Bech-Rafaelsen Melancholia Scale Research Articles

Effects of Psychoactive Massage in Outpatients with Depressive Disorders: A Randomized Controlled Mixed-Methods Study.

The clinical picture of depressive disorders is characterized by a plethora of somatic symptoms, psychomotor retardation, and, particularly, anhedonia. The number of patients with residual symptoms or treatment resistance is high. Touch is the basic communication among humans and animals. Its application professionally in the form of, e.g., psychoactive massage therapy, has been shown in the past to reduce the somatic and mental symptoms of depression and anxiety. Here, we investigated the effects of a specially developed affect-regulating massage therapy (ARMT) vs. individual treatment with a standardized relaxation procedure, progressive muscle relaxation (PMR), in 57 outpatients with depression. Patients were given one ARMT or PMR session weekly over 4 weeks. Changes in somatic and cognitive symptoms were assessed by standard psychiatric instruments (Hamilton Depression Scale (HAMD) and the Bech–Rafaelsen–Melancholia–Scale (BRMS)) as well as a visual analogue scale. Furthermore, oral statements from all participants were obtained in semi-structured interviews. The findings show clear and statistically significant superiority of ARMT over PMR. The results might be interpreted within various models. The concept of interoception, as well as the principles of body psychotherapy and phenomenological aspects, offers cues for understanding the mechanisms involved. Within a neurobiological context, the significance of C-tactile afferents activated by special touch techniques and humoral changes such as increased oxytocin levels open additional ways of interpreting our findings.

Add-on treatment with N-acetylcysteine for bipolar depression: a 24-week randomized double-blind parallel group placebo-controlled multicentre trial (NACOS-study protocol)

BackgroundOxidative stress and inflammation may be involved in the development and progression of mood disorders, including bipolar disorder. Currently, there is a scarcity of useful treatment options for bipolar depressive episodes, especially compared with the efficacy of treatment for acute mania. N-Acetylcysteine (NAC) has been explored for psychiatric disorders for some time given its antioxidant and anti-inflammatory properties. The current trial aims at testing the clinical effects of adjunctive NAC treatment (compared to placebo) for bipolar depression. We will also explore the biological effects of NAC in this context. We hypothesize that adjunctive NAC treatment will reduce symptoms of depression, which will be reflected by changes in selected markers of oxidative stress.Methods and analysisIn the study, we will include adults diagnosed with bipolar disorder, in a currently depressive episode. Participants will undertake a 20-week, adjunctive, randomized, double-blinded, parallel group placebo-controlled trial comparing 3 grams of adjunctive NAC daily with placebo. The primary outcome is the mean change over time from baseline to end of study on the Montgomery–Asberg Depression Rating Scale (MADRS). Among the secondary outcomes are mean changes from baseline to end of study on the Bech-Rafaelsen Melancholia Scale (MES), the Young Mania Rating Scale (YMRS), the WHO-Five Well-being Index (WHO-5), the Global Assessment of Functioning scale (GAF-F), the Global Assessment of Symptoms scale (GAF-S) and the Clinical Global Impression-Severity scale (CGI-S). The potential effects on oxidative stress by NAC treatment will be measured through urine and blood samples. DNA will be examined for potential polymorphisms related to oxidative defences.Trial registration: Registered at The European Clinical Trials Database, ClinicalTrials.gov: NCT02294591 and The Danish Data Protection Agency: 2008-58-0035.

Deep Brain Stimulation in Patients with Parkinson's Disease: Effect on Psychiatric Symptoms and Quality of Life.

