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2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 91 ± 94
91
Hamilton Depression Scale in dementia SEMION G KERTZMAN1, ILAN A TREVES2 , THERESE A TREVES1 , M VAINDER 3 AND AMOS D KORCZYN1,3
Int J Psych Clin Pract Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
1
Department of Neurology, Tel Aviv Medical Center; 2Shalvata Mental Health Center, Hod Hasharon; 3Sackler School of Medicine, Tel Aviv University, Israel
Wide variations in frequency of depression in primary degenerativ e dementia (PDD) and in vascular dementia (VD) have been reported. This may perhaps be due to inadequacy of common diagnostic tools in detecting depression in the face of cognitive decline. We evaluated here the Hamilton Depression Rating Scale (HDRS) in demented patients with PDD and VD. INTRODUCTION:
We examined 50 consecutive patients with PDD and 50 consecutive patients with VD. All patients underwent neurological examination and their depression was evaluated using DSM-III-R criteria and the HDRS. The data obtained were analysed for distribution of depression and pattern of responses obtained in the HDRS. Sensitivity, specificity and Youden’ s J-indices for different cut-off scores of the HDRS in its ability to detect depression in this population were calculated. METHODS:
Dementia was associated with depression in 38% of the patients (DSM-III-R criteria). HDRS scores were higher in depressed patients (z=75.7, P50.0001) with an HDRS cut-off score of 10 being indicative of depression in demented patients. Symptoms related to `affective’ components of the HDRS (such as depressive mood and anxiety) were strongly associated with the diagnosis of depression (Mann-Whitney tests, P50.0001). RESULTS:
Correspondence Address Professor AD Korczyn, Sieratzki Chair of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv 69978, Israel Fax (972-3)-6409113
Depression is frequent in demented patients. The HDRS has good criterion validity in the evaluation of depression in demented patients. (Int J Psych Clin Pract 2002; 6: 91 ± 94) CONCLUSION:
Received 10 May 2000; revised 13 January 2002; accepted for publication 21 February 2002
Keywords primary degenerative dementia vascular dementia Hamilton Depression Rating Scale
INTRODUCTION
D
epression is a common symptom accompanying dementia of the primary degenerative type (PDD), such as Alzheimer’s disease, or dementia of vascular origin.1,2 Data on the frequency of depression among patients with PDD or vascular dementia (VD) are not always consistent: estimates of depression range from 0% to 87% in PDD 2 ± 11 and from 19% to 27% in VD.2,8 ± 10 Reding et al, 7 Fisher et al10 and Kashivas e et al8 found that depression is more common in PDD than in VD, but Cummings et al9 reported the opposite. This discrepanc y possibly results from the application of different diagnostic methods and criteria, but may also reflect selection biases, such as stage of the disease and degree of coexistent
Alzheimer’s Disease depression
somatic disabilit y (e.g., following a stroke), as well as confusion about terms and definitions . The Hamilton Depression Rating Scale (HDRS), originally devised for patients with primary affective disorders, has emerged as a popular measure of the severity of depression (although of course it cannot replace the clinical diagnosis) .12,13 In a previous study, we have demonstrated that the HDRS is valid for the evaluation of depression in patients with Parkinson’ s disease.14 The use of the HDRS as a suitable tool for the evaluation of depression in dementia has been assessed repeatedly, 2,3,8,9,11,15,16 but cut-off scores, when provided, were arbitrarily set.2,8,9,16 Therefore the sensitivit y and specificit y of the HDRS in the detection of depression in dementia is still of interest.
92
SG Kertzman et al
In the present paper we attempt to evaluate the contribution of the HDRS to the diagnosi s of depressio n in patients with dementia.
Int J Psych Clin Pract Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
PATIENTS AND METHODS The study population consisted of 50 consecutive PDD and 50 consecutive VD patients who were examined at our Memory Disorders Clinic between July and December 1992. Information was obtained from the patients and caregivers , using open interviews. Dementia and depressio n (and their type) were diagnosed according to DSM-III-R criteria 17 by the same neurologis t (T.A.T.). Alzheimer’ s Disease (AD) was diagnosed based on the NINCDS-ADRDA criteria. 18 Patients who had features of both PDD (or AD) and VD (defined as ``mixed type’’) were excluded from the study. Further evaluations of cognitive status and depression were performed independentl y by another physician (S.G.K.), using the Mini-Mental State Examination (MMSE),19 and the Hamilton Depression Rating Scale (HDRS). 12
STATISTICAL ANALYSIS Chi-squar e was used for the analysis of gender and diagnosi s distributions and the t-test for comparison of age, schooling and duration of dementia in the different subgroups. The MMSE and the HDRS scores among the different groups were compared using the Mann-Whitney U-test, with Bonferroni correction for multiple comparisons. The association between the MMSE and the HDRS scores was evaluated using the Spearman correlation. Youden J-indices20 were calculated from the sensitivit y and specificit y assessed at cut-off scores suggested by other authors for the HDRS in non-demented patients,8,9,12,13 with the clinical diagnosi s of depression (DSM-III-R criteria) taken as the `gold standard’.
