Are self-report scales as effective as clinician rating scales in measuring treatment response in routine clinical practice?

OBJECTIVE: Recent treatment guidelines have suggested that outcome should be measured in routine clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared three self-report scales of depressive symptoms and the two most widely used clinician administered scales in treatment studies in their sensitivity to change and evaluation of treatment response in depressed patients treated in routine practice. METHODS: At baseline and 4-month follow-up 153 depressed outpatients with DSM-IV MDD completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology-Self-report version (QIDS-SR), and Patient Health Questionnaire (PHQ-9). The patients were rated on the 17-item Hamilton Depression Rating Scale (HAMD) and the Montgomery-Asberg Depression Rating Scale (MADRS). On each scale treatment response was defined as a 50% or greater reduction in scores from baseline. RESULTS: While there were some differences in the percentage of patients considered to be responders on the different scales, a large effect size was found for each scale, with little variability amongst the scales. The level of agreement between the three self-report scales and the clinician rating scales was approximately the same LIMITATIONS: The present study was conducted in a single clinical practice in which the majority of the patients were white, female, and had health insurance. DISCUSSION: When measuring outcome in clinical practice the magnitude of change in depressive symptoms is as great on self-report scales as on clinician rating scales.

A clinically useful self-report measure of psychiatric patients' satisfaction with the initial evaluation.

Patient satisfaction is one component of the quality of care. Studies of satisfaction in samples of established patients are biased because dissatisfied patients are more likely to have dropped out of treatment. We, therefore, sought to develop a new instrument assessing patients' satisfaction with the initial psychiatric evaluation. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we describe the development, reliability, and validity of the Clinically Useful Patient Satisfaction Scale (CUPSS). The CUPSS is a brief, self-administered questionnaire covering 3 areas: clinician's attitude and behavior, office environment and staff, and overall satisfaction. A sample of psychiatric outpatients (n=412) and partial hospital patients (n=500) completed the measure immediately after their initial meeting with the psychiatrist. The scale had high internal consistency, and all item-scale correlations were significant. All items were significantly correlated with each of the indicators of global satisfaction. There was sufficient variability in satisfaction ratings to detect differences amongst clinicians. The results of the present study of psychiatric outpatients and partial hospital patients indicate that the CUPSS was minimally to not at all burdensome to complete, it had good psychometric properties, and it can discriminate amongst clinicians.

Identifying Remission From Depression on 3 Self-Report Scales.

OBJECTIVE: Advocates of measurement-based care approaches toward treatment recommend the use of self-report questionnaires. Many self-report scales have been developed to measure the severity of depression. Because of the significance accorded remission by experts, it is important to compare different scales in their identification of remitted patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared 3 self-report scales that assess the criteria for major depression in the identification of remission in patients treated in routine practice. METHODS: From June 2011 to November 2012, 153 depressed outpatients with DSM-IV major depressive disorder completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR), and Patient Health Questionnaire (PHQ-9). The patients were considered to be in remission according to the cutoff scores recommended by each scale's developers. The patients were also rated on the 17-item Hamilton Depression Rating Scale (HDRS). RESULTS: When the HDRS was used as the "gold standard" definition of remission, the CUDOS had the highest sensitivity for detecting remission (87%) and the QIDS-SR the highest specificity (97%). Overall, though, the level of agreement between the 3 self-report scales and HDRS in determining remission was approximately the same (79%-84%). The rate of remission was significantly higher on the HDRS compared to the QIDS-SR (35% vs 23%, McNemar P < .001), significantly lower than the rate on the CUDOS when a cutoff score of 19 was used (35% vs 47%, McNemar P < .001), and not significantly different from the rate on the PHQ-9 (31%) or the CUDOS when a cutoff score of 10 was used (34%). CONCLUSIONS: There are significant differences between standardized scales in determining remission from depression. It is important for the developers of depression measures to empirically derive cutoff scores that define important constructs such as remission.

Scoring rules and rating formats of Self-report Depression Questionnaires: a comparison of approaches.