To determine the effect on psychiatric symptoms and quality of life in 30 patients with Parkinson's disease (PD) treated with deep brain stimulation (DBS) of both subthalamic nuclei (STN) after 1 year of follow-up. We conducted a prospective 1-year follow-up study with a baseline assessment before and 6 and 12 months after surgery. The following were used as assessment instruments: the Bech-Rafaelsen Melancholia Scale (MES), the Bech-Rafaelsen Mania Scale (MAS), the Beck Scale for Suicidal Ideation (SSI), the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Oviedo Sleep Questionnaire (OSQ), the 36-Item Short Form Health Survey (SF-36), the Unified Parkinson's Disease Rating Scale (UPDRS), the dose of levodopa, and the active contact stereotactic coordinates. We recorded a clinical improvement between baseline with medication use (ON medication) and the results obtained at 6 and 12 months with medication use and stimulation (ON stimulation, ON medication) in MES and OSQ (p < 0.0001) and in SF-36 (p < 0.005). No changes were observed in MAS and SSI. There was a clinical improvement between baseline with ON medication and the results obtained at 12 months with ON stimulation, ON medication in Y-BOCS (p < 0.04). Also, there was a 53.3% reduction in levodopa at 6 months and a 54.7% reduction at 12 months after surgery (p < 0.0001). There was an improvement between baseline with OFF medication and the results obtained at 6 and 12 months OFF medication, ON stimulation (p < 0.0001) in UPDRS-III. There were no statistically significant differences between the initial and final active contact coordinates, or between stimulation parameters. DBS of the STN in patients with PD is associated with an improvement in psychiatric (affective and sleep-wake cycle) symptoms, clinical motor symptoms, and quality of life at 1 year after surgery.

Cognitive functions and cognitive styles in young euthymic patients with bipolar I disorder

BackgroundCognitive deficits impair patients working and functioning status and may have negative impact on other aspects of thinking.ObjectivesAssess the prevalence of cognitive dysfunction in patients with bipolar disorder in euthymic state and to explore cognitive style problems.MethodCase-control naturalistic study, 60 patients with bipolar I disorder in euthymic state according to DSM-IV were recruited and subdivided into two groups each contains of 30 patients; (Group BPM) euthymic patients with recent manic episode, Group BPD euthymic patients with recent depressive episode. Both groups were further compared with control group (Group C) consisted of 30 frequency matched healthy volunteers. Groups were subjected to the following: (1) clinical psychiatric examination, (2) (HAMD-17) and Bech–Rafaelsen Melancholia Scale (MES) for (BPD), (3) (YMRS) and Bech–Rafaelsen Mania Scale (MAS) for (BPM), (4) assessment of euthymic state of mood included both MAS and MES, (5) MMSE, MTS and CDT were performed to assess cognitive functions, (6) cognitive styles evaluation the Social Dysfunction and Aggression Scale SDAS-9 and Arabic Anger Scale.ResultsDefinite cognitive function impairment and different patterns of cognitive style were detected in case groups. MMSE, MTS and CDT scores were statistically significant. Fear of Failure Scale Scores were higher in BPM; 16 (53.33%) reported severe intensity compared to 16 (53.33%) of BPD Group reporting moderate intensity and 30 (100%) of the control group reporting only mild intensity of fear of failure with statistically significant differences.ConclusionsPatients in euthymic state suffer from cognitive dysfunction and some aspects of cognitive styles that negatively interfere with their performance.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Different interventions for post-ischaemic stroke depression in different time periods: a single-blind randomized controlled trial with stratification by time after stroke

Objective: To determine the appropriate treatments for post-ischaemic stroke depression at different times after stroke. Design: A single-blind, randomized, controlled trial that compared three intervention groups, with subgroups stratified by time after stroke. Setting: Outpatient clinic. Subjects: Eligible patients were recruited at discharge (n = 73) and three (n = 67), six (n = 65), and nine months (n = 69) after discharge, and patients completed mood questionnaires. Interventions: Patients were randomly distributed into three groups: Group A received placebos and participated in general discussions; Group B, received citalopram and participated in general discussions; and Group C, received placebos and underwent cognitive behavioural therapy. All three groups participated in rehabilitation during three months of follow-up. Main measures: Outcome was assessed three months after baseline using the 17-item Hamilton Depression Scale (HAMD17) and the Bech–Rafaelsen Melancholia Scale (MES). During treatment, the Udvalg for Kliniske Undersogelser side-effect scale was also administered. Results: When stratification was not considered, the scores of Group B on the Melancholia Scale were lower than those of Group A (P = 0.02); when the four time-based subgroups were analysed, significant differences were observed between Groups A and B (PMES = 0.02, PHAMD17 = 0.02) in the group recruited six months after discharge and between Groups A and C (PMES = 0.01) in the last time period nine months after discharge. Conclusions: The effects of citalopram or cognitive behavioural therapy is similar to the effect of rehabilitation alone for early-onset post-ischaemic depression; rehabilitation and citalopram for delayed-onset post-ischaemic depression; and rehabilitation and cognitive behavioural therapy for late-onset post-ischaemic depression are more effective than rehabilitation alone.

