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Monitoring Improvement Using A Patient Rated Depression Scale During Treatment With Anti Depressants in General Practice A Validation Study On The
Monitoring Improvement Using A Patient Rated Depression Scale During Treatment With Anti Depressants in General Practice A Validation Study On The
Monitoring Improvement Using A Patient Rated Depression Scale During Treatment With Anti Depressants in General Practice A Validation Study On The
To cite this article: Jørgen Holm, Liselotte Holm, Per Bech (2001) Monitoring improvement using
a patient-rated depression scale during treatment with anti-depressants in general practice. A
validation study on the Goldberg Depression Scale, Scandinavian Journal of Primary Health Care,
19:4, 263-266, DOI: 10.1080/02813430152706819
Scand J Prim Health Care 2001;19:263– 266. ISSN 0281-3432 berg Depression Scale was demonstrated. The Loevinger co-
ef cient varied from 0.25 at the time of diagnosis to 0.57, 0.65 and
ObjectiØe – To perform a pilot study on the value of the Goldberg 0.69 by visits two, three and four. Factor analysis identi ed only one
Depression Scale as an instrument for monitoring improvement in general factor explaining 50% or more of the variants, except at visit
depressed patients treated with anti-depressants in general practice. 1. When the Goldberg Depression Scale was correlated to the
Design – A comparative study using simultaneous ratings on the Hamilton Depression Scales, a coef cient of 0.74 was obtained
observer-based 17-item Hamilton Depression Scale and the patient- (p B0.001).
rated Goldberg Depression Scale. Conclusion – This pilot study indicates that the Goldberg Depression
Setting – General practice. Scale is suitable for monitoring improvement in depressed patients
Patients – Twenty-one patients meeting the ICD-10 criteria of a treated in general practice. Further studies are recommended.
moderate depressive episode were assessed at the time of inclusion
and through three follow-up visits. Key words: depression, rating scales, primary health care.
Main outcome measures – Scores on the Goldberg Depression Scale
compared to the Hamilton Depression Scale. Jørgen Holm, General Practice, Klosterplads 9, DK-5700 SØ end-
Results – An acceptable internal and external validity of the Gold- borg, Denmark. E-mail: jorgenholm@dadlnet.dk
General practitioners (GPs) are currently under criti- tient-friendly as possible in ensuring a high degree of
cism for inef ciency in the detection and treatment of applicability in the general practice setting.
the majority of depressed patients (1,2). In this re- The Goldberg Depression Scale (GDS) (8) was the
gard, it may indeed seem strange that, in everyday questionnaire selected as being patient-friendly by the
practice, so little effort is made to monitor the state general practitioner involved in this study. The objec-
of patients during treatment. Few doctors would like tive of this pilot study has been to investigate the
to do without tools when dealing with asthma. value of the Goldberg Depression Scale as an instru-
There are a number of depression rating scales ment for monitoring the improvement of depressed
available today, the Hamilton Depression Scale patients treated in general practice.
(HAM-D) (3) probably being the best known and the
gold standard in research studies. HAM-D is an
observer-rated scale and requires some instruction in METHODS
its use. It has been shown, however, that even experi- Nine general practitioners were recruited (through
enced psychiatrists demonstrate considerable inter- advertising) as clinical investigators and received
observer variation performing a HAM-D score on training in the use of HAM-D.
one and the same patient (4). There are also validated
patient-rated scales available, such as the Zung De- Scales
pression Scale (5) and Beck’s Depression Inventory The Goldberg Depression Scale. The GDS is an
(6), but these have been used as research tools rather 18-item self-rating scale (Fig. 1), with each item rated
than for clinical purposes, and neither has been on a 0 – 5 point Likert scale. The total score can
adopted by general practice to any signi cant extent. therefore range from 0 (complete absence of depres-
In the 1990s, the development of new question- sive symptoms) to 90 (most severe depression). The
naires was concerned, on the one hand, with content GDS was translated into Danish by the authors and
validity covering the DSM-IV dimension of major back-translated into American English. This back-
depression (7) and, on the other, with being as pa- translated version was accepted by Goldberg himself.
The Hamilton Depression Scale. The 17-item ver- For questionnaires like the GDS, the test –retest
sion of the HAM-D followed the original version (3), reliability is often discussed but rarely used. Thus, the
but has been further improved. This Danish version test – retest analysis has to rely on a very stable condi-
was endorsed by Hamilton himself (9) and has been tion of the patient between test and retest. In this
used in several Danish and Scandinavian trials pilot study of the acute therapy of depressive patients
(10,11). The score range of this scale is from 0 (no the situation was not suited for a test –retest
depressive symptoms) to 52 (most severe depression); examination.
the cut-off score for major depression is 18, while full
remission is a score of 7 or lower (9). Validity. The validity of a scale covers both inter-
nal and external validity. Internal validity covers the
Patients extent to which the total score is a suf cient statistic.
