Rating scales in psychiatry
The use of rating scales in clinical research in psychiatry developed increasingly in the late 1950s with the introduction of antipsychotics and antidepressants. To evaluate the effectiveness of these new drugs when compared to placebo in randomised clinical trials it became important to use instruments with a sufficiently high degree of reliability and validity.
The rating scales most widely used in the 1960s and 1970s were the Brief Psychiatric Rating Scale (BPRS) which was mainly used to evaluate the effectiveness of antipsychotics, and the Hamilton Depression and Anxiety Scales (HAM-D and HAM-A) which were used to evaluate the effectiveness of the antidepressants and the antianxiety drugs.
These three scales (BPRS, HAM-D and HAM-A) were not meant to be used as diagnostic scales but as outcome scales. However, with the introduction of the evidence-based diagnostic systems (beginning with DSM-III) in the 1980s, with symptom-derivated diagnoses for mental disorders, an association between the symptom-oriented rating scales (e.g. BPRS, HAM-D and HAM-A) and the clinical diagnoses emerged.
SYMPTOM RATING SCALES
For symptom rating scales the content of the items is, thus, rather similar to the DSM-III (or DSM-IV and ICD-10) diagnoses, but they differ in the way the symptoms are quantified as well as in the way the symptoms are combined.
The symptom rating scales are typically quantified for the individual symptoms on Likert scales for 0 (not present) to 1 (mild), 2 (moderate), 3 (marked), and 4 (severe). In contrast, the diagnostic symptoms are scored 0 (not present) and 1 (present), i.e. checklist-oriented. Moreover, the total score is often the sufficient or appropriate statistic for a symptom rating scale, while an algorithm is used in the diagnostic systems.
Another rating scale approach is the separation of clinician-rated scales (typically performed by the therapist), often classified as observer rating scales, and the patient- or self-rating scales (questionnaires to be completed by the patients themselves).
In this section of the website you are presented with some of the most clinically relevant rating scales. On the following pages your will find a short description of each rating scale as well as in some instances (where possible for copyright and practical reasons) the scale itself included as a pdf-file to download and print out for use with your patients.
(To download the files you need to have the programme "Adobe Reader" installed on the computer. If you haven’t, click on the "Get Adobe Reader" link on the download page for easy installation of the free programme.)
The selection of observer rating scales has been based on their usefulness in clinical research as well as in the daily routine. Short scales have been preferred to more comprehensive scales.
1. OBSERVER RATING SCALES
The following observer rating scales covering the various psychopathological states have been included:
Dementia
Schizophrenia
Mania
Depression
Anxiety
Obsessive Compulsive Disorder
2. SELF-RATING SCALES
Over the last decades self-rating scales have been developed to include not only symptom scales but also scales covering social aspects (often referred to as disability scales) and subjective well-being (often referred to as quality of life scales).
The selection of self-rating symptom scales has been mainly based on their concordance with the DSM-IV or ICD-10, with a couple of exceptions. Beck Depression Inventory (BDI) has been included because of its widespread use and because it represents the gold standard for self-rating depression scales. Symptom Checklist (SCL-90) has been included because this scale over the years has been enlarged to cover important aspects of anxiety states and aggressiveness.
In psychiatric disorders where either the patient’s verbal capacity (e.g. dementia and delirium) or insight (e.g. psychotic conditions) is compromised self-rating scales have obviously very little value. On the other hand, in conditions such as depression and anxiety self-rating scales have been widely used.
Depression
Anxiety
3. DISABILITY SCALES OR HEALTH STATUS SCALES
The selection of self-rating scales measuring disability including health status is based on the most widely used questionnaire, Medical Outcomes Study Short-Form 36 (SF-36).
4. QUALITY OF LIFE QUESTIONNAIRE
The selection of self-rating scales measuring psychological well-being or quality of life has been based on their applicability in different settings.
5. CLINICAL GLOBAL IMPRESSION SCALES
Global scales have mainly been used as observer scales to measure global symptomatology within the group of patients being assessed, e.g. the degree of mania or depression. During clinical trials global scales covering the change in symptomatology over time (global improvement scales) have often been used.
6. GLOBAL ASSESSMENT OF FUNCTIONING (GAF)
Global functional scales covering axis 5 of DSM-IV have often been used as observer scales.
7. SIDE EFFECT SCALES
The measurement of unwanted effects of treatment or side effect scales have mainly been developed as observer scales. The following have been included:
8. PERSONALITY DIMENSIONS
Personality dimensions have often been measured by use of self-rating scales. The Millon Clinical Multiaxial Inventory (MCMI) is associated with axis 2 in DSM-IV and has been included.
9. SCHEDULES FOR CLINICAL ASSESSMENT IN NEUROPSYCHIATRY (SCAN)
SCAN is "a set of instruments and manuals aimed at assessing, measuring and classifying the psychopathology and behaviour associated with the major psychiatric disorders of adult life" (WHO, 1999), with the exception of personality disorders and behavioural disturbances.
SCAN was developed jointly by WHO and NIH, and it consists of four components:
1) PSE-10 (the 10th edition of Present State Examination), which is a semi-structured interview, but it is emphasised that the interview retains the features of a clinical examination. The aim of the interview is to establish which symptoms are present during a designated period of time, and with what degree of severity.
PSE-10 has 2 parts. Part one covers somatoform, dissociative, anxiety, depressive and bipolar disorders, and problems associated with appetite, alcohol and other substance abuse. Part two covers psychotic and cognitive disorders and observed abnormalities of speech, affect behaviour.
2) Glossary of differential definitions of SCAN items, which is a brief instruction manual and thereby the most important component of SCAN. It contains differential definitions of the symptoms, signs and behaviour commonly seen in psychiatric disorders.
3) Item Group Checklist (IGC), which provides the possibility of rating information available only from case records and/ or other informants than the patient. It is useful when the patient cannot provide information about previous episodes of psychiatric illness, when an interview with the patient is impossible, and for research purposes.
4) Clinical History Schedule (CHS), which is a supplement to the information obtained through PSE and IGC. Data related to behavioural and emotional disorders of childhood, educational and intellectual level, social roles and performance, and personality disorders can be recorded here.
Published on CNSforum 22 Feb 2003