Cognitive functions and cognitive styles in young euthymic patients with bipolar I disorder

BackgroundRecent evidences suggest that bipolar disorder patients do not return to premorbid functioning levels during the inter-episode periods. Cognitive deficits may impair patients working and functioning status and may also have negative impact on other aspects of thinking. ObjectivesTo assess the prevalence of cognitive dysfunction in patients with bipolar disorder in euthymic state and to explore any evident cognitive style problems. MethodCase-control naturalistic study 60 patients with bipolar I disorder in euthymic state according to DSM-IV were recruited and subdivided into two groups each contains of 30 patients; (Group BPM) euthymic patients with recent manic episode, and Group BPD euthymic patients with recent depressive episode. Both groups were further compared with control group (Group C) consisted of 30 frequency matched healthy volunteers. Groups were subjected to the following: 1-clinical psychiatric examination, 2-Hamilton Depression Scale (HAMD-17) and Bech–Rafaelsen Melancholia Scale (MES) for patients’ group (BPD), 3-Young Mania Rating Scale (YMRS) and Bech–Rafaelsen Mania Scale (MAS) for patients’ group (BPM), 4-assessment of euthymic state of mood included both MAS and MES, 5-MMSE, MTS and CDT were performed to assess cognitive functions, 6-cognitive styles evaluation included Fear of Failure, Hopelessness Scale, (the Social Dysfunction and Aggression Scale SDAS-9 and Arabic Anger Scale. ResultsDefinite cognitive function impairment and different patterns of cognitive style were detected in case groups. MMSE, MTS and CDT scores were statistically significant. Fear of Failure Scale Scores were higher in BPM; 16 (53.33%) reported severe intensity compared to 16 (53.33%) of BPD Group reporting moderate intensity and 30 (100%) of the control group reporting only mild intensity of fear of failure with statistically significant differences. Although patients were in euthymic state; Hopelessness Scale discriminated between those with affective disorders and controls and other scores for hostility SADS-9 and Arabic Anger Scale. Moreover, measures of cognitive styles showed differences among patients of the case groups who joined psychotherapy program in their management (28) compared to those who did not (32). LimitationCognitive impact of psychotropic drugs could not be eliminated since the current study is naturalistic study. ConclusionsThose with BAD in euthymic state suffer from cognitive dysfunction and some aspects of cognitive styles that may negatively interfere with their performance. Psychotherapeutic programs should consider these findings in their approaches for better impact on patients’ quality of life and overall treatment outcome.

Psychometric validation and clinical validity of the Minor Melancholia Mood Checklist (MMCL-32)

The Minor Melancholia Mood Checklist (MMCL-32) was developed to identify sub-threshold states of major depression. The MMCL-32 can be considered as the counterpole to the Hypomanic Check List (HCL-32). Principal component analysis (PCA) without rotation was used to identify a bidirectorial principal component. To evaluate the clinical validity of the bidirectorial factors, with reference to brief recurrent depression, the Bech-Rafaelsen Melancholia Scale was used. We included 59 patients with bipolar I disorder (SCID criteria) and 57 patients with unipolar depression (more than one major depressive episode without hypomanic or manic episodes). They were all outpatients, but had recently been discharged from inpatient treatment. The PCA identified two contrasting factors: 17 items with negative loadings (psychasthenic depression factor) and 15 items with positive loadings (cognitive depression factor). When PCA was applied exclusively to the bipolar patients, 5 items within the cognitive factor were identified. When applied exclusively to the unipolar patients, 5 items within the psychasthenic factor were identified. The non-remitted bipolar patients scored higher on the cognitive factor (P=0.01) than the remitted. On the psychasthenic factor (P=0.06), the non-remitted unipolar patients scored higher than the remitted patients. The MMCL-32 was found psychometrically valid in measuring sub-threshold states of major depression with rather specific factors for bipolar and unipolar depression. Focusing on these factors could be a clinical aid to distinguish patients at risk of developing a bipolar course.

