Hamilton Rating Scale for Depression HDRS-17

Definition
The Hamilton Depression Scale (HDS or HAMD) is a test measuring the severity of depressive symptoms in individuals, often those who have already been diagnosed as having a depressive disorder. It is sometimes known as the Hamilton Rating Scale for Depression (HRSD) or the Hamilton Depression Rating Scale (HDRS).

Purpose
The HDS is used to assess the severity of depressive symptoms present in both children and adults. It is often used as an outcome measure of depression in evaluations of antidepressant psychotropic medications and is a standard measure of depression used in research of the effectiveness of depression therapies and treatments. It can be administered prior to the start of medication and then again during follow-up visits, so that medication dosage can be changed in part based on the patient's test score. The HDS often used as the standard against which other measures of depression are validated.


The HDS was developed by Max Hamilton in 1960 as a measure of depressive symptoms that could be used in conjunction with clinical interviews with depressed patients. It was later revised in 1967. Hamilton also designed the Hamilton Depression Inventory (HDI), a self-report measure consistent with his theoretical formulation of depression in the HDS, and the Hamilton Anxiety Scale (HAS), an interviewer-rated test measuring the severity of anxiety symptoms.

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Precautions
Some symptoms related to depression, such as self-esteem and self-deprecation, are not explicitly included in the HDS items. Also, because anxiety is specifically asked about on the HDS, it is not always possible to separate symptoms related to anxiety from symptoms related to depression.

Because the HDS is an interviewer-administered and rated measure, there is some subjectivity when it comes to interpretation and scoring. Interviewer bias can impact the results. For this reason, some people prefer self-report measures where scores are completely based on the interviewee's responses.

Description
Depending on the version used, there are either 17 or 21 items for which an interviewer provides ratings. Besides the interview with the depressed patient, other information can be utilized in formulating ratings, such as information gathered from family, friends, and patient records. Hamilton stressed that the interview process be easygoing and informal and that there are no specific questions that must be asked.

The 17-item version of the HDS is more commonly used than the 21-item version, which contains four additional items measuring symptoms related to depression, such as paranoia and obsession, rather than the severity of depressive symptoms themselves.


Examples of items for which interviewers must give ratings include overall depression, guilt, suicide, insomnia, problems related to work, psychomotor retardation, agitation, anxiety, gastrointestinal and other physical symptoms, loss of libido (sex drive), hypochondriasis, loss of insight, and loss of weight. For the overall rating of depression, for example, Hamilton believed one should look for feelings of hopelessness and gloominess, pessimism regarding the future, and a tendency to cry. For the rating of suicide, an interviewer should look for suicidal ideas and thoughts, as well as information regarding suicide attempts.

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Questionnaire HDRS-17 (17 Questions)
Answer the questions below as truly as you can. Record and summarize the obtained results for proper interpretation.
           
  1. Depressed mood
    Sad, hopeless, helpless, worthless
0 = Absent
1 = Gloomy attitude, pessimism, hopelessness
2 = Occasional weeping
3 = Frequent weeping
4 = Patient reports highlight these feelings states in his/her spontaneous verbal and
non-verbal communication.                                                                      

  1. Feelings of guilt
0 = Absent
1 = Self-reproach, feels he/she has let people down
2 = Ideas of guilt or rumination over past errors or sinful deeds
3 = Present illness is punishment
4 = Hears accusatory or denunciatory voices and/or experiences threatening visual
hallucinations. Delusions of guilt.                                                            

  1. Suicide
0 = Absent
1 = Feels life is not worth living
2 = Wishes he/she were dead, or any thoughts of possible death to self
3 = Suicide, ideas or half-hearted attempt
4 = Attempts at suicide (any serious attempt rates 4)                              

  1. Insomnia, early in the night
0 = No difficulty falling asleep
1 = Complaints of occasional difficulty in falling asleep i.e. more than half-hour
2 = Complaints of nightly difficulty falling asleep                                  

  1. Insomnia, middle of the night
0 = No difficulty
1 = Patient complains of being restless and disturbed during the night
2 = Walking during the night – any getting out of bed rates 2 (except voiding bladder)     

  1. Insomnia, early morning hours
0 = No difficulty
1 = Waking in the early hours of the morning but goes back to sleep
2 = Unable to fall asleep again if he/she gets out of bed                         

