Depressed patients’ perspectives of 2 measures of outcome: The Quick Inventory of Depressive Symptomatology (QIDS) and the Remission from Depression Questionnaire (RDQ)Mark Zimmerman, MD
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USAJanine N. Galione, BS
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USANaureen Attiullah, MD
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USAMichael Friedman, MD
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USACristina Toba, MD
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USADaniela A. Boerescu, MD
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USAMoataz Ragheb, MD
Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USA
BACKGROUND: Current operational definitions of remission, at their root, are exclusively symptom-based and therefore limited in scope. In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined patient acceptability of a new measure, the Remission from Depression Questionnaire (RDQ), a scale designed to capture a broader array of domains patients consider relevant to the construct of remission. Patient acceptance of the RDQ was compared with that of the Quick Inventory of Depressive Symptomatology (QIDS), the instrument used to measure outcome in the Sequenced Treatment Alternatives to Relieve Depression study.
METHODS: One hundred and two depressed outpatients in ongoing treatment completed the RDQ, QIDS, and a 9-item measure of patient preference.
RESULTS: Patients indicated the RDQ was a better indicator of their overall state and treatment goals. Patients judged the RDQ to be a more accurate and preferred measure to determine treatment outcome, and a more accurate indicator of remission.
CONCLUSIONS: Patients considered the multifactorial RDQ a more accurate indicator of their treatment goals than a purely symptom measure such as the QIDS.
KEYWORDS: depression, remission, Remission from Depression Questionnaire (RDQ), outcome, assessment
Annals of Clinical Psychiatry 2011;23(3):208-212
For all medical disorders, formulating appropriate treatment goals is a primary consideration when initiating and guiding care. Whether a patient has hypertension, migraine headaches, cancer, epilepsy, major depressive disorder (MDD), or schizophrenia, the clinician providing treatment and the patient receiving treatment should have an idea of the desired or likely outcomes of treatment. Often, treatment goals are clear-cut. In epilepsy, the goal is to be seizure-free.1 When treating patients with migraine headaches, it is to be migraine-free.2 In hypertension, the goal is to reduce blood pressure to a level within a normative range for a given population.3 When treating pneumonia or other acute infections, the goal is to return the individual to a pre-infectious state.
When treating psychiatric disorders, formulating goals is no less important.4,5 However, defining and agreeing upon the goals of depression treatment is less straightforward relative to other medical disorders. One study conducted in a managed care setting noted low concordance between psychiatric clinicians and their patients in rating treatment outcome for depression, with patients considering outcomes more poorly.6 Treatment goals for depressed patients may change as a function of life events that can substantively influence mood, the familiarity the clinician acquires about the patient’s behavior over time, and the knowledge about the disorder and accompanying risk factors accumulated over time. Despite these challenges, initial formulation of reasonable and attainable goals is paramount for increasing the likelihood of successful depression treatment, and such goals should incorporate and reflect, in part, the patient’s viewpoint.
MDD often is a life-long illness characterized by remissions and relapses.4,7 Current treatment standards for MDD recommend achieving remission should be considered the ultimate treatment goal.8-11 Evidence suggests mere response, usually defined as achieving a 50% reduction in symptoms, may not be a sufficient goal. This is because residual or “subsyndromal” symptoms remaining after treatment are associated with a greater risk of recurrence of depressive episodes,12-14 higher morbidity and mortality,15-18 and significantly greater functional impairment.19,20 Despite its emphasis as the primary goal of MDD treatment, remission has proven to be an elusive construct to capture and apply. There are differences in current operational definitions of remission, and at their root, the current definitions are exclusively symptom-based and may be fundamentally limited in scope.5
There is little data to suggest symptom-based, researcher-developed definitions of remission used in outcome studies adequately reflect the perspectives of patients presenting for treatment in routine practice settings. Consider a patient who has completed a course of depression treatment. The patient reports no longer feeling sad or down, and is sleeping and eating normally. The patient may achieve a low score on a measure of severity of depressive symptoms. However, the patient also continues to experience reduced social functioning with friends or family members, barely manages to complete weekly work activities, and experiences little in the way of positive thoughts or feelings throughout the week. Is this patient truly “in remission”? Would current definitions accord with the patient’s report? A recent report from our laboratory suggests ameliorating or eliminating depressive symptoms, although a worthy goal, is not necessarily the primary outcome patients wish to achieve from treatment.21 The 3 factors most frequently judged to be very important in determining remission were the presence of features of positive mental health such as optimism and self-confidence; a return to one’s usual, normal self; and a return to usual level of functioning.
