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Depression scales: Self- or physician-rating? A validation of certain clinically observable phenomena
Depression Scales: Self- or Physician-rating? A Validation of Certain Clinically Observable Phenomena By G. LaVonne Brown and William W. K. Zung
T
HE QUESTION RAISED in the title of this article is of basic importance not only to the researcher but also to the clinician who uses rating scales as an adjunct in the diagnosis and treatment of his depressed patients. To be considered are the ease with which the measurements are made, their accuracy, and the time requisite for that measurement and accuracy. During the course of the evaluation of an experimental antidepressant, observations by one of the authors led to the hypothesis that he could differentiate, on a clinical basis, patients in whom he could expect an unreliable correlation between scores obtained on the Zung Self-Rating Depression Scale’ and the Hamilton PhysicianRating Scale.2 Although there are a number of factors that may influence scores obtained on rating scales, both self3 and physician,4 the knowledge of such factors has not been directly applied to the question of whether to use a self- or physician-rating scale. Our purpose is to show that patients who can be described clinically as either sensitizers or repressors tend to show an unreliable correlation between Zung and Hamilton scores. Sensitizers are defined as individuals who tend to be oversensitive, to overinterpret, and to ruminate about potential or real threats and conflicts. They have a negative self-concept and emphasize their own helplessness and weakness. Repressors are defined as individuals who tend to use avoidance, suppression, repression, and denial of potential threats and conflicts. ’ This sensitization-repression dimension can be determined rather accurately by clinical interviews and seem, as we will attempt to demonstrate, to have some correlation with the degree of ego development. METHOD
A total of 65 inpatients, considered by their primary resident physicians to be potentially depressed, were admitted to the Psychiatric Service of the Durham Veterans Administration Hospital during a 6-month period. They were evaluated using the Zung Self-Rating Depression Scale (SDS) and the Hamilton Physician-Rating Scale (HRS) during the course of a clinical evahration of antidepressant drugs.a A total of 35 patients was selected for pharmacologic treatment of their depressions on the basis of their having scored 25 or more on the HRS. All patients so selected were retested serially with both instruments on days 8 and 28 (termination) of treatment. After the evaluation of the first 21 patients, the hypothesis that stimulated this article led to the establishment of an experimental design in which the principal investigator in the drug study made a clinical global rating for the degree of sensitization-repression on the 14 subsequent patients. The global ratings were: 5 = marked sensitizer, 4 = moderate sensitizer, 3 = a patient in whom neither quality predominates significantly, 2 = moderate repressor, and 1 = marked repressor. A second From Duke UniversityMedical Center and VeteransAdministration Hospital, Durham, N. C. Presented at the annual meeting of American Aychiatric Assort&ion in Washington,D. C., May 1971. Supported in part by USPHS Research Scientist Development Award MH 35232 from the National Institute ofMental Health. G. LaVonne Brown, M.D.: Resident, Duke UniversityMedical Center and Veterans Administmtion Hospital, Durham, N. C. William W. K. Zung, M.D.: Associate Professor of Psychiatry, Duke UniversityMedical Center and Vetemns Administmtion Hospital, Durham, N. C. Comprehensive Psychiatry, Vol. 13, No. 4
(July/August),
1972
361
362
BROWN
AN0
ZUNG
investigator tested those same patients by giving them the appropriate MMPI subscales: the Byrne Repression-Sensitization Scale (R-S)’ and the Ullmann Facilitation-Inhibition Scale, (F-I)8 both of which measure repression (or inhibition) and sensitization (or facilitation). High scores on the Byrne and low scores on the Ullmann indicate sensitization, with the opposite scores for repression, respectively. Ratings of patients were performed as follows: global ratings of the R-S dimension were determined clinically, followed by the depression rating scales (Zung and Hamilton), with the MMPI (from which are derived the Byrne and Ullmann scores) given last. All Byrne and Ullmann scores were determined on the initial depression evaluation (day 0 in the drug study). All APA diagnoses were given by the primary resident physicians, none of whom were directly involved in any of the research design or data collection and analysis. In order to demonstrate more meaningfully just what we mean clinically by sensitization and repression, two brief case history abstracts follow. The former, RDJ, is the most marked example of a sensitizer, and the latter, GLC, is the most marked example of a repressor. CASE
REPORTS
