Assessment Scales in Depression and Anxiety - CORPORATE

(Servier Edn)

Raymond W. Lam, Erin E. Michalaak, Richard P. Swinson

• Publisher: CRC Press
• Year: 2006
• Print ISBN: 9780415414951
• eBook ISBN: 9781135408251
• Topic: Medicine
• Subtopic: Mental Health in Psychology

There are a number of books recently published on assessment scales for depression and anxiety. However, these books are generally more detailed than clinicians require, are specific to one or other condition, or involve specialty populations such as children or geriatrics. To meet the needs of clinicians treating patients with depressive and anxiety disorders, this volume aims to bring together empirically validated assessment scales. In a concise and user-friendly format, Assessment Scales in Depression and Anxiety illustrates the assessment scales used in clinical trials and research studies; shows how to select an assessment scale and to decide which scale to use for a particular clinical situation; and provides sample assessment scales for clinicians to use in their practice.

Chapter 1: Why use assessment scales in clinical practice?

It has long been recognized in psychiatric research that measuring symptom severity across time is helpful in evaluating the course of treatment for psychiatric conditions. For example, all published clinical trials involve measuring outcome by means of scales focused on symptoms of interest. Rating symptoms is also an essential feature of newer psychological treatments such as cognitive-behavioural therapy. Yet, the use of assessment scales has not historically been a routine aspect of patient care for frontline mental health clinicians. In part, this may be due to the influence of psychodynamic psychotherapy, where the understanding of the patient was based primarily on understanding individual traits and where symptoms were only recognized as part of an underlying conflict or dynamic. It may also be because many clinicians (especially physicians, nurses, and social workers) are not trained in the use of assessment scales. Additionally, the nature of clinical practice with the pressure of high patient flow makes it difficult to incorporate yet more tasks into every patient encounter.

However, several recent developments have emphasized that using assessment scales should become a priority for clinicians. First, evidence-based medicine (EBM) has become the prevailing clinical framework for mental health. EBM promotes the use of evidence-based guidelines for clinical interventions and many of these guidelines offer treatment options based on scores from assessment scales. Second, there is much more emphasis on patient self-education and self-management, which includes self-monitoring of symptoms. Third, there is increasing recognition of the importance of residual or subsyndromal symptoms as predictors of poor outcome. These symptoms may not be detected unless an assessment scale is used. Finally, a cornerstone of EBM involves measuring the effectiveness of one’s clinical practice. It is no longer sufficient to evaluate patient or practice out-comes by asking general questions about clinical status.

We can illustrate some of the clinical situations where assessment scales are helpful by comparing the practices of two prototypical clinicians, Dr Gestalt and Dr Scales. Dr Gestalt has always relied on his clinical acumen and a global opinion of how his patient is doing. Dr Scales, however, has incorporated the routine use of rating scales in her clinical practice. Both clinicians use clinical practice guidelines to guide their treatment decisions.

In the first clinical situation, they each see a patient with hand washing symptoms consistent with obsessivecompulsive disorder (OCD). Dr Gestalt determines the overall severity of the hand washing rituals and the germ obsessions, and initiates medication treatment with an SSRI while making a referral to a behavioural therapy clinic. Dr Gestalt is then puzzled when his patient does not return for follow-up and did not take the prescribed medication. Dr Scales, however, uses the Yale-Brown Obsessive Compulsive Scale during her assessment of the patient. By systematically covering the different types of OCD symptoms, she finds that the patient also has significant symptoms involving checking and counting rituals that interfere with taking the medication. Dr Scales is then able to use this information and enlist the help of a family member to administer the medication at home. In this situation, using an assessment scale led to a more thorough assessment and ensured that significant clinical symptoms are not missed.

In another clinical situation, each clinician assesses a patient with depression. They each make a clinical diagnosis of major depressive disorder, initiate treatment with an antidepressant medication, and book a follow-up appointment after 4 weeks. At the follow-up visit, Dr Gestalt asks his patient, ‘How are you doing?’ ‘Terrible,’ she replies, ‘I don’t feel any better than when I started the medication.’ Checking his guidelines, Dr Gestalt decides to increase the dose of the antidepressant because of the lack of response at 4 weeks.

