Self-reports include the Beck Depression Inventory-II (BDI-II),20 the Hospital Anxiety Depression Scale,21 the Zung Depression Rating Scale,22 the 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16),23-25 and the Patient Health Questionnaire-9 (PHQ-9) depression screener.26 The QIDS-SR16 has been found to correspond highly with the clinician-rated version of the QIDS (QIDS-C16). Given the importance of remission, we recommend using those scales that include all the DSM-IV symptom domain criteria for the diagnosis of a major depressive episode—the BDI-II, PHQ-9, and QIDS-SR16—because symptom remission can only be established if all symptom criteria are measured. Both the BDI-II and the PHQ-9 are excellent symptom measures; however, the BDI-II is not in the public domain. The QIDS-SR16, QIDS-C16, and PHQ-9 are available without cost.
Most adverse-effect ratings in clinical research entail a long list of items that were developed for medications undergoing regulatory approval, which precludes easy adoption in practice. The simple 3-item self-report questionnaire called the Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) Scale was developed to gauge adverse effects easily.27 The burden subscale is highly related (not surprisingly) to the frequency and intensity subscale and thus should be sufficient for daily practice. Again, the idea is to provide a metric on which you can collaborate with patients to assess the adverse-effect cost involved in achieving benefit with a specific treatment. A treatment may produce remission but at the cost of significant adverse effects. On the other hand, careful monitoring of the nature and burden of adverse effects may also allow the clinician to address these effects in a timely manner, thereby enhancing patient adherence and satisfaction with care.
After the diagnosis, symptom severity, effect of treatment, and overall adverse effects are established by self-report, but the clinician must decide when and how to modify the treatment when results are suboptimal. Treatment guidelines or algorithms are available for guidance. Algorithms typically recommend regimens for various treatment steps and outline how to use these treatments (starting dosage, dosage titrations, preferred duration of treatment). In the TMAP, we found that patients who received MBC that consisted of symptom and adverse-effect assessment at each treatment visit combined with algorithms-based guidance had better outcomes than did those who obtained symptom reduction with treatment as usual (Figure).11,12
The STAR*D trial found that MBC was easily implemented in busy primary care and psychiatric practice settings.13,14 Clinicians in STAR*D indicated that MBC helped ensure that patients received optimal doses and timely medication changes. Patients also found that such ratings were highly acceptable both in acute and longer-term treatment.
A 39-year-old presented with her third episode of nonpsychotic major depressive disorder. She also had concurrent panic and generalized anxiety disorders. After 4 weeks of treatment with escitalopram (10 mg/d), she reported no effect on her depression symptoms. Her global adverse-effect burden rating was mild. However, her QIDS-SR16 score had decreased from 20 to 15 (a 25% reduction). Rather than switching or adding a treatment, the clinician increased the dosage of escitalopram to 20 mg/d.
When evaluated at week 8, the patient reported that she might be “a little bit better.” Her QIDS-SR16 score was 11. Adverse effects were moderate. She was encouraged to continue with the regimen, and no new treatments were added. By week 12, the patient noted that she was “better but not well.” Her QIDS-SR16 score had dropped to 8. Treatment continued unaltered. By week 16, the QIDS-SR16 score was up to 14, but the patient noted that her marital difficulties had escalated in the prior week. Couples therapy was added to the regimen, but the medication was unchanged. At weeks 20 and 24, her QIDS-SR16 scores were 8 and 4, respectively.
This case illustrates the utility of MBC. It allows the clinician to tailor therapy to the patient and in this case may have prevented the premature or unnecessary addition of an adjunctive therapy or a switch to another treatment.
Optimizing treatment is essential in managing chronic or recurrent depression. When depression recurs during therapy, some patients are reluctant to tell their physician. Monthly self-report symptom measurements can help you gauge the nature and degree of symptom stability (or daily function). We believe this information increases the timely detection of relapses or may document continuing remission with greater certainty. Ultimately, self-reports provide a more accurate appraisal of longer-term outcomes and enhance the likelihood of timely and appropriate treatment revisions when needed.