Jay M. Pomerantz, MD

Rating scales provide a number of clinical benefits which may include:

• Aiding diagnosis •
• Providing a measure of severity•
• Specifying symptoms and providing assurance that all important items are covered in the clinical assessment•
• Quantifying improvement or deterioration of condition (when a scale is repeated over time)•
• Monitoring potential side-effects of treatment 

Schizophrenia
http://www.neurotransmitter.net/schizophreniascales.html
This site has a very complete and downloadable series of tests for schizophrenia including:
PANSS¹
The PANSS measurement is derived from behavioral information observed during the interview plus a clinical interview and reports by primary care hospital staff or reports by family members. The ratings provide summary scores on a 7-item positive scale, a 7-item negative scale and a 16-item general psychopathology scale. The PANSS ratings should be based on the totality of information pertaining to a specified period, normally identified as the previous week. Each of the 30 items is accompanied by a specific definition as well as detailed anchoring criteria for all seven rating points. These seven points represent increasing levels of psychopathology, as follows: 1, absent; 2, minimal; 3, mild; 4, moderate; 5, moderate severe; 6, severe; 7, extreme. In assigning ratings, a physician first considers whether a symptom is at all present, as judging by the item definition. If the item is absent, it is scored 1, whereas if it is present the physician must determine its severity by reference to the particular criteria for the anchoring points. The highest applicable rating point is always assigned, even if the patient meets criteria for lower ratings as well. The rating points 2 to 7 correspond to incremental levels of symptom severity. They are keyed to the prominence of symptoms, their frequency during the observation phase, and above all their disruptive impact on daily living.

Brief Psychiatric Rating Scale (BPRS)²

The BPRS is probably the most widely used rating scale in psychiatry. The scale is used to assess psychopathology (including positive, negative, and affective psychopathology) in patients with, or suspected of having, schizophrenia or other psychotic illnesses. The BPRS has 16 items that can be rated from not present (0) to extremely severe (6) on symptoms such as somatic concern, anxiety, emotional withdrawal, conceptual disorganization, guilt feelings, tension, mannerisms and posturing, grandiosity, depressive mood, hostility, suspiciousness, hallucinatory behavior, motor retardation, uncooperativeness, unusual thought content, and blunted affect. The assessment is based on interview with the patient and with observations of the patient's behavior over the previous 2–3 days (or on reports of the patient's behavior from family members). An electronic version is available at: http://www.testandcalc.com/etc/tests/bprs.asp

Movement Disorders

I. Tardive Dyskinesia 
Abnormal Involuntary Movement Scale--A.I.M.S. 
Designed to assess the occurrence of dyskinesias in patients receiving neuroleptic treatment. The clinician performs the rating.  It takes 5-10 minutes to perform. Dyskinesia is defined as probably present if movements were “mild” in at least two of seven body areas or “moderate” in at least one³ . The test is available at:
http://www.testandcalc.com/etc/tests/aims.asp 

II. Akathisia
Barnes Akathisia Rating Scale (BARS)
This is the most widely used scale to measure akathisia.  It has strong face validity and is simple and easy to use.  Unlike other tests, it differentiates between the experience of restlessness and any associated distress. The global item score may be used as an overall measure of severity, with a score of 2 or more indicating the presence of akathisia.  Both the test and the original article describing it are posted on the Internet at:
http://www.logarithmic.net/pfh/akathisia

Depression

Hamilton Depression Rating Scale (Ham-D)⁴

The HAM-D is the standard depression outcome measure used in clinical trials presented to the Food and Drug Administration by pharmaceutical companies for approval of New Drug Applications. It is also the primary outcome measure in the National Institute of Mental Health collaborative studies comparing pharmacotherapy with psychotherapy for the treatment of depression. The HAM-D is the usual standard against which other depression rating scales are validated. Questions are related to symptoms such as depressed mood, guilty feelings, suicide, sleep disturbances, anxiety levels and weight loss. The higher the score the more severe the depression. A score of 11 is generally regarded as indicative of a diagnosis of depression. A score of 10-13 = mild depression; a score of 14-17 = moderate depression; a score >17 = moderate to severe depression. The full 21-item Ham-D is available at: http://healthnet.umassmed.edu/mhealth/HAMD.pdf

MacArthur Foundation Depression Tool Kit
http://www.depression-primarycare.org/clinicians/toolkits/full/  (in particular pages 14-19 and 38). 