In contrast, Dr Scales uses the 17-item Hamilton Depression Rating Scale (HDRS) in her assessment. At baseline, her patient had an HDRS score of 25, putting her in the moderately to markedly depressed range. At the follow-up appointment, Dr Scales’ patient says exactly the same thing, ‘I don’t feel any better than when I started the medication.’ However, by using the HDRS to rate specific symptoms, Dr Scales finds out that her patient over the past week had slight improvement in sleep and appetite, slightly greater interest in her usual activities and was able to read more easily, resulting in an HDRS score of 19. These changes were not apparent to the patient because her mood had not yet improved. She still had negative cognitions associated with depression and globally felt no better. Despite the lack of subjective mood improvement, however, her HDRS score decreased from baseline by 25%. Checking her clinical guidelines, Dr Scales determines that this mild degree of improvement in symptoms merits a little more time on the same dose of medication. After another 4 weeks, the patient’s HDRS score continued to improve and she began to notice that she was, indeed, feeling better. In this situation, using the HRDS changed the clinical decision and averted an unnecessary increase in the dose of medication.

Let’s consider another clinical scenario with the same patient. Again, both Dr Gestalt and Dr Scales prescribe antidepressant medications for depression. A couple of months later, on a reassessment visit, Dr Gestalt asks his patient, ‘How are you doing?’ His patient replies, ‘I’m doing very well and feeling much better’. Dr Gestalt gives himself a mental pat on his back and maintains the patient on the same dose of medication. He is then surprised when his patient returns two months later, saying that her symptoms are much worse, and it is clear that she has suffered a clinical relapse.

Meanwhile, Dr Scales has been using her HDRS in practice. After 8 weeks of treatment, her patient also says that she is feeling much better. However, on going through the HDRS, it is apparent that she still has some mild disturbances in sleep and energy, and that her concentration and memory have not yet returned to normal. Her HDRS score is still 10, clearly improved from her baseline score of 22 but not yet in full remission (commonly accepted as HDRS score of 7 or less). Recognizing that she still has residual symptoms of depression, Dr Scales continues to follow her closely. She increases the dose of the medication until a full response occurs and her HDRS scores fall into the normal range. She does well through the maintenance period and has no relapse of depression.

In this clinical vignette, keeping track of symptoms with an assessment scale has helped determine that residual symptoms are still present even though a substantial clinical response has occurred. Residual symptoms of depression are associated with poor outcomes, including increased risks of relapse, chronicity, suicide, and poor functioning. Hence, the therapeutic target for acute treatment of depression is now full symptom remission. A global assessment, however, often is not detailed or sensitive enough to detect residual symptoms. Dr Scales knows that certain residual symptoms, such as fatigue, pain, and daytime somnolence, are particularly associated with poor response or early relapse of depression. Using a validated assessment scale makes it much more likely that she will be able to properly assess and monitor these important residual symptoms.

Obviously, a score on an assessment scale should not be the only factor considered when making these clinical decisions, just as a laboratory test cannot substitute for a clinical evaluation. A good clinician will appropriately ask the patient about specific symptoms of depression to determine the degree of clinical improvement. However, a rating scale can make this assessment more systematic and efficient.

Dr Gestalt often complains that he does not have enough time in a brief assessment visit to use a detailed rating scale. For this situation, brief interviewer-rated scales and/or self-rated scales can help to make a clinician’s practice more efficient. For example, the 7-item version of the HDRS can provide a quick measure of clinical improvement in less than ten minutes. Alternatively, patients can complete a self-rated depression scale such as the Patient Health Questionnaire-9 (PHQ-9) at home, in the waiting room, or before a clinical encounter. The clinician can then quickly look over the results and focus in on the symptoms of most concern. Dr Scales finds that using assessment scales actually makes her more efficient and saves her time during a clinical visit.

Rating scales may also be beneficial to detect symptoms that are difficult to assess during a brief visit. Dr Scales recognizes that some of her patients feel more comfortable admitting certain symptoms, such as suicidal thoughts, in a questionnaire format rather than directly to her. She also uses assessment scales to monitor side effects to treatment, especially more sensitive ones such as sexual dysfunction. Many medication side effects can mimic the symptoms of anxiety or depression, hence she uses a side effects scale both before and during treatment. Other side effects, such as extrapyramidal symptoms associated with antipsychotic medications, are subtle and may be easily missed. A systematic approach that includes the use of rating scales is important for early detection and monitoring of these side effects that are critical factors in non-adherence.

Finally, evidence-based psychological treatments for depressive and anxiety disorders, such as cognitive-behavioural therapy (CBT), rely on rating scales as an integral part of the clinical assessment and follow-up. When Dr Gestalt refers a patient for CBT, he knows that a cornerstone of CBT is using a rating scale (e.g., the Beck Depression Inventory) to monitor treatment outcome. However, Dr Gestalt may not be aware of the increasing availability of chronic disease management (CDM) programs for primary care management of depressive and anxiety disorders. CDM programs focus on patient self-management strategies to develop an active therapeutic alliance with health care providers, including the use of patient-rated outcome scales. Dr Gestalt can reinforce and promote self-management by incorporating an assessment scale into his care plans so that his patients can self-monitor results of treatment.

