Clinical Depression

Identification/Assessment Strategies

Several tools are available for performing systematic and objective (a) screening, (b) diagnosis, and (c) monitoring treatment (Galenberg, 2010). Clinical suggestions: Use screening and diagnostic tools routinely to detect and diagnose depression; use patient-rated instruments to save time. Use treatment algorithms and collaborative care to manage depression effectively. Measure depressive symptoms, side effects of treatment, and suicide risk.

(a) Screening tools
Center for Epidemiologic Studies Depression scale (CES-D; Radloff, 1977)
The CES-D is a 20-item scale developed to measure symptoms of depression in community populations. The CES-D has 4 separate factors: Depressive affect, somatic symptoms, positive affect, and interpersonal relations. The CES-D has good internal consistency with alphas of .85 for the general population and .90 for a psychiatric population. Resources: The Center for Epidemiologic Studies Depression Scale (CESD).

9-item Patient Health Questionnaire (PHQ-9; Spitzer, Kroenke, & Williams,  1999)
The PHQ- 9 is a self-report depression assessment tool, derived from the interview-based PRIME-MD. Completion of the instrument takes about 5 minutes. Useful for the diagnosis of major depression in primary care, with acceptable reliability, validity, sensitivity, and specificity (Richardson et al., 2010; Phelan et al., 2010). A shorter version, the PHQ-2, includes the first 2 items of the PHQ-9 and evaluates its presence during the last 2-weeks. (McGuire et al., 2013). Resources: Patient Health Questionnaire (PHQ ) screeners; The MacArthur Initiative on  Depression and Primary Care

The Hospital Anxiety and Depression Scale (HADS; Zigmond, A. S., & Snaith, R. P., 1983)
The HADS is a 14 questions self-rating scale. The scale measures anxiety and depression in both hospital and community settings. The one page scale can be completed in 2 to 5 minutes. The specificity for HADS-A is 0.78 and sensitivity is 0.9. For HADS-D specificity is 0.79 and sensitivity is 0.83 (Bjelland et al., 2002).

Resources: HADScale’s Scoring Sheet.

Zung Self-Rating Depression Scale (Zung SDS; Zung, 1965)
The Zung SDS is a 20-item self-report screening questionnaire, covering affective, psychological and somatic symptoms of depression. Completion takes about 10 minutes. Alpha coefficient ranges from .79 to .88 (Thurver et al., 2002). Monitors changes in depression severity over time (World Health Organization, 2013). Resources: Zung  Depression Scale; Zung Self-Rating Depression Scale.

(b) Diagnostic Instruments
The PHQ-9 and the Zung Depression Scale can be used for diagnosing as well as screening for clinical depression.

(c) Monitoring Instruments
Beck Depression Inventory (BDI; Beck et al., 1961)
The BDI –II is a 21-item self-report inventory measuring the severity of depression in adolescents and adults. The BDI-II is used as an indicator of the severity of depression, but not as a diagnostic tool. The internal scale reliability among older adults and among adults are alpha .86 and alpha .02, respectively. Completion time is about 10 min- utes. Resources: Beck Depression Inventory®–II (BDI®–II).

Hamilton Depression Rating Scale (HDRS; Hamilton, M., 1960)
The HDRS has 17 original items; new versions include as many as 29. Completion of scale takes 20 minutes.  Questions 18-21 may be recorded to give further information about the depression (e.g., diurnal variation or presence of paranoid symptoms), but are not part of the scale. The instrument has acceptable psychometric properties and is available in clinician- and patient-rated versions. Resources: Hamilton Depression Rating Scale.

Quick Inventory of Depressive Symptomatology (QIDS; Rush et al., 2003)
The QIDS is a 16 items instrument that measures similar symptoms as the IDQ. Test-retest reliability’s Cronbach’s alpha= 0.85 for self-rated scale. Resources: The QIDS.

Montgomery-Åsberg Depression Rating Scale (MADRS; Montgomery & Åsberg, 1979)
The MADRS is a 10 items instrument used to assess clients’ mood, feelings of unease, sleep, appetite, ability to concentrate, initiative, emotional involvement, pessimism and zest for life. Higher scores indicate increased depression. The instrument is client or patient administered and completion takes about 20 minutes.

Resources: MADRS Scale.

Other Assessments: Clinically Useful Depression Outcome Scale (CUDOS) is useful to identify remission and assesses psychosocial impairment, and quality of life. Resources: CUDOS.

Adverse effects. The Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale is useful to monitor side effects of depression treatment, as well as their interference with functioning. The scale does not address specific side effects; counselors need to ask about specific concerns. Resources: FIBSER.

Suicidality. Possible suicide and increased suicidal thoughts and behaviors in clients taking antidepressant medications are worldwide concerns. The Columbia Suicide Severity Rating Scale (C-SSRS) is useful to monitor suicidal- ity. Resources: C-SSRS.