Patients ful lling the ICD-10 criteria of an at least Factor analysis has been used to measure the internal
moderate depressive episode demanding medical consistency of the GDS. Thus, an overall, general
treatment were included. They were assessed by GDS factor is indicative of internal validity. The factor
and HAM-D at inclusion and over the course of analysis is extremely sensitive to the dispersion of
three follow-up visits. The doctors were blinded to scale scores in the population investigated (13,14).
the GDS scores. Exclusion criteria were conditions The Loevinger coef cient of homogeneity is a test of
precluding the patients from handling a self-rating uni-dimensionality, i.e. of the summed total score
questionnaire, e.g. dementia or visual impairment. A being a suf cient or adequate statistic. Coef cients of
total of around 20 patients was found suf cient for 0.30 or higher indicate homogeneity or uni-dimen-
testing the validity of the GDS in this pilot study. sionality. The GDS has been compared to the HAM-
D for Loevinger coef cients.
Statistical analysis An essential aspect of external validity is respon-
Reliability. For interview-based scales such as the siveness. This is the ability of a scale to measure
HAM-D, inter-rater reliability is important, and so to improvement in patients during a period of treat-
ensure doctor capability in using the HAM-D, a ment. In the acute therapy of major depression a
WHO videotaped interview was used to measure response is de ned as a 50% (or more) reduction of
inter-rater reliability (12). The WHO interview has an the baseline scores at endpoint. The GDS has been
of cially accepted score of 21.09 2.3. compared to the HAM-D in this way in relation to its
Table I. Factor analysis and Loevinger coef cient of homogeneity at the four visits.
responsiveness and a correlation coef cient was cal- patients (62%) had a reduction of 50% or more on
culated by use of the Spearman rank-order method. the baseline scores at endpoint. On the GDS, 12 of
the 21 (57%) patients had a reduction of 50% or
more. The difference in responsiveness between 62%
RESULTS and 57% was statistically insigni cant. The correla-
Twenty-four patients were included; 3 dropped out tion of the total GDS and HAM-D scores was 0.74
before completing all four visits, thus leaving 21 (p B 0.001).
patients (5 men) ranging in age from 28 to 69 years
(mean 43 years).
The investigator’s inter-rater reliability in using DISCUSSION
HAM-D was adequate with a mean score of 22.2 and Statement of principal ndings
a standard deviation of 2.7 (absolute values 17– 25). In this study, we identi ed one factor with fairly high
Loevinger coef cients of homogeneity through visits
Internal ×alidity two to four (the dispersion at visit one being too
The internal validity of the GDS was acceptable. small for testing homogeneity). This, combined with
Table I gives the Loevinger coef cient of homogene- the nding of high correlation coef cients versus
ity as well as the results of the factor analysis at the HAM-D showing an acceptable external validity, in-
four visits. At visit one (baseline), the Loevinger dicates that the GDS is a uni-dimensional scale for
coef cient was below 0.40, and six factors were iden- measuring the degree of improvement in depressive
ti ed. However, the rst factor was a general one, i.e. states treated in general practice.
all items had positive loadings. The second factor was
bipolar and the scree plot identi ed three factors.
In contrast, the next three visits had accepted
Loevinger coef cients and the scree plot identi ed
only one general factor explaining 50% of the vari-
ance. This re ects the difference between visit one Table II. Rank order of items. At the top, the most inclusive
milder items. At the bottom the most severe items. In paren-
and the other visits in terms of dispersion of the theses the original number as shown in Fig. 1.
Goldberg Scale. Before treatment (visit one) the pa-
tients had a similar level of depression. During the Fatigue (9)
treatment period (visits two to four) the dispersion Great effort to do things (10)
was greater as the patients responded more heteroge- Dif culty making decisions (5)
Sad and unhappy (7)
neously. The result indicates that the 18 items on the Disturbed sleep (14)
scale have a valid rank order and structure. Table II Do things slowly (1)
gives the rank order. The items of fatigue, sadness, Lost interest in things (6)
disturbed sleep and lack of interests are the most Pleasure gone out of life (4)
inclusive items, i.e. are present even in mild degrees of Dif culty concentrating (3)
Depressed even when good things happen (17)
depression. These items are listed in the ICD-10 as Feeling trapped (16)
the most inclusive items. Among the most exclusive Future seems hopeless (2)
items are hopelessness, feelings of guilt and thoughts Feeling agitated (8)
of suicide. Feeling lifeless (13)
Weight changes (18)
Feeling like a failure (12)
External ×alidity Feeling guilty (11)
The corresponding mean scores on the two scales are Suicidal thoughts (15)
given in Table III. On the HAM-D, 13 of the 21