Of course, there are important caveats and questions to consider in using assessment scales. What is the scale designed to measure? How effective is it at carrying out that task? What is the interval of assessment (today, past week, past month, etc.)? Is the scale clinician-administered, or can it be completed by the patient? Many scales require training for proper administration. Copyright issues dictate that some scales must be purchased for clinical use. Other scales are in the public domain and can be used freely. Users of self-rating scales must consider the unique characteristics of the patient—can they read the language, do they understand the questions, is there any cognitive impairment, are there psychiatric reasons why the patient might over- or under-endorse symptoms, etc. Users of interviewer-rated scales must consider issues such as inter-rater reliability and whether scoring conventions and rules are followed. Unstructured interviews are usually the least reliable among different raters, while structured or semi-structured interviews increase reliability by providing standardized questions for patients to answer. Explicit and clear anchor points for each item also improve reliability of assessment scales.

In summary, the therapeutic objective for the treatment of anxiety and depression is full recovery, which includes the full remission of symptoms and a return to pre-morbid psychosocial functioning. Assessment scales are useful to assess clinical symptoms, monitor response to treatment and return of functioning, promote self-management strategies, detect residual symptoms, and ensure that side effects are not limiting treatment. Incorporating assessment scales into routine clinical practice means that treatment decisions can be made based on the best available information. For clinicians, the use of brief clinician-rated scales and/or patient-rated scales can improve the quality and efficiency of their clinical assessments. For patients, systematically tracking outcomes can provide valuable feedback on the effect of clinical interventions as an important component of self-management programmes and evidence-based psychotherapies. In this way, assessment scales can serve to enhance the therapeutic alliance and to promote adherence to both psychological and pharmacological treatment.

Chapter 2: Depression and mania

Mood disorders make up the most common psychiatric conditions in the population and account for a significant burden for individuals and on society. Depressive disorders include major depressive disorder (MDD), dysthymic disorder, and so-called ‘minor depression’. Bipolar disorder consists of at least one manic or hypomanic episode in addition to depressive episodes.

Major depressive episode

The symptom criteria for a major depressive episode are similar in DSM-IV-TR and ICD-10 (Table 2.1). The symptoms of depression can be divided into cognitive/emotional (low mood, loss of interest or enjoyment, trouble concentrating, feelings of guilt or self-blame, thoughts of death and suicide) and vegetative (fatigue, psychomotor changes, disturbances of sleep and appetite/weight).

Dysthymic disorder refers to a low-grade, chronic form of depression. Fewer symptoms are required for the diagnosis compared to MDD but the symptoms must have been present for two years or longer. Cognitive symptoms (difficulty concentrating, feelings of guilt) are more common in dysthymia than are vegetative symptoms. Patients with dysthymia are also likely to experience periodic episodes of MDD. These ‘double depressions’ are often what leads patients to seek care. Dysthymia is seen more frequently in primary care settings than in specialty (psychiatry) clinics.

Table 2.1 Summary DSM-IV-TR symptom criteria for major depressive episode

Although dysthymia and minor depression are often considered ‘subsyndromal’ depression, there is evidence that these conditions lead to significant morbidity and impairment of functioning, as well as being predictive of future episodes of MDD. Similarly, residual symptoms of depression, even when they do not meet criteria for MDD or dysthymia, are associated with poor outcomes such as risk of relapse into MDD, chronic courses of depression, poor psychosocial functioning, and suicide.

Subtypes of major depressive disorder

Major depressive disorder can also be divided into different ‘subtypes’, termed specifiers in DSM-IV-TR. These subtypes are classified according to the specific symptoms that are present during an episode (episode specifiers) or to the pattern of depressive episodes (course specifiers). The clinical importance of differentiating these subtypes is that treatment approach may vary according to subtype of depression (Table 2.2).

Melancholic specifier overlaps ‘typical’ depression with primary symptoms of non-reactive mood, in which the mood does not lift, even temporarily, when something good happens to the person, or loss of pleasure in all or almost all enjoyable activities. Melancholia also includes symptoms of insomnia, particularly terminal insomnia (with early morning wakening), diurnal variability in mood (with morning worsening), and marked appetite and weight lo...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Series preface
• Introduction
• Chapter 1: Why use assessment scales in clinical practice?
• Chapter 2: Depression and mania
• Chapter 3: Anxiety
• Chapter 4: Related symptoms, side-effects, functioning and quality of life
• Chapter 5: Special populations
• Appendix 1: Which scale to use and when
• Appendix 2: Alphabetic list of scales