The Ham-D is not Hamilton’s Depression Scale

Abstract

Introduction

This article will demonstrate that the most widely used versions of the Hamilton Rating Scale for Depression (HAM-D) used in randomized clinical trials, the Guy 1976 HAM-D¹ and the SIGH-D,² have response options that deviate sharply from Max Hamilton’s 1960³ and 1967⁴ guidelines. For example, difficulty in concentration, one of the diagnostic criteria for a Major Depressive Episode according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) since 1980, in editions III, IV, IV-TR and 5,⁵ is something that Hamilton wrote should be measured in his scale, yet it is not measured in either of the presently used HAM-Ds.

Method

A review was conducted of the four key papers related to the development of the Hamilton Rating Scale for Depression: the 1960 and 1967 papers by Max Hamilton; the HAM-D chapter in the 1976 ECDEU Assessment Manual for Psychopharmacology edited by William Guy; and the 1988 article on the Structured Interview Guide for the HAM-D (SIGH-D) by Janet Williams. Additionally, the Janet Williams updated 2013 SIGH-D⁶ is also reviewed.

Results

When comparing the HAM-D and the SIGH-D with the gold standard Hamilton guidelines from his 1960 and 1967 articles, 13 of the 17 items contain significant errors.

Conclusion

Significant differences between the currently used HAM-Ds and the guidelines set forth by Max Hamilton in 1960 and 1967 will be demonstrated. These discrepancies may produce inconsistencies in administration and scoring, leading to unreliable measurements of subjects’ and patients’ depressive symptoms and unreliable measurement of their progress over time.

Introduction

In 1960, Max Hamilton wrote: “The appearance of yet another rating scale … may seem unnecessary. Unfortunately … there is considerable room for improvement [in the existing scales].” (p.56)

In an effort to better understand the Hamilton Rating Scale for Depression (HAM-D), an analysis of the relevant literature was conducted. This analysis included A Rating Scale for Depression (Hamilton, 1960), Development of a Rating Scale for Primary Depressive Illness (Hamilton, 1967), the chapter on the HAM-D in the ECDEU Assessment Manual for Psychopharmacology (Guy, 1976), and A Structured Interview Guide for the Hamilton Depression Rating Scale (Williams, 1988). Additionally, Williams’ more recent version of the HAM-D, the SIGH-D 2013 was reviewed.

Hamilton (1960) wrote, “The scale has undergone a number of changes since it was first tried out … there is room for further improvement.” … “The present scale has been devised for use only on patients already diagnosed as suffering from affective disorder of depressive type … The interviewer may, and should, use all information available. The scale contains 17 variables. Some are … a series of categories of increasing intensity, while others are … a number of equal-valued terms.” (p.56) [Table 1; Appendix II].

Table 1. Hamilton’s Two Different Scoring Guidelines.

Item No.	Range of Scores	Symptom
3	0–4	Example of a series of categories of increasing intensity Suicide Feels life is not worth living Wishes he were dead Suicidal ideas Attempts at suicide
10	0–4	Example of a series of a number of equal-valued terms 1960 Anxiety, psychic: Tension and irritability. Worrying about minor matters. Apprehensive attitude. Fears. 1967—Anxiety (psychic symptoms)-Many symptoms are included here, such as tension and difficulty in relaxing, irritability, worrying over trivial matters, apprehension and feelings of panic, fears, difficulty in concentration and forgetfulness, ‘feeling jumpy’.

“The variables are measured … on five-point or three-point scales, the latter being used where quantification of the variable is either difficult or impossible. No distinction is made between intensity and frequency of symptom, the rater having to give weight to both of them in making his judgement. (p.57) [see Table 2; Appendix I].

Table 2. Hamilton’s Rating Guidelines.

Five-Point Scale (1960)	Five-Point Scale (1967)	Three-Point Scale (1960)	Three-Point Scale (1967)
0 - Absent 1 - Mild or trivial 2 - Moderate 3 - Moderate 4 - Severe	0 - Absent 1 - Doubtful or trivial 2 - Mild 3 - Moderate 4 - Severe	0 - Absent 1 - Slight or doubtful 2 - Clearly present	0 - Absent 1 - Doubtful or mild, trivial or infrequent 2 - Obvious, distinct or severe

Subsequently Hamilton (1967) stated, “A previous account … of the use of a rating scale must be regarded as little more than a preliminary report.” “In … 1960 … the data was based on the results … from a mere forty-nine male patients; the present work describes the results obtained from 152 male and 120 female patients.” (p.278) “Symptoms are rated finely or coarsely; the former are on a five-point scale (0–4) where the numbers are equivalent to absent, doubtful or trivial, mild, moderate and severe. The latter are on a three-point scale (0–2) equivalent to absent, doubtful or mild, and obvious, distinct or severe.” (p.291) [Table 2].

Neither Hamilton’s 1960 nor his 1967 papers came with a complete scale attached. However, they did contain recommendations for the measurement of all the items in the scale, and while Hamilton’s 1960 guidelines were incomplete, they were clarified in his 1967 paper.

Although his Appendix II in 1960 did give some insight into how Hamilton had organized his thinking, the lack of an attached scale and Hamilton’s many subsequent revisions appear to have led to the existence of many different versions of the HAM-D after his 1960 paper. As a result, when William Guy included in the ECDEU Assessment Manual for Psychopharmacology a version of the HAM-D that is now widely used (1976), his stated objective was for one version of the scale to be used in all studies to “compare published findings.” Guy began, “Hamilton’s Depression scale … has been employed in a number of different versions. The present version is, we believe, the author’s version.” (emphasis added) (p.182). This paper will demonstrate that Guy was wrong in that belief. The HAM-D we use is not Hamilton’s scale as it does not use Hamilton’s anchors. Nevertheless, Guy’s ECDEU version became almost exclusively used after 1976 as the official HAM-D and continues to be used as one of the genuine versions of the HAM-D.

Appendix I and II from A Rating Scale for Depression, Max Hamilton, 1960.

However, the HAM-D versions we use deviate significantly from the suggestions in Hamilton’s more definitive 1967 article. In fact, although Guy did accomplish the goal of unifying research around one HAM-D version, the Guy HAM-D is not based upon the information from Hamilton’s 1967 article (except for item 9) although we know that the 1967 article was available to Guy as the 1967 article is included in its entirety in the Hamilton Depression Scale (049-HAMD) chapter of the ECDEU manual. Guy explained in a note about item 9 “The author (Hamilton) prefers the 0–4 range, but the packet was printed before this instruction could be inserted. Subsequent editions of the Adult Packet will contain the 5-point scale and raters are urged to employ the 5-point scale for this item.” Guy’s published HAM-D version corrected item 9, changing it from the 1960 three-point suggestion (“a five-point scale was found impracticable”) to a five-point scale, as evident by a different font on item 9 in the Guy HAM-D compared with all of the other items in the HAM-D, following Hamilton’s 1967 guidelines. [Table 3]

Table 3. Guy’s 1976 ECDEU HAM-D Items 8, 9 and 10.