Self-report measures of depression differ in their construction and scoring rules. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we tested the hypothesis that the loss of information due to scoring rules or rating formats reduces the validity of depression severity assessment. One hundred fifty-three outpatients with DSM-IV major depressive disorder (MDD) who presented for treatment or who were in ongoing treatment and had their medication changed due to lack of efficacy completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology (QIDS) and Remission from Depression Questionnaire (RDQ) at the initiation of treatment and 4 month follow-up. The patients were evaluated with the 17-item Hamilton Depression scale (HAMD). The CUDOS and RDQ were equally highly correlated with the HAMD at baseline and follow-up. There was no significant difference in the correlations between the modified and original scoring algorithms of the QIDS with the HAMD at baseline and the follow-up. On each scale, the patients showed significant levels of improvement from baseline to 4 months, and the effect sizes were similar. These findings suggest that the loss of information due to the scoring rules of the QIDS or the rating format of the RDQ did not reduce the validity of depression severity assessment.

The remission from depression questionnaire as an outcome measure in the treatment of depression.

BACKGROUND: The Remission from Depression Questionnaire (RDQ) assesses multiple domains considered by depressed patients to be relevant to the construct of remission. The present study is the first to examine the validity of the RDQ as an outcome measure. METHODS: One hundred fifty-three depressed patients who presented for treatment, or who were in ongoing treatment and had their medication changed, were evaluated at baseline and at 4-month follow-up. In addition to the RDQ, the patients completed the Quick Inventory of Depressive Symptomatology (QIDS), and they were rated on 17-item Hamilton Rating Scale for Depression (HAMD). RESULTS: The patients showed significant levels of improvement from baseline to 4 months on each scale. The effect size of the RDQ total score was similar to the effect sizes of the HAMD and QIDS. Both the RDQ and QIDS were significantly associated with patients' self-reported remission status. However, the RDQ remained significantly associated with remission status after controlling for QIDS scores, whereas the QIDS was not associated with remission status after controlling for RDQ scores. DISCUSSION: The RDQ is as sensitive to change as purely symptom-based scales such as the QIDS and HAMD. Moreover, the RDQ accounts for variation in patients' self-perceived remission status after controlling for QIDS scores, but the reverse was not true. The RDQ allows clinicians and researchers to gain a broader perspective of depressed patients' status than purely symptom measures, and is more consistent with a biopsychosocial approach toward the treatment of depression.

Speaking a more consistent language when discussing severe depression: a calibration study of 3 self-report measures of depressive symptoms.

OBJECTIVE: We recently found marked disparities between 3 self-report scales that assess the DSM-IV criteria for major depressive disorder in the percentage of depressed outpatients considered to have severe depression. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to calibrate the measures against a clinician-rated criterion standard and to establish a cutoff point on each scale that identifies a similar prevalence of severe depression and increases the level of agreement between the scales in identifying severe depression. METHOD: 353 depressed outpatients (DSM-IV) completed the Clinically Useful Depression Outcome Scale, Quick Inventory of Depressive Symptomatology, and Patient Health Questionnaire from June 2010 to January 2013. The patients were also rated on the 17-item Hamilton Depression Rating Scale (HDRS). The goal of the analyses was to identify the cutoff point on each of the self-report scales that would identify a prevalence of severe depression similar to that identified by the HDRS (defined as a score of 25 and above). RESULTS: On the basis of the scale developers' recommended cutoffs, the prevalence of severe depression varied greatly (range, 15.3%-67.4%), and the level of agreement between the pairs of scales was low. After calibration, the self-report scales identified a similar percentage of patients as severely depressed (range, 22.2%-26.5%), and the level of agreement between the scales in identifying severe depression increased. DISCUSSION: If clinicians are to follow treatment guidelines' recommendations to base initial treatment selection, in part, on depression severity, then it is important to have a consistent method of determining depression severity. The present calibration study of 3 self-report depression questionnaires identified cutoff scores that resulted in similar prevalence rates of severe depression and increased the level of agreement between the scales.

Anxiety symptoms among remitted depressed outpatients: prevalence and association with quality of life and psychosocial functioning.

