Diagnostic Rating Scales and Laboratory Tests

Mood Disorders

Considered the “gold standard” for evaluating the severity of depression in clinical studies, the Hamilton Rating Scale for Depression (HAM-D) may be used to monitor the patient's progress during treatment, after the diagnosis of major depression has been established. This clinician-administered scale exists in several versions, ranging from 6 to 31 items; answers by patients are scored from 0 to 2 or 0 to 4 and tallied to obtain an overall score. Standard scoring for the 17-item HAM-D-17 instrument, frequently used in research studies, is listed in Table 8-1 . A decrease of 50% or more in the HAM-D score is often considered to indicate a positive treatment response, whereas a score of 7 or less is considered equivalent to a remission. The longer versions of the HAM-D include questions about atypical depression symptoms (such as overeating and oversleeping), seasonal depression, psychotic symptoms, psychosomatic symptoms, and symptoms associated with OCD.

The Montgomery–Asberg Depression Rating Scale (MADRS) is a 10-item clinician-administered scale, designed to be particularly sensitive to antidepressant treatment effects in patients with major depression. The HAM-D and the MADRS are well correlated with each other, with the MADRS sampling a smaller symptom set, but including anhedonia and concentration difficulties not collected in the HAM-D. The MADRS provides a short but reliable scale, optimized for rapid clinical use. There is a 15-item version of the MADRS that covers atypical depressive symptoms, such as overeating and oversleeping.

The Beck Depression Inventory (BDI) is a widely used 21-item patient self-rating scale that can be completed in a few minutes. Scores on the BDI can be used both as a diagnostic screen and as a measure of improvement over time. For each item, patients choose from among four answers, each corresponding to a severity rating from 0 to 3. The correlation between total scores and the severity of depression is provided in Table 8-2 . Although easy to administer and to score, the BDI also excludes atypical neurovegetative symptoms.

Fewer rating scales have been designed to assess mania. Two instruments for assessing manic symptoms, the Manic State Rating Scale (MSRS) and Young Mania Rating Scale (Y-MRS) have been designed for use on inpatient units; they demonstrate high reliability and validity. Whereas the 26-item MSRS gives extra weight to grandiosity and to paranoid–destructive symptoms, the Y-MRS examines primarily symptoms related to irritability, speech, thought content, and aggressive behavior. Neither scale has been as extensively evaluated for reliability and validity as have its counterparts geared toward depression. Newer scales, such as the Bipolar Depression Rating Scale (BDRS), have been designed to capture episodes of bipolar depression, focusing more on mixed symptoms than the above-noted studies designed for unipolar depression.

Psychotic Disorders and Related Symptoms

Instruments for assessing psychotic symptoms are nearly always administered by clinicians. Two of the broader and more frequently used instruments are the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS). The BPRS was designed to address symptoms common to schizophrenia and other psychotic disorders, as well as severe mood disorders with psychotic features. Items assessed include hallucinations, delusions, and disorganization, as well as hostility, anxiety, and depression. The test is relatively easy to administer and takes about 20 to 30 minutes. The total score, often used to gauge the efficacy of treatment, provides a global assessment and therefore lacks the ability to track sub-syndromal items (e.g., positive vs negative symptoms). Alternatively, the PANSS includes separate scales for positive and negative symptoms, as well as a scale for general psychopathology. The PANSS requires more time to administer (30 to 40 minutes); related versions for children and adolescents are available.

More focused attention to positive and negative symptoms characterize the Scale for the Assessment of Positive Symptoms (SAPS) and the Scale for the Assessment of Negative Symptoms (SANS), respectively. The 30-item SAPS is organized into domains that include hallucinations, delusions, bizarre behavior, and formal thought disorder; the 20-item SANS covers affective flattening and blunting, alogia, avolition-apathy, anhedonia-antisociality, and attentional impairment. The scales are particularly useful to document specific target symptoms and measure their response to treatment, but their proper administration requires more training than do the global scales.

