When treating our depressed patients, objective clinical measures can help guide interventions and reassure us that the treatment course we are on is appropriate. Depression rating scales rose to popularity in the 1950s, primarily as tools to measure the effect of antidepressant medications.
Today there are many scales to choose from. Psychiatrists familiar with these tools will be better able to interpret clinical trial results and to employ them in assessing patients’ clinical progress. Here we review the most commonly used depression rating scales, as well as some newer web-based tools.
Hamilton Depression Rating Scale
The HAM-D was introduced in 1960 by Max Hamilton as a tool to quantify depressive symptomatology using clinician observation in addition to patient report (Hamilton M, J Neurol Neurosurg Psychiat 1960;23:56–62). In its original form, the scale consists of 21 items, although the 17-item version is more widely used. The HAM-D-17 is scored on a scale of zero to 52. Each item is rated according to its severity as experienced during the past week. Scores indicate mild (7–17), moderate (18–24), and severe (>24) depression. Generally, this scale is weighted toward somatic and behavioral symptoms, although atypical features such as hypersomnia and increased appetite are not strongly represented (Demyttenaere K and De Fruyt J, Psychother Psychosom 2003;72(2):61–70).
The HAM-D is widely used in research and clinical practice, considered by many to be the best depression rating scale. A disadvantage is time of administration, especially compared to self report measures. However, clinicians very familiar with the scale can assign an estimated score during the course of a visit fairly quickly. There have been numerous modifications of the HAM-D including self report versions, one of which can be found at http://bit.ly/ bwB3dA. The full HAM-D can be found at http://bit.ly/G1oIU.
Montgomery-Åsberg Depression Rating Scale (MADRS)
In 1979, Stuart Montgomery and Marie Åsberg introduced a scale designed to combine ease of administration with sensitivity to antidepressant treatment response (Montgomery SA and Åsberg M, Brit J Psychiat 1979;134(2):382–389). The MADRS is a clinician-administered scale, based on a clinical interview and 10 items meant to comprise the core symptoms of depression. The items include symptoms such as reduced sleep, as well as observable signs such as apparent sadness. Each item is rated on a scale from zero to six.
The MADRS is weighted more toward psychic symptoms than somatic (Demyttenaere K and De Fruyt J, op. cit.). Measures of severity are as follows: severe (>30), moderate (25–30), mild (15–24), and recovered (7–14). The MADRS is particularly useful in assessing improvement in symptoms amenable to antidepressant treatment. It is shorter in length and easier to administer than the HAM-D, making it helpful when time is limited.
Beck Depression Inventory (BDI)
The BDI is considered the gold standard of depression self report rating scales. Created by Aaron Beck in 1961, it was originally designed to assess change in patients undergoing psychoanalysis (Cusin C et al. Rating Scales for Depression. In: Baer L and Blais MA, eds. Handbook of Clinical Rating Scales and Assessment in Psychiatry and Mental Health. Humana Press; 2009:7–35). Over time, modifications were made, creating a version more consistent with cognitive behavioral theory and with the DSM-IV. The current version is the BDI-II, which consists of 21 items rated by the patient from zero to three. Cognitive experiences such as feelings of disappointment and failure are heavily weighted on the BDI-II, making it an ideal scale to measure change during psychotherapy. Scores signify mild (10–20), moderate (21–30), and severe (>30) depression. Scoring is easily done by the clinician or patient once the items are completed. Intermittent self assessment using the BDI-II can be therapeutically useful, giving patients a tangible sense of their improvement over the course of therapy, and results can be readily shared with the clinician.
The BDI is copyrighted and available for purchase at www.pearsonassessments. com ($52 for 25 forms).