All the PDD patients fulfilled the NINCDS-ADRDA criteria for probable Alzheimer’ s Disease. The PDD and VD groups were similar in age, gender, educational level and duration of disease, but the PDD patients had lower MMSE scores (Table 1). Depression (DSM-III-R criteria) was diagnose d in 38% of the patients; it was more common among VD (48%) than among PDD patients (28%, Table 2). Patients with depression , as assesse d by the DSM-III-R criteria, had significant ly higher HDRS scores than patients with no depression (Table 2). Only one patient with depressio n (in the PDD group) had an HDRS score lower than 7. HDRS scores were higher among VD than among PDD patients with depression (Table 2). The sensitivity, specificity , and positive and negative predictive values of the HDRS for different scores are given in Table 3. J-indices indicate that an HDRS score of 10 is the optimal cut-off score for detecting depressio n in demented patients (Table 3). The degree of cognitive impairment was not associated with HDRS scores (r=0.04, P=0.34). Depressed mood, suicidal ideation, feeling of guilt and late insomnia were items for which grading was significant ly higher among depressed than among non-depresse d patients (P50.002 for each of them, Mann-Whitney test with Bonferroni correction). General symptoms (such as loss of energy), agitation and loss of insight were not significantl y differently reported by the depressed as compared with the non-depresse d patients (Table 4).
DISCUSSION At the time the study was initiated, the DSM-III criteria were being used. However, in terms of depressio n and dementia, they are similar to the DSM-IV criteria. The depressiv e symptoms observed in our patients were like
Table 2 Frequency distribution of depression in PDD and VD as evaluated from DSM-III-R criteria and Hamilton Depression Rating Scale (HDRS)
Table 1 Patients’ characteristics
Age (years) (SD) Males/females Schooling (years) (SD) MMSE (median) Duration of dementia (years)
RESULTS
PDD (N=50)
VD (N=50)
72 (8) 17/33 6.7 (3) 22 4.5 (1.6)
71 (3) 22/28 7.3 (3) 24 4.9 (2.2)
The groups of primary degenerative dementia (PDD) and vascular dementia (VD) patients did not differ significantly in age, gender distribution, schooling, or the degree or duration of dementia. MMSE=score on Mini-Mental State Examination.
PDD Depression present (DSM-III-R) n HDRS score - median Depression absent n HDRS score - median
VD
Total
14 13
24 15
38 14
36 6
26 9
62 7.5
Note that depression was more frequent in VD than in PDD cases (w2=7.3, P=0.007). HDRS scores were significantly higher in depressed patients (U=361, P
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 91 ± 94
91
Hamilton Depression Scale in dementia SEMION G KERTZMAN1, ILAN A TREVES2 , THERESE A TREVES1 , M VAINDER 3 AND AMOS D KORCZYN1,3
Int J Psych Clin Pract Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
1
Department of Neurology, Tel Aviv Medical Center; 2Shalvata Mental Health Center, Hod Hasharon; 3Sackler School of Medicine, Tel Aviv University, Israel
Wide variations in frequency of depression in primary degenerativ e dementia (PDD) and in vascular dementia (VD) have been reported. This may perhaps be due to inadequacy of common diagnostic tools in detecting depression in the face of cognitive decline. We evaluated here the Hamilton Depression Rating Scale (HDRS) in demented patients with PDD and VD. INTRODUCTION:
We examined 50 consecutive patients with PDD and 50 consecutive patients with VD. All patients underwent neurological examination and their depression was evaluated using DSM-III-R criteria and the HDRS. The data obtained were analysed for distribution of depression and pattern of responses obtained in the HDRS. Sensitivity, specificity and Youden’ s J-indices for different cut-off scores of the HDRS in its ability to detect depression in this population were calculated. METHODS:
Dementia was associated with depression in 38% of the patients (DSM-III-R criteria). HDRS scores were higher in depressed patients (z=75.7, P50.0001) with an HDRS cut-off score of 10 being indicative of depression in demented patients. Symptoms related to `affective’ components of the HDRS (such as depressive mood and anxiety) were strongly associated with the diagnosis of depression (Mann-Whitney tests, P50.0001). RESULTS:
Correspondence Address Professor AD Korczyn, Sieratzki Chair of Neurology, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv 69978, Israel Fax (972-3)-6409113
Depression is frequent in demented patients. The HDRS has good criterion validity in the evaluation of depression in demented patients. (Int J Psych Clin Pract 2002; 6: 91 ± 94) CONCLUSION:
Received 10 May 2000; revised 13 January 2002; accepted for publication 21 February 2002
Keywords primary degenerative dementia vascular dementia Hamilton Depression Rating Scale
INTRODUCTION
D
epression is a common symptom accompanying dementia of the primary degenerative type (PDD), such as Alzheimer’s disease, or dementia of vascular origin.1,2 Data on the frequency of depression among patients with PDD or vascular dementia (VD) are not always consistent: estimates of depression range from 0% to 87% in PDD 2 ± 11 and from 19% to 27% in VD.2,8 ± 10 Reding et al, 7 Fisher et al10 and Kashivas e et al8 found that depression is more common in PDD than in VD, but Cummings et al9 reported the opposite. This discrepanc y possibly results from the application of different diagnostic methods and criteria, but may also reflect selection biases, such as stage of the disease and degree of coexistent
Alzheimer’s Disease depression
somatic disabilit y (e.g., following a stroke), as well as confusion about terms and definitions . The Hamilton Depression Rating Scale (HDRS), originally devised for patients with primary affective disorders, has emerged as a popular measure of the severity of depression (although of course it cannot replace the clinical diagnosis) .12,13 In a previous study, we have demonstrated that the HDRS is valid for the evaluation of depression in patients with Parkinson’ s disease.14 The use of the HDRS as a suitable tool for the evaluation of depression in dementia has been assessed repeatedly, 2,3,8,9,11,15,16 but cut-off scores, when provided, were arbitrarily set.2,8,9,16 Therefore the sensitivit y and specificit y of the HDRS in the detection of depression in dementia is still of interest.
