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62 The APA Publishing Textbook of Mood Disorders, Second Edition
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plished provided that the necessary accommodations are made in planning and implementing the virtual administration.
Montgomery-Åsberg Depression Rating Scale
The MADRS is a 10-item clinician-administered questionnaire designed to assess the
severity of depression (Montgomery and Åsberg 1979). Each of the 10 items has seven
possible response option scores (0–6), with four descriptive anchors for item scores of
0, 2, 4, and 6. Interim anchor points (1, 3, 5) may be used but are not specifically defined. Some believe the extended scale points facilitate the use of the scale, as compared with the more restricted range for each item in the HAM-D (Hamilton 1967).
The scores on each MADRS item are added to yield a single total score; the maximum
total score possible is 60. Individual total scores are often used as a cutoff for admis
sion to a clinical trial. The scale was developed by selecting most of the items that
were found to be sensitive to change in an antidepressant trial from a larger rating
scale and symptoms that were not associated with side effects of antidepressants.
This approach provides a more empirical foundation than many contemporary rating
scales. Correlation with the 17-item HAM-D tends to be high (Hamilton 1967).
Questions have been raised about some of the MADRS item scale points. Item 10
for suicidal thoughts, for example, has been identified as not being reflective of con
temporary evaluations of suicidal thoughts or intent. In addition, the verbal descriptive anchor for a score of 0 (“Enjoys life or takes it as it comes”) on the suicide item is
problematic. One consequence of this unfortunate wording is that most patients in
most studies do not match this descriptive anchor and therefore strictly cannot get a
score of 0 on this item even if they have no suicidality. The verbal anchor for a score
of 0 on this item should instead read “No suicidality at all” or “No suicidal thoughts,
suicidal plan, suicidal intent, suicidal impulses, or suicidal behaviors at all.” Consequently, most patients in a research study will score in the range of 1–3 or maybe 1–4,
which substantially reduces the sensitivity to change of this item in any research
study and narrows the drug versus placebo differences on this item and, by extension, on the total score.
The MADRS is one of the two most widely used depression rating scales (the other
being the HAM-D). Its use has become more frequent in the past two decades, and it
is now used often to measure the depressive symptoms in patients with bipolar depression, treatment-resistant depression, and schizoaffective disorder.
The MADRS was designed to be easily learned and administered. However, clinicians often develop their own, frequently idiosyncratic, interpretations of many of the
items, and interrater reliability can be compromised. Some of the language may be
unfamiliar to U.S. mental health professionals. For example, the word “lassitude” is
rarely used in the United States. Likewise, it is more common to refer to “anhedonia”
than “inability to feel.” For these reasons, the Structured Interview Guide for the
MADRS (SIGMA) (Williams and Kobak 2008) was developed to guide the clinical inquiry by providing a group of semistructured questions that should be used for each
of the 10 MADRS items. The improved standardization increases interrater reliability
of the MADRS and can facilitate video or telephone administration. The SIGMA facilitates training on the scale because inexperienced clinicians are not left to devise
their own questions to assess each item. Because of the growing frequency of scale administration by telephone and video, a study was conducted to compare face-to-face
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versus remote administration of the SIGMA using videoconference and telephone,
yielding results that favored the continued use of remote administration in training
and research (Kobak et al. 2008b).
Although the MADRS is a clinician-rated scale, for the most part it lends itself well
to use as a patient-rated scale, with minimal patient training. I am surprised that the
scale is not more frequently used in this way.
Quick Inventory of Depressive Symptomatology
The Quick Inventory of Depressive Symptomatology (QIDS) (Rush et al. 2003) is a 16item rating scale for depression. It is available in clinician (QIDS-C) and self-rated formats (QIDS-SR). Both formats map to the nine core depressive symptoms of a major
depressive episode in DSM-5. The QIDS measures severity of depressive symptoms
on a four-point (0–3) severity scale. It is a shortened version of the 30-item Inventory
of Depressive Symptomatology (IDS). A score of 5 or less is declared a “remission,”
whereas a score of 21 or higher suggests a very severe depressive episode. One QIDS
study in adolescents recommended that a total score of 5 or less be considered as “no
depression,” 6–10 as mild depression, 11–15 as moderate, 16–20 as severe, and 21 or
higher as very severe (Bernstein et al. 2010). The maximum total score is 27. A score
of 5 on the QIDS corresponds to a total score of 7 on the HAM-D17. A QIDS-SR score
multiplied by 1.3 is a close predictor of the concurrent HAM-D17 score. Unlike the
HAM-D17, the QIDS-SR and the QIDS-C restrict themselves to more pure depressive
symptoms and avoid contamination with other symptom clusters such as anxiety.