The proclivity of neuroleptics to induce motoric side effects has driven the creation of standardized rating scales to assess these treatment-related conditions. The Abnormal Involuntary Movement Scale (AIMS) is the most widely used scale to rate tardive dyskinesia. Ten items evaluate orofacial movements, limb–truncal dyskinesias, and global severity on a 5-point scale; the remaining two items rule out contributions of dental problems or dentures. The Barnes Akathisia Rating Scale evaluates both objective measures of akathisia, as well as subjective distress related to restlessness. Both scales are administered easily and rapidly and may be used serially to document the effects of chronic neuroleptic use or changes in treatment.

Anxiety Disorders

A variety of rating scales are available to assess anxiety symptoms as well as specific anxiety disorders (e.g., panic disorder, social phobia, OCD, PTSD, and generalized anxiety disorder; GAD). Two of the more frequently used scales, both clinically and for research purposes, are described here: the Hamilton Anxiety Rating Scale (HAM-A) and the Yale–Brown Obsessive Compulsive Scale (Y-BOCS). The HAM-A provides an overall measure of anxiety, with particular focus on somatic and cognitive symptoms; worry, which is a hallmark of GAD, receives less attention. The clinician-administered scale consists of 14 items and, when scored, does not distinguish specific symptoms of a specific anxiety disorder. A briefer six-item version, the Clinical Anxiety Scale, is also available. The most widely used scale for assessing severity of OCD symptoms, the Y-BOCS, is also clinician-administered and yields global as well as obsessive and compulsive subscale scores. Newer self-report and computer-administered versions have compared favorably to the clinician-based gold standard. The Y-BOCS has proven useful both in initial assessments and as a longitudinal measure.

Attention Disorders

Rating scales for attention disorders in children are numerous and include clinician-administered instruments, along with self-reports and scales completed by teachers, parents, and other caregivers. Current diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents require impairment across multiple settings, necessitating a multi-informant assessment. The Conners Rating Scales are the most popular and well-researched rating scales and exist in several versions, including parent and teacher questionnaires, an adolescent self-report scale, and both full and abbreviated length scales. The full scale is limited in use by its length (20–30 minutes to administer), but it provides a large normative base and well-tested reliability. Completed by parents or teachers, the ADHD Rating Scale-IV (ADHD RS-IV) derives directly from DSM symptom criteria and provides a faster (5–10 minutes), reliable screening that can help to identify children in need of additional evaluation and monitor treatment effects in children treated for ADHD. The Adult ADHD Self-Report Scale (ASRS) is an 18-item self-rating scale that focuses on difficulties with concentration, organization, and psychomotor restlessness. The checklist takes about 5 minutes to complete and can alert the treating clinician to the need for a more in-depth interview and assessment. A 6-item screening tool, taken out of the full ASRS, provides a rapid (less than 2 minutes) method for screening general clinic populations.

Substance Abuse Disorders

The CAGE Questionnaire ( Table 8-3 ) is a brief, clinician-administered tool used to screen for alcohol problems in many clinical settings. CAGE is an acronym for the four “yes/no” items in the test, which requires less than 1 minute to administer. “Yes” answers to two or more questions indicate a clinically significant alcohol problem (sensitivity has been measured at 0.78 to 0.81, specificity at 0.76 to 0.96), and positive screening suggests the need for further evaluation. The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire designed to detect problem drinkers at the less severe end of the spectrum, prior to the development of alcohol dependence and associated medical illnesses and major life problems from drinking. The AUDIT can quickly screen for hazardous alcohol consumption (sensitivity 0.92 and specificity 0.94) in outpatient settings and permit early intervention and treatment for alcohol-related problems, often before the brief CAGE questions would be positive. A widely used scale to assess past or present clinically significant drug-related diagnoses, the Drug Abuse Screening Test (DAST) is a 28- or 20-item self-administered instrument that takes several minutes to complete. If the subject answers “yes” to five or more questions, a drug abuse disorder is likely. The instrument includes consequences related to drug abuse (without being specific about the drug); it is most useful in settings where drug-related problems are not the patient's chief complaint.