Case I RDJ, a fist psychiatric admission, was a forty-seven-year-old, white, divorced male with a long history of job changes as a radio repairman. During his married life there were many separations. His presenting mood statement was, “I feel unnecessary.” On one occasion, the patient corn plained, “I can’t stand responsibility.” RDJ had had suicidal ruminations, crying spells, and the biological correlates of depression. The patient tended to complain of numerous somatic problems, i.e., headaches, nausea, dizziness, bad nerves, and so forth. The patient had had various gastrointestinal complaints in the past, resulting in a vagotomy and gastroenterostomy 18 months previous to the admission for depression. The patient complained that he could no longer work as a radio repairman because the transistor age had passed him by. However, as numerous attempts were made to help him get a job in radio service work or other areas, he would say in the former case that he already knew the potential employers and knew he would not be able to work with them or, in the latter case he would always find a reason, such as not wanting outside work, to sabotage these efforts. The patient had been a moderate smoker and drinker. He had a seventh grade education. His mother died when he was 20 months old. The patient was diagnosed as a passiveaggressive personality. His primitive defense mechanisms, particularly projection and somatization, his life-long difficulty with object relationships, and the volatile, diffuse anxiety all bespeak of the deficits in his ego development. Case 2 GLC, a first psychiatric admission, was a S&year-old, white, married male with a 25 year history of job stability as a clothes inspector in a textile mill. GLC had had a stable marriage for 27 years, and until 4 -5 months previous to admission had been an amicable, out-going person with hobbies, friends, and the status of a valued employee. GLC’s chief complaint was “I can’t sleep at night.” The patient tended to be quiet and make few complaints. Although his family could think of no change in his life that might have precipitated the depression, the patient had been hospitalized 6 months previous to admission and told that he had a damaged artery in his heart. Acute EKG changes had allegedly persisted for 2 weeks. At admission for depression, GLC specitically stated that he no longer worried about his heart. There was only slight evidence for cardiovascular disease on his EKG during this admission (previous admission had been at another hospital). Master’s test was within normal limits. During the hospital course, the patient was eager to go home for weekends with his family after the depression had improved. The patient had never smoked nor drank. His childhood psychosexual history was essentially unremarkable. The patient’s case was diagnosed as involutional melancholia mainly because of his inhibitions and denial of the significance of the change in his body integrity (cardiovascular disease), along with the depression that temporarily may have been the result of this loss in body integrity. The patient was also rather moralistic in his values and stoic in his outlook. Except for his seeming inability to deal with the cardiac trauma, the patient’s entire past life would seem to bespeak of rather good ego development.
DEPRESSION
363
SCALES
Zung SDS Index Fig. 1, Comparison of Hamilton and Zung scores. Depression scales: Self- or physician-rating? validation of certain clinically observable phenomena.
A
RESULTS
In order to evaluate the correlation of Zung and Hamilton scores in the study group, 135 sets of scores determined throughout the drug study (thirty-five patients tested before, during, and at completion, plus data from the 30 rejects) were plotted. The results obtained from the plotting of all scores are seen in Fig. 1. Curve A is derived from a linear regression analysis (whose product-moment correlation was r = 0.79; p = < O.Ol), and curve B is a plot of mean values of HRS scores against the corresponding SDS scores. A total of 14 patients was evaluated for this study. Correlation of the MMPI subscales (R-S and F-I) and the Zung (SDS) of the 14 patients studied is shown in Fig. 2 against previously derived slopes with corresponding r values based on 159 patients.’ Certain patients, RDJ and GLC, whose significance is discussed below, are indicated by their respective initials in Fig. 2. Last, the data from the 14 patients studied are arranged in order from the most severe sensitizers to the most severe repressors on the basis of the clinically determined global rating. DlSCUSSlON Comparison of our data to earlier work relating sensitization-repression to depressions is in agreement with the findings that depressed patients tend to be sensitizers and are related in a linearly incremental fashion and that depressed patients tend not to be repressors (Fig. 2). Although only 7 of 14 patients were rated clinically as sensitizers (Table l), only 3 of 14 were rated clinically as repressors. Although our
BROWN
364
AND
ZIJNG
120-
@ R-S’T”SCMES 0 F-I SC(uIET
loo-
80R-S ‘T’ 9a#K
0
o-
25
R&l 0 ’
30
,
40
50
60
to
80
90
100
Zung SDS Index Fig. 2. Relationship between sensitization-repression and depression. Depression scales: Self- or physician-rating? A validation of certain clinically observable phenomena.