They can usually be completed in about 5 minutes. The QIDS has much to recommend
it for use in both clinical and research settings and is used with increasing frequency.
It is successful in detecting efficacy signals in clinical trials. The 16-item QIDS-SR is as
sensitive to symptom change as the 30-item QIDS-SR and the HAM-D17. It has accept
able psychometric properties (Bernstein et al. 2010; Rush et al. 2003; Trivedi et al.
2004). In my opinion, it is a better choice than the PHQ-9. The QIDS has been trans
lated into many languages; translated versions are available from Mapi Research
Trust in Lyon, France.
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Patient Health Questionnaire–9
The PHQ-9 is a nine-item self-report inventory of depressive symptoms used for
screening (Kroenke et al. 2001). The nine items map to the nine key symptoms associated with a major depressive episode in DSM-IV and DSM-5. Patients who endorse
at least five of the nine symptoms at a frequency level of “more than half the days”
should then be evaluated in more depth for a mood or other disorder using a struc
tured diagnostic interview. Treatment “response” is said to be a score of 10 or less and
a 50% or greater reduction of the baseline score. The PHQ-9 has some value in tracking the treatment response for the core depressive symptoms of an independently
confirmed major depressive disorder; however, it is not as sensitive to change or efficacy signal detection as the MADRS, HAM-D, IDS, or QIDS. The suicide item is not
an adequate screening question for suicidality and could place a clinician in medicolegal jeopardy for having relied on it if an adverse outcome occurs. Some health care
groups have recommended that their providers use a “PHQ-8” (the PHQ-9 minus the
suicide question) in a “don’t ask, don’t tell” strategy. Participating in such a charade
is irresponsible of a mental health care provider and potentially harmful.
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Beck Depression Inventory
The standard Beck Depression Inventory (BDI) is a 21-item self-rated scale (Beck et al.
1961, 1988). The BDI measures severity of depressive symptoms on a four-point (0–3)
severity scale. Each scale response option is anchored by a carefully worded state
ment, for a total of more than 80 statements in all. A total score of 0–13 is considered
minimal range, 14–19 is mild, 20–28 is moderate, and 29–63 is severe. A score of 20 or
higher suggests a moderate depressive episode in need of treatment. The BDI can usu
ally be completed in about 8 minutes or less. It tends to be more favored by clinical
psychologists and by those involved in cognitive-behavioral therapy than by psychia
trists. Historically, it has not been shown to be reliably successful in detecting efficacy
signals in clinical trials and is no longer used for this purpose. For primary health care
providers, there is a short seven-item FastScreen version available (Golden et al. 2007).
The BDI has been translated into many languages.
In the BDI-II, Beck et al. (1996) attempted to overcome the well-known shortcomings of the earlier version of the BDI, which focused on the milder and more psychological of the depressive symptoms at the expense of assessing other symptoms seen
in more severe MDD and did not map to DSM-IV criteria. BDI-II was designed to con
form better to DSM-IV criteria for major depressive episode, and many BDI statements
were reworded. Some symptoms in the earlier BDI (weight loss, somatic preoccupa
tion, body image, work difficulty) were replaced with symptoms such as concentration difficulty, loss of energy, and agitation. The symptoms reflect a purer and more
“vegetative” depressive cluster without contamination with other symptom clusters,
such as anxiety. They do not map exactly to the nine major depressive episode symptoms in DSM-5. There is also a shorter six-item version (Beck and Beck 1972).
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Depression Inventory Development Scale
Item response theory and other contemporary measurement and psychometric techniques were not used in developing most of the widely used depression rating scales.
More modern approaches to scale development would lead to scales that were more
representative of current concepts or definitions of depression and were more sensitive in detecting treatment effects.