Although the desired treatment outcome should not be dictated entirely by patient preference, if current remission definitions do not adequately reflect patients’ desired or expected outcome goals, then these definitions provide a limited degree of utility.
In this study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the acceptability of 2 self-administered measures of depression: the Quick Inventory of Depressive Symptomatology (QIDS)22 and the Remission from Depression Questionnaire (RDQ). The QIDS is the self-report depression symptom scale that was one of the primary outcome measures used in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study.23 The RDQ is a measure we recently developed to capture a broader array of domains patients consider relevant to the construct of remission.21
The relative acceptability of the QIDS and RDQ was examined in 102 psychiatric outpatients with DSM-IV MDD who were in ongoing treatment. The sample included 31 (30.4%) men and 71 (69.6%) women who ranged in age from 18 to 83 (mean=44.9, SD =13.9). The order of the forms was counterbalanced. After completing the 2 questionnaires the patients completed a 9-item questionnaire asking which measure took less time to complete, was easier to understand, was less burdensome to complete, more accurately described their overall status, better covered the areas related to treatment goals, more accurately reflected the depression experience, more accurately described treatment effectiveness, more accurately indicated recovery, and was preferable for monitoring treatment progress (TABLE). Patients were not aware we had developed 1 of the 2 questionnaires they were comparing. Neither scale listed the authors of the measure. The Rhode Island Hospital institutional review committee approved the research protocol, and all patients provided informed, written consent.
The RDQ is a 41-item, self-administered questionnaire. In contrast to most measures of depression focusing on symptom presence during the past week or 2, the RDQ assesses a broader array of features reported by patients as relevant to determining remission. Specifically, in addition to an assessment of depressive symptoms, the RDQ assesses other symptoms often present in depressed patients such as anxiety and irritability, features of positive mental health, coping ability, functioning, life satisfaction, and a general sense of well-being. The RDQ items were generated after conducting 2 focus groups with depressed patients. A list of items was composed and reviewed by patients and clinicians in regard to their understandability, redundancy, and relevance to the construct of remission. The items refer to the prior week, and are rated on a 3-point rating scale (0=not at all or rarely true; 1=sometimes true; 2=often or almost always true). The internal consistency reliability coefficient (Cronbach’s alpha) of the RDQ for the 102 patients who completed the scale in the present study was .96. The mean of the item-scale correlations was .61.
The QIDS is a commonly used self-administered scale assessing the severity of depressive symptoms. Each item consists of a group of 4 statements arranged in order of increasing symptom severity, and the respondent is asked to select the item that best describes him or her during the past week. The scale includes 16 items for a total of 64 statements. The reliability and validity of the QIDS has been well established.22
We used the χ2 statistic to determine if the order of questionnaire administration impacted the results. To compare the differences between the 2 measures on patient acceptance questions, we conducted 4 separate tests of approximate inference for a single proportion on those patients who made a clear selection. Using this test, a z-score is computed from the observed proportions of favorability for the 2 scales and compared against a null hypothesis of equivalent selection. For each question we examined whether preference for the RDQ or QIDS was associated with patients’ demographic characteristics or symptom severity as measured by the QIDS using the χ2 statistic. Because of the multiple statistical tests, we set the significance level at P < .01.
Depressed patients perceptions of the Remission from Depression Questionnaire (RDQ) and the Quick Inventory of Depressive Symptomatology (QIDS) (n = 102)
||RDQ, % (n)
||QIDS, % (n)
||About the same, % (n)
|Which scale took less time to complete?
|Which scale was more of a burden to complete?
|On which scale were the items easier to understand?
|On which scale can you more accurately describe your overall state?
|Which scale do you feel best covers the areas that are related to your goals in receiving treatment for depression?
|Which scale do you feel more accurately reflects your experiences with depression?
|On which scale can you more accurately describe the effectiveness of treatment?
|On which scale can you more accurately indicate that you have recovered from your depression?
|Which scale would you prefer to complete to monitor your progress in treatment?
