Synopsis: Rating scales for depression are being used routinely in primary care, but not all psychiatrists and therapists are using them. The use of depression rating scales shines a bright spotlight on your current mood and the progress you are making toward full freedom from depression. This article addresses how rating scales can help get you unstuck in your depression treatment.

BY LEN LANTZ, MD / 8.5.20; No. 32 / 8 min read

Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.

Why measure depression?

While at the end of the day, you either have depression or you don’t, if you are not measuring your depression, you could be missing out on the opportunity to document your progress, something that would motivate you and your doctor in your journey to freedom from depression. Also, measuring your depression helps clarify if your treatment plan is working or needs changing.

Consider a different illness, such as diabetes. Imagine trying to get quality treatment for your diabetes if you were unable to measure your blood sugar or other signs of the condition. How would that even work? I suppose you would meet with your endocrinologist every 1-4 weeks. Your endocrinologist might ask you questions about your diet such as, “And when you ate that doughnut, how did that make you feel?” Your endocrinologist might then suggest that you exercise more and that a different medication might help. While this example may seem extreme, it shows the absurdity of treating an illness without enough data.

Now, consider depression. Many people receive treatment for their depression with therapy and antidepressants, yet there are no widely available biological measures, or biomarkers, of depression as there are for diabetes. In the last decade, neuroscientists have begun identifying biomarkers of depression (see Len’s article “The Most Important New Findings in Depression”), which will lead to better treatment that lasts. Until we have widespread biomarkers for depression, the best measures for the average person in the diagnosis and treatment of depression are rating scales.

What are depression rating scales?

Depression rating scales are formal tests or measures of your mood in which you answer questions about various problems that are common in depression. Based on your answers, you can learn more about whether your answers are consistent with major depression and how severe the depression is. Rating scales alone do not diagnose depression, as only your doctor or therapist can make the diagnosis. However, depression rating scales can assist in:

• Confirming a depression diagnosis.

• Improving the understanding of your doctor and therapist about what you are going through.

• Opening up conversations for dealing with depression.

• Measuring your progress.

• Accessing and implementing more intensive, effective treatments.

Commonly used depression rating scales

Since 1960, one of the most commonly used depression rating scales among psychologists and psychiatrists has been the Hamilton Rating Scale for Depression (HAM-D). This is a well-validated, widely-accepted depression rating scale that has been used across the world in both research and clinical settings, and it is considered to be the gold standard for measuring depression severity. While the HAM-D is a great scale, its use is becoming increasingly limited due to pressures on the time available for patient visits. It is clinician-administered, not self-administered, and it takes about 20-30 minutes to administer. Using the scale correctly requires training with feedback.

Another commonly used depression rating scale is the Patient Health Questionnaire (PHQ-9). This depression screening tool is self-administered, well-validated, and short (it has only 10 questions and usually takes less than 3 minutes to complete). The PHQ-9 is used to screen for depression, assists in the diagnosis and has been used as a symptom tracking tool in response to treatment. It has other benefits, such as being free to use/reproduce and is widely used in primary care settings. The only downside I have seen with the PHQ-9 is that it does not capture the severity of depression for a small percentage of patients. When I suspect this is occurring, I have those patients complete the Beck Depression Inventory (BDI-2).

The BDI-2 is a self-administered rating scale with 21 questions. Compared to the PHQ-9, it has greater specificity for major depression, likely, in part, due to its length and ability to ask about a greater variety of depressive symptoms. The BDI-2 is a highly-regarded, well-validated scale for measuring depression. The major downsides of the BDI-2 are that it costs money (the forms are not free to use or reproduce) and takes up to 10 minutes to complete, which is much longer than the PHQ-9.

Completing a depression rating scale gives you advantages in treatment

Millions of people in the US have received treatment and achieved freedom from depression after never having completed a depression rating scale. So, why bother with them? There are many reasons for using depression rating scales, including:

• Research shows that the faster you achieve remission (full freedom from depression), the better your outcomes.

• If you settle for just being partially better rather than seeking full remission, it can set you up for chronic or recurring depression.

• Your doctor or therapist may have no clue how bad your depression is or how much you are suffering.

• You may have limited awareness of the severity of your depression until you use a standard measure.

• The use of depression rating scales inserts a greater degree of objectivity to an otherwise subjective assessment process.

• In medicine, things that are measured are things that can be improved.

Rating scales can help motivate you and your treaters

Completing depression rating scales is your opportunity to provide honest feedback to your psychiatrist and therapist. Their response to your completed scale may provide you the information you need about what to do next in your treatment.