The development of the 19-item Depression Inventory Development (DID) scale
(Vaccarino et al. 2016) is a case in point. The DID is more aligned to modern scale de
velopment than any other scale in this chapter, in that item response theory (IRT) and
Rasch measurement theory (RMT) were used in the scale’s development (see subsection below). Developers used an iterative process between field testing and psychometric analysis. The process involved the collaboration of expert scale developers, as
well as clinical and patient input, and it was empirically driven. The DID was developed following
the selection of items. The current version of the DID scale has 19 items (reduced from
a larger universe of 32 items) and is undergoing validation within the Canadian Biomarker Integration Network for Depression (CAN-BIND) program (Vaccarino et al.
2020). Further publications are expected; stay tuned.
Item response theory and Rasch measurement theory. IRT is a model used in
the design, analysis, and scoring of scales. Unlike earlier models used in designing and
scoring scales, IRT does not assume that each item on a scale and its related response
a very careful evaluation of all existing depression scales to inform
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options are equally difficult and parallel replications of each other. IRT is based on the
assumption that an individual item on the scale has a direct relationship to the con
struct it is supposed to measure (Hays et al. 2000). Just as behavior is believed to be a
function of a person in his or her environment, IRT assumes that there is a relationship
between an individual’s performance on a scale item and that person’s performance
on the overall measure. It uses information from the difficulty of each item and the pattern of the response options to a question in relation to each other (item characteristic
curves) as data to incorporate into the scaling of the items. In contrast, conventional
scale design, such as Likert
1
scaling, assumes that the distance from each response option to the next is equal and that a person’s observed total score on a scale is the sum
of the scores on all of the items or questions. If there is good internal consistency in a
scale, it is assumed that all the items in the scale are parallel replications of each other
and can be added with equal weight into a total score. IRT scaling, also called modern
mental test theory, is generally considered to be superior to classical test theory and to
Likert scaling procedures (Zickar and Broadfoot 2009). It is now used with increasing
frequency in the design of mental health scales. The Rasch model is a further refine
ment of the IRT model and has some advantages over the IRT approach. In assessing
the severity of depression, IRT and RMT take into account each question’s score as a
function of the person’s individual severity of depression and the level of depressive
severity that each question assesses. The most notable recent example of the use of IRT
and Rasch modeling for scale design in mood disorders is in the ongoing development of the DID by Vaccarino et al. (2020), discussed above.
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Clinically Useful Depression Outcome Scale
While acknowledging that there were several good depression scales, Zimmerman et
al. (2008a) considered the existing depression questionnaires and scales to be too long,
lacking in adequate coverage of the DSM-IV diagnostic criteria for MDD, too expensive to purchase, or somewhat complicated to score. These factors reduced the appeal
of the existing measures as outcome tools for use in routine clinical practice. They de
veloped the Clinically Useful Depression Outcome Scale (CUDOS) to meet this need.
The CUDOS contains 18 items assessing all of the DSM-IV/DSM-5 inclusion criteria for MDD as well as psychosocial impairment and quality of life. Compound DSMIV/DSM-5 symptom criteria referring to more than one construct (e.g., problems concentrating or making decisions; insomnia or hypersomnia) were subdivided into
their respective components, and a CUDOS item was written for each component.
This contrasts with the PHQ-9, in which a single item assesses sleep disturbance (increased or decreased sleep), appetite disturbance (increased or decreased), and other
compound diagnostic criteria. Zimmerman and colleagues thought that these distinctions were important for treatment decision making. For example, different medications would be prescribed if the goal was to address increased versus decreased sleep
or increased versus decreased appetite.
The CUDOS is scored on a five-point ordinal scale using the following stem
prompt: “How well the item describes you during the past week, including today”
1
The name Likert (in “Likert scale”) is frequently mispronounced. The correct pronunciation
is “lick-ert,” not “lie-kert.” It is named after the American social psychologist Rensis Likert.
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3=usually true/5–6 days; 4=almost always true/every day). Zimmerman et al.
(2008a) chose an ordinal rating of the symptom statements to keep the CUDOS brief.
In contrast, scales such as the BDI and IDS, described above, assess symptoms with
groups of four or five statements and are thus composed of 80 or more statements.
These scales take respondents 10–15 minutes to complete, and Zimmerman and col
leagues considered this time to be too long for regular use in clinical practice, in which
the scale would be routinely administered at every follow-up appointment.
