A Review of Common Scales Used in Major Depressive Disorder Video

Major depressive disorder (MDD) is a chronic and disabling condition affecting millions of patients. Join a family nurse practitioner for a discussion on the use of psychiatric scales in identifying and managing patients with MDD. Review how standardized psychiatric rating scales, combined with clinical interviews and impressions, can supply us with the information we need to reach an accurate diagnosis and assess the efficacy of interventions throughout a patient’s treatment journey.

Transcript:

Hello, and welcome! I am so glad you have joined me for a discussion of psychiatric scales that can help in identifying and managing patients with major depressive disorder, or MDD. My name is Chris Lambert, and I am a family nurse practitioner with a focus in the mental health space. I am looking forward to sharing some clinical pearls with you today about how clinical rating scales are an important objective assessment tool that can help you identify and manage your patients with MDD. I like to think of scales as a small but integral part of my visit with each patient.

As we know, MDD is a chronic and disabling condition affecting millions of patients. I use several psychiatric rating scales in my practice when caring for these patients. It is important that we understand how standardized psychiatric rating scales can supply us with information we need to potentially reach an accurate diagnosis more quickly, as well as assess the efficacy of interventions applied during the patient’s treatment journey. These scales, used in conjunction with observation of our patients, a thorough patient interview, and talking with the patient’s family, caretakers, and loved ones, if the patient consents, can help ensure evidence-based decision-making on behalf of our patients.

Delays in diagnosis can lead to delays in treatment, which can prolong symptoms and suffering and may lead to worse patient outcomes.¹ So, this earlier identification is key in helping many of our patients with MDD.

This figure illustrates the importance of early and optimized treatment in helping to attain symptomatic and functional recovery.

Measurement-based care utilizes standardized rating scales along with clinical practice guidelines to both screen patients and assess their progress over time. By incorporating these scales into our practice, we can increase the likelihood of early detection of MDD and, ultimately, help improve patient outcomes.² To that end, the American Psychiatric Association, or APA, endorses the use of objective assessment tools, including validated scales, for both screening and monitoring of symptoms over time. They also note that the use of these tools can potentially improve patient outcomes.^2,3

In today’s video, we will discuss several common scales that can be utilized in the screening, diagnosis, and management of major depressive disorder, and we will share practical tips on which scales might be most useful in clinical practice versus those that may be used for evaluation of patients in clinical trials.

When I am choosing a scale to use in my practice, there are several important factors that I consider. First, I consider the disease state that is being screened for, in this case, MDD. Second, I consider whether the scale is validated in that disease state. Validity is the degree of which the scale measures what it is supposed to measure, in this case, symptoms of depression.⁴ Third, I consider whether the scale has been shown to be reliable. Reliability is the ability of a scale to produce consistent and reproducible information across different patients and raters.⁴ And lastly, I consider how the scale is administered; that is, is it clinician-administered or is it a patient self-report scale?

Advantages to using self-rated scales include ease of administration and not requiring clinician or staff time.⁴ However, a disadvantage to using self-rated scales is that reliability may be lower, as patients may lack insight by potentially over- or under-reporting symptoms when completing the scale.⁴ Clinician and self-rated scales may be used together when appropriate to help minimize bias, identify missed symptoms, and increase communication between patients and their providers.^4,5

Some scales, such as the 9-item Patient Health Questionnaire, or PHQ-9, are commonly used in clinical practice. The PHQ-9 is widely used in the primary care setting in screening for and diagnosing major depressive disorder, determining the severity of depressive symptoms, and monitoring response to treatment.^6,7 The PHQ-9 is derived from the depression module of the Patient Health Questionnaire.^8,9 It is a brief, validated, self-rated questionnaire that is used to evaluate depressive symptoms experienced by a patient over the past 2 weeks. This scale can be used as a screening tool and as a diagnostic tool for MDD, which is not the case for all the scales.⁸

One of the reasons the PHQ-9 can be used as a diagnostic tool for patients with depressive symptoms is that the 9 items it contains reflect the diagnostic criteria for MDD as laid out by the APA in the Diagnostic and Statistical Manual of Mental Disorders, or the DSM-5.⁸ MDD can be diagnosed with the PHQ-9 scale if 5 or more of the 9 depressive symptom criteria are present for more than 7 days in the past 2 weeks, and if 1 of those symptoms is depressed mood or anhedonia, which is the loss of interest or pleasure.⁸ The PHQ-9 can also be used to monitor treatment response and determine symptom severity in patients with MDD.⁸

The PHQ-9 takes less than 5 minutes to administer, making it easy to incorporate into a busy clinical setting such as a primary care practice. I make sure that patients are given this scale when they check in for their appointment, and by the time they are brought back from the waiting room to see me, it’s complete, and I can quickly score it.

After scoring the patient’s PHQ-9, I can categorize their depression severity as no or minimal depression, mild depression, moderate depression, moderately severe depression, or severe depression.

It is important for us to remember that MDD is a diagnosis of exclusion. Before making a diagnosis using the PHQ-9, a clinician must conduct a thorough examination and rule out potential physical causes of depression or a history of 1 or more manic episodes.⁸ I also consider environmental stressors and substance-related issues prior to making a diagnosis of MDD.