Slightly more than one-half the 102 patients completed the RDQ before the QIDS (53.9%, n=55). Because there was no significant effect of the order of administration on preference ratings, the results were combined for the entire sample.
TABLE shows the RDQ and QIDS were perceived as being equally acceptable. There was no perceived difference between the scales in their completion time, burden to complete, or understandability of the items.
Significantly more patients indicated the RDQ was a better indicator of their overall status and goals in treatment. Consistent with this, significantly more patients judged the RDQ to be a more accurate indicator of remission, and preferred the measure to determine the outcome of treatment. More patients indicated the RDQ more accurately reflected their experience with depression and the RDQ could more accurately describe the effectiveness of treatment, but these differences were not statistically significant.
For each question the preference for the RDQ or QIDS was not significantly associated with patients’ demographic characteristics or symptom severity as measured by the QIDS.
Most experts agree remission is the desired outcome when treating depression. The usual method for defining remission is a score below a cutoff value on a symptom severity scale. Three years ago, in a study from the MIDAS project we reported depressed patients consider several factors in addition to symptom resolution as critically important in determining whether a depressive episode was in remission.21 In fact, several factors were more frequently rated as very important in determining remission from depression than symptom resolution. These results were consistent with another report from the MIDAS project in which we found that ratings of symptom severity, functional impairment from depression, and quality of life were each significantly and independently associated with patients’ subjectively perceived remission status.24
These studies suggest the need to develop a new outcome measure designed to more broadly evaluate domains depressed patients consider important in determining remission. We are not suggesting patients’ perspectives on remission should be prioritized, but they should be given consideration. As a first test of this multi-factorial approach towards assessing remission, we sought patients’ evaluation of this new scale compared with a widely used self-administered scale. Our approach towards developing new scales has consistently included patients’ evaluations of these tools. One of MIDAS project’s goals has been to develop measures feasible to incorporate into clinical practice. The use of standardized scales has not been embraced in clinical practice.25-27 If there is to be a shift toward measurement-based care,28 it is important scales are as minimally burdensome to patients and disruptive of clinical practice as possible. Consequently, before embarking on a large-scale, expensive effort towards establishing the reliability and validity of the RDQ, we conducted a comparative study of the scale’s perceived burden and relevance to patients’ treatment goals.
This study’s results suggest that patients considered the multifactorial RDQ to be a more accurate indicator of their treatment goals than a purely symptom measure such as the QIDS. Significantly more patients indicated that the RDQ allowed them to more accurately describe their current status, reflect the effectiveness of treatment, and better evaluate treatment goals. Significantly more patients indicated the RDQ could more accurately indicate remission status, and preferred to complete the RDQ to monitor their progress in treatment. Importantly, although the RDQ contains more items than the QIDS (41 vs 16), it was not perceived to be more burdensome to complete. Although we did not formally assess completion time, patients indicated that the RDQ and QIDS took a similar amount of time to complete. Although the RDQ contains more items, the QIDS contains more statements for patients to read because each item consists of a set of 4 statements.
This study was limited to a large general adult out-patient private practice setting in which patients had health insurance. Replication in samples with other demographic characteristics is warranted. Also, we only compared 2 scales: QIDS and RDQ. Comparisons of other self-report depression measures could guide clinicians as to which measure to incorporate into their clinical practice. We studied the QIDS because it is an increasingly popular self-administered scale of established reliability and validity that is available for free and was used by researchers in the STAR*D study. Finally, our measure of scale preference was developed for this study and has not been previously validated.
The RQS, a multifactorial scale that captures a broader array of domains considered to be relevant to the construct of remission, was considered by patients to be a more accurate indicator of their goals of treatment than a purely symptoms measure such as the QIDS.
DISCLOSURES: Dr. Zimmerman receives grant/research support from Eli Lilly and Company. Ms. Galione and Drs. Attiullah, Friedman, Toba, Boerescu, and Ragheb report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
- St. Louis EK. Minimizing AED adverse effects: Improving quality of life in the interictal state in epilepsy care. Curr Neuropharmacol. 2009;7:106–114.
- Cologno D, Torelli P, Manzoni GC. Possible predictive factors in the prognosis of migraine with aura. Cephalalgia. 1999;19:824–830.
