Chandos Te Deum in B-flat Major, HWV281: No. 4, Thou Art the King of Glory, O Christ
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Acta Psychiatr Scand. Using forcasting models to estimate the effects of changes in the composition of claims for selective serotonin reuptake inhibitors on expenditures. Clin Ther. Bakish is adjunct professor in the Department of Psychiatry at the University of Toronto. Kennedy is professor of psychiatry and head of the Department of Psychiatry at the University of Toronto, and chief psychiatrist at the University Health Network. Disclosure: The authors report no financial, academic, or other support of this work.
Please direct all correspondence to: Roger S. Objective: To describe a brief depression rating scale capable of estimating depression symptom severity, establishing and comparing the efficacy of antidepressant treatment, and distinguishing a clinical response to treatment from full symptomatic remission. Method: An extraction technique was employed attempting to identify the most commonly endorsed and sensitive depressive items from a standardized clinician-rated depression scale, the Item Hamilton Rating Scale for Depression HAM-D Data was harvested from a mood disorders clinical database within a tertiary university-affiliated hospital.
The primary aim of this study was to identify a cutoff score to distinguish clinical response from remission. Conclusion: Family physicians prescribing antidepressant treatment should employ a brief valid comprehensive scale to assess depression severity at baseline and monitor patient response to treatment. The contemporary goal in treating depressed patients is full remission of symptoms.
Full remission has been operationalized quantitatively inviting the need for depression rating scales in the routine management of all depressed patients. Major depressive disorder MDD is a highly prevalent heterogeneous disorder which imparts substantial illness burden and humanistic costs. The metric disability-adjusted life years DALYs were employed and estimations of disability and mortality from over diseases in all regions of the world were carried out.
These changes have invited the clinical community to redefine a therapeutic model with clear, practical, and consensually agreed upon treatment goals. The contemporary goal of antidepressant therapy is to achieve full remission of symptoms, prevent recurrence of illness, promote functional restoration, and enhance quality of life. Moreover, the risk of cardiovascular morbidity and mortality in persons with and without preexisting cardiovascular disease and suicidal behavior is significantly enhanced by ongoing depressive symptoms.
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An inverse and parallel gradient between depressive symptom severity and psychosocial functioning has been described. Clinicians require tools to assist them in navigating toward the destination of remission and functional restoration. The HAM-D has been the most frequently employed scale in clinical research. We sought to determine whether we could develop a brief version of the HAM-D 17 , which would improve upon existing psychometric deficiencies. A further clinical aim of this study was to create a valid comprehensive depressive assessment tool that the clinician could administer within several minutes, which could purposefully estimate the severity of depression, monitor symptomatic progress, and distinguish clinician response from remission.
A comprehensive validated scale would have clinical practice utility by virtue of its brevity. Subjects were outpatients with unipolar, nonpsychotic depression who received uncontrolled antidepressant treatment in the Depression Clinic of the Centre for Addiction and Mental Health at the University of Toronto.
Subjects were openly assigned to conventional first-line unimodal antidepressant treatment fluoxetine, sertraline, citalopram, fluvoxamine, paroxetine, venlafaxine extended-release, nefazodone, and moclobemide. All subjects consented to having their clinical information used as part of a larger clinical database. The clinical database protocol required participants to receive treatment for a minimum of 14 weeks to a maximum of 26 weeks.
HAM-D 17 evaluations were available at the baseline and endpoint visits. Efficacy assessments were not determined between these two time points. The items on the HAM-D 17 that were mostly sensitive to antidepressant treatment were identified and extracted to create a more brief yet comprehensive scale.
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We attempted to determine a remission cutoff score that would correlate with the remission score defined by the HAM-D A secondary analysis was carried out to compare our abbreviated scale with preexisting depression subscales. With the exception of middle insomnia, the remaining seven items were also those that were most sensitive to change with treatment, exhibiting change scores calculated as the effects sizes of 0. It was noted that the items included in the Toronto HAM-D 7 Table 2 were similar to those in other abbreviated scales which were based on disparate populations from diverse settings.
To extend this work further, we calculated a remission cut score that would define a full remission comparable to that enumerated for the HAM-D This latter computation eg, the determination of a remission cutoff score extends the previous work with existing depression scales for assessing depression and suggests that the Toronto HAM-D 7 could be a practical, standardized tool for use when the patient has achieved full symptomatic remission.
The Toronto HAM-D 7 is the first ever abbreviated depression scale requiring only minutes to perform which can estimate overall depressive symptom severity, be highly sensitive to antidepressant effectiveness, and offer a determination of full symptomatic remission. A myriad of deficiencies have been described in the management of the depressed patient Table 3. Previous research has shown that clinical global impressions of depressive symptom response are imprecise as a decisive outcome measure.
This potential confound adds to the variability of the scale, decreasing its internal consistency and limiting its power to detect antidepressant effects. One potential deficiency of abbreviated depression scales is statistically the presence of fewer items may result in lower reliability. However, our computed reliability estimates of overall depression severity are comparable to the lengthier HAM-D It has been shown by previous studies, that brief depression scales correlate highly with global psychopathology scales.
It suggested that the Toronto HAM-D 7 be employed at baseline and during the acute phase of treatment.
Recently, the Canadian Psychiatric Association published its clinical guidelines for treatment of depressive disorders www. The Toronto HAM-D 7 has been validated at a mood disorders clinic affiliated with the University of Toronto, which raises questions regarding eneralizability.
It is noted, however, that the items contained in this scale have high face validity and are commonly endorsed by primary care depressed patients. Furthermore, research efforts are under way to prospectively validate this scale in the family practice setting. The diagnosis of depression remains a clinical endeavor buttressed by a careful history and diagnostic assessment.
The scale is to be administered by clinician incorporating both patient response and clinical observation. Clinician rating scales have been found to be more sensitive to antidepressant treatment effects than patient administered scales eg, the Beck Depression Inventory. With increasing emphasis on humanistic- and patient-evaluated outcomes, the Toronto HAM-D 7 may represent an integral tool for the clinician with the patient remaining an important ally in describing their symptoms. This would parallel with a hypertension assessment, insofar as the blood pressure score mmHg is combined with patient experience exercise capacity with an aim to provide careful and precise management of this chronic disease.
The Toronto HAM-D 7 is a brief, validated comprehensive tool that can assist the clinician in assessing the overall severity of depressive symptomatology.
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This scale requires only several minutes to administer and objectively permits the clinician to monitor progress of depressive symptom across time, establish and compare the effectiveness of antidepressant interventions, and distinguish a clinical response from a full remission of symptoms. The items contained in this scale were the most frequently endorsed and most sensitive to change to a variety of commonly employed antidepressant treatments. Canadian Psychiatric Association.
Clinical guidelines for the treatment of depressive disorders. Can J Psychiatry. Cross-national epidemiology of major depression and bipolar disorder. Alternative projections of mortality and disability by cause global burden of disease study.