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a report by

Per Bech

Professor, Applied Psychometrics, University of Copenhagen

Since the paradigmatic change heralded by the release of the Diagnosis

and Statistical Manual of Mental Disorders, Third Edition (DSM-III),1 the

focus in our diagnostic systems for mental disorders has been on signs

and symptoms rather than aetiological factors, and has entailed a high

reliance on the symptom rating scales of psychopathology, especially in

the field of affective disorders.

In the DSM-III (as well as in the DSM-IV2

or the International StatisticalClassification of Diseases and Related Health Problems, 10th Revision

[ICD-10]3), the diagnosis of depression provides a global impression of

the severity of depressive states through their symptoms, e.g. minor

versus major depression or mild, moderate and severe depression. When

Hamilton4 developed his Hamilton Depression Rating Scale (HAM-D), he

made an attempt to characterise the global impression of depressive

states by a total score of the 17 items in the scale (HAM-D17). Since then,

it has consistently been shown that the HAM-D can be used in all forms

of depressive disorders.5 As summarised by Paykel:6 We all know the

appropriate meaning of a Hamilton score of 17, 13 or 26. Over

the last few decades, the HAM-D has been the scale most frequently used

when measuring the outcome of antidepressive therapy. Rating scales foraffective disorders have their major use as outcome scales, and this article

will review the correct use of the various scales for affective disorders in

this respect.

The Mathematics of Rating Scales

Fifty years ago, when the antimanic effect of chlorpromazine or the

antidepressive effect of imipramine were identified but were found to be

controversial by many psychiatrists, the conclusion was that when

examining the effects of these new psychopharmacological drugs, the

physician lacked a system of statements from which the observed facts

could be derived by formal mathematical reasoning.7 Mathematical

reasoning is indeed the most reliable way to measure the mind.8

Using sophisticated software programs such as the Statistical Analysis

System (SAS), the rating scale data can be analysed by the physicians

themselves. However, the sections of psychometrics in the SAS9 designed to

help the physician evaluate the reliability and validity of rating scales refers

to a form of mathematical reasoning that may lead to a misuse of rating

scale data. Thus, the reliability measure co-efficient alpha is recommended,

although Feinstein wrote its obituary two decades ago.10 The factor validity

of rating scales is also recommended in the SAS, although the SAS user is atthe same time warned that factor analysis can be seductive in that it takes a

large number of baffling variables and turns them into a clear-cut set of just

a few factors.9 In the following, the use of rating scales for affective

disorders, as recommended by Feinstein10 and Borsboom,8 will be outlined.

The Clinimetrics of Rating Scales

In his monograph on clinimetrics, Feinstein10 referred to three different

types of rating scale and their rational uses.

The Apgar or Global Impression Type of Rating Scales

The Apgar scale was developed as a rating scale for the clinical condition

of a newborn baby.11

It is probably one of the most commonly usedscales in clinical medicine worldwide. It is a very short scale, containing

five items, each of which can be scored from zero to two. In other words,

the theoretical score range of the sum score is from zero to 10. A high

score indicates a better condition. As the five items are diverse (covering

heart rate, muscular tone, respiration, colour and reflex response), the

total score gives only a rough global impression of the condition. An

Apgar score of five, for example, indicates that the babys condition is not

splendid. However, if we want to determine what is wrong with this

baby, we need to check the individual items. Therefore, a profile score is

often needed as the total score is not sufficient. As pointed out by

Feinstein,10 the Apgar type of scale is not valid for measuring outcome of

a specific treatment.

The Hamilton or Factor-based Type of Rating Scales

The HAM-D17 is a rating scale for assessment of the clinical condition of

depressive states.12 As mentioned above, Hamilton developed his scale to

measure depressive states globally, but not for the monitoring of changes

due to treatment effect. It is a rather large scale, containing at least 17 items,

each of which can be scored either from zero to four or from zero to two,

with a theoretical score range of the sum score from zero to 52. A high score

indicates higher severity of depressive states. Feinstein10 included the HAM-

D17 in his monograph to illustrate a scale that has been produced by factor

analysis.12 Like the Apgar scale, the HAM-D contains diverse symptoms of

depressive states and the total score is therefore only a global impression of

the severity of depression. A score of 18 indicates a severity of depressive

state as seen in major depression and a score of seven indicates remission.

