What is the Hamilton Rating Scale for Depression?

Introduction

The Hamilton Rating Scale for Depression (HRSD), also called the Hamilton Depression Rating Scale (HDRS), abbreviated HAM-D, is a multiple item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery.

Max Hamilton originally published the scale in 1960 and revised it in 1966, 1967, 1969, and 1980. The questionnaire is designed for adults and is used to rate the severity of their depression by probing mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight loss, and somatic symptoms.

The HRSD has been criticised for use in clinical practice as it places more emphasis on insomnia than on feelings of hopelessness, self-destructive thoughts, suicidal cognitions and actions. An antidepressant may show statistical efficacy even when thoughts of suicide increase but sleep is improved, or for that matter, an antidepressant that as a side effect increase sexual and gastrointestinal symptom ratings may register as being less effective in treating the depression itself than it actually is. Hamilton maintained that his scale should not be used as a diagnostic instrument.

The original 1960 version contained 17 items (HDRS-17), but four other questions not added to the total score were used to provide additional clinical information. Each item on the questionnaire is scored on a 3 or 5 point scale, depending on the item, and the total score is compared to the corresponding descriptor. Assessment time is about 20 minutes.

Methodology

The patient is rated by a clinician on 17 to 29 items (depending on version) scored either on a 3-point or 5-point Likert-type scale. For the 17-item version, a score of 0-7 is considered to be normal while a score of 20 or higher (indicating at least moderate severity) is usually required for entry into a clinical trial. Questions 18-20 may be recorded to give further information about the depression (such as whether diurnal variation or paranoid symptoms are present), but are not part of the scale. A structured interview guide for the questionnaire is available.

Although Hamilton’s original scale had 17 items, other versions included up to 29 items (HRSD-29).

Unstructured versions of the HAM-D provide general instructions for rating items, while structured versions may provide definitions and/or specific interview questions for use. Structured versions of the HAM-D show more reliability than unstructured versions with informed use.

Levels of Depression

The UK National Institute for Health & Clinical Excellence (NICE) established the levels of depression in relation to the 17 item HRSD compared with those suggested by the American Psychiatrists Association (APA):

  • Not depressed: 0-7.
  • Mild (subthreshold): 8-13.
  • Moderate (mild): 14-18.
  • Severe (moderate): 19-22.
  • Very severe (severe): >23.

Other Scales

Other scales include:

What is the Montgomery-Asberg Depression Rating Scale?

Introduction

The Montgomery-├ůsberg Depression Rating Scale (MADRS) is a ten-item diagnostic questionnaire which psychiatrists use to measure the severity of depressive episodes in patients with mood disorders.

It was designed in 1979 by British and Swedish researchers as an adjunct to the Hamilton Rating Scale for Depression (HRSD) which would be more sensitive to the changes brought on by antidepressants and other forms of treatment than the Hamilton Scale was. There is, however, a high degree of statistical correlation between scores on the two measures.

Interpretation

Higher MADRS score indicates more severe depression, and each item yields a score of 0 to 6. The overall score ranges from 0 to 60.

The questionnaire includes questions on the following symptoms:

  1. Apparent sadness.
  2. Reported sadness.
  3. Inner tension.
  4. Reduced sleep.
  5. Reduced appetite.
  6. Concentration difficulties.
  7. Lassitude.
  8. Inability to feel.
  9. Pessimistic thoughts.
  10. Suicidal thoughts.

Usual cut-off points are:

  • 0 to 6: normal/symptom absent.
  • 7 to 19: mild depression.
  • 20 to 34: moderate depression.
  • >34: severe depression.

MADRS-S

A self-rating version of this scale (MADRS-S) is often used in clinical practice and correlates reasonably well with expert ratings.

The MADRS-S instrument has nine questions, with an overall score ranging from 0 to 54 points.