Anhedonia and Reward System: Psychobiology, Evaluation, and Clinical Features

Anhedonia can be defined as a condition in which the hedonic capacity is totally or partially lost. From a psychobiological perspective, several researchers proposed that anhedonia has a putative neural substrate, the dopaminergic mesolimbic and mesocortical reward circuit, which involves the ventral tegmental area, the ventral striatum and part of the prefrontal cortex. Anhedonia is, besides depressed mood, one of the two core symptoms of depression; furthermore it is one of the most important negative symptom in schizophrenia. Anhedonia is also present in substance use disorders as part of the abstinence symptomatology, and interrelations between hedonic capability, craving and protracted withdrawal have been found, particularly in opiate-dependent subjects. Although anhedonia is regarded as an important symptom in psychopathology, so far it has received relatively little attention. In general, two main approaches have been utilized to investigate and assess anhedonia or hedonic capacity: laboratory-based measures and questionnaires. Among measurement scales, the most commonly used are the Snaith-Hamilton Pleasure Scale (SHAPS), the Fawcett-Clark Pleasure Scale (FCPS), and the Revised Chapman Physical Anhedonia Scale (CPAS). Nevertheless, other measurement scales, particularly used within broader psychopathological dimensions, are the Anhedonia-Asociality subscale (SANSanh) of the Scale for the Assessment of Negative Symptoms (SANS) and the Bech-Rafaelsen Melancholia Scale (BRMS). In this paper we analyze these different scales, individuating their strengths and limits and their current clinical applications.

Acetyl-l-Carnitine in the treatment of anhedonia, melancholic and negative symptoms in alcohol dependent subjects

Aim of this randomized, double-blind, placebo-controlled study was to evaluate the efficacy of Acetyl-l-Carnitine (ALC), at different dosages, on specific anhedonic symptoms in detoxified alcohol dependent subjects. Secondary endpoints were the effect of ALC on melancholic and negative symptoms. Sixty-four anhedonic alcohol dependent patients with minor or absent withdrawal symptoms were randomized: 23 received ALC at a dosage of 3g/day, 21 received ALC at a dosage of 1g/day, and 20 were given placebo. ALC was given intravenously for 10days, followed by 80days of oral treatment plus a follow-up period of 45days. The presence of anhedonic symptoms was determined by the SHAPS (Snaith-Hamilton Pleasure Scale) and the VASa (Visual Analogue Scale for Anhedonia); negative and melancholic symptoms were evaluated by the SANS (Scale for the Assessment of Negative Symptoms), and the BRMS (Bech-Rafaelsen Melancholia Scale). The natural course of anhedonia in the placebo group showed a decline until day 30 and remains stable for the rest of the study. Intravenously ALC accelerated the improvement of anhedonia reaching constant low levels early, on day 10. At this step levels of anhedonia (SHAPS, VASa) and melancholic symptoms (BRMES) resulted significantly reduced (p<0.05) in both the ALC 3g and ALC 1g groups with respect to placebo; SANS scores significantly reduced only in the ALC 1g respect to placebo (p=0.014). During oral treatment with ALC, anhedonia scores did not differ from placebo. Intravenously ALC was effective in accelerating the abstinence-associated improvement of anhedonia, melancholic and negative symptoms, whereas oral ALC treatment starting on day 10 showed no further improvements. Accordingly, in alcohol dependent subjects, ALC may be considered as a new potentially useful drug for the treatment of anhedonia.