Long-term treatment or treatment-resistance can lead to complacency. Your doctor or therapist may be used to asking, “How have you been?” And you may be used to answering, “About the same. I’m doing okay.” This routine may replay itself for many reasons. One reason is that, without a depression rating scale, your doctor may not know how severe your depression really is.

Another reason may be that if you have depression, have tried several different treatments and finally feel somewhat better, you might not want to try something new. Your doctor, knowing this (but not knowing how severe your depression is) might not push you for further change and instead just renew your medications as is.

However, if it is your goal to achieve full remission of depression, your therapist or psychiatrist will hopefully recognize that you are struggling and be motivated to problem-solve with you to achieve freedom of depression.

Are your needs being met or not?

Doctors and therapists who do not routinely use rating scales are often distressed or surprised when completed scales show how poorly some of their patients are doing. If the results from your depression rating scales show that you are not making progress, they may also encourage you to get a second opinion or start implementing all strategies for depression, rather than just one or two (see Len’s article “A Plan for Stubborn Depression”).

If your scores on a depression rating scale are not improving, they might stimulate your doctor or therapist to revisit your diagnosis to make sure that it is accurate and that your treatments are appropriate for your diagnosis. If your doctor or therapist is not taking action when your depression is not getting better, it might be time for you to get a second opinion on your diagnosis or current treatment.

If you have tried many antidepressants with no lasting therapeutic benefit, it might also be time for you to ask why your doctor has not recommended more intensive treatment, such as transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), residential treatment or ketamine therapy.

A story about the power of measuring depression

“Bill” had been dealing with depression since college, which he finished a decade ago. He recently switched jobs, which forced him to change health insurance, and, to his frustration, to change primary care doctors.

Before his first visit with Dr. Johnson, Bill thought he just wanted a refill on his antidepressant and to get back to work. Dr. Johnson had him complete the PHQ-9 and reviewed his results with him. “How long have you been this depressed?” the new doctor asked. Bill said, “I’m not sure what you mean. I had to try several antidepressants in college and this is the one that worked.”

Dr. Johnson said, “Well, I’m glad you found something that worked. It’s just that your score on this rating scale was 12, which indicates moderate depression. If this medication has helped you feel better, I certainly don’t want to mess up your progress, but I also think there is room for improvement in your mood. The goal of depression treatment is to get you to remission, which is full freedom from depression. That might help some of these higher scores on your rating scale, which show that you have concentration problems and low energy.”

Bill continued the conversation with Dr. Johnson about what things he was doing and what things he was avoiding in treating his depression. By the end of his visit, Bill agreed to start exercising by walking 20 minutes per day (before work or on his lunch break) and to increase the dose of his antidepressant to higher in the therapeutic range.

Four weeks later, his PHQ-9 had improved to a score of 7, which still showed mild depressive symptoms, but Bill clearly felt the improvement, and at that visit, he and Dr. Johnson made additional plans to further improve his mood. One plan was that he agreed he would start psychotherapy if his PHQ-9 did not improve to a score of 5 by his next follow-up visit a month later.

Look for annoying patterns and discrepancies

Completing depression rating scales repeatedly over time can be annoying and even demoralizing, especially if you are not getting better. However, they are critical to continue getting better and shine a spotlight on the fact that you are still struggling.

Another important thing to consider is that not all symptoms that are included on a depression rating scale are due to depression. There is overlap among the symptoms of different psychiatric and medical diagnoses. You may list having concentration problems on a depression rating scale but your problems with focusing may be due to untreated ADHD. You may have low energy due to poor sleep that is unrelated to depression, or your low energy might be due to fibromyalgia or chronic fatigue syndrome. If you find that your depression is getting better but you are consistently having elevated scores on certain questions on a depression rating scale, it is an opportunity to explore and improve those specific areas.

Adding rating scales can transform your treatment

Completing the same depression rating scale over time will serve as data for both you and your doctor or therapist. This information can motivate you to keep pushing forward until you are fully free from depression. Many people are surprised at the progress they have made in their depression over time because the improvement in their mood has been gradual. Things that get measured can be improved. Imagine having one more strategy for fighting depression, one that encourages you and your doctor and therapist to take all steps necessary to get fully free of depression.

For further reading, check out:

• Len’s article “The Most Important New Findings in Depression”.

• Len’s article “A Plan for Stubborn Depression”

• Len’s article “Finding a Good Psychiatrist”

• Len’s article “Finding Quality Psychotherapy – Moving Beyond Talk Therapy“

• A Guide to Rational Living by Drs. Ellis and Harper (See Len’s Book Review)

• Mind Over Mood, Second Edition: Change How You Feel by Changing the Way You Think by Drs. Dennis, Greenberger and Padesky (See Len’s Book Review)

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