data does seem to support the contention that depressed patients tend to be sensitizers, our data gives better evidence that depressed patients tend not to be repressors. In Fig. 1, although Hamilton and Zung scores correlate significantly (curve A), curve B shows that Hamilton and Zung scores are not strictly linearly related. This relative progression to higher scores on the Zung as a patient becomes more depressed may be related to the greater degree of sensitization which is picked up on the self-rating scale. It also may be related to the differences in the item contents of the two scales, or to the differences inherent in one scale’s being objective and the other being subjective. Possibly this latter difference is greatly affected by the degree to which the patient may be a sensitizer. The experimental design employed gives the opportunity of comparing, first, a single set of Hamilton-Zung scores with initially determined repression-sensitization ratings (both Byrne-Ullmamr scores and a clinical global rating) followed, second, by the patients’ course of depression over 28 days as determined by subsequent HamiltonZung scores, a clinical rating of the patients’ response to antidepressant therapy (Table l), and a comparison of the R-S dimension to clinical diagnoses. The experimental design could have been improved by the inclusion of all 35 patients selected for treatment of their depression in the sensitization-repression evaluations. However, as mentioned before, the hypothesis itself was generated from clinical observations on the earlier patients in the depression study; thus, as great a number as possible was subsequently included in the sensitization-repression evaluations. It would seem warranted for further study, using a greater number of patients, to be effected. Although a single set of Hamilton-Zung scores may or may not readily demonstrate that marked sensitizers or marked repressors have the least predictable correlative values, examination of their scores over time will make the lack of a consistent rela-
Passive-aggressive Personality with depression Passive-dependent personality with depression Manic-depressive illness depressed type Passivedependent person&v with depression Depressive neurosis Passive-aggressivepersonality with depression Psychotic depression Depressive neurosis Alcoholism with transient depression Depressive neurosis Depressive neurosis Situational reaction Depressive neurosis Involutional melancholia
Diagnosis
21 20 22 23
4 4 4 4
25 20 25 27 43
24 25 19
10
5
4 3 3
2
5
Ullmann F-l
55 45 45 50 35
58 56 53
60 58
58
62
64
70
Byrne R-S T
736555 59 5341 69-60-56 55-56-35
8580-78 7 l-46-53 46
55-51-41 66-39-36
7861.65
6860-54
64-65-5 1
70-65-73
SDS Index on Days O-S-28
*Patient’s depression was more apparent than real, and he responded quickly to hospitalization alone. ‘Not sufficiently depressed to meet criteria of drug study. *Patient’s multiple complaints diminished rapidly: two sets of scores are on hospital days 1 and 2 with discharge on day 3.