Included are two relatively new screening tools that make screening and even follow-up for depression easier.  The first screening tool consists of two-questions:1)

1. During the past month have you often been bothered by feeling down, depressed, or hopeless? 
2. During the past month have you often been bothered by little interest or pleasure in doing things?  

The use of these 2 screening questions alone showed a sensitivity and specificity of 97% and 67%, respectively, when tested in a primary care setting on patients not currently on psychotropic drugs⁵ . In practice, even one positive answer should expand the inquiry and possibly bring into play a second new tool for diagnosing depression.  

The 9-question Patient Health Questionnaire (PHQ-9) not only shows great validity, but measures severity and can be used at follow-up visits to evaluate the effectiveness of treatment⁶ .  It includes a specific question on suicidality. The PHQ-9 is available at www.pfizer.com/phq-9.

Both of these tests and some additional very useful tools (especially the CAGE for diagnosing alcohol problems, Suicide Screening Instrument, and Bipolar Screen are available from the MacArthur Foundation http://www.depression-primarycare.org/clinicians/toolkits/full/

Inventory of Depressive Symptomatology (IDS) and Quick Inventory of Depressive Symptomatology (QIDS) 

The 30 item Inventory of Depressive Symptomatology (IDS) and the 16 item Quick Inventory of Depressive Symptomatology (QIDS) are designed to assess the severity of depressive symptoms. Both the IDS and the QIDS are available in the clinician (IDS-C₃₀ and QIDS-C₁₆) and self-rated versions (IDS-SR₃₀ and QIDS-SR₁₆). The IDS and QIDS assess all the criterion symptom domains designated by the American Psychiatry Association Diagnostic and Statistical Manual of Mental Disorders - 4th edition (DSM-IV) (APA 1994) to diagnose a major depressive episode. These assessments can be used to screen for depression, although they have been used predominantly as measures of symptom severity. The seven day period prior to assessment is the usual time frame for assessing symptom severity and lends itself to repeated measurements over the course of treatment. The QIDS was used in STAR*D, the Sequenced Treatment Alternatives to Relieve Depression, the recent, large NIMH-funded four-phase trial for major depression. Both the questionnaire and scoring sheet are available in multiple languages at:
http://www.ids-qids.org/tr-english.html

Bipolar Disorder
An article currently in press⁷ suggests that a two-question screen for mood lability may help distinguish bipolar II patients from unipolar major depression.  The questions are: (1) “Are you a person who frequently experiences ups and downs in mood over life?” and (2) “Do these mood swings occur without cause?”  If at least one answer is positive, that indicates mood lability and an increased likelihood of bipolar disorder. [Last year I e-mailed Benazzi and quickly got his permission to re-produce the instrument in one of my articles for DBT]. I can supply his e-mail address if you would like to contact him directly].

Mood Disorder Questionnaire (MDQ) This instrument is a good screening instrument for bipolar disorder.  A copy of the test and scoring directions are available at:
http://www.psycheducation.org/depression/MDQ.htm

Young Mania Rating Scale
This eleven-item scale is intended to be administered by a trained clinician. A severity rating is given for each of the items based on the interview with the patient. The scale is available at:
http://www.atlantapsychiatry.com/forms/ymrs.pdf

