Vol 8, No 2 - Depression in Medicine
Past issues Contributors How to publish Contributions and comments Home
 
epression  rating  scales  were  introduced  into clinical psychiatry in the 1960s, with the advent of anti- depressants such as imipramine and phenelzine.1-3 In the early  trials, both  global  improvement  scales  and  the Hamilton Depression Rating Scale (HAM-D) were used. As discussed by Lam et al,1 historically the use of depres- sion symptom scales such as the HAM-D was not a rou- tine aspect of patient care for frontline mental health clinicians. The present situation seems to be that we are facing two prototypes of clinicians, “Dr Gestalt,” who uses a global clinical impression scale, and “Dr Scales, ” who has incorporated the routine use of rating scales into daily clinical practice.1 When comparing Dr Gestalt with Dr Scales with respect to  limitations  and  pitfalls  in  using  depression  rating scales, it seems appropriate to use the functional analysis proposed by Emmelkamp.2 According to this proposal, we can refer to macroanalysis and microanalysis of rat- ing scales. Macroanalysis focuses on the diagnosis of depression  and  thereby  the  prediction  of  treatment response, while microanalysis focuses on outcome mea- sures of treatment.At the macroanalytic level, it is appro- priate to discuss depression rating scales such as the HAM-D in comparison with a diagnostic system of men- tal disorders such as the Diagnostic and Statistical Manual of  Mental  Disorders, 4th  ed  (DSM-IV),3 while  at  the microanalytic  level  a  direct  comparison  between  Dr Gestalt and Dr Scales is relevant. Macroanalysis Emmelkamp2 used  the  polythetic  algorithms  of  the DSM-IV to illustrate the limitation of the clinical diag- nosis of depression when developing treatment strategies for the patients.According to DSM-IV, in major depres- sion five out of nine depression symptoms have to be 2 0 7 C l i n i c a l  r e s e a r c h D Copyright © 2006 LLS SAS.  All rights reserved www.dialogues-cns.org Rating scales in depression: limitations and pitfalls Per Bech, MD Keywords: depression rating scales; HAM-D; antidepressant; major depression; placebo-controlled trials Author  affiliations: Psychiatric  Research  Unit,  Frederiksborg  General  Hospital, Hillerød, Denmark Address for correspondence: Prof Per Bech, Professor of Psychiatry, Psychiatric Research Unit, Frederiksborg General Hospital, 48, Dyrehavevej, Hillerød, Denmark (e-mail: pebe@fa.dk) Since  the  introduction  of  antidepressants  to  psy- chopharmacology in the 1960s, the Hamilton Depression Rating Scale (HAM-D) has been the most frequently used rating scale for depression. When used as a scale for pre- diction of outcome with antidepressants, the HAM-D, by its total score, has obtained limited use analogous to the Diagnostic and Statistical Manual of Mental Disorders. 4th ed (DSM-IV) diagnosis of major depression. Most research has been devoted to the use of the HAM-D to discriminate between placebo and active drugs or to show dose-response relationship in patients with major depression. An improvement in the total HAM-D score during a drug trial does not, however, in itself qualify the drug as an antidepressant, because the total score is not a sufficient statistic. The problem of statistical versus clinical significance when analyzing placebo-controlled trials, including dose-response relationship, is outlined, with the recommendation to use effect size statistics.   © 2006, LLS SAS Dialogues Clin Neurosci. 2006;8:207-215.