BACKGROUND: Prior studies of remission from depression have only examined the impact of residual depressive, but not anxiety, symptoms. Given that anxiety comorbidity in currently depressed patients is common and is associated with poorer outcomes, residual anxiety symptoms may play a significant role in remitted patients' well-being and vulnerability to relapse. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the frequency of residual anxiety symptoms among depressed outpatients in remission based on the HAM-D and associations among residual anxiety, psychosocial functioning and quality of life. METHODS: We interviewed 274 psychiatric outpatients diagnosed with DSM-IV major depressive disorder. Patients completed measures of depression and anxiety symptoms, psychosocial functioning, and quality of life. RESULTS: Nearly three-quarters of remitted depressed patients endorsed at least one residual anxiety symptom, with a majority experiencing more than one symptom. Anxiety severity was associated with reduced functioning and quality of life across all life domains. Controlling for depression severity, anxiety symptoms were independently related to reduced functioning and quality of life in several domains. LIMITATIONS: We did not assess for specific pre-existing DSM-IV anxiety disorders nor particular treatments patients received, which may have influenced residual anxiety symptoms. Future studies should replicate the results using other measures of remission. CONCLUSIONS: Anxiety symptoms are common in depressed patients in remission, and independently related to reduced functioning and quality of life. Thus, it is important to consider anxiety symptoms in evaluating the completeness of treatment response of depressed patients.

How should residual symptoms be defined in depressed patients who have remitted?

Symptomatic remission has been defined as a complete or near-complete absence of symptoms. Just as the distinction between remitters and nonremitters among treatment responders has clinical significance, the distinction between a complete and near-complete absence of symptoms itself might be important. Recent studies have reported a high frequency of residual symptoms in patients who are presumably in remission, and this raises questions about how residual symptoms are defined. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared the prevalence of residual symptoms based on different cutoff scores on 2 self-report measures of depression and then determined the association between residual symptoms and indices of psychosocial morbidity. We administered the 17-item Hamilton Rating Scale for Depression to 274 psychiatric outpatients diagnosed as having DSM-IV major depressive disorder who were in ongoing treatment. The patients completed the Clinically Useful Depression Outcome Scale (CUDOS) and Quick Inventory of Depressive Symptomatology (QIDS) and measures of psychosocial functioning and quality of life. We examined the frequency of residual symptoms in the 142 patients scoring in the remission range on the Hamilton Rating Scale for Depression. For both the CUDOS and QIDS, the threshold to define symptom presence strongly impacted on the prevalence of residual symptoms. The association between residual symptoms, psychosocial functioning, and quality of life varied according to the threshold used to define the symptoms. On the QIDS, a cutoff of 1 was a more valid indicator of the presence of residual symptoms than a cutoff of 2, whereas on the CUDOS, we recommend a cutoff of 2 be used to indicate the presence of residual symptoms. Examination of the frequency of specific symptoms suggests that the choice of scale might impact on which residual symptoms are considered the most frequent in treatment remitters.

Determining severity subtypes of depression with a self-report questionnaire.

The American Psychiatric Association's recently revised guidelines for the treatment of major depressive disorder indicated that it is important to consider symptom severity in initial treatment selection. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we conducted two studies of psychiatric outpatients examining the correlates of severity classification based on a self-report depression scale. The first sample consisted of 470 depressed outpatients who completed the Clinically Useful Depression Outcome Scale (CUDOS) and measures of psychosocial morbidity at the time of presentation. The second sample consisted of 112 depressed outpatients who completed the CUDOS and were evaluated with the Hamilton Depression Rating Scale at baseline and after 3 months of treatment. Compared to mildly depressed patients, moderately depressed patients reported significantly more psychosocial morbidity across all functional domains. The same differences were found between moderately and severely depressed patients. Greater severity of depression was associated with lower rates of response and remission. The results of the present studies suggest that a self-report depression questionnaire can validly subtype depressed patients according to gradations of severity.

A new type of scale for determining remission from depression: the Remission from Depression Questionnaire.

Current standards for treating major depressive disorder (MDD) recommend that achieving remission should be considered the principal goal of treatment. Recent research suggests that the symptom-based definitions of remission used in efficacy studies do not adequately reflect the perspective of depressed patients receiving treatment in routine clinical settings. We developed the Remission from Depression Questionnaire (RDQ) to capture the broader array of domains considered by patients to be relevant to the construct of remission--symptoms of depression, nondepressive symptoms, features of positive mental health, coping ability, functioning, life satisfaction and a general sense of well-being. The current report is the first study of the reliability and validity of the RDQ. The test-retest reliability of the RDQ was studied in 60 depressed outpatients in ongoing treatment. The convergent and discriminant validity of the RDQ was studied in 274 depressed outpatients who were rated on the 17-item Hamilton Depression Scale (HAM-D) and who completed several self-report scales including the Quick Inventory of Depressive Symptomatology (QIDS). The RDQ demonstrated excellent internal consistency, with a Cronbach's α of .97 for the total scale and above .80 for each of the 7 subscales. The test-retest reliability of the total scale was .85 and above .60 for each subscale. Both the RDQ and QIDS were significantly associated with patients' self-reported remission status. However, the RDQ remained significantly associated with remission status after controlling for QIDS scores (r = -.32, p < .001) whereas the QIDS was not associated with remission status after controlling for RDQ scores (r = -.06). The RDQ is a reliable and valid measure that evaluates the multiple domains that depressed patients consider important in determining remission. The results are consistent with prior research suggesting that depressed patients' perspective of remission goes beyond symptom resolution.

