A Systematic Overview of Measurement-Based Care in the Treatment of Childhood and Adolescent...

Journal of Psychiatric Practice Vol. 16, No. 4 July 2010 217

Major depressive disorder (MDD) is one of the mostprevalent, commonly diagnosed, and life-alteringmental illnesses that affects children and adoles-cents.1 The prevalence of depression is particularlytroubling due to the early manifestation and invasivenature of depressive symptoms during childhood andadolescence and the chronic nature of the disorder,which can result in life-long functional and socialimpairments, such as an increased risk of suicidality,academic and personal difficulties, and substanceabuse.1,2 As a result of the growing concern aboutchildhood and adolescent depression, a significantline of research has been established to examine safe,efficacious, evidence-based antidepressant treat-ments. Research has supported the efficacy of threeprimary treatments for childhood and adolescentdepression: medicine, psychotherapy, or a combina-tion of both treatments, which are differentiallyimplemented based on symptom severity.3–9 Forexample, in children and adolescents, SSRIs are typ-ically indicated only for the treatment of moderate to

severe MDD. Although these treatments have beensuccessful in treating depression, a significant num-ber of children and adolescents experience relapseand continue to struggle with depressive symp-toms.3,4 In order to further address and ultimatelyreduce the significant impairments associated with

Major depressive disorder (MDD) is one of the most prevalent psychiatric disorders affecting chil-dren and adolescents. The significant psychiatric, social, and functional impairments associatedwith this disorder coupled with the high incidence of relapse indicate a need for continued effortsto enhance treatment. Current empirically supported treatments for childhood and adolescent MDDinclude psychotropic medications, psychotherapy, and a combination of both treatments, with selec-tion of the most appropriate strategy depending on symptom severity. One strategy to enhancetreatment outcome is the use of measurement-based care. This article provides a systematic reviewof measurement-based care in the treatment of childhood and adolescent MDD. It also presents acomprehensive analysis of widely used depression rating scales and discusses their utility in clini-cal practice. This review found evidence supporting the utility and benefit of depression ratingscales to document depression severity in children and adolescents. We also found evidence sug-gesting that many of these scales are time efficient, and that both clinician-rated and self-ratedscales provide accurate assessment of depressive symptomatology. Future research is warranted toexamine the utility of measurement-based care in clinical practice with child and adolescent popu-lations. (Journal of Psychiatric Practice 2010;16:217–234)

KEY WORDS: major depressive disorder, child, adolescent, measurement-based care, symptom severity, childdepression rating scale

JOANNA M. ELMQUISTTABATHA K. MELTONPAUL CROARKIN, DO

SHAWN M. McCLINTOCK, PhD

ELMQUIST, MELTON, and CROARKIN: University of TexasSouthwestern Medical Center, Dallas; McCLINTOCK: Univer-sity of Texas Southwestern Medical Center and New YorkState Psychiatric Institute, Columbia University.

Copyright ©2010 Lippincott Williams & Wilkins Inc.

Please send correspondence to: Shawn M. McClintock, PhD,UT Southwestern Medical Center, Department of Psychiatry,5323 Harry Hines Blvd., Dallas, TX 75235-8898.

[email protected]

Acknowledgments: This publication was supported by GrantNumber KL2 RR024983 (PI: Milton Packer) from the NationalCenter for Research Resources (NCRR), a component of theNational Institutes of Health (NIH), and Grant Number R25MH74675 (PI: Graham Emslie) from the National Institute ofMental Health (NIMH).

The authors declare no conflicts of interest.

A Systematic Overview of Measurement-Based Care

in the Treatment of Childhood and

Adolescent Depression

childhood and adolescent depression, a growingmovement to advance the use of measurement-basedcare has arisen in the psychiatric community.10,11

Measurement-based care is defined as “an evi-dence-based practice emphasizing the systematicempirical evaluation of outcomes.”12 Proponents ofmeasurement-based care acknowledge that evidence-based antidepressant regimens involve the use ofdepression rating scales to assess and track the quan-tity (domain and type) and quality (severity level) ofpsychiatric symptoms across time.2,13,14 Previousresearch supports the use of measurement-basedcare in clinical investigations.3,15–17 Despite this evi-dence, the practice of measurement-based care forchild and adolescent depression is limited in the clin-ical psychiatric community,18 primarily due to thecomplex nature of the disorder and the difficultiessometimes involved in psychiatric assessments.10