One study found that in comparison with the BDI, the CUDOS took less time to
complete (<2 minutes on average, and >95% of patients were able to complete it in
<3 minutes), the CUDOS was less of a burden to complete, and the patients preferred
to complete the CUDOS at every visit in order to monitor the outcome of treatment
(Zimmerman and McGlinchey 2008). Patients did not find scale completion burden
some and were willing to complete the CUDOS on a regular basis.
Later versions of CUDOS include brief subscales assessing the DSM-5 anxious distress and mixed features subtypes of MDD (Zimmerman et al. 2014a, 2014b) and modifications to enable the scale to be administered to assess depressive symptoms across
other time frames, including daily and shorter time frames, so that it can be used to
evaluate the efficacy of rapidly effective treatments for depression (Zimmerman et al.
2018). One such version lends itself well to use in ecological momentary assessment
(Zimmerman et al. (2018). The CUDOS and its modifications have undergone the usual
psychometric analyses and have been found to be reliable and valid instruments.
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Remission From Depression Questionnaire
Experts agree that remission is the desired outcome when treating depression (American Psychiatric Association 2000b; Anderson et al. 2000; Stahl 1999; Thase 1999). In
most studies, remission is defined as a score below a cutoff value on a symptom sever
ity scale. Determination of treatment efficacy focuses on symptom improvement; how-
ever, depressed patients consider several factors in addition to symptom resolution
as critically important in determining whether a depressive episode is in remission
(Zimmerman et al. 2006). These factors, which include a return to premorbid func
tioning, having positive mental health, and good quality of life, were more frequently
rated as very important in determining remission from depression than was symp
tom resolution (Zimmerman et al. 2008b).
Zimmerman and colleagues (2013a) designed a new outcome measure to assess the
domains that depressed patients considered important in evaluating treatment outcome. In contrast to most measures of depression that assess only symptom presence
during the past 1 or 2 weeks, the Remission from Depression Questionnaire (RDQ) as
sesses multiple factors (Zimmerman et al. 2013a). The domains covered on the RDQ
were based on a literature review, a study of depressed patients’ ratings of the relative
importance of 16 factors in determining remission from depression, and meetings
with two focus groups of depressed patients. During the focus group meetings, a list
of items was generated and reviewed by patients as to the items’ understandability,
redundancy, and relevance in determining whether treatment for depression was addressing important treatment targets. An initial pool of 77 items that were generated
was reduced to 41 items after pilot testing. The domains assessed are symptoms of depression, other symptoms that are often present in depressed patients such as anxiety
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and irritability, features of positive mental health, coping ability, functioning, life satisfaction, and a general sense of well-being. The items are rated based on the prior
week using a three-point rating scale (not at all or rarely true; sometimes true; often
or almost always true). The items are scored 0, 1, and 2, with higher item values re
flecting greater pathology. Thus, for symptom items (e.g., “I felt sad or depressed”),
a rating of often or almost always true was scored as 2, whereas for the positive men
tal health items (e.g., “When I woke up I looked forward to the day”), a rating of not
at all or rarely true was scored as 2.
In a study of 102 depressed outpatients in ongoing treatment, the patients completed the RDQ and QIDS-SR and a nine-item measure of patient preference (Zimmerman et al. 2011). The patients indicated that the RDQ was a better indicator of
their overall state and their goals in treatment. The patients also judged the RDQ to
be a more accurate and preferred measure to determine the outcome of treatment,
and a more accurate indicator of remission.
In a second study, including nearly 300 depressed outpatients, both the RDQ and
QIDS were significantly associated with patients’ self-reported remission status (Zim
merman et al. 2013a). However, the RDQ remained significantly associated with remission status after controlling for QIDS scores (r=–0.32, P<0.001), whereas the QIDS
was not associated with remission status after controlling for RDQ scores (r=–0.06).
This finding supported the hypothesis that the RDQ measures constructs other than
depressive symptoms that patients consider important in determining remission. A
third study replicated the finding that the RDQ was significantly associated with pa
tient self-reported remission status after controlling for QIDS scores, whereas the
QIDS was not associated with remission status after controlling for RDQ scores (Zim
merman et al. 2014c).
