Journal of Nursing
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Psychiatric Innovations - Hamiltons Scale

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Depression and Psychiatric Nurse care
Many mentally ill patients suffer only when they do not receive adequate care for the symptoms accompanying their serious illness. Nursing empathy, the ability of the nurse to perceive and reason, as well as the capacity to communicate are seen as core characteristics of psychiatric nurse care. Clinical innovations in psychiatry have been playing a vital role in psychiatric nurse care. The Hamilton Rating Scale for Depression, also known as the HAM-D, is one such innovation useful in assessing the symptoms of patients diagnosed with depression (Hamilton, 1960). Depression is a common problem in psychiatric patients. Depression is not just a 'down' feeling or a sign of weakness but an imbalance caused in neurotransmitters resulting in illness that can affect anyone and has a profound effect on everyday life. This process of depression involves psychological and biological symptoms. The psychological symptoms includes dejection, unhappy mood, anxiety, irritability, lack of interest in everyday life, withdrawal from outside world, slow mental activity. Feeling of guilt, hypochondria, loss of libido, restlessness and thoughts of suicide. Biological symptoms sleeplessness, lack of appetite, constipation, fatigue and listlessness. Depression is aetiologically classified either as primary depression and secondary depression or endogenous or reactive depression. Based on symptoms depression is also classified as psychotic or neurotic depression. Postnatal depression, atypical depression, psychotic depression, dysthymia, single episode and recurrent depression are frequently encountered clinical states of depression. The severity of depression can be measured objectively using Rating scales of depression such as Hamilton Depression Rating Scale (Ham-D),Montgomery-Asberg Depression Rating Scale (MADRS),Geriatric Depression Scale (GDS) and Zung Self Rating Scale of Depression.

The Hamilton Rating Scale for Depression (HAM-D)
The Hamilton Rating Scale for Depression, also known as the HAM-D, is useful in assessing the symptoms of patients diagnosed with depression. The scale was created by Max Hamilton. Although the scale contains 21 items, evaluation of the severity of depressive symptoms is typically based on the patient's scores on the first 17 items, with some items graded on a scale of 0 to 4 and others graded on a scale of 0 to 2. The items in the scale includes Depressed Mood (sadness, hopelessness, helplessness, worthlessness), Feelings of Guilt, Suicide, Insomnia - Early, Insomnia - Middle, Insomnia - Late, Work and activities, Retardation (Slowness of thought and speech impaired ability to concentrate; decreased motor activity), Agitation, Anxiety - Psychic, Anxiety - Somatic, Somatic Symptoms - Gastrointestinal, Somatic Symptoms - General, Genital Symptoms (i.e., loss of libido, menstrual disturbances), Hypochondriasis, Weight Loss and Insight. The four additional items are diurnal variation, derealization, paranoid symptoms, and obsessive/compulsive symptoms (Hamilton, 1960). The psychiatric nurse clinicians use the HAM-D scale to quantify results of an interview and its value depends entirely upon the skills of the nurse in eliciting the necessary information from the patient. Although HAM-D scale was primarily designed to measure the severity of depressive symptoms in patients with primary depressive illness, it has been used to assess depressive symptoms in other groups as well. The rating should ideally take place at a fixed time to avoid the influence of diurnal variation. It is usually done within 15-20 minutes at 2 weekly intervals (Jha, 2004).

The Hamilton Rating Scale for Depression has been the Gold standard for assessment of depression for more than 40 years. Since a structured interview only will fetch the desired outcome, attempts have been in place to develop a standardized interview guide for HAMD. It can be effectively used to measure the outcome of Psychotropic medications (Williams, 1988). The Hamilton depression scale is a clinimetric index which focuses on the patient's gravity of the disease. Hence, it contains anxiety symptoms that emerge often in depressive episodes though not diagnostic of depression. The scale gives an insight into the illness from mild to severe illness. Hamilton developed his rating scale as an improvement of other rating scales for measuring mental disorder considering the limitations of the various rating scales. He opined that the weightage given to the symptoms should not give a linear relationship .For example, in Schizophrenia, the amount of anxiety is of no importance but in anxiety states it is very important.

