title: Severity classification on the Hamilton Depression Rating Scale.
abstract: BACKGROUND
  Symptom severity as a moderator of treatment response has been the subject of debate over the past 20 years. Each of the meta- and mega-analyses examining the treatment significance of depression severity used the Hamilton Depression Rating Scale (HAMD), wholly, or in part, to define severity, though the cutoff used to define severe depression varied. There is limited empirical research establishing cutoff scores for bands of severity on the HAMD. The goal of the study is to empirically establish cutoff scores on the HAMD in their allocation of patients to severity groups.
  
  
  METHODS
  Six hundred twenty-seven outpatients with current major depressive disorder were evaluated with a semi-structured diagnostic interview. Scores on the 17-item HAMD were derived from ratings according to the conversion method described by Endicott et al. (1981). The patients were also rated on the Clinical Global Index of Severity (CGI). Receiver operating curves were computed to identify the cutoff that optimally discriminated between patients with mild vs. moderate and moderate vs. severe depression.
  
  
  RESULTS
  HAMD scores were significantly lower in patients with mild depression than patients with moderate depression, and patients with moderate depression scored significantly lower than patients with severe depression. The cutoff score on the HAMD that maximized the sum of sensitivity and specificity was 17 for the comparison of mild vs. moderate depression and 24 for the comparison of moderate vs. severe depression.
  
  
  CONCLUSIONS
  The present study was conducted in a single outpatient practice in which the majority of patients were white, female, and had health insurance. Although the study was limited to a single site, a strength of the recruitment procedure was that the sample was not selected for participation in a treatment study, and exclusion and inclusion criteria did not reduce the representativeness of the patient groups. The analyses were based on HAMD scores extracted from ratings on the SADS. However, we used Endicott et al.'s (1981) empirically established formula for deriving a HAMD score from SADS ratings, and our results concurred with other small studies of the mean and median HAMD scores in severity groups.
  
  
  CONCLUSIONS
  Based on this large study of psychiatric outpatients with major depressive disorder we recommend the following severity ranges for the HAMD: no depression (0-7); mild depression (8-16); moderate depression (17-23); and severe depression (≥24).
authors.affiliation: Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, 146 West River Street, Providence, RI, United States. mzimmerman@lifespan.org
authors.forename: Mark
authors.initials: M
authors.lastname: Zimmerman
authors.forename: Jennifer H
authors.initials: JH
authors.lastname: Martinez
authors.forename: Diane
authors.initials: D
authors.lastname: Young
authors.forename: Iwona
authors.initials: I
authors.lastname: Chelminski
authors.forename: Kristy
authors.initials: K
authors.lastname: Dalrymple
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003865:Major Depressive Disorder / Q000145:classification / Q000175:diagnosis* / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010045:Outpatients; D011569:Psychiatric Status Rating Scales; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D055815:Young Adult
keywords: Depression; Hamilton depression rating scale; Severity