The RDQ is a reliable and valid measure that assesses the multiple domains that
depressed patients consider important in evaluating treatment efficacy and particu
larly remission. The findings of the studies of the RDQ are consistent with prior research suggesting that depressed patients’ perspectives of treatment efficacy and
remission go beyond symptom improvement and resolution.
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Rapid-Acting Antidepressant Scales
Although no scales have been specifically developed to measure rapid action of antidepressants, researchers are using one or a few items (e.g., depressed mood, anhedonia, concentration problems) from the MDD scales to conduct repeated assessments
(e.g., every few minutes, hourly, or daily) over short periods of time to detect the onset of the antidepressant effect. There is still no consensus about how best to measure
this effect, but many alternative approaches are currently under study, which vary depending on the specific research question or treatment target. The optimal solution
will differ by target. For example, the best way to measure an antidepressant’s effect
on suicidality will be different from the best way to measure its effect on depression.
Pediatric Depression Rating Scales
The Children’s Depression Rating Scale—Revised (CDRS-R) (Poznanski and Mokros
1996) is the most widely used depression scale for children ages 6–12 years. It is a clinician-rated scale, based on a semistructured interview taking about 10–15 minutes.
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The original CDRS (Poznanski et al. 1984) had 15 items, with a total score of up to 61
points. The CDRS-R has 17 items, with a total score of up to 113 points. The response
options range from 1 to 5 in the CDRS (normal, doubtful, mild, moderate, severe) and
from 1 to 7 in the CDRS-R; the CDRS-R has additional response options between mild
and moderate and between moderate and severe. In a study of depressed children,
the CDRS-R was found to show greater effect size for differentiating drug and pla
cebo than the MADRS (Jain et al. 2007).
The majority of depression scales for children are self-rated. These self-rated children’s depression scales include the Birleson Depression Self-Rating Scale for Children (DSRS-C) (Birleson 1981), the Children’s Depression Inventory (CDI) (Kovacs
1981, 1983; Saylor et al. 1984; Zalsman et al. 2005), and the Children’s Affective Rating
Scale (CARS) (McKnew et al. 1979). The DSRS-C has 18 items rated on a 3-point scale
for severity. The CDI has 27 items rated on a 3-point scale for severity. The CARS is a
27-symptom checklist rated on a 10-point scale for severity without subcategory defi
nitions.
Personal Favorites Among the Many Depression Scales
My favorites among the depression scales are the MADRS and the 16-item QIDS-SR.
The DID also shows great promise, and its development has been very sophisticated.
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Mania Rating Scales
The Young Mania Rating Scale
The 11-item clinician-rated Young Mania Rating Scale (YMRS) (Young et al. 1978) is
the most widely used scale to assess manic/hypomanic symptoms in clinical trials for
bipolar disorder. This scale has been extensively studied psychometrically and is
available in many translations. It is sensitive in detecting the efficacy signal of antimanic medications and remains the first choice for this purpose in the United States
and the United Kingdom. It lends itself well to use in clinical settings as well as research because of its brevity.
Bipolar Inventory of Symptoms Scale
The Bipolar Inventory of Symptoms Scale (BISS) is a 44-item scale that was designed
to assess the comprehensive domains and wide spectrum of symptoms in bipolar disorders (Bowden et al. 2007). It discriminates well between depressed, manic/hypomanic, and mixed episodes and remission status specifiers for bipolar disorders. It
has acceptable psychometric properties. It compares very favorably with the combi
nation of the MADRS and the YMRS (Bowden et al. 2007; Gonzalez et al. 2008).
I have long thought that “bipolar disorder” was a quadripolar disorder rather than
a bipolar disorder, with mania, depression, anxiety, and irritability as the four domains. These domains do not track each other synchronously in their progression
over time or in their response to the same treatments. One of the most common clinical presentations in outpatients with bipolar disorder (particularly in episodes with
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mixed features) is anxiety, which prompted us to conduct several double-blind studies on “bipolar anxiety.” We found that the anxiety domain responded differently to
treatment than would have been predicted from the expected responses to the other
domains (Sheehan et al. 2013). Consistent with this line of thinking, Thompson et al.
(2010), in an exploratory factor analytic study of the BISS that used the maximum likelihood factor extraction method, followed by oblique rotation of the extracted factor
loadings, found five factors: mania, depression, irritability, anxiety, and psychosis.
