J Clin Psychiatry. 2012 Jun;73(6):790-5
Authors: Zimmerman M, Martinez JA, Attiullah N, Friedman M, Toba C, Boerescu DA, Rahgeb M
Abstract
OBJECTIVE: In treatment studies of depression, remission is typically defined narrowly, based on scores on symptom severity scales. Patients treated in clinical practice, however, define the concept of remission more broadly and consider functional status, coping ability, and life satisfaction as important indicators of remission status. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined how many depressed patients in ongoing treatment who scored in the remission range on the 17-item Hamilton Depression Rating scale (HDRS) did not consider themselves to be in remission from their depression. Among the HDRS remitters, we compared the demographic and clinical characteristics of patients who did and did not consider themselves to be in remission.
METHOD: From March 2009 to July 2010, we interviewed 274 psychiatric outpatients diagnosed with DSM-IV major depressive disorder who were in ongoing treatment. The patients completed measures of depressive and anxious symptoms, psychosocial functioning, and quality of life.
RESULTS: Approximately one-half of the patients scoring 7 and below on the HDRS (77 of 140 patients for whom self-reported remission status was available) did not consider themselves to be in remission. The self-described remitters had significantly lower levels of depression and anxiety than the patients who did not consider themselves to be in remission (P < .001). Compared to patients who did not consider themselves to be in remission, the remitters reported significantly better quality of life (P < .001) and less functional impairment due to depression (P < .001). Remitters were significantly less likely to report dissatisfaction in their mental health (P < .01), had higher positive mental health scores (P < .001), and reported better coping ability (P < .001).
CONCLUSIONS: Some patients who meet symptom-based definitions of remission nonetheless experience low levels of symptoms or functional impairment or deficits in coping ability, thereby warranting a modification in treatment. The findings raise caution in relying exclusively on symptom-based definitions of remission to guide treatment decision-making in clinical practice.
PMID: 22569085
A score of 0 to 7 is considered “normal”, non-depressed, not clinically ill, and in-remission when using the HAM-D Rating Scale.
A serious problem is that a HAM-D score of 1 to 7 still means significant illness is present. Further, a score of Zero does not guarantee remission since the HAM-D does not cover all symptoms and signs of depression – for example, many cognitive and social problems. Nor does it cover the pathophysiology involved – e.g. elevated pro-inflammatory cytokine signaling, thyroid hormone disturbance, hypothalamic-pituitary-adrenal axis dysregulation, nutritional deficiencies, etc. etc. The HAM-D is woefully incomplete. The patients with scores of 0 to 7 may NOT be in remission despite being defined in research as being in remission.
For example, if a person is unable to work as a result of their illness, that person has a HAM-D score of 4!
A person who “Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations” and is thus still psychotic has a HAM-D score of 4!
Defining “remission” as a score of 0 to 7 is inaccurate since the patient may still be significantly or even severely ill.
It is disingenuous to use such a definition in research since patients generally use “zero symptoms” and “feeling well” as a definition of remission.
Understandably, such a weasel definition may need to be used in research since tested treatments of depression generally do not address the full pathophysiology of illness and would fail if wiggle room in the definition of remission was not used. However, I would not even use the term “remission” in this case since clearly it is unachievable if treatment addresses only part of the pathology. I would rather see “significant improvement” or some other relative term be used to define the goal of treatment.
What would help matters is if 1) the mind were defined, 2) the pathophysiology of depression is determined as best as possible (given its generally complex pathophysiology), 3) objective measurements of the pathophysiology are used to help gauge improvement. Medication treatments change physiology. It thus would be best if physiological measurements – e.g. measures of inflammatory signaling severity, hormone status, nutritional status, temperature, physical signs, etc. – were also used to monitor progress. With these changes we can actually move the field of psychiatry forward rather than being mired in guess-work. trial-and-error, and mediocre outcomes.