However, the total score is not a sufficient statistic for measuring the specific

The Use of Rating Scales in Affective Disorders

T O U C H B R I E F I N G S 2 0 0 8

Per Bech is a Professor of Applied Psychometrics at the

University of Copenhagen. Prior to this he was a Professor

of Clinical Psychiatry at Odense University and Head of the

Psychiatric Unit at Frederiksborg General Hospital. He was

one of the founder members of the European College of

Neuropsychopharmacology (ECNP) in 1987, Past President

of the Association of European Psychiatrists (AEP)

(19921994) and Head of the Research Unit at the World

Health Organization (WHO) Centre for Psychometrics

(19852005). Professor Bech has published several books on applied psychometrics and

approximately 400 papers in the field of psychometrics, clinical psychiatry and

psychopharmacology. He received his MD from the University of Copenhagen in 1969, and in

1972 he received the Gold Medal in Psychiatry for studies of the doseresponse effect of

cannabis on psychological tests at the University of Aarhus. He specialised in clinicalpsychiatry 1978, and in 1981 he obtained his DScM for rating scales of affective disorder.

E: [email protected]

Affective Spectrum Disorders Current Issues

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antidepressive effect of an experimental drug compared with placebo or

demonstrating the doseresponse relationship. Due to the many items

included in the HAM-D17, a profile score of the individual items is too

complex. In this situation, factor scores are often recommended, and

surprisingly this solution seems to have been accepted by physicians.10 In the

most important handbook for psychopharmacological investigators inclinical psychiatry, the factors shown in Table 1 have been recommended

when using the HAM-D17 or other rating scales in trials with patients

suffering from psychotic depression (the Brief Psychiatric Rating Scale

[BPRS]), major depression (HAM-D), dysthymia or general anxiety (the

Hamilton Anxiety Rating Scale [HAM-A] or the Symptom Checklist-90 [SCL-

90]).13 Even Hamilton himself showed that the HAM-A was insufficient

for the monitoring of changes due to treatment effect when total score

was used.14

The most interesting example of a HAM-D subscale produced by factor

analysis is the five-item subscale identified by Gonzales-Pinto et al.,15 who

used a principal component analysis to identify bipolar depression. Amongthe items are obsessivecompulsive symptoms but not psychomotor

retardation or anhedonia. This illustrates the point that factor analysis is

very sensitive in relation to the individual sample of patients from whom

the HAM-D data are collected. To test the validity of bipolar depression we

need a clinical theory of the severity of depressive states, and factor

analysis has no place in this stage of inquiry. 8

The Guttman or Unidimensional Type of Rating Scale

Feinstein10 included the Guttman scalogram analysis to illustrate the ideal

scale for measuring a specific treatment effect because a Guttman scale is

unidimensional, implying that the total score is a sufficient statistic for the

dimension under investigation. It is a consistently monotonic scale in

which a score on a low-prevalence item has to be preceded by a score on

a higher-prevalence item. The Guttman scale is sometimes called a

cumulative scale; however, unidimensional is the most appropriate term.

Table 1: Rating Scales for Affective Disorders

Scale Factors

1 2 3 4 5 6 7

BPRS Anxiety/depression Anergia Thought disturbance Activation/excitement Hostility/suspicion

HAM-D Anxiety/somatisation Weight Cognitive disturbance Diurnal variation Retardation Sleep

HAM-A Somatic anxiety Psychic anxiety

SCL-90 Somatisation Obsessive/compulsive Interpersonal sensitivity Depression Anxiety Anger/hostility Phobic anxiety

Descriptions of rating scales for affective disorders measuring outcome of trials with psychopharmacological drugs by their factorial validation.13

BPRS = Brief Psychiatric Rating Scale; HAM-D = Hamilton Depression Rating Scale; HAM-A = Hamilton Anxiety Rating Scale; SCL-90 = Symptom Checklist-90.