AJS JES+ FHES HP0 GLC
WRG CTR CMC*
CFR Cl-T
JMD
WJV
WMcW
RDJ
Patient (Initials)
Global Rating (Clinical) R-S
Table 1. Clinical Comparison of Sensitization-Repression and Depression Scores
31-20-14 24 31-16 30-19-13 26-27-8
36-30-25 30-13-g 11
Good Good
Fair -
Fair Good -
Good Excellent
37-30-13 30- 17-4
None
27-27-27
Fair
Good
36-25-l 2
28-15-16
Fair
Global Rating (Clinical) Drug Response
36-20-26
HRS on Days O-S-28
v)
E
::
D
z
z 5
366
BROWN
AND
ZUNG
tionship become more apparent. For example, RDJ, as a marked sensitizer, showed an unequivocal (although with only fair results) response to treatment when rated by the Hamilton. However, from the Zung index or the patient’s own verbal attestation, results of his treatment were poor, and we might question the efficacy of his treatment despite clear improvement in depressive biological correlates that not only manifested themselves in both scale results but also could be noted from hospital-chart and resident-physician evaluations of the biological correlates. On the other end of our R-S gradient, GLC, as a marked repressor, had initial scores on both Zung and Hamilton that would indicate mild-to-moderate depression. However, clinical evaluation and objective impression by both his resident physician and an author would have led us to expect him to score higher on both instruments. In contrast to most of the patients in the drug study who had initial responses to treatment within 7-10 days (as documented by day 8 testing), GLC did not show any drug response until after approximately 3 weeks of treatment. Perhaps the unusual treatment response in this patient is consistent with his diagnosis of involutional melancholia, often accompanied by inhibition and rigidity;’ furthermore, if we take into consideration his repressive outlook, we would not be surprised that what appears as change (whether getting sick or getting well) to the observer is hardly perceived as change by the patient himself. Of all 14 patients in the study group, both RDJ and GLC deviated the farthest from the previously determined relationship between R-S, F-I values and SDS scores as shown in Fig. 2. An overall comparison of the R-S dimension to clinical diagnoses in Table 1 is striking in that patients with diagnoses that correspond generally to poorer ego development show more sensitization and less repression, consistent with most psychodynamic theories of personality (ego) development. In such cases of poorly predictable correlations, most clinicians would choose to rely upon their own ratings, which are not necessarily more valid than the patient’s rating of himself. Although the patient cannot compare his subjective rating with that of any other patient whom he judges to be comparable, the physician is able to request colleagues with comparable competence to make an objective rating of a patient and can use, as well, a blind system should this additional degree of validation be desired. SUMMARY
AND
CONCLUSION
(1) Those patients who correlate the lease predictably in terms of the Zung SelfRating and the Hamilton Physician-Rating Depression scores (either initially or longitudinally over a clinical course) tend to fall into groups of marked sensitizers or marked repressors, both of whom are easily identifiable clinically and may be further objectively determined by the use of appropriate MMPI subscales. (2) Depressed patients in general tend to be sensitizers and not repressors. (3) The Zung and Hamilton Depression scales correlate significantly with r = 0.79, p = < 0.01. (4) The Zung Depression Scale has the advantage of ease of administration, and there seems to be no significant differences between the accuracy of the Zung and Hamilton. Only in those clinical cases described as marked sensitizers or marked repressors does it seem unwarranted to depend singly on one or the other test without thorough clinical validation of either rating scale score. (5) Greater sensitization and less repression correspond generally to diagnoses indicating poorer ego development in terms of most psychodynamic theories of personality (ego) development.
DEPRESSION
367
SCALES
REFERENCES 1. Zung, W. W. K.: A Self-rating Depression Scale. Arch. Gen. Psychiat. 12:63, 1965. 2. Hamilton, M.: A rating scale for depression. J. Neurol. Neurosurg. Psychiat. 12:56, 1960. 3. Zung, W. W. K.: Factors influencing the Self-rating Depression Scale. Arch. Gen. Psychiat. 16:543, 1967. 4. Hamilton, M.: Lectures on the Methodology of Clinical Research. Livingstone, Edinburgh and London, p. 123,196l. 5. Zung, W. W. K., and Gianturco, J. A.: Personality dimension and the Self-rating Depression Scale. J. Clin. Psychol. 27:247, 1971. 6. Brown, G. L., Green, R. L., Jr., and Mar-
tin, R. M., Jr.: Double-blind, non-crossover study of imipramine and A-10749. J. Clin. Pharmacol. 12:40, 1972. 7. Byrne, D.: The repression-sensitization scale: rationale, reliability, and validity. J. Personality 29:334,1961. 8. Ullmann, L.: An empirically derived MMPI scale which measures facilitation-inhibition of recognition of threatening stimuli. J. Chn. Psychol. 18:127, 1962. 9. Ford, H.: Involutional psychotic reaction. In Freedman, A., and Kaplan, H. (Eds.): Comprehensive Textbook of Psychiatry. Baltimore, William and Wilkins, 1967, p. 697.