8.	RETARDATION (Slowness of thought and speech; impaired ability to concentrate; decreased motor activity) 0 = Normal speech and thought 1 = Slight retardation at interview 2 = Obvious retardation at interview 3 = Interview difficult 4 = Complete stupor
9.	AGITATION 0 = None 1 = Fidgetiness 2 = Playing with hands, hair, etc. 3 = Moving about, can’t sit still 4 = Hand wringing, nail biting, hair-pulling, biting of lips
10.	ANXIETY, PSYCHIC 0 = No difficulty 1 = Subjective tension and irritability 2 = Worrying about minor matters 3 = Apprehensive attitude apparent in face or speech 4 = Fears expressed without questioning

Janet Williams (1988) began a project that “grew out of an assumption that it should be possible to increase the reliability of the individual items by standardizing the way in which the rating information is obtained.” Although Williams’ article was written in 1988, she only referenced Hamilton’s 1967 article in the final paragraph of her 1988 paper. She relied on the 1960 article, as did Guy, in producing her response options anchors when she developed her SIGH-D. She referenced Guy’s HAM-D and used it to develop her structured interview. Evidence for this is that her response options are essentially the same as Guy’s. Moreover, the 2013 SIGH-D only references the 1960 Hamilton article, Guy’s, and her own 1988 article. In that 1988 article, Williams reported that her research was conducted on only 23 patients, with an average HAM-D score of 13.5/12.5 on test/retest respectively. Significantly, only seven of her subjects suffered from Major Depressive Disorder. In contrast Hamilton (1967) noted that each subject in his sample of 272 patients suffered from depressive states.

Although Hamilton (1967) expounded, “the value of the ratings … depends entirely on the skill and experience of the rater and on how adequate is the information … It is desirable to obtain additional information from relatives, friends, nurses, etc … whenever there is doubt,” the presently used 2013 SIGH-D versions direct us to only use information on the psychomotor agitation and retardation items and the insight item related to what can be observed during the interview. (p.291)

Janet Williams told this paper’s author in June 2004 when information contained in this paper was first presented in a poster session at the 2004 NCDEU (New Clinical Drug Evaluation Unit), that she had written to Max Hamilton about her SIGH-D and had asked for his input. Janet Williams told this author that Dr. Max Hamilton wrote back to her, stating that he was not interested in commenting on her SIGH-D because “those are not my anchors.” At that same poster session, a gentleman who reported that he had worked with Dr. Hamilton and had translated Hamilton’s work into different languages for publication, presented himself at this author’s poster and said, “someone finally got it right.”

Method

Below, the scoring guidelines and anchors from Williams’ 1988 SIGH-D and the Guy 1976 HAM-D are contrasted with the Hamilton’s 1960 and 1967 articles via direct quotes from those articles. An analysis follows, demonstrating that the 1976 Guy HAM-D/1988 SIGH-D does not accurately represent Hamilton’s 1960 and 1967 guidelines in relationship to the response option anchors. The 2013 SIGH-D, a refinement of the 1988 SIGH-D, is then also shown to not be Hamilton’s HAM-D. This article will demonstrate that the extant HAM-Ds—the 1976 Guy HAM-D, the 1988 SIGH-D and the 2013 SIGH-D—do not accurately represent Hamilton’s eponymous scale, a well-researched scale whose guidelines remain available to us in his 1960 and 1967 publications. As a result, a Max Hamilton—Depression Rating Scale © (MHAM-D)™ based on the 1967 article, is proposed for review.

Results

HAM-D Question 1 [Guy 1976/SIGH-D 1988]

1. DEPRESSED MOOD (sadness, hopeless, helpless, worthless): 0 - absent 1 - indicated only on questioning 2 - spontaneously reported verbally 3 - communicated non-verbally, i.e., facial expression, posture, voice, tendency to weep 4 - VIRTUALLY ONLY those feeling states reported in spontaneous verbal and non-verbal Communication

Hamilton’s 1960 Guidelines

Depressed Mood: (0–4)

Gloomy attitude, pessimism about the future

Feelings of sadness

Tendency to weep

 Sadness, etc.……………... 1

 Occasional weeping……... 2

 Frequent weeping……….. 3

 Extreme symptoms…….... 4 (Hamilton, 1960, p.62)

Hamilton’s 1967 Guidelines

Depressed mood is not easy to assess. One looks for a gloomy attitude, pessimism about the future, feelings of hopelessness, and a tendency to weep. As a guide, occasional weeping could count as 2, frequent weeping as 3, and severe symptoms allotted 4 points. When patients are severely depressed they may ‘go beyond weeping’ (Hamilton, 1967, p.291–294).

Analysis

I began my research into the Hamilton Depression Rating Scale because of my confusion about response option 2 in this item (“spontaneously reported verbally”) in the present version of the HAM-D. It seemed surprising that Hamilton would place this response option in item number 1 if he intended to provide the patient with time to be spontaneous. I wondered, “How long do I wait?” Review of the 1960 and 1967 articles revealed that Hamilton never mentions “spontaneously reported verbally.” Instead, in item 1, “a gloomy attitude, pessimism about the future, feelings of hopelessness, and a tendency to weep,” are each to be rated as a series of a number of equal-valued terms on a five-point scale. “As a guide,” Hamilton list the anchors for “tendency to weep” along a continuum of severity. The inference is that the other three categories, “a gloomy attitude, pessimism about the future, feelings of hopelessness” equal-valued terms, are each to be rated along a continuum of severity.

2013 SIGH-D Depressed Mood (sadness, hopeless, helpless, worthless)

0	Absent
1	Indicated only on questioning (occasional, mild depression)
2	Spontaneously reported verbally (persistent, mild to moderate depression)
3	Communicated non-verbally, i.e., facial expression, posture, voice, tendency to weep (persistent, moderate to severe depression)
4	VIRTUALLY ONLY those feeling states reported in spontaneous verbal and non-verbal communi- cation (persistent, very severe depression, with extreme hopelessness or tearfulness)

2013 SIGH-D Analysis: While the descriptors in parentheses are closer to Hamilton’s guidelines related to, “a number of equal-valued terms,” i.e., “depressed mood, sadness, hopeless, helpless, worthless,” Hamilton’s 1–4 categories measure severity from trivial to severe, but the SIGH-D are skewed to a more severe rating, with the 1–4 ratings measuring from mild to very severe/extreme; while ”extreme symptoms” is used in 1960, it is not used in the text of 1967 article. Additionally, the meaning of “persistent” in the 2013 SIGH-D is unclear, as it is listed in response options 2, 3 and 4.

HAM-D Question 2 [Guy 1976/SIGH-D 1988]

2. FEELINGS OF GUILT: 0 - absent 1 - self-reproach, feels he has let people down 2 - ideas of guilt or rumination over past errors or sinful deeds 3 - present illness is a punishment. Delusions of guilt. 4 - hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations

Hamilton’s 1960 Guidelines

 Guilt: (0–4)

 Self-reproach, feels he has let people down

Ideas of guilt

Present illness is a punishment

Delusions of guilt

Hallucinations of guilt (Hamilton, 1960, p.62)

Hamilton’s 1967 Guidelines

This is fairly easy to assess but judgment is needed, for the rating is concerned with pathological guilt. From the patient’s point of view, some action of his which precipitated a crisis may appear as a ‘rational’ basis for self-blame, which persists even after recovery from his illness. For example, he may have accepted a promotion but the increased responsibility precipitated his breakdown. When he ‘blames’ himself for this, he is ascribing a cause and not necessarily expressing pathological guilt. As a guide to rating, feelings of self-reproach count 1, ideas of guilt 2, belief that the illness might be a punishment 3, and delusions of guilt, with or without hallucinations, 4 points (Hamilton, 1967, p.292).

Analysis

Item numbers 2, 3 and 15 in Appendix II (1960) each have a downward arrow (↓) indicating these are the items are a series of “categories of increasing intensity.” Additionally, Hamilton clearly states (1967) that “delusions of guilt with or without hallucinations” should be rated “4 points,” yet in the HAM-D, delusions are incorrectly anchored, given a value of 3 points. Incorrectly scoring someone who is delusional with 3 points instead of 4 points could limit a possible 4-point improvement to only 3 points.

