Every patient, every visit: Routine tests yield clinically useful data

Box 2

By analyzing Mini-SCID data from >1,000 of our outpatients, we learned that this screening test can improve our diagnosis of bipolar disorder in patients presenting with depressive symptoms (Box 1).²

Symptom Checklist-90 (SCL-90). This tool adds another layer of support for bipolar illness diagnosis (Box 1). It also is useful in conjunction with rating scales specific to other diagnostic categories, such as depression and anxiety.

The SCL-90³ consists of 90 statements that measure the severity of 9 dimensions of psychopathology: somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Using a scale of 0 (not at all) to 4 (a great deal), patients rate how much they are bothered by the feelings expressed in each statement.

In its standard scoring, the SCL-90 returns a score for 9 scales. Hunter et al⁴ developed an alternate set of 8 scales that uses SCL-90 questions to screen for depression, mania, schizophrenia, antisocial personality disorder, somatization disorder, obsessive-compulsive disorder, panic disorder, and agoraphobia. These SCL-90 diagnostic scales showed good reliability as an aid to the Mini-SCID in identifying diagnoses among 1,457 adult psychiatric outpatients.

Temperament evaluation. The Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS) is a 39-item, self-report scale designed to measure 5 different temperaments: cyclothymic, depressive, irritable, hyperthymic, and anxious.⁵ It is especially useful for identifying bipolar spectrum patients (Box 2).⁶

Clinical Global Impressions scale. The CGI uses a 7-point Likert scale to describe the clinician’s impression of change in a patient’s condition. This scale:

• transcends symptom checklists by incorporating knowledge of the patient’s history, symptoms, and behaviors
  
• lends itself easily to repeated measures of change and severity of the condition being rated.¹
  

I use the CGI-Severity scale for baseline assessment and the CGI-Change when I see patients on follow-up.

Every office visit

At the screening visit and before every office visit, my patients complete 2 depression rating tests to document changes between visits and over time: a visual analog scale (VAS) and the QIDS.

The VAS’ 10-cm line with the left side marked “worst ever” and the right side marked “best ever” is a simple tool. It captures patients’ subjective impressions of their mood states in answer to the question, “How do you feel today?” I used the VAS as an outcome measure in a study of modafinil augmentation of antidepressant therapy.⁷

The QIDS is a 16-item screen that measures 9 depressive symptoms.⁸ It has been validated against the Hamilton Depression Rating Scale (HAM-D)⁹ and was used as the outcome measure in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.¹⁰ The QIDS-16 is available online for free use in many languages (see Related Resources).¹¹

The QIDS-16 allows you to track the severity of each depressive symptom and provides an overall depression score. It includes 3 questions on insomnia (for early, middle, and late symptoms) and 1 on hypersomnia. Routine use of the QIDS-16 provided data for a poster on the high frequency of persistent insomnia in 145 consecutive outpatients in our practice whose depressive symptoms were in remission.¹²

Until recently, our office performed routine depression screening with the 52-item Carroll Depression Rating Scale (CDRS),¹³ a self-administered inventory designed to mirror results from the HAM-D. I published articles using the CDRS as the primary outcome measure in a chart review of long-term effectiveness of antidepressant monotherapy (Box 3)^13,14 and in a study of modafinil’s effectiveness as adjunctive therapy in patients with unipolar depression.⁷