Should we use rating scales in our clinical practices? And if so, which ones? Do the benefits of scales compensate for the extra time it takes to administer them?
As you may have surmised from reading journal articles, there are an awful lot of rating scales out there, making the process of choosing one a daunting task. According to one recent book, there are at least 30 different scales available to assess depression and suicidality alone, and there are at least as many focusing on anxiety problems.
In my own practice, I use scales primarily for my more “difficult” patients-that is, those whose symptoms are chronic and do not obviously respond to my usual treatments. For these patients, scales help me to detect subtle improvement with greater sensitivity.
The king of all scales is surely the Hamilton Depression Rating Scale (Br J Soc Clin Psychol 1967; 6:278-96, free download at http://healthnet. umassmed.edu/mhealth/HAMD.pdf). Widely used for over 40 years, it pops up in journal articles all over the world. However, if you’ve ever tried to use it, you’ve found that it overemphasizes somatic symptoms of depression (reflecting the fact that it was originally developed for more severely ill, hospitalized patients). The common 17-item version takes at least 15 minutes to administer and thus is not practical for most of us, but a more recent 7-item version is available and less unwieldy (Primary Psychiatry 2003; 10:39-42; free download from http://www.cfpc.ca/ cfp/2004/Oct/vol50-octcme-1.asp).
Self-administered scales are much easier (at least for clinicians), and it turns out that the PHQ-9 (Patient Health Questionnaire 9), available as a free download at, http://www. depressionprimarycare.org/ clinicians/toolkits/materials/forms/ phq9/questionnaire/, has excellent sensitivity and specificity for picking up depression and for tracking response. It takes only a couple of minutes to score (J Gen Intern Med 2001 Sep; 16(9):606-13).
In terms of anxiety, the field is very crowded, but the Beck Anxiety Inventory (BAI) has been a popular self-report form and is especially good for monitoring panic symptoms. While free copies of the BAI seem to find their way to generations of psych residents (and can be downloaded at http://blue.butler.edu/%7Edluechau/ questionnaires/beckanxietyinventory. doc) it is actually under copyright, and you can purchase it at https:// harcourtassessment.com/hai/ International.aspx.
For OCD, the Yale-Brown Obsessive Compulsive Scale (YBOCS) is famous, but also famously time-consuming to administer. However, a self-administered form is available as a free download (http:// healthnet.umassmed.edu/mhealth/ YBOCRatingScale.pdf) and can be completed and scored quickly–very handy for assessing response in this chronic condition.
Tracking the progression of dementia is a difficult clinical problem, and there are scales aplenty to help. The ADAS-cog (Alzheimer’s Disease Assessment Scale-Cognitive component) is the one most commonly used in research, but don’t try it in the office, as it will set you back about a half-hour. Many clinicians use the good old MMSE to track response to cognition-enhancing medications, on the theory that in untreated Alzheimer’s Disease, MMSE scores decrease by 2-4 points per year (see Agronin, Dementia, Lippincott Williams & Wilkins 2004), and that medication slows this deterioration a bit.
Because there are innumerable possible side effects from our medications, we sometimes forget to ask about them. Unfortunately, there is no brief side effect questionnaire to screen for everything. There is, however, a nice scale that covers sexual side effects of psychotropics, the ASEX (Arizona Sexual Experiences Scale). While I could not find a downloadable version on the web, many drug reps are happy to pass it along. It is a 5-item self-report scale with separate versions for men and women, and it may allow your patients to be more honest than they would be in conversation.
We’ve covered scales for specific symptoms, but there are several “all-purpose” rating scales available. The CGI (Clinical Global Impression) is widely used and is almost ludicrously easy, being at its most basic form a rating of the overall severity of your patient’s illness, in relation to your “total clinical experience with this particular population.”
Aside from all the formal and well-validated scales we’ve covered, many clinicians use a simple and intuitive “1 to 10” scale, adaptable for many different symptoms. For example, “On a scale of 1 to 10, 1 being not at all depressed and 10 being the most depressed you can imagine, how have you been feeling over the past month?” This poor man’s (or poor woman’s) scale works quite well for tracking various other discrete symptoms as well, such as anxiety, mania, anger, and fatigue. The more you use this, the more confident you will become in interpreting the responses.
We’ve only scratched the surface of this topic, of course. Two highly recommended books with more information, including scales that you can photocopy, are Assessment Scales in Depression, Mania, and Anxiety, Lam, Michalak and Swinson (Eds.), Taylor & Francis, 2005; and Rating Scales in Mental Health, 2nd Ed., Sajatovic and Ramirez (Eds.), Lexi-Comp, 2003.
TCR VERDICT: Pick a scale or two, and use it!