Validity of the Definite and Semidefinite Questionnaire version of the Hamilton Depression Scale, the Hamilton Subscale and the Melancholia Scale. Part I

Instruments for self-rating in depression are available, but their psychometric properties have not been fully explored; discrepancies with clinician ratings have been identified. This study was longitudinal with 85 patients fulfilling the DSM-III-R diagnosis of Seasonal Affective Disorder. Self-reporting versions (definitely and semidefinitely anchored) corresponding to the Hamilton Depression Scale (HAMD), the Hamilton Subscale (HAM₆), and the Bech-Rafaelsen Melancholia Scale (MES) were compared to each other and the clinician-rated version. The unidimensional property of the sum score in each scale was tested by the item-response theory model ad modum Rasch. The scales were also tested for their sensitivity to discriminate between placebo and citalopram therapy. The sum scores and the sum score variances of the definite self-rating versions did not differ significantly from the sum scores of the corresponding observer scales at any of the five time points. The semidefinite scales significantly over-scored at all time points. The convergent validity between corresponding definite self-ratings and observer ratings was very high with correlations exceeding 0.90. Only item responses from the MES, the HAM₆, and their corresponding definite versions of the self-rating questionnaires DMQ and DHAM₆ were accepted by the Rasch analysis, and only these four valid scales discriminated significantly between the effect of citalopram and placebo treatment. Our results are limited to patients with moderate depression. Two new self-report scales with unparalleled construct validity, reliability, sensitivity, and convergent validity have been identified (DMQ and DHAM₆). We have also identified a crucial importance of format for the means and variances of self-rating scales. These findings are of high practical and scientific value.

Efficacy of an Algorithm-Guided Treatment Compared With Treatment as Usual

Medication algorithms have been proposed as effective means to offer optimal treatment and improved outcome for patients with severe mental illness. This single-center prospective study compared the efficacy and effects on treatment prescriptions of an algorithm-guided treatment regimen with treatment as usual (TAU) in depressed inpatients. Depressed inpatient participants were randomized to an algorithm-guided standardized stepwise drug treatment regimen (SSTR, n = 74) or TAU (n = 74). The SSTR regimen included sleep deprivation, antidepressant monotherapy, lithium augmentation, monoamine oxidase inhibitor therapy, or electroconvulsive therapy guided by scores on the clinician-rated Bech-Rafaelsen Melancholia Scale. The primary outcome was time to remission (defined as a Bech-Rafaelsen Melancholia Scale score of < or =7). Secondary outcomes were remission rates, number of changes in treatment strategies (types), and the number of different prescribed medications over the treatment period. Patients receiving SSTR had a significantly shorter time to remission (7.0 +/- 0.9 weeks vs 12.3 +/- 1.8 weeks for TAU). Compared with that in remitters in SSTR, the number of strategy changes was significantly higher in TAU remitters (3.0 +/- 2.7 and 1.0 +/- 1.5) and had more psychotropic medications (fix agents: 3.0 +/- 1.5 and 1.9 +/- 1.1; optional agents: 1.5 +/- 1.0 and 0.9 +/- 0.7). Although more patients dropped out of the SSTR group (33 of SSTR, 12 of TAU), the probability of remission tended to be higher in SSTR. Algorithm-guided treatment produces better outcomes and less frequent medication changes than TAU. A systematic, stepwise, measurement-based approach to the treatment of depressed inpatients is warranted.

Temperament and Character Inventory Dimensions and Anhedonia in Detoxified Substance-Dependent Subjects

In this study we aimed to investigate the relationship between anhedonia, craving and temperament and character dimensions in a sample of 50 patients with alcohol and opiate dependence recruited after a period of detoxification. The following scales were applied: Snaith–Hamilton Pleasure Scale (SHAPS), Bech–Rafaelsen Melancholia Scale (BRMS), Scale for the Assessment of Negative Symptoms (SANS), Visual Analogue Scales (VAS) for craving, and Temperament and Character Inventory (TCI). The temperament dimension of Novelty Seeking was positively correlated to craving and anhedonia (p <. 01), with a higher score of Novelty Seeking in the subsample of anhedonic subjects with respect to both non-anhedonic and control subjects. In our study, the possibility that difficulty in experiencing pleasure in psychiatric disorders can lead to the use of psychoactive substances in an attempt to decrease anhedonia, is extended to subjects without psychiatric disorders who may try substances to counterbalance a tonic state of anhedonia.