Table 2: Items in the Hamilton Depression Rating Scale

NO Item HAM-D17 HAM-D6 MES MADRS10 MADRS6 Items

1 Depressed A=Apparent

mood A R A R R=Reported

sadness

2 Low self-esteem, Pessimistic

feelings of guilt thoughts

3 Suicidal thoughts Suicidal

thoughts

4 Insomnia: initial

5 Insomnia: middle

6 Insomnia: late

7 Social life activities I=Inability to

and interests I L I L feel

L=Lassitude

8 Psychomotor

retardation

9 Psychomotor

agitation

10 Anxiety: psychic Inner tension

11 Anxiety: somatic

12 Gastrointestinal Reduced

appetite13 Somatic symptoms:

general

14 Sexual

disturbances

15 Hypochondriasis

(somatisation)

16 Insight

17 Weight loss

18 Insomnia: Reduced

general sleep

19 Decreased

motor activity

20 Decreased

verbal activity

21 Concentration Concentration

difficulties difficulties

22 Introversion

23 Tiredness

Total HAM-D17 HAM-D6 MES MADRS10 MADRS6

The universe of items in the HAM-D17with reference to the first two depression scales

released independently before DSM-III.18 HAM-D17= 17-item Hamilton Depression Rating

Scale; HAM-D6 = Six-item Hamilton Depression Rating Scale; MES = Bech-Rafaelsen

Melancholia Scale; MADRS10 = 10-item MontgomeryAsberg Depression Rating Scale;

MADRS6 = Six-item Montgomery Asberg Depression Rating Scale.

Table 3: Universe of Items in the Mania Assessment Scale andthe Young Mania Assessment Scale

MAS (044) YMRS (044/060)

Evaluated mood (04) Evaluated mood (04)

Increased verbal activity (04) Speech (08)

(accelerated speech)

Increased social contact (04) (intrusiveness)

Increased motor activity (04) Increased motor activity (04)

Sleep (04) Sleep (04)

Social activity (04) (distractibility)

Hostility (04) Irritability (08)

Noise level (04) Destructive behaviour (08)

Increased sexual interest (04) Sexual interest (04)

Increased self-esteem (04) Content of thoughts (08)

Flight of thoughts (04) Thought disturbances (04)

Insight (04)

Appearance (04)

The universe of items in the first two mania scales released independently before the Diagnosis

and Statistical Manual of Mental Disorders, Third Edition (DSM-III).19,20 In the Young Mania

Rating Scale (YMRS), items with asterisks have been doubled up, hence the two score ranges.

MAS = BechRafaelsen Mania Assessment Scale; YMRS = Young Mania Rating Scale.

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The Guttman scale model is a deterministic version of the item response

theory models, of which the Rasch analysis is a parametric version and the

Mokken analysis a non-parametric version.8 Thus, statistical probability has

been taken into account in the Rasch and Mokken models.

According to Feinstein10 and Borsboom,8 the clinical (face) validity of

rating scales is a non-statistical problem. Thus, as stated by Guttman,16

the face validity of items to be included in a rating scale is the extent

to which they belong to the universe of items accepted by experienced

clinicians (clinical validity). The scale function tested by the item

response theory analysis is the unidimensional meaning of more orless, which is meaningful only for scales when the total score is a

