Bech.qxp 26/6/08 05:04 Page 15
The Use of Rating Scales in Affective Disorders
Table 1: Rating Scales for Affective Disorders
Scale Factors
12 3 4 5 67
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 Table 3: Universe of Items in the Mania Assessment Scale and
the Young Mania Assessment Scale
NO Item HAM-D
17
HAM-D
6
MES MADRS
10
MADRS
6
Items
1 Depressed ■■■■ ■■ ■A=Apparent MAS (0–44) YMRS (0–44/0–60)
mood A R A R R=Reported Evaluated mood (0–4) Evaluated mood (0–4)
sadness Increased verbal activity (0–4) Speech (0–8)
2 Low self-esteem, ■■■■ ■Pessimistic (accelerated speech)
feelings of guilt thoughts Increased social contact (0–4) (intrusiveness)
3 Suicidal thoughts ■■■Suicidal Increased motor activity (0–4) Increased motor activity (0–4)
thoughts Sleep (0–4) Sleep (0–4)
4 Insomnia: initial
■
Social activity (0–4) (distractibility)
5 Insomnia: middle
■
Hostility (0–4) Irritability (0–8)
6 Insomnia: late
■
Noise level (0–4) Destructive behaviour (0–8)
7 Social life activities
■■■■ ■■ ■
I=Inability to Increased sexual interest (0–4) Sexual interest (0–4)
and interests I L I L feel Increased self-esteem (0–4) Content of thoughts (0–8)
L=Lassitude Flight of thoughts (0–4) Thought disturbances (0–4)
8 Psychomotor ■■ Insight (0–4)
retardation Appearance (0–4)
9 Psychomotor ■
The universe of items in the first two mania scales released independently before the Diagnosis
agitation
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.
10 Anxiety: psychic ■■■■ ■Inner tension
MAS = Bech–Rafaelsen Mania Assessment Scale; YMRS = Young Mania Rating Scale.
11 Anxiety: somatic ■
12 Gastrointestinal Reduced
appetite
most important handbook for psychopharmacological investigators in
13 Somatic symptoms: ■■
clinical psychiatry, the factors shown in Table 1 have been recommended
general when using the HAM-D
17
or other rating scales in trials with patients
14 Sexual ■
suffering from psychotic depression (the Brief Psychiatric Rating Scale
disturbances
[BPRS]), major depression (HAM-D), dysthymia or general anxiety (the
15 Hypochondriasis ■
Hamilton Anxiety Rating Scale [HAM-A] or the Symptom Checklist-90 [SCL-
(somatisation)
16 Insight
90]).
13
Even Hamilton himself showed that the HAM-A was insufficient
■
17 Weight loss ■
for the monitoring of changes due to treatment effect when total score
18 Insomnia:
■■
Reduced
was used.
14
general sleep
19 Decreased ■
The most interesting example of a HAM-D subscale produced by factor
motor activity
analysis is the five-item subscale identified by Gonzales-Pinto et al.,
15
who
20 Decreased ■
used a principal component analysis to identify bipolar depression. Among
verbal activity
the items are obsessive–compulsive symptoms but not psychomotor
21 Concentration ■■ Concentration
difficulties difficulties
retardation or anhedonia. This illustrates the point that factor analysis is
22 Introversion ■
very sensitive in relation to the individual sample of patients from whom
23 Tiredness ■ 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
Total HAM-D
17
HAM-D
6
MES MADRS
10
MADRS
6 analysis has no place in this stage of inquiry.
8
The universe of items in the HAM-D17 with 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
The Guttman or Unidimensional Type of Rating Scale
Melancholia Scale; MADRS10 = 10-item Montgomery–Asberg Depression Rating Scale;
Feinstein
10
included the Guttman scalogram analysis to illustrate the ideal
MADRS6 = Six-item Montgomery Asberg Depression Rating Scale.
scale for measuring a specific treatment effect because a Guttman scale is
antidepressive effect of an experimental drug compared with placebo or unidimensional, implying that the total score is a sufficient statistic for the
demonstrating the dose–response relationship. Due to the many items dimension under investigation. It is a consistently monotonic scale in
included in the HAM-D
17
, a profile score of the individual items is too which a score on a low-prevalence item has to be preceded by a score on
complex. In this situation, factor scores are often recommended, and a higher-prevalence item. The Guttman scale is sometimes called a
surprisingly this solution seems to have been accepted by physicians.
10
In the cumulative scale; however, ‘unidimensional’ is the most appropriate term.
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