Psychopharmacology Series 9 T h e - - - Hamilton Scales Editors Per Bech Alec Coppen With 4 Figures Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona PER BECH M.D., Ph.D. Head of Psychiatric Department, Frederiksborg General Hospital, 3400 Hillen>ld, Denmark Dr. ALEC COPPEN Director, MRC Neuropsychiatry Research Laboratory, West Park Hospital, Epsom, Surrey KT19 8PB, United Kingdom Cover illustration: The three clinical components of the Hamilton Depression Scale Vols. 1 and 2 of this series appeared under the title .,Psychopharmacology Supplementum" ISBN-13:978-3-642-75375-6 e-ISBN-13:978-3-642-75373-2 DOl: 10.1007/978-3-642-75373-2 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. 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Typesetting: International Typesetters Inc., Makati, Philippines 2125/3130(3011)-543210 - Printed on acid-free paper Preface The European College of Neuropsychopharmacology (ECNP) is a scientific and educational association which represents a variety of disciplines. The first ECNP congress took place in Copenhagen, May 1985, where a working group of European scientists within the field of psychopharmacology was elected to prepare a constituent ECNP congress in Brussels, 1987. Among the most active members of this group was Max Hamilton. At the second ECNP congress in Brussels Max Hamilton was elected as the first honorary member of the ECNP. When we received the message of his death we decided at once to arrange a Max Hamilton memorial symposium at the third ECNP congress, May 1989, in Gothenburg, Sweden. This monograph contains the proceedings of the Max Hamilton symposium which was chaired by the editors. The opening lecture of the third ECNP congress was a Max Hamilton lecture: "A life devoted to science in psychiatry" which was presented by Sir Martin Roth. It seemed obvious to include Sir Martin's lecture as the opening article of this monograph. Although G .E. Berrios was unable to participate in the ECNP congress we have found it logical to include his manuscript on "The Hamilton Depression Scale and the Numerical Description of the Symptoms of Depression" as another personal contribution to Max Hamilton and his rating scales. The participants in the Max Hamilton symposium have all covered important aspects of the scales constructed by Max Hamilton three decades ago. At the symposium it was found that the presentations followed each other in a meaningful way. The different European and American experiences with the Hamilton scales emphasized their in ternational utility, comparable to the standard classification systems of clinical psychiatry, such as the ICD or DSM. For the purpose ofd rawing conclusions across studies in depression or anxiety the Hamilton scales are mandatory. Psychometrically, it seems natural to compare the work of Max Hamilton on affective disorders with the work of Alfred Binet on mental retardation. It is our hope that with this monograph the ECNP has both honoured Max Hamilton personally and paid tribute to his great contribution to psychiatry. This publication was made possible by the sponsorship ofDuphar and the support of Novo-Nordisk. Copenhagen, Epsom PER BECH • ALEC COP PEN Contents Max Hamilton: A Life Devoted to Psychiatric Science M. ROTH ............................................. . The Hamilton Depression Rating Scale in a WHO Collaborative Program M. GASTPAR and U. GILSDORF. With 2 Figures 10 The Impact of the Hamilton Rating Scale for Depression on the Development of a Center for Clinical Psychopharmacology Research L. CONTI and G.B. CASSANO. With I Figure . . . . . . . . . . . . . . . .. 20 The Different Versions of the Hamilton Depression Rating Scale F.G. ZITMAN, M.F.G. MENNEN, E. GRIEZ, and C. HOOIIER 28 French Experiences with the Hamilton Scales in Comparison with Other Scales for Depression and Anxiety C.B. PULL ................................................ 35 Use of the Hamilton Depression Scale in General Practice E.S. PAYKEL. With 1 Figure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 40 Structured Interview Guides for the Hamilton Rating Scales J.B.W. WILLIAMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 The Hamilton Depression Scale and Its Alternatives: A Comparison of Their Reliability and Validity W. MAIER............................................. 64 VIII Contents Psychometric Developments of the Hamilton Scales: The Spectrum of Depression, Dysthymia, and Anxiety P. BEeR ............................................... 72 The Hamilton Depression Scale and the Numerical Description of the Symptoms of Depression G.E. BERRIOS and A. BULBENA-VILLARASA . . . . ...... . . .... . . 