sufficient statistic. The first depression rating scale designed according to

the Guttman type of scale for measuring changes in depressive states

during antidepressive treatment was the CronholmOttosson Depression

Scale.17 The BechRafaelsen Melancholia Scale (MES) was developed with

reference to this scale and the HAM-D.17

Rating Scales for Measuring Outcome of Treatment in

Patients with Affective Disorders

Table 2 shows a scoring sheet with the three most important

clinician-rated scales for the measurement of symptom change during

antidepressive treatment. All three scales (the HAM-D17, MES and

Montgomery-Asberg Depression Rating Scale [MADRS]) were developed

before the introduction of the DSM-III in 1980.18 Table 3 shows the range

of symptoms in the two most frequently used clinician-rated scales for the

measurement of symptom change during treatment with antimanic

drugs. They were also developed before the introduction of the DSM-III

(BechRafaelsen Mania Assessment Scale [MAS] and Young Mania Rating

Scale [YMRS]).19,20 Table 4 shows the inter-rater reliability and validity of

the scales shown in Tables 2 and 3. For all the scales the reliability

co-efficients are of statistical significance, although most problems haveemerged with the YMRS.21

As most investigators still show the classic co-efficient alpha for testing

of internal consistency, this co-efficient is included in Table 4. However,

this is not a test of unidimensionality, nor is factor analysis a test for

unidimensionality. Thus, for the testing of the psychometric validity of

bipolar depression, item response theory models have to be used.22

The Measure of Response to Treatment in

Patients with Affective Disorders

The most conservative measure of response to treatment in patients with

affective disorders in the acute treatment phase is a 50% reduction ormore of the baseline total score at end-point (typically after six to eight

weeks with antidepressants and after two to four weeks with

antimanics). This corresponds with the much improved or very much

improved of the Clinical Global Impression Scale (CGI-S).13

In doseresponse relationship trials of antidepressants, the effect size

statistic has been found to be the most sensitive response measure when

comparing experimental drugs with placebo.2325 In these trials it was

shown that the HAM-D6 and MADRS6 were more similar than HAM-D17

or MADRS10 in showing a doseresponse relationship. Even when

analysing each single item within the HAM-D17 for its sensitivity to

measure change (experimental drug versus placebo), the HAM-D6 itemswere found to be the most valid.26 An effect size of 0.40 or higher when

comparing the experimental drug with placebo was shown to be a

clinically significant response.25 It has been demonstrated that an effect

size of 0.40 equals a number needed to treat (NNT) of 4.5.27

In trials with antimanics it is not possible to include placebo for ethical

reasons. In such trials, the plasma level of the experimental drug in relation

to the clinical effect by total rating scale score seems most convincing. In

fixed-dose trials using plasma level at end-point, a negative correlation

co-efficient will express the clinical relation so that higher plasma levels are

associated with lower rating scale scores.19 It has been shown that a

significant negative correlation between the rating scale score and plasma

level of olanzapine after two weeks of therapy with a fixed dose of

20mg/day emerged in manic patients using the MAS but not using the

YMRS.28 When using rating scales for affective disorders to express a

Table 4: Psychometric Description of Interview-based RatingScales for Affective Disorders

Scales

(Pearsons/Interclass)

Classic Modern

Co-effic ients Internal Consistency Item Response Models

Co-efficient AlphaCo-efficient of Rasch Analysis

Homogeneity Acceptance

HAM-D17

0.480.97 0.460.91 0.190.27

HAM-D6 0.780.96 0.670.80 0.400.44 +

MES 0.750.93 0.91 0.49 +

MADRS 0.650.97 0.90 0.430.46

MAS 0.800.99 0.88 0.40 +

YMRS 0.360.95 0.84 0.24 ?

Psychometric description by reliability and validity (classical and modern) of the most used

interview-based rating scales for affective disorders.19,4346 HAM-D17= 17-item Hamilton

Depression Rating Scale; HAM-D6 = Six-item Hamilton Depression Rating Scale; MES = Bech-

Rafaelsen Melancholia Scale; MADRS = MontgomeryAsberg Depression Rating Scale;

MAS = BechRafaelsen Mania Assessment Scale; YMRS = Young Mania Rating Scale.