The primary purpose of this paper is to present asystematic review of measurement-based care in thetreatment of childhood and adolescent depression. Wealso provide a comprehensive analysis of widely useddepression rating scales and their utility in clinicalpractice. The systematic literature review presentedin this article was based on three independentsearches using Ovid SP Medline (1950–present),PubMed (1948–present), and PsychInfo (1806–pres-ent). The following terms were included in the inde-pendent searches: depressive disorder (includingmajor depressive disorder; psychology, drug therapy,and prevention and control), child (including psychia-try and psychology), adolescent (including psychiatryand psychology), measurement-based care, psychiatricstatus, rating scales, and symptom severity.* Toorganize the material and prevent redundancy, all ofthe references obtained in the searches were import-ed into Endnote (version X2 for Windows, TheThomson Corp., New York, NY). We then included inthe review only those articles that dealt with MDD,child, adolescent, measurement-based care, anddepression rating scales, for a total of 93 articles.These articles were published between 1980 and

2009 in the United States and the United Kingdom,and the methodologies varied from reviews to ran-domized, controlled trials.

Major Depressive Disorder in Children andAdolescents

Prevalence. Interest in and concern about theassessment and treatment of childhood and adoles-cent depression has been growing among both clini-cians and researchers,1,2 largely as a result of thegrowing prevalence of MDD among children and ado-lescents.1 Currently, the prevalence of depression isestimated to be 1%–2% among children (ages 6–12years) and 4%–8% among adolescents (ages 12–18years), which suggests that the prevalence of depres-sion increases with age and more than doubles atpuberty.17,19–21 Moreover, the lifetime prevalence ofdepression through adolescence (percentage whodevelop depression before reaching adulthood) hasbeen estimated to be approximately 13%–20%.21–23

The nature and severity of MDD symptoms have alsocontributed to the growing concern about childhoodand adolescent depression.

Symptoms and diagnosis. The main symptoms ofMDD in children and adolescents are persistentdepressed mood or irritability, increased ordecreased need for sleep, changes in appetite, fatigueand decreased energy, loss of interest or boredom,suicidal ideation, low self-esteem, increased anger,loss of concentration, somatic or physical complaints,and feelings of guilt and helplessness.24,25 In order tobe diagnosed with MDD, children and adolescentsmust have experienced a loss of interest (i.e., anhe-donia) or depressed mood, as well as four additionalsymptoms (as mentioned above) for a period of 2weeks.24,25 Per the criteria for MDD in the Diagnosticand Statistical Manual of Mental Disorders, FourthEdition, Text Revision (DSM-IV-TR), children andadolescents may present with irritable rather thandepressed mood, as well as a failure to attain theirexpected weight. As a result of these symptoms,depressed youth often face significant life impair-ments, which may include poor school performance,relationship problems, increased risk of substanceabuse, and increased risk of suicidality.23–26

The symptoms of and diagnostic criteria for MDDfor children, adolescents, and adults are somewhatsimilar; however, there are certain differences in the

MEASUREMENT-BASED CARE IN CHILDHOOD AND ADOLESCENT DEPRESSION

Journal of Psychiatric Practice Vol. 16, No. 4218 July 2010

*The complete list of words examined in the searches includedthe following: psychometrics, questionnaires, severity of illnessindex, psychological tests, self-assessment (psychology), evi-dence-based medicine (including evidence-based practice andevidence-based care), Children's Depression Scale-Revised,Children's Depression Inventory, Quick Inventory of DepressiveSymptomology, Mood and Feelings Questionnaire, BeckDepression Inventory Youth, Beck Depression Inventory-II,Reynolds Adolescent Depression Scale.

clinical presentation and assessment of youth andadult depression.24–26 In terms of clinical presenta-tion, children and adolescents are more likely toreport somatic complaints, irritability, and socialwithdrawal, while adults are more likely to reportanhedonia, guilt, and suicidality.19,24 These differ-ences have largely been attributed to developmentaldifferences between children and adolescents andadults.19,24 In addition, there are differences in theassessment of youth and adult depression. Specifi-cally, children and adolescents rarely seek treatmentfor depressive symptoms on their own; thus assess-ments are typically based on reports from parents orcaregivers.24 Moreover, the assessment of depressionin youth may be more time consuming because clini-cians have to integrate information from multiplesources or reports, since children and adolescentsmay be unable to verbalize their symptoms, in partic-ular external behavioral symptoms.19,24 Thus, a thor-ough assessment should include an interview withthe child to assess his or her internal symptomaticstate and an interview with the parent to documentexternal symptom behaviors.