Psychometric properties
The Psychometric properties like reliability and validity of the scale has been examined explicitly since 1979. An evaluation of an internal 'Construct Validity' has proved the criticism that HAM-D score is a week index of depressive syndrome severity wrong (Gibbons, 1993). Hamilton's scale has been found to exhibit high internal consistency and support for its 'Construct Validity' has been demonstrated by correlations with other measures of depression, anxiety and depression related cognition(Dozois, 2003). The majority of Hamilton scale items show adequate reliability with six items meeting the reliability criteria in every sample during studies including guilt; middle insomnia, psychic anxiety, somatic anxiety gastrointestinal and general somatic The internal, interrater and retest reliability are good ( Bagby et.al,2004). A study to compare the psychometric properties of the Hamilton Rating Scale for Depression (Ham-D) in patients with stroke, Alzheimer's dementia (AD), and Parkinson's disease (PD), has shown that the concurrent validity of the Ham-D with the DSM-IV criteria for major depressive disorder is high in each of these groups (Naarding et.al,2002). Thus, the psychometric properties of the HAM-D scale are excellent and adequate. But, studies point that instructions provided by its author are widely overlooked. There is also considerable evidence to show that the instruction that the HAMD should be used only in patients with a prior diagnosis of a primary depressive illness is often ignored (Snaith, 1996). Large meta-analysis studies have proved that the Hamilton depression scale actually is better than the Montgomery-Åsberg Depression Rating Scale in sensitivity to change and in detecting early change with treatment (Carroll and Wilson, 2000). The consistency of the Hamilton Depression Scale (HDS) as a measure of the severity of depressive states has also been examined by using logistic models (Bech et.al, 1981).

Criticisms on HAM-D
Evaluation of item response indicates that many individual variables are poorly designed and provide a score which is not clear. Rasch analysis, when, applied to the scale shows six items previously shown to have properties associated with unidimensionality which on combination formed a shorter scale fulfilling Rasch's criteria (Bagley, 2004).Further, many variables of the scale are poor in their contribution to the measurement of severity of depression with no scope of replication across samples. Research shows that revision can rectify a number of Psychometric problems. Various revised scales like HAM-D7 with 7 variables and GRID-HAMD have been devised by employing several methodological advances.

Conclusion
The Hamilton Rating Scale for Depression has been the Gold standard for assessment of depression for more than 40 years. Hamilton depression scale is a clinimetric index whose value depends entirely upon the skills of the nurse in eliciting the necessary information from the patient. Studies have proved that the Hamilton depression scale actually is better than the Montgomery-Åsberg Depression Rating Scale in sensitivity to change and in detecting early change with treatment.

 

References

  • Carroll BJ, Wilson WH (2000): HAM-D and MADRS as depression change measures, in New Clinical Drug Evaluation Unit (NCDEU) Program Abstracts, 40th Annual Meeting. Rockville, Md, National Institute of Mental Health, poster number 9.
  • Ching - Lin Hsieh (2005).Why the Hamilton Rating Scale Endures. Am J Psychiatry 162; 2395.
  • David J.A.Dozois (2003).The Psychometric characteristics of the Hamilton Depression Inventory. Journal of Personal Assessment 80 (1); 31-40.
  • Emmanuelle Corruble (2005).Why the Hamilton Depression Rating Scale Endures? Am.J.of psychiatry 162:2394-a.
  • Gibbons RD. et.al (1993). Exactly what does the Hamilton Depression Rating Scale  Measure? Journal of Psychiatric Res. 27(3): 259- 73.
  • Hamilton M (1960).A rating scale for depression. Neurol Neurosurg Psychiatry 23:56-62.
  • Maier W, Philip M (1985).Improving the assessment of severity of depressive states: a reduction of the Hamilton Depression Rating States: a reduction of the Hamilton Depression Rating Scale. Pharmaco psychiatry 18; 114 - 115.
  • Paul Naarding, Albert F. G. Leentjens, Fop van Kooten and Frans R.J. Verhey (2002). Disease-Specific Properties of the Hamilton Rating Scale for Depression in Patients with Stroke, Alzheimer's Dementia, and Parkinson's disease. Neuropsychiatry Clin Neurosci 14:329-334.
  • Prusoff B and Klerman GL (1974). Differentiating depressed from anxious neurotic out patients. Arch Gen Psychiatry 30; 302 - 309.
  • R.Michael Bagby et.al (2004).The Hamilton Depression Rating Scale: Has the Gold Standard Become a Lead Weight? Am J Psychiatry 161:2163-2177.
  • RP Snaith (1996). Present use of the Hamilton Depression Rating Scale: observation on method of assessment in research of depressive disorders. The British Journal of Psychiatry 168: 594-597.
  • Shashi Kant Jha (2004) Am J Psychiatry. 161:2163 - 2177.
  • Williams JB (1988). Arch Gem Psychiatry.45 (8): 742-747.

 

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