Anxiety
HAM-A⁸
The Hamilton Anxiety Scale consists of 14 items, each defined by a series of symptoms. As was the case with the HAMD, Hamilton provided only general guidelines regarding the administration and scoring of the scale. No standardized probe questions to elicit information from patients or behaviorally specific guidelines were developed for determining item scoring. Similar to the HAMD, each item is rated on a 5-point scale, ranging from 0 (not present) to 4 (severe).  An electronic version of the test is available at: 
http://www.anxietyhelp.org/information/hama.html

Zung Anxiety Self Assessment Scale
A pdf of the scale and its interpretation is contained in an article from the Journal of the American Society of Consultant Pharmacists on page 7 at:
http://www.ascp.com/public/pubs/cc/pdf/ccsupp4.pdf

Liebowitz Social Anxiety Scale (LSAS) 
The LSAS is a questionnaire whose objective is to assess the range of social interaction and performance situations that individuals with social phobia may fear and/or avoid. It is also a popular measurement tool used by researches to evaluate the efficiency of various social anxiety disorder treatments, including pharmacological trials. A modified social anxiety scale exists for children and adolescents. An electronic version of the test is available at:
http://www.anxietyhelp.org/information/leibowitz.html

Attention Deficit Hyperactivity Disorder
Two good screening instruments for ADHD developed by the World Health Organization are: ASRS ADHD Self Report System Checklist (18 questions) and the ASRS Adult Self Report Screener (6 questions).  Both are available at:
http://www.med.nyu.edu/psych/psychiatrist/adhd.html

A variety of ADHD rating scales in the public domain are available at:
http://www.neurotransmitter.net/adhdscales.html

These scales include both the home and school versions of the ADHD RS IV based on the criteria in DSM IV and the Wender Utah Rating Scale for Adults.  The Adult ADHD/ADD Quiz (Jasper/Goldberg) is also sometimes quite informative with 24 items about behavior in adult life.  This quiz is available by clicking at the above hyperlink and can either be downloaded or filled in and scored on line. The neurotransmitter net site also provides links to the widely used Conners rating scales (which much be purchased).

Dementia

Mini mental state examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is widely used to assess cognition.  It is commonly used to screen for dementia.  In the time span of about 10 minutes, it samples various functions, including arithmatic, memory, and orientation.  As a clinical instrument, the MMSE has been used to detect impairment, follow the course of an illness, and monitor response to treatment. The MMSE has also been used as a research tool to screen for cognitive disorders in epidemiological studies and follow cognitive changes in clinical trials.  The test provides a total score that places the individual on a scale of cognitive function. The normative data for different ages and educational levels are presented below, as is a list of references on the use of the MMSE. Further information on the MMSE may be obtained at www.minimental.com. A copy of the examination is available at: http://en.wikipedia.org/wiki/Mini_mental_state_examination

The Cornell Scale for Depression in Dementia
A pdf of the scale and its interpretation is contained in an article from the Journal of the American Society of Consultant Pharmacists on page 8 at:
http://www.ascp.com/public/pubs/cc/pdf/ccsupp4.pdf

Obsessive Compulsive Disorder

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)⁹   (with pdf-file for download) This scale is administered by a clinician.  A symptom checklist that is used to identify the content of obsessive-compulsive symptoms precedes it. Interviewer then asks the subject to identify the three obsessions and compulsions that are most distressing and to focus on them during the Y-BOCS interview, which thus assesses the severity of the symptoms. This scale has become the gold standard for assessing obsessive-compulsive symptoms. It is well suited for assessing the severity of obsessive-compulsive symptoms and for monitoring change with treatment. The instrument is divided into two subscales: the Obsessions subscale and the Compulsions subscale. Is not a diagnostic instrument?