T
HE QUESTION RAISED in the title of this article is of basic importance not only to the researcher but also to the clinician who uses rating scales as an adjunct in the diagnosis and treatment of his depressed patients. To be considered are the ease with which the measurements are made, their accuracy, and the time requisite for that measurement and accuracy. During the course of the evaluation of an experimental antidepressant, observations by one of the authors led to the hypothesis that he could differentiate, on a clinical basis, patients in whom he could expect an unreliable correlation between scores obtained on the Zung Self-Rating Depression Scale’ and the Hamilton PhysicianRating Scale.2 Although there are a number of factors that may influence scores obtained on rating scales, both self3 and physician,4 the knowledge of such factors has not been directly applied to the question of whether to use a self- or physician-rating scale. Our purpose is to show that patients who can be described clinically as either sensitizers or repressors tend to show an unreliable correlation between Zung and Hamilton scores. Sensitizers are defined as individuals who tend to be oversensitive, to overinterpret, and to ruminate about potential or real threats and conflicts. They have a negative self-concept and emphasize their own helplessness and weakness. Repressors are defined as individuals who tend to use avoidance, suppression, repression, and denial of potential threats and conflicts. ’ This sensitization-repression dimension can be determined rather accurately by clinical interviews and seem, as we will attempt to demonstrate, to have some correlation with the degree of ego development. METHOD
A total of 65 inpatients, considered by their primary resident physicians to be potentially depressed, were admitted to the Psychiatric Service of the Durham Veterans Administration Hospital during a 6-month period. They were evaluated using the Zung Self-Rating Depression Scale (SDS) and the Hamilton Physician-Rating Scale (HRS) during the course of a clinical evahration of antidepressant drugs.a A total of 35 patients was selected for pharmacologic treatment of their depressions on the basis of their having scored 25 or more on the HRS. All patients so selected were retested serially with both instruments on days 8 and 28 (termination) of treatment. After the evaluation of the first 21 patients, the hypothesis that stimulated this article led to the establishment of an experimental design in which the principal investigator in the drug study made a clinical global rating for the degree of sensitization-repression on the 14 subsequent patients. The global ratings were: 5 = marked sensitizer, 4 = moderate sensitizer, 3 = a patient in whom neither quality predominates significantly, 2 = moderate repressor, and 1 = marked repressor. A second From Duke UniversityMedical Center and VeteransAdministration Hospital, Durham, N. C. Presented at the annual meeting of American Aychiatric Assort&ion in Washington,D. C., May 1971. Supported in part by USPHS Research Scientist Development Award MH 35232 from the National Institute ofMental Health. G. LaVonne Brown, M.D.: Resident, Duke UniversityMedical Center and Veterans Administmtion Hospital, Durham, N. C. William W. K. Zung, M.D.: Associate Professor of Psychiatry, Duke UniversityMedical Center and Vetemns Administmtion Hospital, Durham, N. C. Comprehensive Psychiatry, Vol. 13, No. 4
(July/August),
1972
361
362
BROWN
AN0
ZUNG
investigator tested those same patients by giving them the appropriate MMPI subscales: the Byrne Repression-Sensitization Scale (R-S)’ and the Ullmann Facilitation-Inhibition Scale, (F-I)8 both of which measure repression (or inhibition) and sensitization (or facilitation). High scores on the Byrne and low scores on the Ullmann indicate sensitization, with the opposite scores for repression, respectively. Ratings of patients were performed as follows: global ratings of the R-S dimension were determined clinically, followed by the depression rating scales (Zung and Hamilton), with the MMPI (from which are derived the Byrne and Ullmann scores) given last. All Byrne and Ullmann scores were determined on the initial depression evaluation (day 0 in the drug study). All APA diagnoses were given by the primary resident physicians, none of whom were directly involved in any of the research design or data collection and analysis. In order to demonstrate more meaningfully just what we mean clinically by sensitization and repression, two brief case history abstracts follow. The former, RDJ, is the most marked example of a sensitizer, and the latter, GLC, is the most marked example of a repressor. CASE