Table 5: Standardisation of Rating Scales for Affective Disorders

Symptom Rating Scales CGI Minimum CGI Moderate

(two or fewer) (four or more)

Remission Relapse

HAM-D17 7 18

HAM-D6 4 9

MES 6 15MADRS 12 25

MAS 6 15

YMRS 8 20

Standardisation of rating scale for affective disorders19,44 with reference to the Cinical Global

Impression Scale (CGI-S).13 HAM-D17= 17-item Hamilton Depression Rating Scale;

HAM-D6 = Six-item Hamilton Depression Rating Scale; MES = Bech-Rafaelsen Melancholia

Scale; MADRS = MontgomeryAsberg Depression Rating Scale ; MAS = BechRafaelsen Mania

Assessment Scale; YMRS = Young Mania Rat ing Scale.

The use of rating scales is of special

interest when assessing response to

treatment (e.g. in doseresponse

studies) or to identify remission.

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quantitative response, for example in doseresponse trials or plasma

concentrationresponse, only scales that have been accepted by item

response theory models (total score a sufficient statistic) are recommended.

Self-rating Scales versus Clinician-administrated Scales

The use of self-reported rating scales within affective disorders has

become more and more important in depression. Scales such as the Beck

Depression Inventory (BDI) or the Zung Self-rating Depression Scale (SDS)

were previously often used as supplements to the HAM-D. However,

recently self-reported HAM-D versions have been published.29 In order to

have a closer face validity with the ICD-10 or DSM-IV than that of the BDI,

the Major Depression Inventory (MDI) has been developed.30 The self-

rated version of the HAM-D6 and the MDI fulfil the item response theory

models, i.e. the total score is a sufficient statistic.

The use of self-reported rating scales to measure manic states is limited

to hypomanic states because in more severely manic states the response

pattern reflects that the patients are playing the manic game. Recently,

patient-reported questionnaires have been published to identify previousepisodes of hypomania in depressed patients in order to test for the

existence of bipolar II disorder. It seems that the Hypomanic Checklist is

superior to the Mood Disorder Questionnaire in this respect.31 The most

comprehensive self-reported scale covering depression and hypomania

(aggression) as well as the different anxiety disorders is the SCL-90. 13

From the SCL-90, a subscale analogue to the self-rated HAM-D6 has

been derived containing the following items: feeling blue, blaming

yourself for things, feeling no interests in things, feeling that everything

is an effort, worrying too much about things and feeling low in energy.

Like the HAM-D6, this depression SCL-90 subscale fulfils the items

response theory model and the items are included in the SCL-90 factor

solution by Lipman.32

Standardisation of Rating Scales for Affective Disorders

As mentioned above, the HAM-D was originally developed to measure a

global impression of depressive states. The CGI-S13 is probably the most

frequently used global assessment of depressive or manic states. This

scale has a score range from one (not at all ill) to seven (among the most

extremely ill patients suffering from depression or mania).13 However,

the inter-rater reliability of this CGI-S has not been found to be high,33

and in most trials with antidepressants a cut-off score on HAM-D17 of

7 has been used to define remission (which implies that the signs and

symptoms of illness are absent or almost absent). This cut-off score for

remission was introduced by Reisby et al.34 and equals a CGI-S score ofone and two (minimally depressed/manic symptomatology). A

modification of the CGI scales for use in bipolar illness (the CGI-BP) has

been suggested by Spearing et al.33 The CGI-BP gives a severity rating of

mania, depression and overall bipolar illness during treatment of an

acute episode as well as in long-term prophylaxis.

