Journal of Clinical Geropsychology, Vol. 5, No.

4, 1999

Effectiveness of the Hamilton Anxiety Rating Scale

with Older Generalized Anxiety Disorder Patients
J. Gayle Beck,1 Melinda A. Stanley,2 and Barbara J. Zebb3

To expand the collection of instruments available for assessment of anxiety in the elderly,
this report examined the original and revised Hamilton anxiety scales in a sample of 50 older
adults diagnosed with Generalized Anxiety Disorder (GAD) and 93 normal community par-
ticipants (ages 55—82). Although the revised anxiety scale had better discriminant validity
(lower correlation with the revised Hamilton depression scale) than the original anxiety and
depression scales, a considerable amount of shared variance still existed (41% shared vari-
ance, GAD sample alone; 17% control sample alone; 74% shared variance, both samples
combined). Near-perfect group classification was possible using 7 items from the original
anxiety scale and 10 items from the revised anxiety scale. Results are discussed in light of
their implications for use of the Hamilton anxiety rating scale with older anxiety-disordered
patients.
KEY WORDS: Hamilton Anxiety Rating Scale; generalized anxiety; elderly.

INTRODUCTION

Given increasing attention to anxiety disorders in older adults (Hersen and Van Hasselt,
1992; Salzman and Lebowitz, 1991), the need for information about specific assessment
strategies is clear. As discussed previously (e.g., Hersen et al., 1993; Stanley and Beck,
1997), it is unwise to assume that measures that have been validated with samples of younger
adults will necessarily prove valid or sound when used with older adults. Given that the
phenomenology of anxiety may be different in older adults (e.g., Lawton et al., 1993),
careful consideration of specific clinician-rated and self-report measures is warranted prior
to their inclusion in larger-scale studies of the psychopathology and treatment of anxiety in
older adults.
The initial steps in this process have been taken, as several investigations have exam-
ined measurement characteristics of self-report instruments when used with older adults
(e.g., Beck et al., 1995; Himmelfarb and Murrell, 1983; Kabacoff et al., 1997; Patterson
1
Department of Psychology, State University of New York at Buffalo, 230 Park Hall, Buffalo, NY 14260; e-mail:
jgbeck@acsu.buffalo.edu.
2
Department of Psychiatry, University of Texas Health Sciences Center.
3
Department of Psychology, State University of New York at Buffalo; Currently, Department of Psychology, Texas
Tech University.

281
1079-9362/99/1000-0281$16.00/0© 1999 Plenum Publishing Corporation
282 Beck et al.

et al., 1980; Stanley et al., 1996). Of equal importance are investigations into the reliability
of semistructured interviews when administered to older adults. For example, Segal et al.
(1993) reported good interrater reliability (IRR) for the general category of anxiety disorders
(kappa = 0.77) with the Structured Clinical Interview for DSM-III-R (Spitzer et al., 1988),
using relatively inexperienced interviewers. These results were replicated (Segal et al.,
1995) and suggest that semistructured interviews can be used reliably to diagnose psychi-
atric problems in older adults. Similarly, using the Anxiety Disorders Interview Schedule
(DiNardo and Barlow, 1988), Beck et al. (1996) report excellent IRR (kappa = 1.00) for the
diagnoses of Social Phobia, Specific Phobia, and Panic Disorder and moderate reliability
(kappa = 0.58) for Major Depressive Episode, in a sample of older adults diagnosed with
Generalized Anxiety Disorder. Thus, it would appear that semistructured interviews that
are commonly employed in research on the anxiety disorders can be used reliabily with
older adults.
Although this represents an advance in the assessment of older adults, it is necessary to
augment categorical diagnostic instruments with clinician measures that provide symptom
ratings on a continuous scale. In particular, the Hamilton Anxiety Rating Scale (HARS;
Hamilton, 1959) is often used to assess somatic and psychological symptoms of anxiety.
The HARS has the advantage of providing a quantitative measure of anxiety symptoms,
which can be interpreted against a substantial database (e.g., Rapee and Barlow, 1991).
However, it is unclear how the HARS performs with older anxious patients, particularly
given the overlap between somatic symptoms of anxiety (e.g., muscle tension) and medical
ailments that are common in aging individuals.
Additionally, concern has been expressed that the HARS confounds the measure-
ment of anxiety and depression (e.g., Mountjoy and Roth, 1982; Riskind et al., 1987).
Toward the goal of better distinguishing these two clinician-rated measures, Riskind et al.
(1987) reconstructed the HARS and its companion scale, the Hamilton Rating Scale of
Depression (HRSD; Hamilton, 1960) to enhance their construct and discriminant valid-
ity. The revised scales consist of item sets that were empirically and rationally selected
from the original HARS and HRSD and seem to provide non-overlapping assessment
of anxiety and depression. In their report, Riskind et al. (1987) noted that the recon-
structed scales had higher internal consistency, better differentiated patients with Major
Depressive Disorder from those with Generalized Anxiety Disorder (GAD), and were
less highly correlated (r = .15) than the original HARS and HRSD. However, a sub-
sequent examination using a large sample of anxiety-disorder patients with and with-
out comorbid depressive disorders (Moras et al., 1992) indicated that the reconstructed
scales shared considerable variance (r = .61) and did not improve discrimination be-
tween those patients with and without comorbid mood disorders, relative to the original
scales.
Given this concern, it is important to explore the measurement qualities of the HARS
when used with older adults. In particular, some authors have noted that anxiety and depres-
sion may be indistinguishable in older adults, given close covariation of these symptoms
in older adults, although these studies have tended to rely exclusively on self-reported
symptoms (e.g., Larkin et al., 1992; Parmelee et al., 1993). The intent of this report is to
examine specific properties of the original and revised Hamilton anxiety scales in a sample
of older adults with GAD and older normal control participants (ages 55-82). This report
focuses on three issues: (1) the internal consistency of the original and revised Hamilton
anxiety scales; (2) intercorrelations with the original and revised versions of the HRSD and