How can we use depression severity to guide treatment selection when measures of depression categorize patients differently?

OBJECTIVE: Treatment guidelines for depression suggest that severity should be taken into account when initiating treatment. If clinicians are to consider illness severity in selecting among treatment options for depression, then it is important to have reliable, valid, and clinically useful methods of distinguishing between levels of depression severity. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared 3 self-report scales that assess the DSM-IV criteria for major depressive disorder on the basis of how these scales distribute patients into severity categories. METHOD: From June 2010 to November 2011, 245 depressed outpatients completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology (QIDS), and Patient Health Questionnaire (PHQ-9). The study was conducted at Rhode Island Hospital, Providence, Rhode Island. The patients were subdivided into severity categories according to the cutoff scores recommended by each scales' developers. The patients were also rated on the 17-item Hamilton Depression Rating Scale (HDRS-17). RESULTS: The correlations between the HDRS-17 and the 3 self-report scales were nearly identical. Yet the scales significantly differed in their distribution of patients into severity categories. On the CUDOS and HDRS-17, moderate depression was the most frequent severity category, whereas on the PHQ-9 and QIDS, the majority of the patients were classified as severe. Significantly fewer patients were classified as severely depressed on the CUDOS compared to the PHQ-9 (McNemar = 153.8; P < .001) and QIDS (McNemar = 114.0; P < .001). CONCLUSIONS: If clinicians are to follow treatment guidelines' recommendations to base initial treatment selection on the severity of depression, then it is important to have a consistent method of determining depression severity. The marked disparity between standardized scales in the classification of depressed outpatients into severity groups indicates that there is a problem with the use of such instruments to classify depression severity. Caution is warranted in the use of these scales to guide treatment selection until the thresholds to define severity ranges have been empirically established.

Symptom differences between depressed outpatients who are in remission according to the Hamilton Depression Rating Scale who do and do not consider themselves to be in remission.

OBJECTIVE: Remission is usually defined as a score below a predetermined cutoff on a symptom severity scale. Depressed patients' global perception of their remission status only partially overlaps with scale-based definitions of remission. Patients' self-perceived remission status is likely to impact on their desire for modification in their treatment. The identification of specific symptoms that distinguish patients who do and do not consider themselves to be in remission could represent the most salient targets of add-on treatment strategies desired by patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the symptom profiles of patients who were in remission on the Hamilton Rating Scale for Depression (HAMD) who did and did not consider themselves to be in remission. METHODS: We interviewed 274 psychiatric outpatients diagnosed with DSM-IV major depressive disorder who were in ongoing treatment. The patients completed the Clinically Useful Depression Outcome Scale (CUDOS). RESULTS: Approximately half of the patients scoring 7 and below on the HAMD did not consider themselves to be in remission. The mean number of symptoms on the CUDOS was significantly higher in the self-described non-remitters. Almost all symptoms were less frequent in the self-rated remitters, though the absolute frequency of the individual symptoms was related to the threshold used to define symptom presence. DISCUSSION: Consistent with the findings of other studies we found high rates of residual symptoms in patients who were considered to be in remission, and patients with residual symptoms typically had more than 1 such symptom. These results raise questions about the strategy of add-on treatments targeting specific individual symptoms. LIMITATIONS: Remission was defined according to the 17-item version of the HAMD. We focused on the 17-item HAMD because it is the most commonly used measure in antidepressant efficacy trials, and the cutoff used to define remission has been generally accepted. We would anticipate that our findings would be similar in studies of longer versions of the HAMD as well as other depression severity scales such as the Montgomery-Asberg Depression Rating Scale. Self-perceived remission status was based on the patients' response to a single question. The sample was drawn from a single, large, general adult outpatient private practice setting in which the majority of the patients were white, female, and in their 30s and 40s. Generalizability to samples with different demographic characteristics needs to be demonstrated.