REPORTS
Case I RDJ, a fist psychiatric admission, was a forty-seven-year-old, white, divorced male with a long history of job changes as a radio repairman. During his married life there were many separations. His presenting mood statement was, “I feel unnecessary.” On one occasion, the patient corn plained, “I can’t stand responsibility.” RDJ had had suicidal ruminations, crying spells, and the biological correlates of depression. The patient tended to complain of numerous somatic problems, i.e., headaches, nausea, dizziness, bad nerves, and so forth. The patient had had various gastrointestinal complaints in the past, resulting in a vagotomy and gastroenterostomy 18 months previous to the admission for depression. The patient complained that he could no longer work as a radio repairman because the transistor age had passed him by. However, as numerous attempts were made to help him get a job in radio service work or other areas, he would say in the former case that he already knew the potential employers and knew he would not be able to work with them or, in the latter case he would always find a reason, such as not wanting outside work, to sabotage these efforts. The patient had been a moderate smoker and drinker. He had a seventh grade education. His mother died when he was 20 months old. The patient was diagnosed as a passiveaggressive personality. His primitive defense mechanisms, particularly projection and somatization, his life-long difficulty with object relationships, and the volatile, diffuse anxiety all bespeak of the deficits in his ego development. Case 2 GLC, a first psychiatric admission, was a S&year-old, white, married male with a 25 year history of job stability as a clothes inspector in a textile mill. GLC had had a stable marriage for 27 years, and until 4 -5 months previous to admission had been an amicable, out-going person with hobbies, friends, and the status of a valued employee. GLC’s chief complaint was “I can’t sleep at night.” The patient tended to be quiet and make few complaints. Although his family could think of no change in his life that might have precipitated the depression, the patient had been hospitalized 6 months previous to admission and told that he had a damaged artery in his heart. Acute EKG changes had allegedly persisted for 2 weeks. At admission for depression, GLC specitically stated that he no longer worried about his heart. There was only slight evidence for cardiovascular disease on his EKG during this admission (previous admission had been at another hospital). Master’s test was within normal limits. During the hospital course, the patient was eager to go home for weekends with his family after the depression had improved. The patient had never smoked nor drank. His childhood psychosexual history was essentially unremarkable. The patient’s case was diagnosed as involutional melancholia mainly because of his inhibitions and denial of the significance of the change in his body integrity (cardiovascular disease), along with the depression that temporarily may have been the result of this loss in body integrity. The patient was also rather moralistic in his values and stoic in his outlook. Except for his seeming inability to deal with the cardiac trauma, the patient’s entire past life would seem to bespeak of rather good ego development.
DEPRESSION
363
SCALES
Zung SDS Index Fig. 1, Comparison of Hamilton and Zung scores. Depression scales: Self- or physician-rating? validation of certain clinically observable phenomena.