  1. Work and activities
0 = No difficulty
1 = Thoughts and feelings of incapacity related to activities: work or hobbies
2 = Loss of interest in activity – hobbies or work – either directly reported by patient or
indirectly seen in listlessness, in decisions and vacillation (feels he/she has to push
self to work or activities)
3 = Decrease in actual time spent in activities or decrease in productivity. In hospital,
rate 3 if patient does not spend at leas three hours a day in activities
4 = Stopped working because of present illness. In hospital rate 4 if patient engages
in no activities except supervised ward chores                                        

  1. Retardation 
    Slowness of thought and speech; impaired ability to concentrate; decreased motor activity
0 = Normal speech and thought
1 = Slight retardation at interview
2 = Obvious retardation at interview
3 = Interview difficult
4 = Interview impossible                                                                          

  1. Agitation
0 = None
1 = Fidgetiness
2 = Playing with hands, hair, obvious restlessness
3 = Moving about; can’t sit still
4 = Hand wringing, nail biting, hair pulling, biting of lips, patient is on the run       

  1. Anxiety, psychic
    Demonstrated by:
  • subjective tension and irritability, loss of concentration
  • worrying about minor matters
  • apprehension
  • fears expressed without questioning
  • feelings of panic
  • feeling jumpy
0 = Absent
1 = Mild
2 = Moderate
3 = Severe
4 = Incapacitating                                                                                     

  1. Anxiety, somatic
    Physiological concomitants of anxiety such as:
  • gastrointestinal: dry mouth, wind, indigestion, diarrhea, cramps, belching
  • cardiovascular: palpations, headaches
  • respiratory: hyperventilation, sighing
  • urinary frequency
  • sweating
  • giddiness, blurred vision
  • tinnitus
0 = Absent
1 = Mild
2 = Moderate
3 = Severe
4 = Incapacitating

  1. Somatic symptoms: gastro-intestinal
0 = None
1 = Loss of appetite but eating without staff encouragement. Heavy feelings in abdomen.
2 = Difficulty eating without staff urging. Requests or requires laxatives or medication for bowels or medication for gastro-intestinal symptoms.

  1. Somatic symptoms: general
0 = None
1 = Heaviness in limbs, back or head; backaches, headaches, muscle aches, loss of energy, fatigability
2 = Any clear-cut symptom rates 2                                                          

  1. General Symptoms
    Symptoms such as: loss of libido, menstrual disturbances
0 = Absent
1 = Mild
2 = Severe                                                                                                 

  1. Hypochondriasis
0 = Not present
1 = Self-absorption (bodily)
2 = Preoccupation with health
3 = Strong conviction of some bodily illness
4 = Hypochondrial delusions                                                                   

  1. Loss of Weight
    Rate either ‘A’ or ‘B’:
A When rating by history:
0 = No weight loss
1 = Probable weight loss associated with present illness
2 = Definite (according to patient) weight loss
B Actual weight changes (weekly):
0 = Less than 1 lb (0.5 kg) weigh loss in one week
1 = 1-2 lb (0.5 kg-1.0 kg) weight loss in week
2 = Greater than 2 lb (1 kg) weight loss in week
3 = Not assessed                                                                                       

  1. Insight
0 = Acknowledges being depressed and ill
1 = Acknowledges illness but attributes cause to bad food, overwork, virus, need for rest, etc.
2 = Denies being ill at all                                                                          

Scoring and Results
In the 17-item version, nine of the items are scored on a five-point scale, ranging from zero to four. A score of zero represents an absence of the depressive symptom being measured, a score of one indicates doubt concerning the presence of the symptom, a score of two indicates mild symptoms, a score of three indicates moderate symptoms, and a score of four represents the presence of severe symptoms. The remaining eight items are scored on a three-point scale, from zero to two, with zero representing absence of symptom, one indicating doubt that the symptom is present, and two representing clear presence of symptoms.

For the 17-item version, scores can range from 0 to 54. One formulation suggests that scores between 0 and 6 indicate a normal person with regard to depression, scores between 7 and 17 indicate mild depression, scores between 18 and 24 indicate moderate depression, and scores over 24 indicate severe depression.

There has been evidence to support the reliability and validity of the HDS. The scale correlates highly with other clinician-rated and self-report measures of depression.

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