Using the Pearson correlation coefficient to determine the strength of the relationship,
the authors found that the mania factor score correlated only weakly with the other
four factors. This makes very good clinical sense and challenges the clinician to mon
itor the response to treatment in all five of these domains. That the BISS can identify
each of these domains makes this scale unique and deserving of much more wide
spread use. Its development was very thoughtful, and I highly recommend it.
Singh et al. (2013) found that a small subset of symptoms captured in the BISS, several of which are absent in the DSM-IV-TR (American Psychiatric Association 2000a)
and DSM-5 criteria and traditional rating scales for bipolar disorder studies, help in
distinguishing mixed episodes from depressive or manic/hypomanic episodes.
Bech-Rafaelsen Mania and Melancholia Scales
The Bech-Rafaelsen Mania Scale (BRMaS) (Bech 2002a; Bech et al. 1978) is an 11-item
clinician-rated scale. Items are rated from 0 to 4; the sum is used to assess the severity
of manic symptoms. A score of less than 15 suggests hypomania, scores around 20
suggest moderate mania, and scores around 28 suggest severe mania. This scale has
been found to be superior to the Clinical Global Impression—Severity scale (Guy
1976) (see later section “Global Severity and Improvement Scales”) in detecting responsiveness to treatment and has been very sensitive in detecting placebo-drug differences
in a wide range of studies of antimania treatments. The items on the companion sixitem clinician-rated Bech-Rafaelsen Melancholia Scale (BRMeS) (Bech 2002b) are a sub
set of items from the BDI. The BRMeS is very sensitive in detecting efficacy signals of
antidepressants in the depressive melancholic cluster of symptoms. Both Bech-Rafael
sen scales have been widely used and studied, especially in Europe (Bech 1981, 2002a,
2002b; Bech et al. 1978).
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Mood Disorder Questionnaire
The Mood Disorder Questionnaire (MDQ) (Hirschfeld et al. 2000) is a 13-item selfrated questionnaire with binary (yes/no) response options. It maps well to DSM-IV
and DSM-5 symptom criteria for a manic/hypomanic episode. A score of 7 or higher
has good sensitivity (0.73) and specificity (0.9) as a quick one-page pencil-and-paper
test in screening for bipolar I disorder, bipolar II disorder, and bipolar disorder not
otherwise specified. The MDQ is useful in clinical practice settings but is not designed
for use in efficacy signal detection as a treatment outcome measure. Because bipolar
disorders are so frequently missed in clinical practice, the MDQ should be used more
frequently, especially when any depression scale is used in mental health screening.
There are several good reviews of mood scales in bipolar disorders (Berk et al.
2007; Miller et al. 2009; Sajatovic et al. 2015; Vieta 2011). They are all worth reading.
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Irritability and Anhedonia Scales
Irritability Scales
Irritability is a troublesome symptom that is often comorbid with mood disorders, especially bipolar disorders. It can continue to cause impairment as a residual symptom
following treatment. For some families and in work and social settings, it can cause
substantial disruption. In some cases, irritability is the most disruptive symptom to
other people. Effective monitoring and treatment of the irritability are often critical in
restoring family social and workplace harmony. Validated scales that specifically as
sess the severity of irritability include the Concise Associated Symptom Tracking
(CAST) scale (Jha et al. 2018, 2019) and the Sheehan Irritability Scale (SIS) (Khan et al.
2016; Mannix et al. 2016).
Anhedonia Scales
Measuring anhedonia and apathy is of principal interest in schizophrenia. More recently, anhedonia is being studied as a treatment target in mood disorders. Some
medications may have more ability than others to improve apathy and anhedonia.
For example, monoamine oxidase inhibitors (MAOIs) have long been believed to be
more effective than tricyclic antidepressants or selective serotonin reuptake inhibitors
or serotonin-norepinephrine reuptake inhibitors in improving anhedonia and apathy.
This effect is believed to be due to the dopamine uptake–inhibiting effects of MAOIs.
Triple reuptake inhibitors—which inhibit the uptake of norepinephrine and serotonin
in addition to the uptake of dopamine—are being studied for the treatment of anhedonia, because the additional dopaminergic effect is hypothesized to play a central
role in improving anhedonia (Sharma et al. 2015). Although there are several candi
date anhedonia scales, it is not yet clear which scale is the most sensitive in discriminating between drug and placebo on the anhedonia domain in mood disorders (Chapman
et al. 1976; Leventhal et al. 2006; Nakonezny et al. 2010).