Inventory of Depressive Symptomatology (IDS)
In 1986, A John Rush introduced a new tool meant to improve on existing scales by providing interchangeable patient- and clinician-rated versions, DSM applicability, and clearly defined rating anchors for each item (Rush AJ et al, Biol Psychiatry 2003;54:573–583). The initial IDS consists of 30 items, each rated from zero to three, 28 of which are used to calculate a final score from zero to 84. The IDS measures symptoms that correlate with DSM-IV depression criteria as well as atypical and melancholic features and other common symptoms. The clinician rated version (IDS-C) has a self report correlate (IDS-SR), which is basically identical in content.
A shortened version was introduced in 2000 called the Quick Inventory of Depressive Symptomatology (QIDS-C and QIDS-SR). It has 16 items that correspond to DSM-IV criteria. Full versions of this scale in multiple languages as well as scoring guides and result interpretations are available at www.ids-qids.org. High internal consistency and validity have been established for all forms of the IDS (Trivedi MH et al, Psychological Medicine 2004;34(1):73–82).
Given its accessibility, availability in clinician and self report versions, and DSM relevance, the IDS is very well suited to practicing clinicians monitoring patients with depression.
Web-Based Assessment Tools
My Mood Monitor (M3)
My Mood Monitor is a web-based instrument for use by patients and providers to screen for and monitor psychiatric symptoms. Each “screen,” which is easily accessed by patients at www.whatsmym3.com, consists of 27 items that assess symptoms of various mood, anxiety, and substance use disorders. After completing a screen, patients are given an “M3 score,” as well as the estimated probability that they suffer from a psychiatric disorder. Scores above 33 imply likelihood of a psychiatric condition. The rating is then broken down and scored on four dimensions: depression, anxiety, bipolar, and PTSD (considered separate from anxiety for these purposes), and diagnostic probabilities are given as above. If an item is rated that raises a red flag (such as suicidality), referral to an emergency room or crisis hotline is suggested.
M3 scores are accessible by providers through Microsoft Health Vault, a free health organizing website for patients. Patients may choose to grant access to their screen results to their providers. Providers must pay a monthly fee to access M3 scores entered by their patients, roughly $3 per screen per month, and pricing includes access to all past screens as well. Each screen provides a total M3 score, scores on the four subscales, graphs displaying clinical trends, as well as specific flags such as suicidality, drug use, and impairment in functioning. Fields are provided for providers to enter information regarding medication treatment, compliance, side effects, etc. The M3 website advertises compatibility with some EMR systems.
Overall, M3 may be a useful tool to enhance communication between patients and physicians regarding mood and general psychiatric issues. Given the broad, nonspecific nature of the items, it may be more useful as a screen in the primary care setting. Cost and lack of validation are issues to consider, as well.
Mood 24/7 is a text message-based application used to improve compliance with mood charting for patients with diagnosed depression. Developed and studied at Johns Hopkins, the program sends daily text messages to patients, prompting them to rate their mood on a scale of one to 10 and providing space for any additional comments. Results are stored on a secure website, which physicians can access free of charge. Improved patient compliance was shown in initial studies. The technology is still being developed and is less comprehensive than M3. However it could be useful for patients with well-established MDD diagnoses who require frequent mood monitoring or struggle with compliance.
Available at www.moodtracker.com, this tool is essentially a computerized mood chart, similar to those used by many of our patients with bipolar disorder. Patients enter daily mood ratings, choosing one of seven levels from severely depressed to severely elevated. Information may also be entered to rate anxiety, irritability, hours of sleep, and missed doses of medication. Providers log in to view the information in color coded graph form over any chosen time frame. The site is funded by sponsored ads and is free for use by patients and doctors. A paid version, with a few extra features and no ads, is available for about $25 per year.
There are many other web-based mood monitors, as well as mobile apps. While none has gained widespread use, this type of tool will clearly gain importance as the technology develops.
TCPR’S VERDICT: Depression rating scales can be helpful in monitoring patient response to treatment. For an adaptable and easy to use scale, check out the QIDS-16. Keep an eye on web-based instruments—these may be the wave of the future, but none stands out just yet.