Clinical Global Impression (CGI)

CGI is a three-item scale used to assess treatment response in psychiatric patients. The CGI refers to the global impression of the patient and requires clinical experience with the syndrome under assessment. There are seven categories of severity ranging from "Not ill" to "Extremely severe". They are: Severity of Illness; Global Improvement; Efficacy Index. Item 1 is rated on a seven-point scale (1=normal to 7=extremely ill); item 2 on a seven-point scale (1=very much improved to 7=very much worse); and item 3 on a four-point scale (from 'none' to 'outweighs therapeutic effect').  The Severity of Illness item requires the clinician to rate the severity of the patient's illness at the time of assessment, relative to the clinician's past experience with patients who have the same diagnosis. Considering total clinical experience, a patient is assessed on severity of mental illness at the time of rating according to: normal (not at all ill); borderline mentally ill; mildly ill; moderately ill; markedly ill; severely ill; or extremely ill.  The Global Improvement item requires the clinician to rate how much the patient's illness has improved or worsened relative to a baseline state. Compared to condition at baseline, a patient's illness is compared to change over time, and rated according to: very much improved; much improved; moderately improved; minimally improved; no change; minimally worse; moderately worse; much worse; or very much worse.

Global Assessment of Functioning (GAF)

The Global Assessment of Functioning, or GAF scale, is a numeric scale (0 through 100) used by mental health clinicians and doctors to rate the social, occupational and psychological functioning of adults. The scale is presented and described in the DSM-IV-TR on page 32. It may be accessed on the Internet at: http://en.wikipedia.org/wiki/GAF

 Children and adolescents under the age of 18 are evaluated on the Childre’s Global Assessment Scale, or  Children’s Global Assessment Scale, or C-GAS.

Clinical Outcomes

NetOutcomes Solutions (University of Arkansas for Medical Sciences’ (UAMS) Center for Outcomes Research) https://www.netoutcomes.net/NO_Solutions/NO_Main/NO_Home.asp?menu=nethome This Internet site provides a set of advanced behavioral health outcomes assessment tools created specifically to utilize the speed and economies of the Internet. This no- or low-cost fully confidential program has been developed by the University of Arkansas for Medical Sciences’ (UAMS) Center for Outcomes Research and Effectiveness (CORE), the nation’s leading behavioral health services research center.

NetOutcomes Solutions assessment instruments address the treatment outcomes for specific conditions such as major depression, substance abuse, schizophrenia and adolescent problems. Incorporating case mix adjustment and disease severity indexing, these instruments provide fair and accurate comparisons of patient populations and provider effectiveness. Of proven validity and reliability, they address patient characteristics and care components crucial to understanding treatment outcomes. Some of the many areas included are: comorbid medical and psychiatric conditions; patient compliance with care; functional status and productivity; psychotropics and psychotherapies administered. Current modules include: 

• Depression Outcomes Module (DOM) 
• Substance Abuse Outcomes Module (SAOM) 
• Schizophrenia Outcomes Module (SCHIZOM) 
• Adolescent Treatment Outcomes Module (ATOM)

¹ Kay SR, Fiszbein A, Opler LA: The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13:261-276, 1987a.
² Overall JE, Gorham DR: The Brief Psychiatric Scale. Psychological Reports 10:799–812, 1962
³ Halliday J, Farrington S, Macdonald S, MacEwan T, Sharkey V, McCreadie R. Nithsdale Schizophrenia Surveys 23:movement disorders. British J Psychiatry 2002;181:422-427
⁴ Hamilton M. A rating scale for depression. J Neurology Neurosurgery Psychiatry. 1960;23:56-62.
⁵ Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 2003;327:1144-1146
⁶ Lowe B, Kroenke K, Herzog W, Grafe K. Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord 2004;81(1):61-66
⁷ Benazzi F, Akiskal HS. A downscaled practical measure of mood lability as a screening tool for bipolar II. Journal of Affective Disorders 2004. Article in Press.
⁸ Hamilton M: The assessment of anxiety states by rating. British Journal of Medical Psychology 32:50–55, 1959.
⁹ Goodman WK, Price LH, Rasmussen SA, et al.: The Yale-Brown Obsessive Compulsive Scale, I: development, use, and reliability. Archives of General Psychiatry 46:1006-1011, 1989a.