2013 SIGH-D Feelings of Guilt

0	Absent
1	Self-reproach, feels he has let people down
2	Ideas of guilt or rumination over past errors or sinful deeds (feelings of guilt, remorse or shame)
3	Present illness is a punishment. Delusions of guilt. (severe, pervasive feelings of guilt)
4	Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations

2013 SIGH-D Analysis: This SIGH-D continues to list delusions in option 3, not option 4 as was recommended by Hamilton. Severe is now added to option 3 while Hamilton said severe is 4.

HAM-D Question 3 [Guy 1976/SIGH-D 1988]

3. SUICIDE: 0 - absent 1 - feels life is not worth living 2 - wishes he were dead or any thoughts of possible death to self 3 - suicidal ideas or gesture 4 - attempts at suicide

Hamilton’s 1960 Guidelines

Suicide: (0–4)

Feels life is not worth living

Wishes he were dead

Suicidal ideas

Attempts at suicide (Hamilton, 1960, p.62)

Hamilton’s 1967 Guidelines

The scoring ranges from feeling that life is not worth living 1, wishing he were dead 2, suicidal ideas and half-hearted attempts 3, serious attempts 4. Judgment must be used when the patient is considered to be concealing this symptom, or conversely, when he is using suicidal threats as a weapon, to intimidate others, obtain help and so on (Hamilton, 1967, p.292).

Analysis

Hamilton’s guidelines and the presently used anchors in this Item 3 are identical. These four categories are “a series of categories of increasing intensity,” as indicated in Appendix II. His 1967 guideline that half-hearted suicide attempts are to be rated 3 gives insight into his thoughts on ratings.

2013 SIGH-D Suicide

0	Absent
1	Feels life is not worth living
2	Wishes he were dead or any thoughts of possible death to self
3	Suicidal ideas or gesture
4	Attempts at suicide

2013 SIGH-D Analysis: There is no difference between the 1976 Guy/SIGH-D and the 2013 SIGH-D version for this item, and both are consistent with Hamilton’s recommendations.

HAM-D Questions 4–6 [Guy 1976/SIGH-D 1988]

4. INSOMNIA EARLY (INITIAL INSOMNIA): 0 - no difficulty falling asleep 1 - complains of occasional difficulty falling asleep—i.e., more than 1/2 hour 2 - complains of nightly difficulty falling asleep

5. INSOMNIA MIDDLE: 0 - no difficulty 1 - complains of being restless and disturbed during the night 2 - waking during the night—any getting out of bed (except to void)

6. INSOMNIA LATE (TERMINAL INSOMNIA): 0 - no difficulty 1 - waking in early hours of morning but goes back to sleep 2 - unable to fall asleep again if gets out of bed

Hamilton’s 1960 Guidelines:

 Insomnia, Initial: (0–2)

 Difficulty in falling asleep

 Insomnia, Middle: (0–2)

 Patient restless and disturbed during the night

 Waking during the night

 Insomnia, Delayed: (0–2)

 Waking in early hours of the morning and unable to fall asleep again (Hamilton, 1960, p.62)

Hamilton’s 1967 Guidelines

Mild, trivial, and infrequent symptoms are given 1 point, obvious and severe symptoms are rated 2 points. Both severity and frequency should be taken into account. Middle insomnia is the most difficult to assess, possibly because it is an artifact of the system of rating. When insomnia is severe, it generally affects all phases. Delayed insomnia (early morning wakening) tends not to be relieved by hypnotic drugs and is not often present without other forms of insomnia (Hamilton, 1967, p.292).

Analysis

The Guy HAM-D took Hamilton’s categories of a number of equal-valued terms and incorrectly (there is no downward arrow next to these items in Appendix II for items 5 and 6) made them categories of increasing intensity. Using Hamilton’s guidelines for equal-valued terms, Item 6, Insomnia, Delayed: (0–2) should not be arbitrarily divided and scored as 1 point for waking in early hours of the morning and 2 points for unable to fall asleep again, but should be scored as a number of equal-valued terms. Waking in early hours of the morning and unable to fall asleep again, using Hamilton’s 1960 and 1967 guidelines for a three-point scale:

 (0) Absent

   (1) Slight or doubtful; mild, trivial and infrequent

   (2) Clearly present; obvious, distinct or severe

2013 SIGH-D Insomnia Early (Initial Insomnia)

0	No difficulty falling asleep
1	Complains of occasional difficulty falling asleep (i.e., 30 minutes or more, 2–3 nights)
2	Complains of nightly difficulty falling asleep (i.e., 30 minutes or more, 4 or more nights)

2013 SIGH-D Insomnia Middle

0	No difficulty
1	Complains of being restless and disturbed during the night (or occasional difficulty, i.e., 2–3 nights, 30 minutes or more)
2	Waking during the night - any getting out of bed (except to void) (often, i.e., 4 or more nights of difficulty, 30 minutes or more)

2013 SIGH-D Insomnia Late (Terminal Insomnia):

0	No difficulty
1	Waking in early hours of morning but goes back to sleep (occasional, i.e., 2–3 nights difficulty)
2	Unable to fall asleep again if gets out of bed (often, i.e., 4 or more nights difficulty)

2013 SIGH-D Analysis: the additional descriptors are still not consistent with this item’s 1967 recommendations: 0 = absent; 1 = mild, trivial and infrequent and 2 = obvious and severe.

HAM-D Question 7 [Guy 1976/SIGH-D 1988]

7. WORK AND ACTIVITIES: 0 - no difficulty 1 - thoughts and feelings of incapacity, fatigue or weakness related to activities, work or hobbies 2 - loss of interest in activity, hobbies or work - by direct report of the patient or indirect in listlessness, indecision and vacillation (feels he has to push self to work or activities) 3 - decrease in actual time spent in activities or decrease in productivity. In hospital, pt. spends less than 3 hrs./day in activities (hospital job or hobbies) exclusive of ward chores 4 - stopped working because of present illness. In hospital, no activities except ward chores, or fails to perform ward chores unassisted.

Hamilton’s 1960 Guidelines

Work and Interests: (0–4)

Feelings of incapacity

Listlessness, indecision and vacillation

Loss of interest in hobbies

Decreased social activities

Productivity decreased

Unable to work (Hamilton, 1960, p.62)

Difficulties at work and loss of interest in hobbies and social activities are both included. The patient who has given up work solely because of his illness is rated 4 (Hamilton, 1960, p.57).

Hamilton’s 1967 Guidelines

It could be argued that the patient’s loss of interest in his work and activities should be rated separately from his decreased performance, but it has been found too difficult to do so in practice. Care should be taken not to include fatigability and lack of energy here: the rating is concerned with loss of efficiency and the extra effort required to do anything. When the patient has to be admitted to hospital because his symptoms render him unable to carry on, this should be rated 4 points, but not if he has been admitted for investigation or observation. When the patient improves he will eventually return to work, but when he does so may depend on the nature of his work; judgment must be used here (Hamilton, 1967, p.292).