Olanzapine in the treatment of depression with psychotic features: A prospective open-label study

Objective. Depression with psychotic features is a severe subtype of major depression associated with the presence of delusions, hallucinations and specific neurobiological features. Despite clinical consensus and guideline recommendations, data comparing the efficacy of combining antipsychotics with antidepressants compared to antidepressants alone remain inconclusive. The aim of the study was to investigate effectiveness and tolerability of the atypical antipsychotic olanzapine in acute depression with psychotic features. Methods. Seventeen inpatients with major depressive disorder with psychosis (MDDp) were treated with a combination of an antidepressant and olanzapine for 6 weeks in a prospective open-label study. Depressive and psychotic symptoms, extrapyramidal and general side effects were assessed every 2 weeks. Sixteen patients were eligible for final analysis. Results. The Brief Psychiatric Rating Scale (BPRS) showed a 30% symptom reduction after week 2, a 45% symptom reduction after week 4 and no considerable improvement thereafter. Depressive symptoms (Bech–Rafaelsen Melancholia Scale, BRMS) receded by 37% after week 2 and 50% after week 4. No extrapyramidal side effects occurred. Conclusion. Olanzapine is effective and tolerable in combination with an antidepressant in an MDDp inpatient sample. The results concur with data supporting good efficacy in negative and depressive symptoms of patients with schizophrenic and schizoaffective diseases.

The Assessment of Post-Detoxification Anhedonia: Influence of Clinical and Psychosocial Variables

Anhedonia, or the inability to experience pleasure, may be regarded either as a temperamental trait or as a state symptom of negative schizophrenia or melancholic depression. In substance use disorders, anhedonia was linked to hypoactivity of the dopaminergic mesolimbic system during protracted withdrawal. The authors investigated the influence of recent clinical and social-environmental factors on the hedonic capability and related psychopathology in a sample of 70 patients manifesting substance dependence (alcohol, opiates, multiple drugs) without severe comorbidity. Three symptom scales covering anhedonia (Snaith-Hamilton Pleasure Scale, SHAPS; Scale for the Assessment of Negative Symptoms, SANS; Bech-Rafaelsen Melancholia Scale, BRMES) were administered together with the European adaptation of the Addiction Severity Index (EuropASI). The composite scores from the seven areas of the EuropASI were introduced as independent factors in a stepwise regression analysis having symptom scores of anhedonia as dependent variables. Overall, the EuropASI composites do not explain the variability of the scores of anhedonia. Only in few cases, the regression models show a weak predictive capacity for medical status, alcohol use, and drug use composite scores, with R-square values ranging from 10 to 22%. Even if the study's limitations are noted, anhedonia appears as a psychopathological entity independent from other clinical and psychosocial features of treated addicts.

C.04.01 Misdiagnosis caused by overlapping symptoms in mood disorders

The Minor Melancholia Mood Checklist (MMCL-32) was developed to identify sub-threshold states of major depression. The MMCL-32 can be considered as the counterpole to the Hypomanic Check List (HCL-32).Principal component analysis (PCA) without rotation was used to identify a bidirectorial principal component. To evaluate the clinical validity of the bidirectorial factors, with reference to brief recurrent depression, the Bech–Rafaelsen Melancholia Scale was used.We included 59 patients with bipolar I disorder (SCID criteria) and 57 patients with unipolar depression (more than one major depressive episode without hypomanic or manic episodes). They were all outpatients, but had recently been discharged from inpatient treatment.The PCA identified two contrasting factors: 17 items with negative loadings (psychasthenic depression factor) and 15 items with positive loadings (cognitive depression factor). When PCA was applied exclusively to the bipolar patients, 5 items within the cognitive factor were identified. When applied exclusively to the unipolar patients, 5 items within the psychasthenic factor were identified. The non-remitted bipolar patients scored higher on the cognitive factor (P = 0.01) than the remitted. On the psychasthenic factor (P = 0.06), the non-remitted unipolar patients scored higher than the remitted patients.The MMCL-32 was found psychometrically valid in measuring sub-threshold states of major depression with rather specific factors for bipolar and unipolar depression. Focusing on these factors could be a clinical aid to distinguish patients at risk of developing a bipolar course.

