Many healthcare providers – from psychiatrists to general practitioners – don’t ask their patients to complete a basic depression assessment. According to a study published in the Journal of Clinical Psychiatry, more than 80 percent of psychiatrists indicated that they did not routinely use scales to monitor outcomes when treating depression.
“Some clinicians ask only broad, global questions such as ‘How are you feeling?’ or ‘How are you doing?’ Many patients reply with global responses such as ‘Okay’ or ‘Fine.’ However, these responses often do not accurately reflect the patient’s clinical status,” wrote Mark Zimmerman, MD, in an article for UptoDate. “As a result, it is increasingly recognized that incorporating standardized scales into clinical practice to measure depression may help clinicians evaluate the patient’s current status more accurately.”
Depression scales can serve an important purpose during treatment: to measure progress against treating the disease. If a healthcare provider asks the patient to fill out the questionnaire at the beginning of treatment, the results will provide a baseline from which to work. As treatment progresses, re-administering the scale can quantify the patient’s progress.
There are several types of depression screening tools available, including the Patient Health Questionnaire (PHQ), the Hamilton Depression Rating Scale (HAM-D), and the Geriatric Depression Scales. Additionally, there are other tools that can help in the treatment of depression, including the MARS (Medication Adherence Rating Scale) and ASEC (Antidepressant Side-Effect Checklist).
Measuring the Severity of Depression: The PHQ and HAM-D
Two scales are commonly used to test the severity of depression – the PHQ and the HAM-D.
There are several different versions of the PHQ depression scales. The most commonly used and most validated version is the PHQ-9. According to the University of Washington’s AIMS Center, the PHQ-9 can be “a powerful tool to assist clinicians with diagnosing depression and monitoring treatment response.”
Comprised of nine questions scored on a scale of 0 to 3, the PHQ-9 includes nine questions assessing symptoms and one additional question assessing functional impairment. A two-question version, the PHQ-2 asks the first two questions of the PHQ-9; if the patient answers affirmatively to either question, the healthcare provider should then administer the PHQ-9.
Developed in the 1960s, the Hamilton Rating Scale for Depression-17(HAM-D17) is the most used depression diagnostic tool. In contrast to the PHQ-9, this 17-question clinician rated test generally takes 20 minutes to complete.
After tallying the score, clinicians can give the patient an assessment of his/her depression severity using the following scale:
- 0-7: No Depression
- 8-13: Mild Depression
- 14-23: Moderate Depression
- 24+: Severe Depression
A potential limitation to the scale, according to the Handbook of Clinical Rating Scales and Assessment, is that it “fails to include all symptom domains of major depressive disorder (MDD), in particular, reverse neurovegetative symptoms.”
Testing Medication Adherence
If you are concerned that your patient is not taking his/her medication as prescribed, the Medication Adherence Rating Scale (MARS) can help.
MARS is a 10-question survey, requesting yes or no answers to attitudes, beliefs and practices of the patient. According to Psych Congress, the MARS self-reporting tool helps providers evaluate a patient’s feelings about taking medication, as well as whether they are actually taking the medication.
Some sample questions include:
- Do you ever forget to take your medication?
- When you feel better, do you sometimes stop taking your medication?
- It is unnatural for my mind and body to be controlled by medication
- By staying on medication, I can prevent getting sick.
- I feel weird, like a ‘zombie’ on medication
However, Psych Congress cautions that “scoring requires some interpretation as answering ‘yes’ does not necessarily indicate a positive attitude or behavior.”
Evaluating Side Effects from Antidepressants
Another scale useful to practitioners is the Antidepressant Side-Effect Checklist (ASEC). This scale includes 21 possible side effects (among which include nausea, weight gain, tremors, and blurred vision) and asks patients to rank them on a scale from zero (patient has not experienced that side effect) to three (a severe experience of the side effect). The survey also asks three open-ended questions to determine if there are other consequences of the medication.
The Sussex Partnership, which developed ASEC, cautions that it is important for healthcare providers to administer the survey beforethe patient begins medication, as “many physical complaints listed among adverse effects may be more common in patients with depression.” Administering the checklist before and during medication treatment allows the healthcare provider to evaluate treatment against a comparative baseline.
Depression Screening is the First Step
These depression scales can be helpful in many ways, and self-administered depression screening may be an effective first-step tool helping healthcare providers in their patient evaluations.
“Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings,” wrote Dr. Zimmerman in a Psychiatric Times article. “To determine the impact of treatment it is not simply a matter of evaluating outcome, but rather a matter of measuring outcome.”
You can read about how the HAM-D depression screening tool was used in the largest depression pharmacogenomic trial, the GUIDED Study, here.