Treatment. The three treatments for childhood andadolescent MDD for which there is the most empiri-cal support are psychopharmacology (i.e., antidepres-sants), psychotherapy, and a combination of bothtreatments.3–5 For each strategy, treatment is dividedinto acute, continuation, and maintenance phases.19

The primary aim of the acute phase is to achievesymptom remission; the primary aim of the continu-ation phase is to prevent relapse; and the primaryaim of the maintenance phase is to prevent recur-rences or new depressive episodes.19

Currently, the most widely prescribed antidepres-sant and the antidepressant for which there is themost empirical support in the treatment of child andadolescent depression is fluoxetine, a selective sero-tonin reuptake inhibitor (SSRI).19 Research has foundthat fluoxetine is more efficacious than placebo andhas relatively few side effects.3 In a recent study thatlooked at longer term outcomes in 327 patients fromthe Treatment for Adolescents with Depression Study(TADS), the research team found that depressed ado-lescents responded to treatment more quickly whenfluoxetine was included in the treatment: theresponse rate at 12 weeks for a combination of fluox-etine and cognitive-behavioral therapy (CBT) was73%, while the response rate for fluoxetine alone was

69%, and the response rate for CBT alone was 48%.8

At week 18, the response rates were 85% for combi-nation therapy, 69% for fluoxetine therapy, and 65%for CBT, while at week 36, the response rates were86% for combination therapy, 81% for fluoxetine ther-apy, and 81% for CBT. Thus, as the course of treat-ment progressed, there was little clinical difference inresponse rates among the antidepressant strategies.One notable difference among the treatment strate-gies was the observation of less suicidal ideation inpatients receiving combination therapy (8.4%) or CBT(6.3%) relative to fluoxetine (14.7%).

Psychotherapy, specifically CBT, is another widelyused treatment for childhood and adolescent depres-sion. It includes a variety of evidence-based tech-niques (e.g., skills training, cognitive restructuring)for the treatment of depression.19,20 CBT has beenfound to be effective in the reduction of symptomseverity during the acute phase of treatment, while itscontinued use during the continuation phase mini-mizes the likelihood of relapse.5 Recently, a significantnumber of empirical investigations have found that acombination of an antidepressant medication and psy-chotherapy was more effective in reducing depressivesymptoms and preventing depressive relapse than theuse of either of these modalities separately.5–9

Despite empirical evidence supporting the efficacyof these three treatments in the reduction of depres-sive symptomology, relapse and recurrence rates ofchildhood and adolescent MDD are high. It is esti-mated that between 34%–75% of children and adoles-cents will relapse during or after treatment at somepoint in their lives.5 There is also a 20%–60% likeli-hood of recurrence 1–2 years after remission, and thisrate increases to 70% after 5 years.19 As a result ofthese high relapse and recurrence rates, and thechronic nature of childhood and adolescent MDD,new approaches to the treatment of depression in thispopulation have been investigated and adopted.Specifically, an increasing number of researchers andclinicians support the use and efficacy of measure-ment-based care in the treatment and assessment ofchildhood and adolescent depression.

Measurement-Based Care

Measurement-based care involves the use of qualita-tive and quantitative measures to assess and tracksymptom severity, changes in symptoms, and treat-ment outcomes. Rating scales completed by a patient,



observer, or both can be used to assess symptomseverity and/or treatment efficacy.2,14,27 Observer-rated scales are symptom assessments done by a par-ent or caregiver or the clinician.14 They are thought tobe a more reliable and valid assessment of depressivesymptoms in youth, because children and adolescentsoften have difficulty verbalizing their symptoms.2

However, observer-rated scales also have a number ofdisadvantages: they are time-consuming, costly, andrequire the use of a trained professional.2 Self-ratedscales based on children’s and adolescents’ assess-ments of their depressive symptoms have the advan-tages of being less time consuming and costly.2

However, these scales produce scores with relativelylimited reliability and validity, likely due to children’sand adolescents’ somewhat inaccurate recognitionand assessment of their depressive symptoms.2

