Elsevier

Comprehensive Psychiatry

Volume 48, Issue 2, March–April 2007, Pages 113-117
Comprehensive Psychiatry

Heterogeneity among depressed outpatients considered to be in remission

https://doi.org/10.1016/j.comppsych.2006.10.005Get rights and content

Abstract

More than a decade ago, a consensus panel recommended that remission be defined on the 17-item version of the Hamilton Rating Scale for Depression (HAM-D) as a cutoff of less than 7. Recently, some investigators have suggested that this threshold to define remission may be too high. If true, this means that heterogeneity exists within the group of treatment remitters accounting for variance in psychosocial function and relapse risk. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether there is heterogeneity within the group of patients that are typically classified as remitters. Three hundred three depressed psychiatric outpatients were rated on the Standardized Clinical Outcome Rating for Depression, an index of Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition remission status, and the 17-item HAM-D. Approximately half of the patients completed a measure of psychosocial impairment. Treatment responders were divided into 2 groups, remitters (HAM-D ≤7) and nonremitters (HAM-D ≥8). The treatment remitters were further subdivided into 2 groups, remitters with and without mild residual symptoms (HAM-D 3-7 vs 0-2). We refer to these 3 nonoverlapping groups as responders, partial remitters (ie, remitters with mild residual symptoms), and full remitters (remitters without residual symptoms). Responders scored statistically significantly higher, indicating greater psychosocial impairment, than the entire group of remitters, and the partial remitters scored significantly higher than the full remitters. Among the responders, the correlation between remission status and functioning was −.49 (P < .01). Among the remitters, the correlation between residual symptom status and functioning was nearly as high (−.42, P < .05). These results suggest that there is as much heterogeneity among patients who are typically considered to be in remission as there is among responders. This supports recommendations to lower the cutoff on the HAM-D to define remission.

Section snippets

Methods

Participants were 303 psychiatric outpatients who were being treated for a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) major depressive episode in the Rhode Island Hospital Department of Psychiatry outpatient practice. This private practice group predominantly treats individuals with medical insurance on a fee-for-service basis, and it is distinct from the hospital's outpatient residency training clinic that predominantly serves lower-income, uninsured, and

Results

The mean score on the 17-item HAM-D for the entire sample of 303 patients was 11.4 (SD, 8.4). Slightly more than one half of the sample were treatment responders (SCOR-D rating of ≤3) (n = 154, 50.8%), and more than one third were in remission (HAM-D ≤7) (n = 118, 38.9%). Psychosocial functioning was assessed in 144 (47.5%) patients. There were no demographic differences between patients who did and did not provide this information.

In the 50 patients who responded to treatment and completed the

Discussion

Keller [16] recently noted that a measurable, identifiable end point for the treatment of depression is as important to establish as it has been for the treatment of other chronic conditions such as diabetes, hypertension, and hypercholesterolemia. Improvement in the symptoms of depression has long been the goal of treatment, and the development of instruments such as the HAM-D and Beck Depression Inventory more than 40 years ago enabled the tracking of treatment response by repeated

References (22)

  • M. Zimmerman et al.

    The treatment validity of DSM-III melancholic subtyping

    Psychiatry Res

    (1985)
  • J. Ballenger

    Clinical guidelines for establishing remission in patients with depression and anxiety

    J Clin Psychiatry

    (1999)
  • A. Nierenberg et al.

    Evolution of remission as the new standard in treatment of depression

    J Clin Psychiatry

    (1999)
  • I. Ferrier

    Treatment of major depression: is improvement enough?

    J Clin Psychiatry

    (1999)
  • A. Rush et al.

    Consensus guidelines in the treatment of major depressive disorder

    J Clin Psychiatry

    (1998)
  • A. Rush et al.

    Treating depression to remission

    Psych Annals

    (1995)
  • S. Stahl

    Why settle for sliver, when you can go for gold? Response vs. recovery as the goal of antidepressant therapy

    J Clin Psychiatry

    (1999)
  • M. Thase

    Evaluating antidepressant therapies: remission as the optimal outcome

    J Clin Psychiatry

    (2003)
  • E.S. Paykel et al.

    Residual symptoms after partial remission: an important outcome in depression

    Psychol Med

    (1995)
  • M.E. Thase et al.

    Relapse after cognitive behavior therapy of depression: potential implications for longer courses of treatment

    Am J Psychiatry

    (1992)
  • C. Faravelli et al.

    Depressive relapses and incomplete recovery from index episode

    Am J Psychiatry

    (1986)
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