Analysis

While this might be viewed as a list of categories of increasing intensity, unlike items 3 and 15 which each lists 4 items under the heading “0–4,” and are labelled with a downward arrow, these six items are a number of equal-valued terms. Using Hamilton’s anchors, one should rate a patient with severe symptoms, a 4. Hamilton does not say a complete reduction in work, productivity, interests, activities, or hobbies is required to score a 4. In contrast to Hamilton’s suggestions, the presently used HAM-D anchors appear to restrict a 4 to only someone who has completely stopped working. The fact that there are six categories and that Hamilton notes that this item measures (1) decreased interest in work, (2) decreased interest in activities and (3) decreased performance, all in one item means all of these are to be measured in response option 4, not just work issues. These are a number of equal-valued terms to be measured along a continuum of severity. By example, other ways to get a 4 on this item, including, i.e., an outpatient whose symptoms render him or her, ”unable to carry on” with work or activities.

2013 SIGH-D Work and Activities

0	No difficulty
1	Thoughts and feelings of incapacity, fatigue or weakness related to activities, work or hobbies (mild reduction in interest or pleasure; no clear impairment in functioning)
2	Loss of interest in activity, hobbies or work - by direct report of the patient or indirect in listlessness, indecision and vacillation (feels he has to push self to work or activities· clear reduction in interest. pleasure or functioning)
3	Decrease in actual time spent in activities or decrease in productivity. In hospital patient spends less than three hours/day in activities (hospital job or hobbies) exclusive of ward chores (profound reduction in interest, pleasure, or functioning)
4	Stopped working because of present illness. In hospital, no activities except ward chores, or fails to perform ward chores unassisted (unable to work or fulfill primary role because of illness, and total loss of interest)

2013 SIGH-D Analysis: Again, Hamilton’s guidelines are for a list of equal valued terms. Work and Interests: (0–4): Feelings of incapacity; Listlessness, indecision and vacillation; Loss of interest in hobbies; Decreased social activities; Productivity decreased; Unable to work – to be rated on a scale − 0 = absent, 1 = doubtful or trivial, 2 = mild, 3 = moderate, and 4 = severe. These anchors: 1 = mild reduction; 2 = clear reduction; 3 = profound reduction; 4 = total reduction are not Hamilton’s.

HAM-D Question 8 [SIGH-D 1988]

RATING BASED ON OBSERVATION DURING INTERVIEW 8. RETARDATION (slowness of thought and speech; impaired ability to concentrate; decreased motor activity): 0 - normal speech and thought 1 - slight retardation at interview 2 - obvious retardation at interview 3 - interview difficult 4 - complete stupor

Hamilton’s 1960 Guidelines

Retardation: (0–4)

Slowness of thought, speech, and activity

Apathy

Stupor

 Slight retardation at interview…...…… 1

 Obvious retardation at interview…...… 2

 Interview difficult………...…………... 3

 Complete stupor………...…………..... 4 (Hamilton, 1960, p.62)

A grade 4 patient is completely mute, and is therefore unsuitable for rating on the scale. Grade 3 patients need much care and patience to rate, but it can be done (Hamilton, 1960, p.57).

Hamilton’s 1967 Guidelines

Severe forms of this symptom are rare, and the mild forms are difficult to perceive. A slight flattening of affect and fixity of expression rate as 1, a monotonous voice, a delay in answering questions, a tendency to sit motionless count as 2. When retardation makes the interview extremely prolonged and almost impossible, it is rated 3, and 4 is given when an interview is impossible (and symptoms cannot be rated) (Hamilton, 1967, p.292).

Analysis

The statement “RATING BASED ON OBSERVATION DURING INTERVIEW,” is nowhere to be found in Hamilton’s papers, nor is it in Guy’s 1976 HAM-D. It was not something Hamilton, who in addition to advocating for two raters to improve the validity of ratings would have supported or envisioned, as he recommended not staying with confines of the evaluation, but “obtain(ing) additional information from relatives, friends, nurses, etc…whenever there is doubt.”

Additionally, while the presently used HAM-D anchors are somewhat similar to Hamilton’s (1960) anchors listed under “Stupor,” the other symptoms Hamilton measured on this item in 1960, “Slowness of thought, speech, or activity” and “Apathy,” are not reflected in the present anchors.

Finally, since this item in the present version of the HAM-D includes in its subheading, “impaired ability to concentrate,” it would be expected that symptoms related to concentration would be measured in this item in the presently used HAM-Ds. However, trouble concentrating is not anchored in this item or in any of the 17 items in the present version of the HAM-D. While this discrepancy can be partially understood because Hamilton, in 1967, included “impaired ability to concentrate” as a symptom in Item 10 (Anxiety, Psychic) rather than in this Item 8 (Retardation), the failure to measure concentration in any item in the presently used HAM-D confirms that the present HAM-D anchors are not Hamilton’s. Anchors 1 and 2 of this presently used item 8 include the word retardation, an adjective that is usually used in conjunction with psychomotor retardation rather than within the context of diminished concentration. Psychomotor retardation is not the same symptom as trouble concentrating. The present anchors appear to be only based upon Hamilton’s 1960 article and not on the 1967 article. Concentration was included in item 10 by Hamilton when he validated the HAM-D in 1967, yet it is now not measured at all by those of us who use the present HAM-D in either item 8 or in item 10.

2013 SIGH-D Retardation (slowness of thought and speech; impaired ability to concentrate; decreased motor activity)

0	Normal speech and thought
1	Slight retardation at interview (mild psychomotor retardation)
2	Obvious retardation at interview (moderate; some difficulty with interview, noticeable pauses and slowness of thought)
3	Interview difficult (severe psychomotor retardation; very long pauses)
4	Complete stupor (extreme retardation; interview barely possible)

2013 SIGH-D Analysis: Hamilton’s guidelines: 0 = absent, 1 = doubtful or trivial, 2 = mild, 3 = moderate, and 4 = severe are still not used, instead the ratings go from 0 = mild to 4 = extreme.

HAM-D Question 9 [SIGH-D 1988]

RATING BASED ON OBSERVATION DURING INTERVIEW 9. AGITATION: 0 - none 1 - fidgetiness 2 - playing with hands, hair, etc. 3 - moving about, can’t sit still 4 - hand-wringing, nail biting, hair-pulling, biting of lips

Hamilton’s 1960 Guidelines

Agitation: (0–2)

Restlessness associated with anxiety (Hamilton, 1960, p.62)

Unfortunately, a five-point scale was found impracticable, and therefore, this variable is rated on a three-point scale. The mildest degrees of agitation cause considerable difficulty (Hamilton, 1960, p.57).

Hamilton’s 1967 Guidelines

Severe agitation is extremely rare. Fidgetiness at interview rates as 1, obvious restlessness with picking at hands and clothes should count as 2. If the patient has to get up during the interview, he is given 3, and 4 points are given when the interview has to be conducted ‘on the run’, with the patient pacing up and down, picking at his face and hair and tearing at his clothes. Although agitation and retardation may appear to be opposed forms of behavior, in mild form they can co-exist (Hamilton, 1967, p.292).

Analysis

Hamilton wrote in the second paragraph of his 1967 paper, “The interviewer may, and should, use all information available to help him with his interview and in making the final assessment.” The presently used HAM-D instead directs the rater to complete the exam using, “Rating based on observation during interview.” This goes against Hamilton’s suggestion of using “all information available.” Hamilton changed this item from a three-point anchor in 1960 to a five-point anchored item in 1967. The different font of this item 9 on Table 3 in this paper reflects Guy’s explanation that Guy corrected item 9 just prior to publication of the ECDEU HAM-D. Guy was aware that Hamilton had changed his approach to the rating of this item, even though Hamilton had said in 1960, “a five-point scale was found impracticable.” Although the 1967 article updated Hamilton’s approach to this item, the scale that Guy published in ECDEU appears to not have taken any of the other 1967 updates and clarifications that are highlighted in this paper into consideration.