Why do some depressed outpatients who are not in remission according to the hamilton depression rating scale nonetheless consider themselves to be in remission?

BACKGROUND: In treatment studies of depression, remission is typically defined narrowly-based on scores on symptom severity scales. Patients treated in clinical practice, however, define the concept of remission more broadly and consider functional status, coping ability, and life satisfaction as important indicators of remission status. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined how many mildly symptomatic depressed patients in ongoing treatment who did not score in the remission range on the 17-item Hamilton Depression Rating Scale (HAMD) nonetheless considered themselves to be in remission from their depression. Among the mildly symptomatic HAMD nonremitters, we compared the demographic and clinical characteristics of patients who did and did not consider themselves to be in remission. METHODS: We interviewed 274 psychiatric outpatients diagnosed with DSM-IV major depressive disorder who were in ongoing treatment. The patients completed measures of psychosocial functioning and quality of life. RESULTS: Approximately one-quarter of the patients scoring 8-12 on the HAMD considered themselves to be in remission. Compared to patients who did not consider themselves to be in remission, the remitters reported significantly better quality of life, less functional impairment due to depression, higher positive mental health scores, and better coping ability. DISCUSSION: Some patients who do not meet symptom-based definitions of remission nonetheless consider themselves to be in remission. The findings raise caution in relying exclusively on symptom-based definitions of remission to guide treatment decision making in clinical practice.

Why do some depressed outpatients who are in remission according to the Hamilton Depression Rating Scale not consider themselves to be in remission?

OBJECTIVE: In treatment studies of depression, remission is typically defined narrowly, based on scores on symptom severity scales. Patients treated in clinical practice, however, define the concept of remission more broadly and consider functional status, coping ability, and life satisfaction as important indicators of remission status. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined how many depressed patients in ongoing treatment who scored in the remission range on the 17-item Hamilton Depression Rating scale (HDRS) did not consider themselves to be in remission from their depression. Among the HDRS remitters, we compared the demographic and clinical characteristics of patients who did and did not consider themselves to be in remission. METHOD: From March 2009 to July 2010, we interviewed 274 psychiatric outpatients diagnosed with DSM-IV major depressive disorder who were in ongoing treatment. The patients completed measures of depressive and anxious symptoms, psychosocial functioning, and quality of life. RESULTS: Approximately one-half of the patients scoring 7 and below on the HDRS (77 of 140 patients for whom self-reported remission status was available) did not consider themselves to be in remission. The self-described remitters had significantly lower levels of depression and anxiety than the patients who did not consider themselves to be in remission (P < .001). Compared to patients who did not consider themselves to be in remission, the remitters reported significantly better quality of life (P < .001) and less functional impairment due to depression (P < .001). Remitters were significantly less likely to report dissatisfaction in their mental health (P < .01), had higher positive mental health scores (P < .001), and reported better coping ability (P < .001). CONCLUSIONS: Some patients who meet symptom-based definitions of remission nonetheless experience low levels of symptoms or functional impairment or deficits in coping ability, thereby warranting a modification in treatment. The findings raise caution in relying exclusively on symptom-based definitions of remission to guide treatment decision-making in clinical practice.

Further evidence that the cutoff to define remission on the 17-item Hamilton Depression Rating Scale should be lowered.

BACKGROUND: In 1991, the recommendations of a consensus conference were that a cutoff of 7 on the 17-item Hamilton Depression Rating Scale (HAM-D) be used to define remission from depression, and since then this has been the most commonly used definition of remission. The cutoff was not derived from empirical study. In the present report from the MIDAS project, we examined the level of current psychosocial morbidity in depressed patients identified as being in remission according to different thresholds on the 17-item HAM-D. METHODS: We interviewed 274 depressed outpatients in ongoing treatment. The patients completed measures of depressive and anxious symptoms, psychosocial functioning, and quality of life. RESULTS: Compared to patients scoring 3-7 on the HAM-D, patients scoring 0-2 had significantly lower levels of depression and anxiety on self-report symptom scales, better psychosocial functioning, better quality of life, and greater satisfaction with their mental health. Similar results were found comparing patients scoring 0-2 versus 3-5. CONCLUSIONS: The results of this study indicate that significant heterogeneity exists among patients scoring 7 and below on the HAM-D. Whatever cutoff score is used to define remission on a symptom severity scale such as the HAM-D, some error will be inherent in dichotomizing a continuously distributed variable. We propose distinguishing between patients who are highly likely to be in remission (0-2 on the HAMD) from patients who are possibly in remission (scoring 3-7).