Intervention Strategies

Cognitive-based therapies (CT)
Cognitive therapy (CT) is a time limited, collaborative therapy (Beck, 1967). The goals of CT are to change thoughts, improve skills, and modify emotional states that contribute to mental disorders. Cognitive therapy can be applied in multiple ways using techniques from Beck’s (Beck, 1967) cognitive therapy model, Ellis’s (Ellis, 1973; Ellis & Grieger, 1986) rational emotive behavioral therapy model, or Meichenbaum’s (1977) cognitive behavioral modification program, all of whom are major contributors to the field of Cognitive Behavioral Therapy (CBT). CBT treatment for clinical depression is efficacious and specific (Hollow & Ponniah, 2010; Zalaquett & Stens, 2006). Resources: Beck Institute; Academy of Cognitive Therapy; The Association for Behavioral and Cognitive  Therapies; GoodTherapy.org

Interpersonal Psychotherapy (IPT)
Interpersonal psychotherapy (IPT) for depression focuses on interpersonal roles and conflicts (Kennedy & Tanen- baum, 2000). IPT includes three phases of treatment addressing two of four main problem areas: grief, interpersonal disputes, role transition, and interpersonal deficits. Short-term IPT usually involves up to 20 weekly hour- long sessions. IPT treatment for clinical depression is efficacious and specific (Hollow & Ponniah, 2010; Zalaquett & Stens, 2006). Resources: International Society for Interpersonal Psychotherapy; Interpersonal Therapy for depression; Interpersonal Psychotherapy: An overview:

Behavior Therapy (BT)
Behavioral interventions include contextual approaches based on functional analyses (contingency management and behavioral activation), social skills training, self-control therapy, problem-solving therapy, and behavioral marital therapy. Common therapeutic strategies include self-monitoring, self-reinforcement, graded task assignments, activity scheduling, and targeted improvements in social skills through assertiveness training, modeling, and role-playing. Relaxation training is used to cope with anxiety or insomnia. BT treatment for clinical depression is efficacious and specific (Hollow & Ponniah, 2010; Zalaquett & Stens, 2006). Resources: Behavior Therapy vs.Cognitive Therapy For Depression: Here We Go Again.

Brief Dynamic Therapy (BDT)
BDT explores unconscious processes, process lifetime developmental issues, and facilitates client insight and life changes. Main goal is to increase insight into the unconscious processes by leading clients to repeat past experiences and to institute corrective experiences through the interaction with their therapists (Nordhus & Nielsen, 1999); transference and countertransference are important (Gatz et al., 1998). BDT treatment for clinical depression is possible efficacious (Hollow & Ponniah, 2010). Resources: Brief Dynamic Therapy; Short-Term Psychodynamic  Therapy for Depression:

Emotionally focused therapy (EFT)
Emotionally focused therapy (EFT) is a short-term (8-20 sessions) structured therapeutic approach to working with individuals, couples and families. It is based in attachment theory but includes elements of experiential, person-centered, constructivist, and systems theory. EFT treatment for clinical depression is possible efficacious (Hollow & Ponniah, 2010). Resources: The International Centre for Excellence in Emotionally Focused Therapy  (ICEEFT ); FAQ’s - Emotion Focused Therapy.
Newer psychological interventions are as efficacious as medication in the treatment of clinical depression (Hollon& Ponniah, 2010).

Other therapeutic options
Antidepressant medication, repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and electroconvulsive therapy (ECT).

Additional Resources
The Macarthur Initiative on Depression and Primary Care: Depression Management Tool Kit.
The Center for the Study of Traumatic Stress: Courage to Care – Depression in Primary Care.

The Importance of Cultural Constructs
A culturally-sensitive therapeutic approach is of essence. There are recognized cross-cultural variations in present- ing symptoms of depression. For example, guilt, self-blame, amount of suicidal ideation, and somatization vary across different U.S. cultural groups. Considerable variability between countries in the management of clinical de- pression led to the development of the International Consensus Statement on Major Depressive Disorder. Experts adapted Japan’s treatment algorithm and offered specific recommendations for screening, diagnosing, and treating depression. Resources: International Consensus Statement on Major Depressive Disorder.

Hollon, S. D., & Ponniah, K. (2010). A review of empirically supported psychological therapies for mood disorders in adults. Depression and Anxiety. 27, 891–932. doi: 10.1002/da.20741PMCID: PMC2948609

Kennedy, G. J., & Tanenbaum, S. (2000). Psychotherapy with older adults. American Journal of Psychotherapy, 54, 386–407.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve- month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62, 617-27.

Kroenke. K,. Spitzer, R., L,, & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care. 41, 1284–1292. doi:10.1097/01.MLR.0000093487.78664.3C

Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. New York: Plenum.

McGuire, A. W., Eastwood, J., Macabasco-O’Connell, A., Hays, R. D., & Doering, L. V. (2013). Depression screening: Utility of the patient health questionnaire in patients with acute coronary syndrome. American Journal of Critical Care, 22, 12-19.

Montgomery, S. A., & Åsberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382–389. doi:10.1192/bjp.134.4.382

National Instititute of Mental Health (2013, a). Major depressive disorder among adults. Downloaded from http://www.nimh.nih.gov/statistics/1MDD_ADULT.shtml

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Nordhus, I. H., & Nielsen, G. H. (1999). Brief dynamic psychotherapy with older adults. Journal of Clinical Psychiatry, 55, 935–947.

Phelan, E., Williams, B., Meeker, K., Bonn, K., Frederick, J., LoGerfo, J., & Snowden, M. (2010). A study of the diagnostic accuracy of the PHQ-9 in primary care elderly. BMC Family Practice, 11, 63-72.

Radloff, L.S. (1977). The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. doi:10.1177/014662167700100306

Richardson, L. P., McCauley, E., Grossman, D. C., McCarty, C. A., Richards, J., Russo, J. E., Rockhill, C., & Katon, W. (2010). Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics, 126, 6, . DOI: 10.1542/peds.2010-0852

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Rush, A. J., Trivedi, M.H., Ibrahim, H. M., et al. (2003). The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biological Psychiatry, 54, 573–583. doi:10.1016/S0006-3223(02)01866-8

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Spitzer, R. L., Kroenke, K., Williams. J. B. (1999). Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. Journal of the American Medical Association, 282, 1737–1744. doi: 10.1001/jama.282.18.1737

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