception of his/her family and the perception held by other family members. Suicide-attempting depressed inpatients perceived their family functioning to be worse than did their families. Suicidal patients also viewed their families more negatively than did depressed nonsuicidal inpatients, who actually viewed their family functioning more positively than did their family members. The clinical implications of these findings are discussed.