While the PHQ-9 offers valuable insight into a patient’s depression from their own perspective, another rating scale, the 17-item Hamilton Depression Rating Scale, also known as the HAM-D-17, provides a comprehensive and nuanced assessment from the perspective of the trained clinician. The HAM-D is a clinician-administered tool used to assess depressive symptoms experienced by a patient in the past week. Unlike the PHQ-9, the HAM-D-17 is not intended for diagnosis, but rather to assess the severity of depressive symptoms and response to treatment in patients already diagnosed with a depressive disorder.¹⁰ This scale is commonly used in clinical trials, unlike the PHQ-9.¹¹ Also, the HAM-D-17 includes items assessing somatic symptoms, whereas the PHQ-9 does not include items for somatic symptoms and has shown a low correlation with somatic indicators assessed using the HAM-D-17.¹²

The HAM-D-17 includes these 17 items rated on a Likert scale. These include items assessing depressed mood, suicidal thoughts, sleep disturbances, anxiety, changes in weight, and functional outcomes such as engagement in work or interests – to name just a few symptom domains.¹⁰

Items are scored on a scale of 0 to 4 or 0 to 2. A score of 0 to 7 is considered to be a normal range, while higher scores indicate depression of increasing severity.¹⁰

There is also a third scale that can be used in clinical practice, the Beck Depression Inventory-II, or BDI-II. This is a 21-item, self-rated scale used in screening for depressive symptoms, assessing symptom severity, and monitoring treatment response. Unlike the PHQ-9, it is not validated for the use of diagnosis of MDD. However, the BDI-II is more similar to the HAM-D-17 in that it is used in assessing the severity of depressive symptoms. The BDI-II is used in both clinical practice and clinical trials.⁵

The BDI-II contains a broad range of items covering negative mood and emotions, functional impairment, and potential for self-harm, as shown in this table.

Each item is rated on a 4-point Likert-type scale ranging from 0 to 3. Total scores can range from 0 to 63, with the higher scores indicating more severe depressive symptoms.¹³

As you can see in this table, scoring the BDI-II will also allow clinicians to categorize patients by depression severity, with a score of 0 to 13 indicating minimal depression, a score of 14 to 19 indicating mild depression, a score of 20 to 28 indicating moderate depression, and a score of 29 or greater indicating severe depression.

Another option used in both clinical practice and clinical trials is the 16-item Quick Inventory of Depressive Symptomatology, or QIDS. Clinicians can choose either the self-report version, known as the QIDS-SR16, or the clinician-report version, known as the QIDS-C16.¹⁴ Like the PHQ-9 and BDI-II, the QIDS questionnaire was designed for screening and diagnosing MDD, assessing symptom severity, and monitoring response to treatment.¹⁵

As you can see, the 16 items on the QIDS ask the patient about these 9 domains, such as questions about sleep, concentration, and energy. The scoring system for the QIDS converts the patients’ responses to these 16 separate items into the 9 DSM depression symptom criterion domains shown here.¹⁶

The total score range for the QIDS-SR is 0 to 27, with higher scores again indicating greater severity of symptoms.¹⁶

The Zung Self-Rating Depression Scale, or SDS, is yet another option.¹⁷ This 20-item self-rated scale evaluates depressive symptoms in a patient over the past week. Its validated uses include screening and assessment of treatment responses and symptom severity.¹⁷ The SDS is used in both clinical practice and clinical trials.

Ten items rate negative experiences or feelings, and 10 items rate positive experiences or feelings. Negative items are scored on a scale of 1 (“A Little of The Time”) to 4 (“Most of the Time”). Positive items are also rated on a 4-point scale, but with the values reversed. A score of 1 corresponds to “Most of the Time,” whereas a score of 4 corresponds to “A Little of the Time.”¹⁸

Using this method, higher scores indicate a higher severity of depressive symptoms. Normal score range is 25 to 49, with scores of 50 to 59 corresponding to mild depression, scores of 60 to 69 indicating moderate depression, and scores of 70 and higher correlating with severe depression.

For some patients, especially those with an extensive history of treatment and/or inadequate responses to those treatments, clinicians may consider using the Massachusetts General Hospital Antidepressant Treatment Response Questionnaire, or ATRQ. The ATRQ is a scale used to assess treatment response or nonresponse to adequate treatment trials among patients with MDD.¹⁹ It can be self-reported or clinician rated.^19,20 This scale examines the adequacy of duration and dose of prior and current antidepressant treatment trials.²¹ The ATRQ also assesses the degree of improvement in depressive symptoms in the medication trial or in trials during the current depressive episode.²¹ One important use of this scale is that it can allow a patient-report tool to take the place of a potentially lengthy clinician interview in assessing past antidepressant treatment adequacy and efficacy.¹⁹ It is used in both clinical practice and clinical trials. However, it is important to consider the time this questionnaire may take to complete, particularly in patients with an extensive past treatment history.

So, today we have reviewed the Patient Health Questionnaire-9, the 17-item Hamilton Depression Rating Scale, the Beck Depression Inventory-II, the 16-item Quick Inventory of Depressive Symptomatology, the Zung Self-Rating Depression Scale, and the Antidepressant Treatment Response Questionnaire. Overall, it is important for clinicians who evaluate and treat mental health patients to consider using measurement-based care as a part of their standard practice. Research suggests that using measurement-based care, such as including validated scales in your practice, can result in improved patient outcomes.²²

By continuing to obtain quantitative data from validated scales, healthcare providers may be better able to assess patient response to treatment to inform their clinical decision-making. Tracking patient outcomes via clinical scale scores can help us to understand if a patient is responding adequately to a management strategy, or if it is time to discuss alternate treatment plans. It is important to remember that scales should be used in combination with a full clinical evaluation and a provider’s clinical judgment.

Thanks for joining me today for a review of the importance of a measurement-based care in managing patients with major depressive disorder. More information on all of the scales we have discussed today can be found in easy-to-understand summaries at the NP Psych Navigator in the Psychiatric Scale NPsychlopedia section.   

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.

NP Psych Navigator is sponsored by AbbVie Medical Affairs. The contributor is a paid consultant for AbbVie Medical Affairs and was compensated for their time.  

This is not a diagnostic tool and is not intended to replace a clinical evaluation by a healthcare provider. 

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