A
RESULTS
In order to evaluate the correlation of Zung and Hamilton scores in the study group, 135 sets of scores determined throughout the drug study (thirty-five patients tested before, during, and at completion, plus data from the 30 rejects) were plotted. The results obtained from the plotting of all scores are seen in Fig. 1. Curve A is derived from a linear regression analysis (whose product-moment correlation was r = 0.79; p = < O.Ol), and curve B is a plot of mean values of HRS scores against the corresponding SDS scores. A total of 14 patients was evaluated for this study. Correlation of the MMPI subscales (R-S and F-I) and the Zung (SDS) of the 14 patients studied is shown in Fig. 2 against previously derived slopes with corresponding r values based on 159 patients.’ Certain patients, RDJ and GLC, whose significance is discussed below, are indicated by their respective initials in Fig. 2. Last, the data from the 14 patients studied are arranged in order from the most severe sensitizers to the most severe repressors on the basis of the clinically determined global rating. DlSCUSSlON Comparison of our data to earlier work relating sensitization-repression to depressions is in agreement with the findings that depressed patients tend to be sensitizers and are related in a linearly incremental fashion and that depressed patients tend not to be repressors (Fig. 2). Although only 7 of 14 patients were rated clinically as sensitizers (Table l), only 3 of 14 were rated clinically as repressors. Although our
BROWN
364
AND
ZIJNG
120-
@ R-S’T”SCMES 0 F-I SC(uIET
loo-
80R-S ‘T’ 9a#K
0
o-
25
R&l 0 ’
30
,
40
50
60
to
80
90
100
Zung SDS Index Fig. 2. Relationship between sensitization-repression and depression. Depression scales: Self- or physician-rating? A validation of certain clinically observable phenomena.
data does seem to support the contention that depressed patients tend to be sensitizers, our data gives better evidence that depressed patients tend not to be repressors. In Fig. 1, although Hamilton and Zung scores correlate significantly (curve A), curve B shows that Hamilton and Zung scores are not strictly linearly related. This relative progression to higher scores on the Zung as a patient becomes more depressed may be related to the greater degree of sensitization which is picked up on the self-rating scale. It also may be related to the differences in the item contents of the two scales, or to the differences inherent in one scale’s being objective and the other being subjective. Possibly this latter difference is greatly affected by the degree to which the patient may be a sensitizer. The experimental design employed gives the opportunity of comparing, first, a single set of Hamilton-Zung scores with initially determined repression-sensitization ratings (both Byrne-Ullmamr scores and a clinical global rating) followed, second, by the patients’ course of depression over 28 days as determined by subsequent HamiltonZung scores, a clinical rating of the patients’ response to antidepressant therapy (Table l), and a comparison of the R-S dimension to clinical diagnoses. The experimental design could have been improved by the inclusion of all 35 patients selected for treatment of their depression in the sensitization-repression evaluations. However, as mentioned before, the hypothesis itself was generated from clinical observations on the earlier patients in the depression study; thus, as great a number as possible was subsequently included in the sensitization-repression evaluations. It would seem warranted for further study, using a greater number of patients, to be effected. Although a single set of Hamilton-Zung scores may or may not readily demonstrate that marked sensitizers or marked repressors have the least predictable correlative values, examination of their scores over time will make the lack of a consistent rela-
Passive-aggressive Personality with depression Passive-dependent personality with depression Manic-depressive illness depressed type Passivedependent person&v with depression Depressive neurosis Passive-aggressivepersonality with depression Psychotic depression Depressive neurosis Alcoholism with transient depression Depressive neurosis Depressive neurosis Situational reaction Depressive neurosis Involutional melancholia
Diagnosis
21 20 22 23
4 4 4 4
25 20 25 27 43
24 25 19
10
5
4 3 3
2
5
Ullmann F-l
55 45 45 50 35
58 56 53
60 58
58
62
64
70
Byrne R-S T
736555 59 5341 69-60-56 55-56-35
8580-78 7 l-46-53 46
55-51-41 66-39-36
7861.65
6860-54
64-65-5 1
70-65-73
SDS Index on Days O-S-28
*Patient’s depression was more apparent than real, and he responded quickly to hospitalization alone. ‘Not sufficiently depressed to meet criteria of drug study. *Patient’s multiple complaints diminished rapidly: two sets of scores are on hospital days 1 and 2 with discharge on day 3.
