Fifty Years with the Hamilton Scales for Anxiety and Depression

Abstract

From the moment Max Hamilton started his psychiatric education, he considered psychometrics to be a scientific discipline on a par with biochemistry or pharmacology in clinical research. His clinimetric skills were in operation in the 1950s when randomised clinical trials were established as the method for the evaluation of the clinical effects of psychotropic drugs. Inspired by Eysenck, Hamilton took the long route around factor analysis in order to qualify his scales for anxiety (HAM-A) and depression (HAM-D) as scientific tools. From the moment when, 50 years ago, Hamilton published his first placebo-controlled trial with an experimental anti-anxiety drug, he realized the dialectic problem in using the total score on HAM-A as a sufficient statistic for the measurement of outcome. This dialectic problem has been investigated for more than 50 years with different types of factor analyses without success. Using modern psychometric methods, the solution to this problem is a simple matter of reallocating the Hamilton scale items according to the scientific hypothesis under examination. Hamilton’s original intention, to measure the global burden of the symptoms experienced by the patients with affective disorders, is in agreement with the DSM-IV and ICD-10 classification systems. Scale reliability and obtainment of valid information from patients and their relatives were the most important clinimetric innovations to be developed by Hamilton. Max Hamilton therefore belongs to the very exclusive family of eminent physicians celebrated by this journal with a tribute.

Is the antidepressive effect of second-generation antidepressants a myth?

“…Hamilton developed his scale (Hamilton, 1987) to enable clinicians to focus on the current symptomatology of patients, implying that the total scores on HAMD 17 should give a global impression of the burden of the illness (Bech, 2009). However, the dimension on which the antidepressive drugs act clinically is that of the HAMD 6 symptoms ; this is also in accord with Kuhn (1958Kuhn ( , 1970.…”

“…Therefore, a drug such as mirtazapine, in which no dose-response relationship has been demonstrated (Pinder & Zivkov, 1998), has been favoured by compared, for example, with duloxetine or venlafaxine in which a dose-response relationship has been demonstrated (Bech, 2009). …”

“…In contrast to factor analysis which focuses on conceptual knowledge, item response theory models, e.g. the Rasch model (Rasch, 1980), focus on perceptual knowledge by considering the individual items to be placed on the graduated line on which the severity of the depressive state is listed (Bech, 2009).…”

The ABC profile of the HAM-D17

“…In a patient with primary or secondary depression, suicidal thoughts are often activated if there is a lack of insight on the part of the patient into his disorder 3 . When Hamilton developed his scale 4 , he consulted Kraepelin's original description of primary depression (manic-depressive illness), as well as Kraepelin's description of secondary depression (exhaustion depression). However, Hamilton also made focusinterviews with his depressed patients and their relatives 4 .…”

“…When Hamilton developed his scale 4 , he consulted Kraepelin's original description of primary depression (manic-depressive illness), as well as Kraepelin's description of secondary depression (exhaustion depression). However, Hamilton also made focusinterviews with his depressed patients and their relatives 4 . This was the background for his selection of the 17 items in the HAM-D.…”