Rating Scales for Depression in the Elderly

The aim of the study was to assess the external and internal validity of the 6- and 17-item versions of the Hamilton Rating Scale for Depression (HAM-D(6) and HAM-D(17)), the Bech-Rafaelsen Melancholia Scale, the 15- and 30-item versions of the Geriatric Depression Scale, and the Cornell Scale for Depression in Dementia in a population of depressed demented and nondemented Danish elderly. Two clinicians performed independent, blinded assessments of the study population, which was drawn from psychogeriatric outpatient clinics, and a control group of elderly subjects. Concurrent and convergent validity were assessed using correlation coefficient analyses, and to evaluate the internal validity, item response analysis using the Mokken coefficient and Rasch analysis was performed. A coefficient of homogeneity of 0.40 or higher indicated scalability. Data collection took place between October 2001 and April 2004. 145 subjects were included; 102 were female (mean age = 78.6 +/-6.8 years), and 43 were male (mean age = 72.4 +/-5.6 years). In the study group (N = 109), 73 subjects had depression only, and 36 had both depression and dementia; in the control group (N = 36), 11 subjects had dementia. The item-response analysis made a clear distinction between the scales. The HAM-D(6) was the only scale that fulfilled the criterion of total scalability in both the cognitively intact and the impaired populations. In terms of standardization according to the Clinical Global Impressions-Severity of Illness scale (CGI-S), the HAM-D(6) had the most convincing external validity overall. In terms of general correlation to the CGI-S, only small differences were shown between the scales. The HAM-D(6) should be separately considered even when longer HAM-D versions are used for the measurement of depression in elderly persons.

Why the Hamilton Depression Rating Scale Endures

Back to table of contents Previous article Next article Letter to the EditorFull AccessWhy the Hamilton Depression Rating Scale EnduresRASMUS W. LICHT, M.D., , and PER BECH, M.D., RASMUS W. LICHTSearch for more papers by this author, M.D., Risskov, Denmark, and PER BECHSearch for more papers by this author, M.D., Frederiksborg, DenmarkPublished Online:1 Dec 2005https://doi.org/10.1176/appi.ajp.162.12.2394-bAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: The review of the psychometric properties of the Hamilton depression scale by Dr. Bagby et al. included the most relevant studies published from January 1980 to May 2003 that examine both interrater reliability and validity. It clearly demonstrated that the 17-item version, which in this period has been the gold standard as the outcome measure in trials with antidepressive therapies, is a multidimensional scale.One potential evolutionary solution for a one-dimensional gold standard, as suggested by the authors, would be to use the six core items of the dimension of depression comprising depressed mood, guilt, work and interests, psychomotor retardation, psychic anxiety, and general somatic symptoms—the 6-item Hamilton depression scale—when we measure the outcome of antidepressive interventions because this subscale has been proven to be more effective than the 17-item version in detecting differences between active drug therapy and placebo in trials on the acute therapy of depression. Also, this subscale fulfills criteria for unidimensionality. However, the authors rejected this solution, arguing that the truncated set of six items seems limited in that these items do not “permit capture of the full depressive syndrome” (p. 2174). Exactly this argument was behind the development of the Bech-Rafaelsen Melancholia Scale (1), which contains 11 items covering the various aspects of the full depressive syndrome and is the opposite of what is seen in the full manic syndrome, as measured by the Bech-Rafaelsen Mania Scale (2), that, together with the Bech-Rafaelsen Melancholia Scale, is still the only scale for the bipolar spectrum to fulfill the item-response theory model for unidimensionality (1, 2). In the light of this, we wonder why the authors did not mention this scale in their discussion of a replacement for the Hamilton depression scale.In a recent study (3), we confirmed in a large sample of depressed patients that the Bech-Rafaelsen Melancholia Scale and the 6-item—but not the 17-item—Hamilton depression scale have been accepted by item-response theory models to be unidimensional depression scales.Both the 6-item Hamilton depression scale and the Bech-Rafaelsen Melancholia Scale can serve as gold standards for measuring pure antidepressive activity, whereas the other 17-item Hamilton depression scale dimensions (e.g., anxiety and sleep) might serve to identify other aspects of the treatment being examined.