2013 SIGH-D Agitation

0	None
1	Fidgetiness (slight agitation or mild restlessness)
2	Playing with hands, hair, etc. (moderate to marked restlessness or agitation)
3	Moving about, can’t sit still (cannot remain seated)
4	Hand-wringing, nail biting, hair-pulling, biting of lips (interview cannot be conducted; severe agitation)

2013 SIGH-D Analysis: Hamilton’s guidelines: 0 = absent, 1 = doubtful or trivial, 2 = mild, 3 = moderate, and 4 = severe are more closely followed than in item 8, but Hamilton suggested mild = 2, and in this SIGH-D it is scored 1.

HAM-D Question 10 [Guy 1976/SIGH-D 1988]

10. ANXIETY, PSYCHIC: 0 - no difficulty 1 - subjective tension and irritability 2 - worrying about minor matters 3 - apprehensive attitude apparent in face or speech 4 - fears expressed without questioning

Hamilton’s 1960 Guidelines

Anxiety, psychic: (0–4)

Tension and irritability

Worrying about minor matters

Apprehensive attitude

Fears (Hamilton, 1960, p.62)

Hamilton’s 1967 Guidelines

Anxiety (psychic symptoms)—Many symptoms are included here, such as tension and difficulty in relaxing, irritability, worrying over trivial matters, apprehension and feelings of panic, fears, difficulty in concentration and forgetfulness, ‘feeling jumpy’. The rating should be based on pathological changes that have occurred during the illness and an effort should be made to discount the features of a previous anxious disposition (Hamilton, 1967, p.292–293).

Analysis

This item has a number of errors if one considers that the HAM-D should be based on Hamilton’s 1967 work. We have already discussed that just because there are four categories in an item, it does not mean that the four items are categories of increasing severity. The four lines of symptoms listed in Hamilton’s 1960 guidelines are equal-valued terms. We know that because Hamilton’s 1967 article listed ten terms in this item and he included “difficulty in concentration and forgetfulness” in this item. These ten categories are equal-valued terms to be measured across a continuum of severity. In the presently used HAM-D, impaired ability to concentrate is listed in the Item 8 description of symptoms, but impaired ability to concentrate is not measured in any of that item’s response options. According to Hamilton’s 1967 guidelines, difficulty concentrating should be measured in item 10. In total, there are ten symptoms of psychic anxiety (measures of anxiety, irritability, memory loss and concentration difficulties) to be measured in item 10, but we are only measuring five in the presently used HAM-D.

This failure to measure concentration, despite Hamilton including it in item 10 in 1967, has resulted in a problem with the face validity of the presently used HAM-D. Concentration is a diagnostic symptom of a Major Depressive Episode but it has not been measured in the commonly used HAM-Ds since 1976.

Each of these ten equal-valued terms are rated on a five-point scale in which 0 is absent, 1 is doubtful or trivial, 2 is mild, 3 is moderate and 4 is severe, but incorrectly in the present HAM-D, tension and irritability is scored 1, worrying about minor matters is scored 2, apprehensive attitude is scored 3, and spontaneous fears are scored 4. This is a significant problem as a patient who presents for the final visit of a research study and spontaneously and without questioning expresses worry about coming off of the study medication could be scored a 4—spontaneous fears—according to the present HAM-D guidelines. Equally problematic, a patient with severe irritability, anger, fighting, argumentativeness, or disagreeability would be scored a 1 according to the present HAM-D guidelines instead of a score of a score of 4 that would be given had the guidelines from Hamilton’s 1967 been used.

2013 SIGH-D Anxiety Psychic

0	No difficulty
1	Subjective tension and irritability (mild, occasional)
2	Worrying about minor matters (moderate, causes some distress)
3	Apprehensive attitude apparent in face or speech (severe; significant impairment in functioning due to anxiety)
4	Fears expressed without questioning (symptoms incapacitating)

2013 SIGH-D Analysis: as above, this remains a series of a number of equal-valued terms not a series of categories of increasing intensity. The additional modifiers in parentheses do not correct the significant errors in this item (concentration is still not measured, and irritability is scored = 1, errors which are noted above.

HAM-D Question 11 [Guy 1976/SIGH-D 1988]

Tell me if you’ve had any of the following physical symptoms in the past week. (READ LIST) 11. ANXIETY SOMATIC (physiologic concomitants of anxiety, such as  GI - dry mouth, gas, indigestion, diarrhea, stomach cramps, belching, urinary frequency  CV - heart palpitations, headaches  Resp - hyperventilating, sighing, sweating): 0 - not present 1 - mild 2 - moderate 3 - severe 4 - incapacitating

Hamilton’s 1960 Guidelines

Anxiety, somatic: (0–4)

Gastrointestinal, wind, indigestion

Cardiovascular, palpitations, headache

Respiratory, genito-urinary, etc.

(Hamilton, 1960, p.62)

Hamilton’s 1967 Guidelines

These consist of the well-recognized effects of autonomic over-activity in the respiratory, cardiovascular, gastro-intestinal and urinary systems. Patients may also complain of attacks of giddiness, blurring of vision and tinnitus. These last three symptoms appear to be more common in women than in men (Hamilton, 1967, p.293–294).

Analysis

While the Guy (1976) and Williams (1988) HAM-D includes 12 symptoms of autonomic hyperactivity in the respiratory, cardiovascular, gastrointestinal, and urinary systems, Hamilton (1967) identified three additional symptoms, noting that the patient may complain of attacks of giddiness (British vernacular for lightheadedness),⁷ blurring of vision, and tinnitus. These three symptoms are not mentioned in either the Guy HAM-D or the SIGH-D versions, although they are sometimes seen in less frequently used versions of the HAM-D. It is unclear why they were left out, although the definition of giddiness may have been misinterpreted as representing a mood swing. With the omission of the three 1967 symptoms—attacks of giddiness, blurring of vision, and tinnitus—the present HAM-D inaccurately reflects Max Hamilton’s wishes. Moreover, the anchors “mild, moderate, severe, and incapacitated,” are used in the present HAM-D in contrast to Hamilton’s (1967) guidelines of “trivial or doubtful, mild, moderate and severe.” These newer non-Hamiltonian anchors require a higher threshold to score a 4 on this item than Hamilton would have required. At the same time, the SIGH-D does contain the excellent recommendation that every single symptom of this item be read out loud, an instruction not specifically articulated by Hamilton.

2013 SIGH-D Anxiety Somatic (physiologic concomitants of anxiety, such as

GI - dry mouth, gas, indigestion, diarrhea, stomach cramps, belching

CV- heart palpitations, headaches

Resp - hyperventilating, sighing

Urinary frequency

Sweating):

0	Not present
1	Mild (symptom(s) present only infrequently, no impairment, minimal distress)
2	Moderate (symptom(s) more persistent, or some interference with usual activities, moderate distress)
3	Severe (significant impairment in functioning)
4	Incapacitating

2013 SIGH-D Analysis: Hamilton’s guidelines: 0 = absent, 1 = doubtful or trivial, 2 = mild, 3 = moderate, and 4 = severe are not used. Incapacitating remains as a 4 instead of severe = 4.

HAM-D Question 12 [Guy 1976/SIGH-D 1988]

12. SOMATIC SYMPTOMS GASTROINTESTINAL: 0 - none 1 - loss of appetite but eating without encouragement 2 - difficulty eating without urging

Hamilton’s 1960 Guidelines

Somatic Symptoms, Gastrointestinal: (0–2)

Loss of appetite

Heavy feelings in abdomen

Constipation

These occur in connection with both anxiety and depression. Considerable clinical experience is required to evaluate them satisfactorily. The definitions given have been found very useful in practices (Hamilton, 1960, p.57).

