CMAJ • April 11, 2006; 174 (8). doi:10.1503/cmaj.1060025.
© 2006 CMA Media Inc. or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

One size fits all?

Roger S. McIntyre*, Jakub Z. Konarski{dagger} and Sidney H. Kennedy{ddagger}

*University Health Network, Department of Psychiatry, University of Toronto; {dagger}Department of Psychiatry, Institute of Medical Science; {ddagger}University Health Network, Department of Psychiatry, University of Toronto, Institute of Medical Science, Toronto, Ont.

[Three of the authors respond:]

We thank Dr. J. Ellen Anderson for her comments.

As part of the HAMD-7 primary-care validation initiative, family physicians were asked to evaluate a depressed patient with several psychometric tools including the Hamilton Depression Rating Scale 7-item (HAMD-7), HAMD-17, Montgomery Asberg Depression Rating Scale (MADRS) and Clinical Global Impression (CGI). The interrater reliability ({kappa}W) was determined for each scale and was determined to be: HAMD-7 0.83, HAMD-17 0.98, MADRS 0.89, CGI-S 0.80, respectively.1

These data are in keeping with the view that there is an overall high level of agreement amongst family physicians on more global measures of depression, as well, as with the briefer tool (i.e., the HAMD-7).

We would agree that contextual issues always need to be considered in evaluating a depressed patient, nevertheless a consistently applied validated metric is a preferred tool. The HAMD-7 has been validated and a remission cut-score has been operationalized (HAMD-7 total score < 3) in both primary and tertiary care settings.2 In a subsequent analysis, we have determined that the depressive symptoms most frequently endorsed by depressed persons in primary care are highly similar to patients in the tertiary care setting.

We agree that the PHQ-9 is a useful tool to track symptomatic progress in patients who are treated for depression.3 We agree that suicide should be a constituent item in any valid depression metric (both the PHQ-9 and the HAMD-7 include a suicide item). Any patient reporting a score greater than zero (i.e., suicidal ideation/plan/attempt) on the suicide item of the HAMD-7 should be further probed.

We feel that the evaluation of quality of life and function is essential when evaluating antidepressant effectiveness. When patients are asked to report what remission means to them, the presence of positive mental health, such as optimism and self-confidence, and a return to one's usual self and functioning, were just as, if not more, important than depressive symptom abatement.4 We are of the opinion that exploration of these domains should be part of the routine evaluation of the patient. This would be similar to managing the hypertensive patient in which blood pressure quantification is supplemented with questions regarding patient's subjective well-being, activity level and overall functioning.

Measurement-based care has been shown to enhance patient outcome in the management of depression in real-world settings.5 We would encourage the routine use of validated symptom measurement tools (e.g., HAMD-7, PHQ-9) that have been validated in multiple settings.

REFERENCES

  1. McIntyre RS, Konarski JZ, Mancini DA, et al. Measuring the severity of depression and remission in primary care: validation of the HAMD-7 Scale [published erratum in CMAJ 2006;174(2):207]. CMAJ 2005;173(11):1327-34.[Free Full Text]
  2. McIntyre R, Kennedy S, Bagby RM, et al. Assessing full remission. J Psychiatry Neurosci 2002;27(4): 235-9.[Medline]
  3. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;282(18):1737-44.[Abstract/Free Full Text]
  4. Zimmerman M, McGlinchey JB, Posternak MA, et al. How should remission from depression be defined? The depressed patient's perspective. Am J Psychiatry 2006;163(1):148-50.[Abstract/Free Full Text]
  5. Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry 2006;163(1):28-40.[Abstract/Free Full Text]




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