Anhedonia and Substance-Related Symptoms in Detoxified Substance-Dependent Subjects: A Correlation Study

Anhedonia is a condition in which the capacity of experiencing pleasure is totally or partially lost, frequently occurring in mood disorders, as a negative symptom in schizophrenia, and in substance use disorders. In order to test a set of instruments for anhedonia in a population of detoxified opiate, alcohol and multiple substance-dependent subjects, 70 individuals were recruited from three different clinical settings. The following scales were applied: Snaith-Hamilton Pleasure Scale (SHAPS), Bech-Rafaelsen Melancholia Scale (BRMS), Scale for the Assessment of Negative Symptoms (SANS), specific withdrawal scales, and visual analogue scales (VAS) for hedonic capability and substance craving. The scales measuring anhedonia either directly (SHAPS, VAS for hedonic capability) or in some key items (SANS, BRMS) were significantly correlated with each other. The period of time since detoxification was inversely correlated with anhedonia and withdrawal symptomatology. Craving was positively correlated with anhedonia. Out of the total sample, only 18.5% could be defined as psychometrically anhedonic. The same correlations were found in this subsample. The composite instrument employed for assessing anhedonia and hedonic capability was found to be sensitive enough to detect such a dimension in the population considered, with the single scales significantly interrelated. In conclusion, we found interrelations between hedonic capability, craving and protracted withdrawal, particularly in opiate-dependent subjects. The strongest association occurred between hedonic capability and craving.

Validation of the Bech–Rafaelsen Melancholia Scale and the Hamilton Depression Scale in patients with major depression; is the total score a valid measure of illness severity?

Evaluation of antidepressant drug efficacy requires adequate rating scales for measuring the severity of depression. However, to measure the illness severity by such a total score, the scale needs to fulfil criteria of unidimensionality. On this background, we aimed at comparing the unidimensionality of the Bech-Rafaelsen Melancholia Scale (MES) and the 17-item Hamilton Depression Rating Scale (HAM-D(17)). A total of 1629 patients aged between 18 and 65 years with a major depressive episode were treated openly with sertraline at a fixed oral dose of 50 mg daily during 4 weeks. The HAM-D(17) and the MES were applied at baseline and at weeks 2 and 4. Unidimensionality was tested with Mokken and Rasch analysis. Unidimensionality of the HAM-D(17) could not be confirmed. However, the 6-item Hamilton Depression Subscale (HAM-D(6)), was accepted by the Rasch analysis both at baseline and after 2 and 4 weeks of therapy. For the MES (as well as for the HAM-D(6)), a Loevinger coefficient of homogeneity above 0.40 (suggesting acceptance) was found at week 4. The HAM-D(6) and the MES did fulfil criteria for unidimensionality while the HAM-D(17) did not. Therefore, the extended use of the HAM-D(17) in drug trials may be questioned.

Once-daily high-dose pindolol for SSRI-refractory depression

Selective serotonin reuptake inhibitor (SSRI) augmentation with the 5-HT 1A antagonist pindolol has met with mixed results. Recent studies using positron emission tomography (PET) suggest that pindolol doses used in these studies were too low to effect 5-HT 1A autoreceptor blockade. To test the hypothesis that a single higher dose of pindolol would effectively augment antidepressant responses in SSRI-refractory patients, nine subjects with major depression unresponsive to paroxetine 40 mg/day given for 2 months or more were randomized to AM pindolol 7.5 mg ( n=4) or placebo ( n=5). Subjects were administered the Hamilton Depression Scale (HAM-D), the Hamilton Anxiety Scale (HAM-A), the Bech–Rafaelsen Melancholia Scale, and the Zung Depression Inventory at baseline and weeks 1, 2, 3, and 4. Subjects receiving pindolol exhibited significant improvements in all ratings beginning at week 2 which continued through week 4. Aside from transient dizziness and a five-point decrease in systolic/diastolic blood pressure associated with pindolol, no adverse effects were reported. Although results must be verified in a larger sample, these findings support previous studies indicating that pindolol can accelerate antidepressant responses during SSRI therapy. In addition, results reported here suggest that a single high dose of pindolol (7.5 mg) is a more effective augmentation strategy in SSRI-refractory patients compared with the same total dose given at 2.5 mg tid.