- Whitworth JA. World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. 2003;21:1983–1992.
- Keller MB. Past present, and future directions for defining optimal treatment outcome in depression: remission and beyond. JAMA. 2003;289:3152–3160.
- Rush AJ, Kraemer HC, Sackeim HA, et al. Report by the ACNP Task Force on response and remission in major depressive disorder. Neuropsychopharmacology. 2006;31:1841–1853.
- Cuffel B, Azocar F, Tomlin M, et al. Remission, residual symptoms, and nonresponse in the usual treatment of major depression in managed clinical practice. J Clin Psychiatry. 2003;64:397–402.
- Shelton RC, Tomarken AJ. Can recovery from depression be achieved? Psychiatr Serv. 2001;52:1469–1478.
- Practice guideline for the treatment of patients with major depressive disorder (revision) Washington DC: American Psychiatric Association; 2000.
- Anderson IM, Nutt DJ, Deakin JF. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2000;14:3–20.
- Stahl S. Why settle for silver when you can go for gold? Response vs. recovery as the goal of antidepressant therapy. J Clin Psychiatry. 1999;60:213–214.
- Thase ME. Defining remission in patients treated with antidepressants. J Clin Psychiatry. 1999;60(suppl 22)3:635–36.
- Faravelli C, Ambonetti A, Pallanti S, et al. Depressive relapses and incomplete recovery from index episode. Am J Psychiatry. 1986;143:888–891.
- Paykel ES, Ramana R, Cooper Z, et al. Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995;25:1171–1180.
- Simons AD, Murphy GE, Levine JL. Relapse after treatment with cognitive therapy and/or pharmacotherapy: results after one year. Arch Gen Psychiatry. 1986;43:43–48.
- Everson SA, Robert RE, Goldberg DE, et al. Depressive symptoms and increased risk of stroke mortality over a 29-year period. Arch Intern Med. 1998;158:1133–1138.
- Judd LL, Akiskal HS, Paulus MP. The role and clinical significance of subsyndromal depressive symptoms (SSD) in unipolar major depressive disorder. J Affect Disord. 1997;45:5–18.
- Murphy J, Monson R, Olivier D, et al. Affective disorders and mortality. A general population study. Arch Gen Psychiatry. 1987;44:473–480.
- Vaccarino V, Kasl SV, Abramson J, et al. Depressive symptoms and risk of functional decline and death in patients with heart failure. J Am Coll Cardiol. 2001;38:199–205.
- Miller IW, Keitner GI, Schatzberg AF, et al. The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine. J Clin Psychiatry. 1998;59:608–619.
- Wells KB, Stewart A, Hayes RD, et al. The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA. 1989;262:914–919.
- Zimmerman M, McGlinchey JB, Posternak MA, et al. How should remission from depression be defined? The depressed patientÂ’s perspective. Am J Psychiatry. 2006;163:148–150.
- Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54:573–583.
- Trivedi MH, Rush AJ, Wisniewski SR, et al, and the STAR*D Study Team. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D implications for clinical practice. Am J Psychiatry. 2006;163:28–40.
- Zimmerman M, McGlinchey JB, Posternak MA, et al. Remission in depressed patients: more than just symptom resolution. J Psychiatr Res. 2008;42:797–801.
- Gilbody S, House A, Sheldon T. Psychiatrists in the UK do not use outcomes measures. National survey. Br J Psychiatry. 2002;180:101–103.
- Zimmerman M, McGlinchey JB. Why don’t psychiatrists use scales to measure outcome when treating depressed patients? J Clin Psychiatry. 2008;69:1916–1919.
- Zimmerman M, McGlinchey JB, Chelminski I. An inadequate community standard of care: lack of measurement of outcome when treating depression in clinical practice. Prim psychiatry. 2008;15:67–75.
- Trivedi MH, Rush AJ, Gaynes BN, et al. Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology. 2007;32:2479–2489.
CORRESPONDENCE: Mark Zimmerman, MD Bayside Medical Center, 235 Plain Street, Providence, RI 02905 USA, E-MAIL: firstname.lastname@example.org
Annals of Clinical Psychiatry ©2011 Quadrant HealthCom Inc.