Hamilton’s 1967 Guidelines

The characteristic symptom in depression is loss of appetite, and this occurs frequently. Constipation also occurs, but is relatively uncommon. On rare occasions, patients will complain of ‘heavy feelings’ in the abdomen. Symptoms of indigestion, wind and pain are rated under Anxiety (Hamilton, 1967, p.293).

Analysis

Hamilton’s (1960) Appendix I listed grading guidelines [Table 2] for three-point scales, suggesting that this item be scored as follows: 0 for no gastrointestinal symptoms, 1 for slight or doubtful gastrointestinal symptoms, and 2 for clearly present gastrointestinal symptoms. The Guy HAM-D 2-point anchor for this item reads “difficulty eating without staff urging. Requests or requires laxatives or medication for bowels or medication for G.I. symptoms.” The SIGH-D 2-point anchor reads “difficulty eating without urging,” only. Both of these anchors are very concrete, being examples of only one or two specific gastrointestinal symptoms. However, Hamilton (1960) wanted us to score a 2 for any clearly present symptom, i.e., clearly present loss of appetite, clearly present heavy feelings in abdomen, or clearly present constipation. Hamilton’s 1960 Guidelines list a set of three equal-valued terms to be measured across a continuum of severity.

2013 SIGH-D Somatic Symptoms Gastrointestinal

0	None
1	Loss of appetite but eating without encouragement (appetite somewhat less than usual)
2	Difficulty eating without urging (or appetite significantly less than usual)

2013 SIGH-D Analysis

This item is a series of equal valued terms—Loss of appetite, heavy feelings in abdomen and constipation—that Hamilton had intended to be measured 0 for no gastrointestinal symptoms, 1 for slight or doubtful gastrointestinal symptoms, and 2 for clearly present gastrointestinal symptoms. The response options in the 2013 SIGH-D still do not match Hamilton’s guidelines.

HAM-D Question 13 [Guy 1976/SIGH-D 1988]

13. SOMATIC SYMPTOMS GENERAL: 0 - none 1 - heaviness in limbs, back, or head. Backaches, headaches, muscle aches. Loss of energy and fatigability. 2 -any clear-cut symptoms

Hamilton’s 1960 Guidelines

Somatic Symptoms, General: (0–2)

Heaviness in limbs, back, or head

Diffuse backache

Loss of energy and fatigability (Hamilton, 1960)

In depression these are characteristically vague and ill defined, and it is extremely difficult to get a satisfactory description of them from the patient (Hamilton, 1960, p.62).

Hamilton’s 1967 Guidelines

These fall into two groups: The first is fatigability, which may reach the point where the patients feel tired all the time. In addition, patients complain of ‘loss of energy’ which appears to be related to difficulty in starting up an activity. The other type of symptoms consists of diffuse muscular achings [sic], ill-defined and often difficult to locate, but frequently in the back and sometimes in the limbs; these may also feel ‘heavy’ (Hamilton, 1967, p.293–295).

Analysis

This is another three-point item.

Three-Point Scale 1960 0 - Absent 1 - Slight or doubtful 2 - Clearly present

Three-Point Scale 1967 0 - Absent 1 - Doubtful or mild Trivial and infrequent 2 - Obvious, distinct or severe

According to Hamilton (1960), any clear-cut symptoms should be rated as 2. For a three-point item, Hamilton recommended in 1967, on a three-point scale (0) equivalent to absent, (1) doubtful or mild, (and added trivial and infrequent in Item 4, 5 and 6) (2) obvious, distinct or severe. This item is written in a way that is close to Hamilton’s recommendations, although it is not entirely obvious to score this item as a 1 if the equal-valued symptoms are slight, doubtful or mild, trivial or infrequent.

2013 SIGH-D Somatic Symptoms General

0	None
1	Heaviness in limbs, back, or head. Backaches, muscle aches. Loss of energy and fatigability (somewhat less energy than usual; mild, intermittent loss of energy or muscle aches/heaviness)
2	Any clear-cut symptoms (persistent, significant loss of energy or muscle aches/heaviness)

2013 SIGH-D Analysis

For a three-point item, Hamilton recommended in 1967, on a three-point scale (0) equivalent to absent, (1) doubtful or mild, and (2) obvious, distinct or severe. These anchors are close to Hamilton’s.

HAM-D Question 14 [Guy 1976/SIGH-D 1988]

14. GENITAL SYMPTOMS (such as loss of libido, menstrual disturbances): 0 - absent 1 - mild 2 - severe

Hamilton’s 1960 Guidelines

Genital Symptoms: (0–2)

Loss of libido

Menstrual disturbances (Hamilton, 1960)

Hamilton’s 1967 Guidelines

This is a common and characteristic symptom of depression, but it is difficult to assess in older men and especially those unmarried whose sexual activity is usually at a low level. The assessment is based on a pathological change, i.e. a deterioration obviously related to the patient’s illness. In women whose sexual experience is satisfactory, this symptom will appear as increasing frigidity, progressing to active dislike of sexual intercourse. Women who are partially or completely frigid find that their customary toleration of sex also changes to active dislike. In the absence of adequate information of a pathological change, a zero rating should be given. Disturbed menstruation and amenorrhea have been described in women suffering from severe depression, but they are very rare (Hamilton, 1967, p.293–295).

Analysis

For this item there is good agreement between Hamilton and the presently used HAM-D, with the equal-valued items measured on a continuum of severity.

2013 SIGH-D Genital Symptoms (such as loss of libido, menstrual disturbances)

0	Absent
1	Mild (somewhat less interest than usual)
2	Severe (a lot less interest than usual)

2013 SIGH-D Analysis

For this item in the 2013 SIGH-D there is good agreement with Hamilton’s recommendations for equally-valued items (Loss of libido and Menstrual disturbances) measured on a continuum.

HAM-D Question 15 [Guy 1976/SIGH-D 1988]

15. HYPOCHONDRIASIS: 0 - not present 1 - self-absorption (bodily) 2 - preoccupation with health 3 - frequent complaints, requests for help, etc. 4 - hypochondriacal delusions

Hamilton’s 1960 Guidelines:

Hypochondriasis: (0–4)

Self-absorption (bodily)

Preoccupation with health

Querulous attitude

Hypochondriacal delusions (Hamilton, 1960)

This is easy to rate when it is obviously present, but difficulties arise with hypochondriacal preoccupations (Hamilton, 1960, p.57).

Hamilton’s 1967 Guidelines

The severe states of this symptom, concerning delusions and hallucinations of rotting and blockages, etc., which are extremely uncommon in men, are rated as 4. Strong convictions of the presence of some organic disease which accounts for the patient’s condition are rated 3. Much preoccupation with physical symptoms and with thoughts of organic disease are rated 2. Excessive preoccupation with bodily functions is the essence of the hypochondriacal attitude and trivial or doubtful symptoms count as 1 point (Hamilton, 1967, p.293).

Analysis

The downward arrow in Appendix II indicates that this item is correctly interpreted as a series of categories of increasing intensity.

2013 SIGH-D Hypochondriasis

0	Not present
1	Self-absorption (bodily) (some inappropriate worry about his/her health OR slightly concerned despite reassurance)
2	Preoccupation with health (often has excessive worries about his/her health OR definitely concerned has specific illness despite medical reassurance)
3	Frequent complaints, requests for help, etc. (is certain there is a physical problem which the doctors cannot confirm; exaggerated or unrealistic concerns about body and physical health)
4	Hypochondriacal delusions

2013 SIGH-D Analysis

This SIGH-D remains correctly interpreted as a series of categories of increasing intensity.