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Functional Impairment Scales
Including functional impairment in the assessment of mood disorder symptoms is
important for two reasons. First, improvement in functional impairment does not
align exactly at any one point in time or in its progression over time with symptom
improvement. In fact, it is often desynchronous with symptom improvement. One patient may have severe symptoms but function fairly well. The next patient may have
mild symptoms, but function poorly. Patients can have impairment of functioning
even when they have no symptoms and can have symptoms even when they have no
impairment (Samara et al. 2014).
Second, although employers and governments may or may not care about suffering related to mental illness, they do care about days lost from work, days underproductive at work, and impairment in social life, leisure activities, and family life/home
responsibilities. After all, these have direct economic and financial impacts. Improve-
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ment in functional impairment is also high on patients’ lists of important factors in
recovery and remission. Table 4–1 lists the most commonly used functional impairment scales in order of their length.
The Global Assessment of Functioning (GAF) scale (American Psychiatric Association 1994) is well known because it was used as Axis V of DSM-IV-TR. Consisting of
only one item, it is scored from 0 to 100, with high scores indicating good functioning
and low scores reflecting poor functioning. The GAF has the advantage of simplicity.
The instrument, however, has well-documented issues. A modification of the Global
Assessment Scale (GAS) (Endicott et al. 1976), a measure of overall severity of psychiatric disturbance, the GAF does not specifically assess functioning. Rather, it assesses
a concurrent mixture of several domains that include symptoms, signs, behaviors,
suicidality, and functioning as well as psychotic symptoms and signs. In my opinion,
it would have been better named the Global Psychological Symptoms Scale. Other
drawbacks are psychometric problems related to its reliability as well as its concur
rent and predictive validity (Aas 2011). The lack of interval constancy across the
scale’s spectrum of response options created problems for clinicians trying to score it
in everyday clinical practice. In spite of many attempts to remedy these issues, the
GAF was never able to circumvent its innate drawbacks and was abandoned in DSM-
5. It makes no sense to use the GAF or to resuscitate it in its DSM-IV form.
In contrast, the one-item Social and Occupational Functioning Assessment Scale
(SOFAS) in DSM-IV has much to recommend it as a single-score, single-domain
global measure of social and occupational functioning. Like the GAF, it is scored from
0 to 100, but unlike the GAF, SOFAS focuses exclusively on an individual’s social and
occupational functioning (American Psychiatric Association 1994; Goldman et al.
1992; Samara et al. 2014). The Personal and Social Performance (PSP) scale (Morosini
et al. 2000) attempts to improve on the SOFAS, using a similar 100-point, single-item
scale that is subdivided into 10 equal intervals. The PSP scale is said to have better
face validity and psychometric properties than the SOFAS and is therefore a good
choice for a quick and valid measure of personal and social functioning.
The GAF was replaced in DSM-5 by the World Health Organization Disability Assessment Schedule (WHODAS 2.0) (Üstün et al. 2010), a scale that more closely measures functioning. However, with 36 items, the WHODAS 2.0 is too lengthy and
unwieldy for routine clinical use and is now rarely used in clinical settings in the way
that the GAF was. The WHODAS 2.0 violates the brevity and simplicity rule. It covers
seven domains of functioning: understanding and communicating, getting around,
self-care, getting along with people, life activities—household, life activities—school/
work, and participation in society. The standard WHODAS 2.0 has 36 items, although
there is a 12-item version of the instrument. Both versions of the WHODAS 2.0 are designed not just for mental health settings but also for use across all diseases. They are
linked to the International Classification of Functioning, Disability and Health (World
Health Organization 2001). The WHODAS 2.0 is well thought out, is well designed,
is useful for epidemiology studies, and has much to recommend it in cross-sectional
research studies. Its value and utility as a sensitive change measure or research effi
cacy signal detector is less clear at this time (Üstün et al. 2010).
The three-item Sheehan Disability Scale (SDS) (Sheehan and Sheehan 2008; Sheehan et al. 1996) is now the most widely used measure of functional impairment in
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