92
SG Kertzman et al
In the present paper we attempt to evaluate the contribution of the HDRS to the diagnosi s of depressio n in patients with dementia.
Int J Psych Clin Pract Downloaded from informahealthcare.com by QUT Queensland University of Tech on 10/31/14 For personal use only.
PATIENTS AND METHODS The study population consisted of 50 consecutive PDD and 50 consecutive VD patients who were examined at our Memory Disorders Clinic between July and December 1992. Information was obtained from the patients and caregivers , using open interviews. Dementia and depressio n (and their type) were diagnosed according to DSM-III-R criteria 17 by the same neurologis t (T.A.T.). Alzheimer’ s Disease (AD) was diagnosed based on the NINCDS-ADRDA criteria. 18 Patients who had features of both PDD (or AD) and VD (defined as ``mixed type’’) were excluded from the study. Further evaluations of cognitive status and depression were performed independentl y by another physician (S.G.K.), using the Mini-Mental State Examination (MMSE),19 and the Hamilton Depression Rating Scale (HDRS). 12
STATISTICAL ANALYSIS Chi-squar e was used for the analysis of gender and diagnosi s distributions and the t-test for comparison of age, schooling and duration of dementia in the different subgroups. The MMSE and the HDRS scores among the different groups were compared using the Mann-Whitney U-test, with Bonferroni correction for multiple comparisons. The association between the MMSE and the HDRS scores was evaluated using the Spearman correlation. Youden J-indices20 were calculated from the sensitivit y and specificit y assessed at cut-off scores suggested by other authors for the HDRS in non-demented patients,8,9,12,13 with the clinical diagnosi s of depression (DSM-III-R criteria) taken as the `gold standard’.
All the PDD patients fulfilled the NINCDS-ADRDA criteria for probable Alzheimer’ s Disease. The PDD and VD groups were similar in age, gender, educational level and duration of disease, but the PDD patients had lower MMSE scores (Table 1). Depression (DSM-III-R criteria) was diagnose d in 38% of the patients; it was more common among VD (48%) than among PDD patients (28%, Table 2). Patients with depression , as assesse d by the DSM-III-R criteria, had significant ly higher HDRS scores than patients with no depression (Table 2). Only one patient with depressio n (in the PDD group) had an HDRS score lower than 7. HDRS scores were higher among VD than among PDD patients with depression (Table 2). The sensitivity, specificity , and positive and negative predictive values of the HDRS for different scores are given in Table 3. J-indices indicate that an HDRS score of 10 is the optimal cut-off score for detecting depressio n in demented patients (Table 3). The degree of cognitive impairment was not associated with HDRS scores (r=0.04, P=0.34). Depressed mood, suicidal ideation, feeling of guilt and late insomnia were items for which grading was significant ly higher among depressed than among non-depresse d patients (P50.002 for each of them, Mann-Whitney test with Bonferroni correction). General symptoms (such as loss of energy), agitation and loss of insight were not significantl y differently reported by the depressed as compared with the non-depresse d patients (Table 4).
DISCUSSION At the time the study was initiated, the DSM-III criteria were being used. However, in terms of depressio n and dementia, they are similar to the DSM-IV criteria. The depressiv e symptoms observed in our patients were like
Table 2 Frequency distribution of depression in PDD and VD as evaluated from DSM-III-R criteria and Hamilton Depression Rating Scale (HDRS)
Table 1 Patients’ characteristics
Age (years) (SD) Males/females Schooling (years) (SD) MMSE (median) Duration of dementia (years)
RESULTS
PDD (N=50)
VD (N=50)
72 (8) 17/33 6.7 (3) 22 4.5 (1.6)
71 (3) 22/28 7.3 (3) 24 4.9 (2.2)
The groups of primary degenerative dementia (PDD) and vascular dementia (VD) patients did not differ significantly in age, gender distribution, schooling, or the degree or duration of dementia. MMSE=score on Mini-Mental State Examination.
PDD Depression present (DSM-III-R) n HDRS score - median Depression absent n HDRS score - median
VD
Total
14 13
24 15
38 14
36 6
26 9
62 7.5
Note that depression was more frequent in VD than in PDD cases (w2=7.3, P=0.007). HDRS scores were significantly higher in depressed patients (U=361, P