80 Subject Index .......................................... 93 List of Contributors You will find the addresses at the beginning of the respective contribution Bech, P. 72 Hooijer, C. 28 Berrios, G .E. 80 Maier, W. 64 Bulbena-Villarasa, A. 80 Mennen, M.F.G. 28 Cassano, G.B. 20 Paykel, E.S. 40 Conti, L. 20 Pull, C.B. 35 Gastpar, M. 10 Roth, M. 1 Gilsdorf, U. 10 Williams, J.B.W. 48 Griez, E. 28 Zitman, F.G. 28 Max Hamilton: A Life Devoted to Psychiatric Science M. ROTHI The death of Max Hamilton on 16 August 1988 has deprived psychiatry in Great Britain and the world of one of its most vigorous, incisive and indepen dent minds, and a personality of rare. boldness and integrity. He had gained worldwide renown for his studies of psychopathology and his contributions to its quantitative assessment using reliable and valid techniques. Like many men endowed with originality, Max Hamilton's sociocultural origins were complex and probably responsible in part for the detachment, objectivity and the abhorrence of received wisdom that characterised his out look. He was born in Frankfurt-am-Main in Germany and came to England with his parents in 1914, when he was 2 1/2 years old. He was inclined to attribute his mathematical talents to the inspired teaching of the headmaster of the famous Grammar School,' The Central Foundation School in London, where he received his secondary education. He was disinclined, erroneously I believe, to give credit to his natural many-sided talents. Max Hamilton had stated that he chose medicine as a profession because of the scientific interest of the problems it posed rather than the desire to engage in clinical practice as a doctor. Not surprisingly he was bored by the didactic teaching and dogmatic interpretation of clinical evidence that often predominat ed in the clinical education a half century ago. "Make the diagnosis while you are taking the history and then confirm it by your physical examination -" was a favourite exhortation of one of my own teachers almost 50 years ago. There was little, if any, heed given to refutation or self-immolation on the altar of truth, in the sense of Popper. Max Hamilton's undergraduate career was there fore undistinguished and, as with many medical men destined to make their mark in science, examinations in clinical medicine were to prove a recurring problem. But once he had qualified, he went on to become a perceptive, skilful as well as compassionate doctor. He continued until the end of his distinguished career to teach students that the care of patients had to be given the same top priority in academic departments within a clinical school as in the course of ordi nary clinical practice in the hospital or community. The identity he came to assume as clinical professor was shaped, to some extent, by long-established unwritten law which continues to prevail in British schools of medicine. This I University of Cambridge Clinical School, Addenbrooke's Hospital (Level 5), Hills Road, Cambridge CB22QQ,UK The Hamilton Scales Editors: Per Bech and Alec Coppen (Psychoplwmarology Series 9) @Springer-VeriagBerlinHeidelberg 1990 2 M.Roth ordains that any professor or lecturer who attempts as far as he can to delegate his clinical responsibilities and never responds personally to requests for con sultation should be invisible; it seeks further to ensure that on committees in which he competes for space facilities and funds, his pleas will impinge upon deaf ears. However, the priority Max Hamilton gave to the care of patients stemmed mainly from deep conviction. 1 Early Career in Psychiatry His career and outlook were characterised by other features that were highly distinctive. A profound scepticism respecting accepted teaching about clinical practice or theory was a firmly ingrained trait. Whether in the most lowly or the highest positions that he held in psychiatry, he probed the phenomena he encountered with challenging questions that called for investigation. Engaged as a general practitioner to aged pensioners and unemployed in 1936, he was puzzled by the recurrent attacks of hypoglycaemia experienced by many of his patients. As it turned out, the scientifically estimated diets they had been pres cribed had proved too costly and complicated for this poverty-stricken and deprived clientele. At the outbreak of war Max Hamilton joined the RAP. He was appointed Medical Officer of a unit comprised of many men who had been promoted or down-graded from fighting units following emotional breakdown. In the hope of discouraging others, the diagnosis that had been promulgated for such per sons - who had in many cases flown on 30-40 bombing raids - used the humili ating label "lowered moral fibre". This was Max Hamilton's first close encoun ter with mental suffering. Having decided on a career in psychiatry, he took the unusual course of preparing for the first part of the Diploma in Psychological Medicine (DPM), then the standard qualification, without having had any clinical experience in psychiatry. In the course of his readings in basic neurobiological sciences he read Woodworth's "Introduction to Psychology". His was a prepared mind and he clearly understood, for the first time, the difference between the posing and critical testing of hypotheses and other forms of mental reasoning. 