A crucial component in establishing the efficacy ofmeasurement-based care is confirming the merit ofthe scores produced by the rating scales being used.Such confirmation is dependent on the scales’ psy-chometric properties, including reliability, validity,and sensitivity to change.2 Reliability measuresthe consistency of scores on a scale.27 Correlationcoefficients are generally used to measure reliabili-ty, with a correlation of 0.70–0.80 considered to indi-cate good reliability.2 Validity assesses whether ascale measures what it is supposed to measure,through an evaluation of its content, criterion, orconstruct validity.2,27 Measures of validity are alsotypically assessed using correlation coefficients,with values of 0.80 or higher considered to indicategood validity.2 A psychometric property that isessential for scales being used in clinical practice issensitivity to change, which assesses a scale’s abil-ity to reflect changes in symptom severity overtime.2 Sensitivity to change is important becauserating scales need to accurately assess change overtime in order to adequately measure treatment out-comes.2 One method used to assess sensitivity tochange is to measure the correlation between par-ticipants’ pre and post-treatment scores and theclinician’s global severity rating score.2 Scales witha correlation value of 0.80 or higher are consideredto demonstrate sensitivity to change.2

Currently, measurement-based care and depres-sion rating scales are primarily used in research set-tings.3,4,6–9,15–17 Empirical research on childhood,adolescent, and adult depression relies on the use ofrating scales as the primary measure to assess treat-

ment response and efficacy.28 For example, theNIMH funded Sequenced Treatment Alternatives toRelieve Depression (STAR*D) was a multi-site seriesof trials that investigated treatment options foradults suffering from treatment-resistant depres-sion.29–31 During the 12-week trial, symptom severi-ty and response to treatment were measured usingtwo depression rating scales, the 17-item HamiltonRating Scale for Depression32 and the 16-item QuickInventory of Depressive Symptomatology-ClinicianRated.29–31,33 At weeks 4, 6, 8, 10, and 12, partici-pants’ symptom severity and response to treatmentwere assessed using these rating scales. Based onthese scores, clinicians either continued with theparticipants’ current treatment, augmented the cur-rent treatment, or switched the patient to treatmentwith another psychotropic medication or psychother-apy.29 Clinicians’ treatment decisions were based onscores on the depression rating scales, thus high-lighting the use of depression severity scales toimplement measurement-based care for the treat-ment of adult depression.29

A growing number of empirical studies have alsoused depression rating scales to track symptomseverity and treatment response in children andadolescents. For example, in the large, multi-centerTreatment for Adolescents with Depression (TADS)study, adolescents with MDD were randomlyassigned to receive one of four treatments: pharma-cotherapy (i.e., fluoxetine), psychotherapy (i.e.,CBT), a combination of the pharmacotherapy andpsychotherapy, or a placebo control condition.6–9 TheChildren’s Depression Rating Scale-Revised, wasthe primary outcome measure.6,34 As noted above,scores on the depression rating scale indicated thatparticipants in the combination condition were morelikely to respond after 12 weeks than participants inthe pharmacotherapy alone, psychotherapy alone,and placebo control conditions.6 Specifically, in thefull set of 439 patients treated in the first 12 weeksof this study, the response rate was 71% for the com-bination condition, 60.6% for the pharmacotherapyalone condition, 43.2% for the psychotherapy alonecondition, and 34.8 % for the placebo control condi-tion.6 Similar to adult research, research on theassessment and treatment of childhood and adoles-cent depression relies on the use of measurement-based care.

Although measurement-based care has beenfound beneficial in research on childhood and ado-



lescent depression, its implementation in clinicalpractice is limited. Zimmerman and McGlincheyexamined psychiatrists’ use of depression ratingscales in clinical practice.18 Of the 306 psychiatriststhey sampled, only 6.5% reported that they alwaysused scales to measure symptom severity and treat-ment efficacy, while 32% reported that they rarelyused rating scales and 28.8 % reported that theynever used rating scales.18 The authors also exam-ined possible reasons for clinicians’ limited use ofrating scales and found that the two most commonreasons provided by psychiatrists were that theywere not trained to use rating scales (34.3%) andthat the rating scales required too much time toadminister (33.9%).18 Furthermore, 19% of psychia-trists suggested that use of rating scales wouldimpede their clinical practice,18 a point that mayhave merit, given that clinicians’ busy schedules canlimit their ability to search for and become knowl-edgeable about which depression rating scales willbe the most effective and useful for their individualpractices. Therefore, in order to increase the use ofmeasurement-based care, this article provides acomprehensive analysis of commonly used depres-sion rating scales that can facilitate the use ofmeasurement-based care in clinical practice.