The cut-off levels are based on both unipolar patients with depression

and bipolar patients with depression and mania. When making such a

standardisation for remission and relapse with reference to CGI-S or

CGI-BP, all of the symptom rating scales in Table 5and the CGI versions

themselves refer to a global impression of illness. Therefore, the total

score does not need to be a sufficient statistic. It is of interest that, while

the HAM-D17 remission score of seven or lower has been found to be

adequate in most studies, it is still problematic for the MADRS to establish

a consensus for the cut-off score of 12 (which is a rather high score but

was recently confirmed for bipolar depression by Vieta et al.44). For

unipolar depression a cut-off score on MADRS of nine or lower has

recently been suggested.35

The report by the American College of Neuropsychopharmacology

(ACNP) task force on response and remission in major depressive

disorders35 suggests a special focus on the HAM-D symptoms of

depressed mood when defining remission or the core items of the

scale being used. For manic episodes the definition of remission should

focus on the MAS or YMRS symptoms of elevated mood and/or

hostility (destructive behaviour). In an analysis using the HAM-D item

of depressed mood as index of validity, the results showed that

a score of zero (depressed mood absent) corresponded to an HAM-D17

score of seven or less.36 A score on depressed mood of one (doubtful

or minimal) corresponded to an HAM-D17 score of 13 or less, while a

I would like to extend to you a warm invitation to join us at the

XIV World Congress of Psychiatry, taking place in Prague in

the autumn of 2008.

All of our 130 Member Societies and 60 Scientific Sections are

expected to be present, along with a full representation of all

of our partners in mental healthcare, from our patients (who

are at the centre of our work) to health professionals, health

planners and relevant industry.

You would not want to miss this special encounter, where new

psychiatric findings and perspectives will be discussed, and where

current partnerships will be strengthened and new ones forged.

Professor Juan E Mezzich

President, XIV World Congress of Psychiatry

Topics include: addiction, affective disorders, animal models in

psychiatry, anxiolytics, biological markers, clinical psycho-

pharmacology, emergency psychiatry, public health and

psychiatry, somatoform disorders, urban mental health,

cultural psychiatry and molecular neurobiology.

Honorary and Supervisory Committee includes: Jaroslav Blahos

(Chair, Czech Medical Association), Jan Brza (Director, General

Faculty Hospital, Prague), Milan Kubek (President, Czech

Medical Chamber) and Mario Maj (Chair, Scientific Committee,

World Congress of Psychiatry).

Contact:

E: [email protected]

T: +420 284 001 444

F: +420 284 001 448

www.wpa-prague2008.cz

XIV World Congress of Psychiatry

2025 September 2008Prague Congress Centre, Czech Republic

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1. American Psychiatric Association, Diagnosis and stat ist ical

manual of mental disorders, Third Edn, (DSM-III), Washington

DC, 1980.

2. American Psychiatric Association, Diagnosis and stat ist ic manual

of mental disorders, Third Edn (DSM-IV), Washington DC, 1994.

3. World Health Organization, The ICD-10 class if icat ion of mental

and behavioural disorders, Diagnost ic cr i ter ia for research, World

Health Organizat ion, 1993.

4. Hamilton M, A rating scale for depression,J Ne uro l Ne uro su rg

Psychiatry, 1960;23:5662.

5. Roth M, Hamilton M, a life devoted to psychiatric science. In:

Bech P, Coppen A (eds), The Hamilton Scales, Berlin: Springer

1990;19.

6. Paykel ES, Use of the Hamilton Depression Scale in general

practice. In: Bech P, Coppen A (eds), The Health Scales, Berlin

Springer 1990;4047.

7. Editorial comments, Rose is a rose is a rose is a rose, Psychiatr

Quart , 1957;31:34661.

8. Borsboom D, Measur ing the mind. Conceptual issues in

contemporary psychometr ics, Cambridge University Press, 2005.

9. Cody RP, Smith JK,Ap pl ied st ati sti cs an d the SA S pr og ram min g

language, 4th Edn, Prentice-Hall, 1997.10. Feinstein AR, Clinimetr ics, Yale University Press, 1987

11. Apgar V, A proposal for a new method of evaluation of a

newborn infant, Curr Res Anesth Analg, 1953;32:26067.

12. Hamilton M, Development of a rating scale for primary

depressive illness, Br J Soc Cl in Psychol, 1967;6:27896.

13. Guy W, Ear ly cl inical drug evaluat ion (ECDEU) assessment

manual, Rockvill, National Institute Mental Health, 1976.

14. Hamilton M, Treatment of anxiety states. Components of

anxiety and their response to benactyzine, J Me nt Sc i,

1958;104:10628.