Determining remission from depression on two self-report symptom scales: a comparison of the Quick Inventory of Depressive Symptomatology and the Clinically Useful Depression Outcome Scale.

To answer fundamental questions regarding the effectiveness of treatments for depression in real-world clinical practice, it is necessary to incorporate the measurement of outcome. Self-report questionnaires are a cost-effective option to systematically, reliably, and validly evaluate clinical status because they are inexpensive in terms of professional time needed for administration, and do not require special training for administration. While there are many self-administered depression scales, only a limited number cover all of the diagnostic criteria for major depressive disorder (MDD) and have had cutoff scores derived corresponding to the Hamilton Depression Rating Scale (HAM-D) definition of remission. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared 2 scales in their respective ability to identify remission as defined by the HAM-D. We administered the 17-item HAM-D to 274 depressed outpatients in ongoing treatment. The patients completed the Quick Inventory of Depressive Symptomatology (QIDS) and the Clinically Useful Depression Outcome Scale (CUDOS). Based on the cutoffs recommended by the developers of the scales to identify remission, the 2 scales performed similarly overall though the sensitivity was higher for the QIDS than the CUDOS (95.5% vs. 78.7%), whereas specificity was higher for the CUDOS than the QIDS (73.0% vs. 50.0%). On the CUDOS, the cutoff that maximized the sum of sensitivity and specificity was similar to cutoff initially derived for this purpose; however, for the QIDS, the optimal cutoff was higher than the cutoff originally derived for this purpose. In conclusion, the CUDOS and the QIDS were equally highly related to the HAM-D definition of remission. The CUDOS takes less time to complete than the QIDS and, therefore, may be preferable to use in routine clinical practice.

Depressed patients' perspectives of 2 measures of outcome: the Quick Inventory of Depressive Symptomatology (QIDS) and the Remission from Depression Questionnaire (RDQ).

BACKGROUND: Current operational definitions of remission, at their root, are exclusively symptom-based and therefore limited in scope. In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined patient acceptability of a new measure, the Remission from Depression Questionnaire (RDQ), a scale designed to capture a broader array of domains patients consider relevant to the construct of remission. Patient acceptance of the RDQ was compared with that of the Quick Inventory of Depressive Symptomatology (QIDS), the instrument used to measure outcome in the Sequenced Treatment Alternatives to Relieve Depression study. METHODS: One hundred and two depressed outpatients in ongoing treatment completed the RDQ, QIDS, and a 9-item measure of patient preference. RESULTS: Patients indicated the RDQ was a better indicator of their overall state and treatment goals. Patients judged the RDQ to be a more accurate and preferred measure to determine treatment outcome, and a more accurate indicator of remission. CONCLUSIONS: Patients considered the multifactorial RDQ a more accurate indicator of their treatment goals than a purely symptom measure such as the QIDS.

Underrecognition of clinically significant side effects in depressed outpatients.

OBJECTIVE: The presence of medication side effects is one of the most frequent reasons depressed patients discontinue medication, and premature discontinuation of medication is associated with poorer outcome in the treatment of depression. Despite the clinical importance of detecting side effects, few studies have examined the adequacy of their detection and documentation by clinicians. We are not aware of any studies comparing psychiatrists' clinical assessments to a standardized side effects checklist in depressed patients receiving ongoing treatment in clinical practice. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to test the hypothesis that fewer side effects would be recorded by psychiatrists in their patients' charts compared to the number reported by patients on a side effects checklist. METHOD: Three hundred depressed outpatients (diagnosed according to DSM-IV criteria) in ongoing treatment completed a self-administered version of the Toronto Side Effects Scale (TSES). The patients rated the frequency of each of the 31 side effects and the degree of trouble caused by them. A research assistant reviewed patients' charts to extract side effects information recorded by the treating psychiatrist. The study was conducted from June 2008 to July 2008. RESULTS: The mean number of side effects reported by the patients on the TSES was 20 times higher than the number recorded by the psychiatrists (P < .01). When the self-reported side effects were limited to frequently occurring or very bothersome side effects, the rate was still 2 to 3 times higher (P < .01). CONCLUSIONS: Psychiatrists may not be aware of most side effects experienced by psychiatric outpatients receiving ongoing pharmacologic treatment for depression.