AJS JES+ FHES HP0 GLC
WRG CTR CMC*
CFR Cl-T
JMD
WJV
WMcW
RDJ
Patient (Initials)
Global Rating (Clinical) R-S
Table 1. Clinical Comparison of Sensitization-Repression and Depression Scores
31-20-14 24 31-16 30-19-13 26-27-8
36-30-25 30-13-g 11
Good Good
Fair -
Fair Good -
Good Excellent
37-30-13 30- 17-4
None
27-27-27
Fair
Good
36-25-l 2
28-15-16
Fair
Global Rating (Clinical) Drug Response
36-20-26
HRS on Days O-S-28
v)
E
::
D
z
z 5
366
BROWN
AND
ZUNG
tionship become more apparent. For example, RDJ, as a marked sensitizer, showed an unequivocal (although with only fair results) response to treatment when rated by the Hamilton. However, from the Zung index or the patient’s own verbal attestation, results of his treatment were poor, and we might question the efficacy of his treatment despite clear improvement in depressive biological correlates that not only manifested themselves in both scale results but also could be noted from hospital-chart and resident-physician evaluations of the biological correlates. On the other end of our R-S gradient, GLC, as a marked repressor, had initial scores on both Zung and Hamilton that would indicate mild-to-moderate depression. However, clinical evaluation and objective impression by both his resident physician and an author would have led us to expect him to score higher on both instruments. In contrast to most of the patients in the drug study who had initial responses to treatment within 7-10 days (as documented by day 8 testing), GLC did not show any drug response until after approximately 3 weeks of treatment. Perhaps the unusual treatment response in this patient is consistent with his diagnosis of involutional melancholia, often accompanied by inhibition and rigidity;’ furthermore, if we take into consideration his repressive outlook, we would not be surprised that what appears as change (whether getting sick or getting well) to the observer is hardly perceived as change by the patient himself. Of all 14 patients in the study group, both RDJ and GLC deviated the farthest from the previously determined relationship between R-S, F-I values and SDS scores as shown in Fig. 2. An overall comparison of the R-S dimension to clinical diagnoses in Table 1 is striking in that patients with diagnoses that correspond generally to poorer ego development show more sensitization and less repression, consistent with most psychodynamic theories of personality (ego) development. In such cases of poorly predictable correlations, most clinicians would choose to rely upon their own ratings, which are not necessarily more valid than the patient’s rating of himself. Although the patient cannot compare his subjective rating with that of any other patient whom he judges to be comparable, the physician is able to request colleagues with comparable competence to make an objective rating of a patient and can use, as well, a blind system should this additional degree of validation be desired. SUMMARY
AND
CONCLUSION
(1) Those patients who correlate the lease predictably in terms of the Zung SelfRating and the Hamilton Physician-Rating Depression scores (either initially or longitudinally over a clinical course) tend to fall into groups of marked sensitizers or marked repressors, both of whom are easily identifiable clinically and may be further objectively determined by the use of appropriate MMPI subscales. (2) Depressed patients in general tend to be sensitizers and not repressors. (3) The Zung and Hamilton Depression scales correlate significantly with r = 0.79, p = < 0.01. (4) The Zung Depression Scale has the advantage of ease of administration, and there seems to be no significant differences between the accuracy of the Zung and Hamilton. Only in those clinical cases described as marked sensitizers or marked repressors does it seem unwarranted to depend singly on one or the other test without thorough clinical validation of either rating scale score. (5) Greater sensitization and less repression correspond generally to diagnoses indicating poorer ego development in terms of most psychodynamic theories of personality (ego) development.
DEPRESSION
367
SCALES
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tin, R. M., Jr.: Double-blind, non-crossover study of imipramine and A-10749. J. Clin. Pharmacol. 12:40, 1972. 7. Byrne, D.: The repression-sensitization scale: rationale, reliability, and validity. J. Personality 29:334,1961. 8. Ullmann, L.: An empirically derived MMPI scale which measures facilitation-inhibition of recognition of threatening stimuli. J. Chn. Psychol. 18:127, 1962. 9. Ford, H.: Involutional psychotic reaction. In Freedman, A., and Kaplan, H. (Eds.): Comprehensive Textbook of Psychiatry. Baltimore, William and Wilkins, 1967, p. 697.