15. Gonzales-Pinto A, Ballesteros J, Aldama A, Principal

components of mania, J Aff ec t Dis , 2003;76:95102.

16. Guttman L, A basis for scaling quantitative data,Ame ric an

Sociological Review, 1944;9:13950.

17. Bech P, CronholmOttosson Depression Scale: the first

depression scale designed to rate changes during treatment,

Ac ta Ps yc hia tr Sc an d, 1991;84:43945.

18. Bech P, The Bech, Hamilton and Zung Scales for Mood Disorders:

Screening and Listening. A twenty years update with reference to

DSM-IV and ICD-10, SpringerVerlag, 1996.

19. Bech P, Lunde M, Bech-Andersen G, et al., Psychiatric outcome

studies (POS): Does treatment help the patients? A Popperian

approach to research in clinical psychiatry, Nord J Psychiatry,

2007;61(Suppl. 46):180.

20. Goodwin FK, Jamison KR, Manic-depress ive i l lness, 2nd Edn,

New York, Oxford University Press, 2007

21. Mackin P, Targum SD, Kalali A, et al., Culture and assessment

of manic symptoms, Br it J Psychiatr , 2006;189:37980.

22. Bech P, Eriksson H, The pure ant idepress ive effect of quet iapine

in the acute therapy of bipolar depress ion, submitted for

publication 2008.

23. Bech P, Cialdella P, Haugh M, et al., A meta-analysis of

randomised controlled trials of fluoxetine versus placebo and

tricyclic antidepressants in the short-term treatment of major

depression, Br J Psychiatry, 2000;176:4218.

24. Bech P, Tanghj P, Andersen HF, Over K, Citalopram

dose-response revisited using an alternative psychometric

approach to evaluate clinical effects of four fixed citalopram

doses compared to placebo in patients with major depression,

Psychopharmacol, 2002;163:2025.

25. Bech P, Andersen HF, Wade A, Effective dose of escitalopram in

moderate versus severe DSM-IV major depression,

Pharmacopsychiatry, 2006;39:12834.26. Santen G, Gomeni R, Danhof M, Della Pasqua O, Sensitivity of

the individual items of the Hamilton depression rating scale to

response and its consequences for the assessment of efficacy,

J Ps yc hia tr Re s, 2008; in press.

27. Kraemer HC, Kupfer DJ, Size of treatment effects and their

importance to clinical research and practice, Biol Psychiatry,

2006;59:99096.

28. Bech P, Gex-Fabry M, Aubry J-M, et al., Olanzapine plasma

level in relation to antimanic effect in the acute therapy of

manic states, Nord J Psychiatry, 2006;60:1812.

29. Bent-Hansen J, Lauritzen L, Clemmensen L, et al., A definite

and a semi-definite questionnaire version of the

Hamilton/Melancholia scale,J Af fec t Dis , 1995;33:14350.

30. Olsen LR, Jensen DV, Noerholm V, et al., The internal and

external validity of the Major Depression Inventory in measuring

severity of depressive states, Psychol Med, 2003;33:3516.

31. Angst J, Adolfsson R, Benazzi F, The HCL.32: towards a self-

assessment tool, J Aff ec t Dis , 2005;88:21733.

32. Lipman RS, Depression scales derived from the Hopkins

Symptom Checklist. In: Sartorius N, Ban TA (eds), As se ss me nt of

Depress ion, Berlin: Springer, 1986;23248.

33. Spearling MK, Post RM, Leverich GS, et al., Modification of the

Clinical Global Impression (CGI) Scale for use in bipolar illness,

Psychiatry Research, 1997;73:15971.

34. Reisby N, Gram LF, Bech P, Nagy P, Imipramine: Clinical effects

and pharmacokinetic variability, Psychopharmacology, 1977;54:

26372.

35. Rush AJ, Kraemer HC, Sackeim HA, et al., Report by the ACNP

task force on response and remission in major depressive

disorder, Neuropsychopharmacology, 2006;31:184153.

