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.