HAM-D Question 16 [Guy 1976/SIGH-D 1988]

16. LOSS OF WEIGHT When rating by history: 0 - no weight loss or weight loss NOT caused by present illness. 1 - probable weight loss due to current depression 2 - definite (according to patient) weight loss due to depression

Hamilton’s 1960 Guidelines

Loss of Weight: (0–2) (Hamilton, 1960)

Ideally this would be measured in pounds or kilograms, but few patients know their normal weight and keep a check on it. It was therefore necessary to use a three-point scale (Hamilton, 1960, p.62).

Hamilton’s 1967 Guidelines

The simplest way to rate this would be to record the amount of loss, but many patients do not know their normal weight. For this reason, an obvious or severe loss is rated as 2 and a slight or doubtful loss as 1 point (Hamilton, 1967, p.293).

Analysis

In Hamilton’s 1967 article, Item 16, loss of weight, is preceded by Item 17, insight, which specifically notes, “In case of doubt, inquiries should be directed to the patient’s attitude of his symptoms … ” Perhaps Hamilton had meant for this approach to be taken on this item as well. Hamilton (1960) noted that this item was one of the worst for inter-rater reliability. The addition to the SIGH-D anchor the advisory that weight loss that is not caused by the present illness be scored a 0 is probably not an acceptable clarification of Hamilton’s (1960) anchors; Hamilton did not include this recommendation in either of his papers.

2013 SIGH-D Loss of Weight

Rate by History

0	No weight loss
1	Probable weight loss due to current depression
2	Definite (according to patient) weight loss due to depression

2013 SIGH-D Analysis

As above, Hamilton recommended that “Symptoms are rated coarsely … on a three-point scale (0–2) equivalent to absent, doubtful or mild, and obvious, distinct or severe.” This SIGH-D does not rate using those three-point guidelines.

HAM-D Question 17 [Guy 1976/SIGH-D 1988]

17. INSIGHT: 0 - acknowledges being depressed and ill OR not currently depressed 1 - acknowledges illness but attributes cause to bad food, overwork, virus, need for rest, etc. 2 - denies being ill at all

Hamilton’s 1960 Guidelines

Insight: (0–2)

No loss………………………………….. 0

Partial or doubtful loss……………….…. 1

Loss of insight………………….……..… 2 (Hamilton, 1960)

This must always be considered in relation to the patient’s thinking and background of knowledge. It is important to distinguish between a patient who has no insight and one who is reluctant to admit that he is “mental” (Hamilton, 1960, p.57).

Hamilton’s 1967 Guidelines

This is not necessarily present when the patient denies that he is suffering from mental disorder. It may be that he is denying that he is insane and may willingly recognize that he has a ‘nervous’ illness. In case of doubt, enquiries should be directed to the patient’s attitude to his symptoms of Guilt and Hypochondriasis (Hamilton, 1967, p.293).

Analysis

This item’s anchors in the present HAM-D are overly specific and do not completely reflect Hamilton’s 1967 recommendations. A patient who is paranoid regarding the etiology of his depression, convinced that he has been poisoned but admitting to being ill, would be scored a 2 by Hamilton for a clearly present loss of insight, but might be scored a 1 according to this HAM-D item.

2013 SIGH-D Insight

0	Acknowledges being depressed and ill OR not currently depressed
1	Acknowledges illness but attributes cause to bad food, overwork, virus, need for rest, etc.
2	Denies being ill at all

2013 SIGH-D Analysis

As above, these do not follow Hamilton’s guidelines for a three-point scale.

Conclusion

There are significant differences between the Guy HAM-D and the SIGH-D, both in widespread use, and the original work of Max Hamilton, validated in 1960 and then more rigorously validated in 1967. These significant differences between the currently used HAM-Ds and the original guidelines set forth by Max Hamilton in 1960 and 1967 produce inconsistencies in administration and scoring, leading to measures of patient illness different from the measures originally validated by Hamilton in 1960 and 1967. Although some of Hamilton’s recommendations were somewhat confusing in his 1960 article, including specifying the rating of moderate on a five-point scale to be either a 2 or a 3 (see Appendix I), this was corrected in the 1967 paper (see Table 2) as were almost all of the 1960 ambiguities. Nevertheless, the discrepancies in 13 of the 17 items between Hamilton and Guy/Williams, discussed in this paper, are noted in Table 4 above. To a large degree, the systemic error in the Guy HAM-D is that, although he succeeded in his effort to find one scale that was Hamilton’s, the one scale he chose was a 1960 vintage Hamilton, not a 1967 Hamilton. So, although Williams validated her SIGH-D in 1988, she used a 1960—based HAM-D to do this. Evidence for this is from the fact that Guy primarily used a 1960—based HAM-D in his 1976 publication, from her own 1988 paper where she only referenced the 1967 Hamilton article in the last paragraph, from the lack of a reference to the 1967 Hamilton article in her 2013 paper, and from her written communication with Max Hamilton that she showed to this author.

Table 4. Errors Noted.

ERRORS IN THE HAM-D CURRENTLY IN USE WHEN COMPARED WITH HAMILTON’S 1960 AND 1967 GUIDELINES
	HAMILTON ITEM NUMBER
TYPE OF ERROR	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17
Wrong anchors used
Series of categories of increasing intensity ignored or misinterpreted
List of a number of equal-valued terms misinterpreted as being a list of categories of increasing intensity
Graded scoring system ignored or misinterpreted
No Error    Error

Williams additional systemic error is only using a limited number of subjects, and only those suffering from a mild major depressive disorder. Williams tested her scale in a mere (italics added) twenty-three subjects, while Hamilton wrote in 1967, “A previous account … of the rating scale must be regarded as little more than a preliminary report.” “In … 1960 … the data was based on the results … from a mere forty-nine male patients; the present work describes the results obtained from 152 male and 120 female patients.” (p.278)

In summary, the problems with the currently used HAM-Ds are as follows:

In twelve items in the presently used HAM-D, Hamilton’s 1960 and 1967 suggested anchors are ignored or misinterpreted [Table 4]; The presently used HAM-D anchors that are consistent with Hamilton’s recommendations are typically from Hamilton’s 1960 article and not from his updated 1967 article;

Hamilton provided two different grading systems for scoring; one method was a series of categories of increasing intensity while the other was a number of equal-valued terms to be measured along a continuum of severity from absent to severe. Unfortunately, these two different scoring methods have been merged by mistake or ignored in the present HAM-D in seven items [Table 4];

Hamilton gave generic rating guidelines for both three-point items and five-point items [Table 2], but these guidelines are ignored in eleven items in the presently used HAM-D [Table 4];

In the retardation item (Item 8) the symptoms listed in the subheadings do not match the anchors;

There is no anchor for concentration, an acknowledged criterion of a Major Depressive Episode (MDE);

The presently used SIGH-D script has not been validated for an adequate number of patients;

The presently used SIGH-D script has not been validated in patients with moderate to severe (MDE);

While Hamilton validated his research findings in 1960 and again in 1967, the present HAM-D anchors are not consistent with Hamilton’s research. As a result, they have not been validated for an adequate number of patients. Therefore, the widely used HAM-Ds may lead to unreliable measures of patients’ and subjects’ severity of illness and lead to unreliable measures of their progress over time;

In total, when comparing the HAM-Ds currently in use with Hamilton’s guidelines from his 1960 and 1967 articles, 13 of the 17 items have significant errors in the response option anchors.

