How Psychiatrists Use Depression Rating Scales

How Psychiatrists Use Depression Rating Scales

Psychiatrists sometimes use rating scales as one way to assess the nature and severity of a patients’ symptoms and monitor their clinical progress. Depression rating scales are standardized instruments that measure the severity of depression symptoms during a period of time. The scales provide descriptive words and phrases that indicate the severity of depression symptoms. When researchers use depression rating scales, they may make judgments and rate a patient based on a specified scale while taking observed characteristics into account.

Instead of being used alone to diagnose depression, depression rating scales are used to determine whether a person should be further evaluated to receive a diagnosis for a depressive disorder. Depending on the score levels that a scale possesses, the score can signal progress or worsening to clinicians—providing guidance toward the clinician’s next steps for treating the patient.

Although psychiatrists can use depression rating scales to significantly improve diagnostic clarity and quality of care, studies show that most psychiatrists do not use them. In 2000, a survey was sent to 500 psychiatrists in the United Kingdom in which 340 responded. Among the respondents, 58 percent said that they never used a scale to measure clinical change of depression and anxiety.

An additional survey in 2006 to 2007 found that 39 percent of 306 psychiatrists said that they never used scales, while 32 percent said they rarely used scales. The psychiatrists who never used standardized scales explained that lack of training and time prevented them from utilizing them. Some of the psychiatrists did not believe that scales would be clinically helpful.

Rather than assessing a depressed patients’ progress through regulated scales, mental health clinicians often assess progress through unstructured interactions that yield unquantified judgments and results. These interactions typically consist of broad questions asked by clinicians such as “How are you feeling?” with patients replying with blanket responses such as “Good.”   Since these kinds of responses are not an accurate or thorough reflection of the patient’s clinical status, clinicians risk misdiagnosing patients. Standardized scales are becoming increasingly recognized and incorporated into clinical practice to measure depression—helping clinicians evaluate the patient’s current status more precisely.

Types of Depression Rating Scales

Psychiatrists have a wide variety of available depression rating scales to utilize within their clinical practice. These scales consist of clinician-rated scales, patient self-report scales, and scales that incorporate both administrations. Generally, both the patient self-report scale and the clinician-rated scale provide significant relevance in diagnostic assessment.

Clinician-Rated Scales

Depression rating scales that are completed by the psychiatrist are classified as clinician-rated scales. Each scale has a different set of psychometric properties, that can include: item-level, scale-level, and dimensionality.

Hamilton Depression Rating Scale (HDRS)

The HDRS, abbreviated as HAM-D, is the most widely used clinician-rated depression rating scale. It is a multiple item questionnaire that addresses depression indicators, including insomnia and appetite, to evaluate the recovery of depressed patients. The test takes about 15 to 20 minutes to complete.

The original version developed Max Hamilton in 1960 contains 17 items (HDRS-17) relating to symptoms of depression experienced over the past week. Each item is rated on a scale from zero to three. The HDRS was originally developed for hospital inpatients, but revisions have been made over the years and semi-structured interview guides provided improvements to the test.

A later 21-item version (HDRS-21) included 4 items intended to subtype the depression, but which are sometimes, incorrectly, used to rate severity.

Montgomery-Asberg Depression Rating Scale (MADRS)

The MADRS was designed in 1979 by Stuart Montgomery and Marie Åsberg to combine ease of administration with research responses that are more sensitive to antidepressant treatment changes. British and Swedish researchers developed the MADRS to supplement the HDRS. The MADRS is a clinician-administered scale comprised of a clinical interview and 10 items that cover the core symptoms of depression. The items include symptoms such as reduced appetite, as well as observable signs such as apparent sadness. Each item is rated on a scale from zero to six.

Although the HDRS is more commonly used, the MADRS is helpful when time is limited for psychiatrists because the test is shorter and easier to administer.

Patient Self-Report Scales

Some depression rating scales can be completed by the patient.

Beck Depression Inventory (BDI)

The BDI is considered the highest regarded and utilized self-report rating scale for depression. Beck Depression Inventory scales were created by Aaron Beck in 1961 to assess change in patients undergoing psychoanalysis. It focuses on the patient’s thoughts and experiences. Over time, modifications were made, creating a version more consistent with cognitive behavioral theory—the BDI-II.

Currently, the BDI-II consists of 21 items rated by the patient from zero to three. The test emphasizes assessing cognitive experiences such as feelings of disappointment, making it an ideal scale to measure change during psychotherapy. Once the test is completed, scoring can easily be done by the clinician or patient. Periodic self-assessment using the BDI-II can be useful, giving patients a tangible sense of their improvement over the course of therapy.

The Edinburgh Postnatal Depression Scales (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS) was made to identify patients who are suffering from postpartum depression and consists of a 10-item questionnaire. Items within the questionnaire were carefully selected to recognize clinical depression symptoms such as feelings of guilt, sleep disturbance, low energy, anhedonia, and suicidal thoughts.

Patients complete this comprehensive assessment within 8 weeks of postpartum, but can also be used to identify depression symptoms during pregnancy. Like most other scales, higher scores correlate to higher levels of depressive symptoms. The EPDS is a highly recommended screening tool for women to detect and combat postpartum depression in the early stages.

Clinician-Rated and Patient Self-Report Scales

Today, many depression rating scales are becoming increasingly more versatile. Some scales have versions that can be completed by the clinician and the patient. Many self-report scales can be assessed online now, but it is always recommended to get further assessment by a clinical professional.

Primary Care Evaluation of Mental Disorders (PRIME-MD)

Clinicians and patients are each assigned a component to complete within the PRIME-MD. After the patient answers the patient questionnaire, the clinician will evaluate the completed questionnaire in an interview with the patient. The PRIME-MD contains 27 “yes or no” questions concerning depressive symptoms experienced in the past month, while incorporating observed and reported behavior. On average, the test takes eight minutes to perform. The PRIME-MD has been validated in adults and adolescents over age 13.

The PHQ-9

The PHQ-9, a 9-question depression scale, is a self-administered version of PRIME-MD.  The PHQ-9 is often used in primary care settings. A patient may take the PHQ-9 in written form or be asked the survey items by clinic staff. The PHQ-9 questions are based on diagnostic criteria of depression from DSM-IV and ask about the patient’s experience in the last 2 weeks. Questions are about the level of interest in doing things, feeling down or depressed, sleep, energy levels, eating habits, self-perception, ability to concentrate, speed of functioning and thoughts of suicide.

Depression Rating Scales: Get Assessed at Mid City TMS

With the advancements in technology, depression rating scales can be easily accessed by anyone. It is important to visit your local clinician if you experience significant results from these online tests.

Mid City TMS is a New York-based medical center specializing in providing thorough evaluations and offering alternative treatment options for depression. At your initial visit, you will be thoroughly assessed and presented with recommended treatment options. As part of our initial evaluation, we typically have patients complete the BDI-II and PHQ-9 as one way to assess the severity and type of depressive symptoms. We also have patients complete these instruments once a week during the course of TMS treatment to assess their clinical improvement.

TMS is a safe, noninvasive depression treatment that delivers long-lasting relief.  To learn more about Mid City TMS, give us a call at 212-517-1867, contact us online, or schedule an appointment today.

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