2 The Maudsley and University College London and Springfield Hospital After acquiring his DPM, Max Hamilton managed to gain admission in 1945 to the "Holy of Holies" of British psychiatry, the Maudsley Hospital, where he did not prove a success. A special form of interrogation from on high by some of the "high priests in the temple" helped to make psychiatrists of some, but was not formative for others. Max had a certain respect for book learning but his approach to problems was empirical. He could not conjure up respect for authority, asked too many questions and would accept neither a dogmatic "yes" Max Hamilton: A Life Devoted to Psychiatric Science 3 or a "no" for an answer. Thus, he gravitated towards the Department of Psychology where he developed his knowledge of multivariate statistics and became one of the first psychiatrists to apply factor analysis and later other multivariate methods to psychiatric problems. Although familiar with Moore's attempt at validation of existing psychiatric taxonomy with the aid of factor analysis, the problems Max Hamilton was to tackle were of a different com plexion. A junior post as part-time lecturer at University College, London between 1945 and 1947 afforded a portal of entry to the department of Cyril Burt, whose teaching made a lasting imprint, as did the discussions with the many eager young men aspiring to research careers who had, at that time, gathered around Burt from every part of the world. The later revelations which testified to Burt's scientific dishonesty in certain of his enquiries were to cause Max perplexity for the rest of his life. It appeared out of character and without purpose in a man of immense intellectual powers and scientific achievement. But these reve lations were to burst upon the world decades later. A reasoned, objective and methodologically stringent approach to the study of mental life were to become the main weapons in Max Hamilton's intellectual armoury after his exposure to investigative psychology in Burt's department. Some decades later he was to be elected president of the British Psychological Association, the only clinical psychiatrist on whom this honour has been con ferred to my knowledge. From this period there came his lucid and illuminating book on Psychosomatics, published in 1955. Its inspiration had issued from investigations into the personality of patients with gastric and duodenal ulcer which had ·also formed the subject of his doctoral thesis. After a short period in Kings College Hospital (1951-1952), he moved to the lowly position of Senior Hospital Medical Officer at Springfield Hospital for a 2-year period. He had by then entered his forties. He cannot have been unaware of his true intellectual stature. A lesser man might have acknowledged defeat and lapsed in bitterness and resentment into a state of apathy and inertia. Max dedicated himself instead to the care of the deteriorated, demoralised and apathetic patients treated mainly with sedatives and occasionally with unmod ified ECT. He kept painstaking records with a card for each patient, which he always carried with him. A sphygmomanometer and opthalmoscope not previ ously seen at this hospital made their appearance there. He continued to pose questions when relaxants came on the scene. He discovered a means of check ing whether or not a patient had had a convulsion by occluding the circulation to one arm before the relaxant was injected into the other. A comparison of the results of insulin coma therapy in schizophrenic patients and ECT given to those who had been rejected for this treatment brought to light no differences in outcome between the two treatments even when confounding variables had been eliminated. This report gained the Regional Research Prize but, like a number of other investigations he had car ried out, this study was not deemed by him to be worthy of publication. Patients had not been randomly allocated to the two treatments.