The discrepancies between the HAM-D as it was validated by Hamilton and the HAM-Ds that we currently use may be one reason that we are having difficulty using this instrument to separate drug from placebo in the study of medications that treat Major Depressive Episodes. Given the demonstrated flaws in the present HAM-D, it is not surprising that the various solutions that have been tried to modify Guy’s HAM-D, including the SIGH-D, have failed. Perhaps more success would have been achieved if any modifications that were attempted had been applied to Hamilton’s original scale as he intended.

The most popular forms of the HAM-D, Guy’s HAM-D and the SIGH-D modifications to the Guy HAM-D, and the iterations of interactive voice recognition systems (IVRS), the GRID HAM-D, and the various computerized versions for measuring the HAM-D, all have errors in 13 of the 17 items compared with the well-researched recommendations of Hamilton. Based upon the information presented in this paper, if we want to use Hamilton’s research as the benchmark for a depression rating scale, neither Guy’s HAM-D or the SIGH-D are adequate ways to use Hamilton’s research. By extrapolation, whether these scales are used face to face, on a computer, self-rated, IVRS, or centrally rated, the problems with Guy’s HAM-D response option anchors and the SIGH-D remain, because, as Max Hamilton wrote to Janet Williams, “those are not my anchors.” There is no need to modify, grid, structure the interview or create a somewhat modified version of the presently used HAM-D, because the HAM-D we are using is not the one Hamilton intended for our use sixty years ago.

Max Hamilton - Depression Rating Scale © (MHAM-D)™

MHAM-D™ 1. DEPRESSED MOOD (gloomy attitude, feelings of sadness, lowering of spirits, pessimism about the future, feelings of hopelessness and a tendency to weep.)  0 - absent  1 - doubtful or trivial  2 - mild (i.e., occasional weeping, etc.)  3 - moderate (i.e., frequent weeping, etc.)  4 - severe (i.e., extreme symptoms that go beyond crying)

MHAM-D™ 2. FEELINGS OF GUILT  0 - absent  1 - self-reproach, feels he has let people down  2 - ideas of guilt or rumination over past errors or sinful deeds  3 - present illness is a punishment.  4 - delusions of guilt. Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations

MHAM-D™ 3. SUICIDE  0 - absent  1 - feels life is not worth living  2 - wishes they were dead or any thoughts of possible death to self  3 - suicidal ideas or gesture  4 - attempts at suicide

MHAM-D™ 4. INSOMNIA EARLY (INITIAL INSOMNIA)  0 - no difficulty falling asleep  1 - slight, doubtful, mild, trivial, or infrequent symptoms  2 - clearly present, obvious, distinct, or severe symptoms

MHAM-D™ 5. INSOMNIA MIDDLE  0 - no difficulty with being restless or disturbed during the night, or with waking during the night  1 - slight, doubtful, mild, trivial, or infrequent symptoms  2 - clearly present, obvious, distinct, or severe symptoms

MHAM-D™ 6. INSOMNIA DELAYED (TERMINAL INSOMNIA)  0 - no difficulty with waking in early hours of the morning or, if awakened, no difficulty with falling asleep again  1 - slight, doubtful, mild, trivial, or infrequent symptoms  2 - clearly present, obvious, distinct, or severe symptoms

MHAM-D™ 7. WORK AND ACTIVITIES This rating is concerned with loss of interest, decreased performance, loss of efficiency in work and activities and the extra effort required to do anything. [Do not include fatigability and lack of energy here. Patients may complain of inability to feel affection for their families. This could be rated here, but it could be rated under other symptoms, depending upon its meaning and setting. Care should be taken not to rate it in two places.] Listlessness, indecision and vacillation Loss of interest in hobbies Decreased social activities Productivity decreased Unable to work  0 - absent  1 - doubtful or trivial  2 - mild  3 - moderate  4 - severe

MHAM-D™ 8. RETARDATION Slowness of thought and speech; decreased motor activity:  0 - normal speech and thought  1 - a slight flattening of affect and fixity of expression  2 - a monotonous voice, a delay in answering questions, a tendency to sit motionless.  3 - retardation makes the interview extremely prolonged and almost impossible  4 - interview is impossible

MHAM-D™ 9. AGITATION  0 - none  1 - fidgetiness at interview  2 - obvious restlessness with picking at hands and clothes  3 - the patient has to get up during the interview  4 - the interview has to be conducted ‘on the run,’ with the patient pacing up and down, picking at his face and hair and tearing at his clothes

MHAM-D™ 10. ANXIETY PSYCHIC Many symptoms are included here: Tension, difficulty in relaxing, irritability, worrying over trivial matters, apprehension, feelings of panic, fears, difficulty in concentration, forgetfulness, ‘feeling jumpy’  0 - absent  1 - doubtful or trivial  2 - mild  3 - moderate  4 - severe

MHAM-D™ 11. ANXIETY SOMATIC (Read List) Physiologic concomitants of anxiety, such as: giddiness (lightheadedness), blurry vision, and tinnitus Gastrointestinal - dry mouth, wind, indigestion, diarrhea, stomach cramps, belching, abdominal pain  Cardiovascular - palpitations, headaches  Respiratory - hyperventilating, sighing, sweating Genito-urinary  0 - absent  1 - doubtful or trivial  2 - mild  3 - moderate  4 - severe

MHAM-D™ 12. SOMATIC SYMPTOMS GASTROINTESTINAL Loss of appetite, heavy feelings in abdomen and constipation  0 - absent  1 - slight, doubtful, mild, trivial, or infrequent symptoms  2 - clearly present, obvious, distinct, or severe symptoms

MHAM-D™ 13. SOMATIC SYMPTOMS GENERAL Heaviness in limbs, back or head Diffuse backache Loss of energy and fatigability Diffuse muscle aches in limbs or back Difficulty in starting up an activity  0 - absent  1 - slight, doubtful, mild, trivial, or infrequent symptoms  2 - clearly present, obvious, distinct, or severe symptoms

MHAM-D™ 14. GENITAL SYMPTOMS Loss of libido, loss of drive or loss of responsiveness (assessment based on a pathological change, i.e. deterioration obviously related to the patient’s illness) Amenorrhea. (only be scored in this item if the disturbance in the menstrual cycle is obviously related to the severe depression).  0 - absent, or inadequate or no information  1 - slight, doubtful, mild, trivial, or infrequent symptoms  2 - clearly present, obvious, distinct, or severe symptoms

MHAM-D™ 15. HYPOCHONDRIASIS Excessive preoccupation with bodily functions is the essence of the hypochondriacal attitude  0 - not present  1 - trivial or doubtful symptoms  2 - much preoccupation with physical symptoms and with thoughts of organic disease  3 - strong convictions of the presence of some organic disease which accounts for the patient’s condition  4 - delusions and hallucinations of rotting and blockages, etc.

MHAM-D™ 16. LOSS OF WEIGHT Ideally this would be measured in pounds or kilograms In case of doubt, inquiries should be directed to the patient’s attitude to his symptoms  0 - no weight loss or weight loss  1 - slight or doubtful loss  2 - obvious or severe loss

MHAM-D™ 17. INSIGHT Insight must be interpreted in terms of patient’s understanding and background In case of doubt, inquiries should be directed to the patient’s attitude to his symptoms  0 - no loss  1 - slight, doubtful, mild, trivial, or infrequent loss  2 - clearly present, obvious, distinct, or severe loss