36. Bech P, Depressed mood as a core symptom of depression,

Medicographia, 2008;30:1217.

37. Zitman FG, Mennen MF, Griez E, Hooijer CI, The different

versions of the Hamilton Depression Rating Scale,

Psychopharmacol Ser, 1990:9:2834.

38. Hamilton M, Shapiro CM, Depression, In: Peck DF, Shapiro CM

(eds), Measur ing Human Problems, Wiley, 1990;2565.

39. Bech P, Kastrup M, Rafaelsen OJ, Mini-compendium of rating

scales for states of anxiety, depression, mania and

schizophrenia with corresponding DSM-III syndromes,


40. Bech P, Gram LF, Kragh-Srensen P, et al., Standardized

assessment scales and effectiveness of antidepressants, NordPsykiatr Tidsskr, 1988;42:51115.

41. Bischoff R, Grtelmeyer BD, Rat ing Scales for Psychiatry,

Weinheim, Beltz Test, 1990.

42. Sartorius N, Kuyken W, Translation of health status

instruments. In: Orley J, Kuyken W (eds), Qual ity of l i fe

assessment: internat ional perspect ives, Berlin: Springer,

1994;319.

43. Bagby RM, Ryder AG, Schiller DR, Marchall MB, The Hamilton

Depression Rating Scale, Am J Ps yc hi atr y, 2004;161:216377.

44. Vieta E, Bobes J, Ballesteros J, et al., Validity and reliability of

the Spanish versions of the BechRafaelsens mania and

melancholia scales for bipolar disorders, 2007:19.

45. Dew MA, Switzer GE, Myaskovsky L, et al., Rating scales for

mood disorders. In: Stein DJ, Kupfer JD, Schatzberg AF (eds),

Textbook of mood disorders, American Psychiatric Publishing,

2005;6997.

46. Licht RW, Qvitzau S, Allerup P, Bech P, Validation of the

BechRafaelsen Melancholia Scale and the Hamilton

Depression Scale in patients with major depression,


score on depressed mood of two (mild depression) corresponded to

a score of 16 plus or minus four.

Translation Validity of Rating Scales

Although the HAM-D is the most commonly used scale worldwide in

affective disorders, different translations of the scale are often used.37

The American translation13 was never accepted by Hamilton himself,38

but he did go on to accept the updated version used by the Danish

University Antidepressant Group (DUAG) in their trials.39,40 This

updated version has been translated into French, German and

Spanish,41 but only recently has a major attempt been made (by

Emmanuelle Weiller and her group) to perform a translation of the

correct HAM-D version (including the Melancholia Scale) into several

European and Asian languages. The World Health Organization (WHO)

procedure for the translation of rating scales is recommended.42

Summary

The rating scales for affective disorders have been classified by their

psychometric or clinimetric properties as Apgar type scales (measuring aglobal impression of affective states), Hamilton-type scales (measuring

factors or sub-scores of affective states) and Guttman-type scales

(measuring outcomes of treatment by the total scale score). The use of

rating scales is of special interest when assessing response to treatment

(e.g. in doseresponse studies) or to identify remission. In doseresponse

studies, unidimensional Guttman scales are meaningful because the total

score is then a sufficient statistic. The HAM-D6 or MADRS6 subscales or

the MES have been found to be unidimensional depression scales.

Among the mania scales, the MAS is still the only scale found to be

unidimensional. Self-rating scales are of major use in depressive states. A

self-reported version of the HAM-D6 has been released, and the MD has

been developed to measure depression according to ICD-10 or DSM-IV.

Standardisation of rating scales is an important aspect of their clinimetric

use, especially in order to define remission in affective states during

treatment. Table 5 shows standardisation, in terms of remission andrelapse, of the various rating scales included in Table 4. The translation

problems when using scales in Europe have been discussed and the WHO

procedure for translation of rating scales has been recommended.

Acknowledgement

This study has received an educational grant from the Lundbeck Foundation.

The use of self-reported rating

scales within affective disorders has

become more and more important

in depression.

hamd17

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