Beck Depression Inventory-II (BDI-II)

Description. The Beck Depression Inventory (BDI)was created in 1961 by Beck et al.35 The most recentversion, the BDI-II, was published in 1996, havingbeen revised to optimize its content validity andimprove its consistency with the diagnostic criteria ofthe fourth edition of the Diagnostic and StatisticalManual of Mental Disorders (DSM-IV).36,37 The BDI-II is a widely used measure of depressive symptoma-tology because of its quick administration time(approximately 10 minutes total to administer andscore) for patients aged 13 to 80 years of age.36,37

The BDI-II is a self-report instrument consisting of21 items that assess the severity of cognitive, behav-ioral, affective, and somatic symptoms associated withMDD, with each item rated on a 4-point ordinal scale(severity of 0–3).38 The inventory asks the respondentto take into account the presence of symptoms for theprior 2 weeks, which parallels the DSM-IV diagnosticcriteria for MDD.38 The BDI-II severity score is deter-mined by summing the highest rating for each item.The following guidelines are used to interpret symp-

tom severity: 0–13 = minimal, 14–19 = mild, 20–28 =moderate, and 29–63 = severe.38

Psychometric properties. Several studies have con-firmed that the BDI-II is a psychometrically soundinstrument with estimates of high internal reliabilityranging from 0.89 to 0.93.36–39 In a study conductedby Krefetz et al. of 100 adolescents 12–17 years ofage, the correlation between the BDI-II and theReynolds Adolescent Depression Scale40 was found tobe high (r = 0.84), signifying convergent validity.41–43

Similar studies by Kumar et al.44 and Osman et al.43

found that the BDI-II had high discriminant and con-vergent validity in adolescent psychiatric inpatients.

Advantages. In addition to sound psychometricproperties, the BDI-II has the following advantagesfor use in both clinical and research settings: it isquick to administer and easy to score (approximately10 minutes total), discriminates between depressionand anxiety, is available in several languages,36 andcan be used over time to track depressive symptomsfrom adolescence to adulthood.36 In a study conduct-ed by Osman et al., expert raters and adolescent psy-chiatric inpatients evaluated the BDI-II items anddetermined that the scale had high face and contentvalidity.43 The expert raters noted that it was usefulin assessing severity of depression, and the adoles-cent inpatients reported that it was easy to complete.

Limitations. The limitations of the BDI-II are thatit is easy for adolescents to inaccurately completethe scale because it does not indicate if an examineeis falsifying information. The BDI-II also does notassess or measure school functioning, nor does itallow for collection of collateral information since nosupplemental parent/teacher forms are available.When used in a clinical setting, experts advise thatthe BDI-II not be used as a diagnostic tool as itmeasures depressive symptomology, not diagnosticcriteria.39

Summary. The psychometric strength and time effi-ciency of the BDI-II, in conjunction with the scale’sability to track symptom severity across time, make ita useful assessment tool. Clinicians should be awarethat this scale is limited by not including a supple-mental parent or teacher form or an assessment ofschool functioning, and it does not control for the pos-sibility of false reports on the part of the examinee.



Beck Depression Inventory for Youth (BDI-Y)

Description. The Beck Depression Inventory forYouth (BDI-Y) is one of the five Beck YouthInventories (depression, anxiety, anger, disruptivebehavior, and self-concept). It was created by Beck etal. and published in 2005.45 Like the BDI-II, the BDI-Y measures depression severity using a brief self-report questionnaire format, but it was designed fora younger age group (individuals 7–18 years of age).

The BDI-Y consists of 20 statements that identifysymptoms of depression in children and adolescents,including negative thoughts about self/life andfuture, feelings of sadness, and physiological indica-tions of depression.46 Items are rated on a 4-pointscale that ranges from 0 (never) to 3 (always). Thetotal raw score is computed by summing all itemscores for a total range of 0–60. Scores are interpret-ed as follows: For 7–10 year olds: 0–19 = averagedepressive symptomatology, 20–24 = mildly elevated,25–34 = moderately elevated, and 35+ = extremelyelevated.47 For 11–14 year olds, 0–16 = averagedepressive symptomatology, 17–20 = mildly elevated,21–28 = moderately elevated, and 29+ = extremelyelevated.47 The BDI-Y can be administered andscored in a maximum of approximately 10 minutesdepending on the child’s age, reading ability, and cog-nitive status.45,46 If necessary, the administrationtime can easily be adjusted to compensate for theneeds of the individual child.45,46

Psychometric properties. Normative data collect-ed by Beck et al. showed that the BDI-Y has goodinternal consistency (Cronbach’s alpha coefficientsranging between 0.86 and 0.96), reliability (stan-dard error of measurement ranging between 2.00and 3.39), and convergent validity with otherdepression rating instruments for all age groups.46

Stapleton et al. replicated and expanded on thesefindings in a large school-based sample (N = 859) offemale students who were 9 to 13 years of age.47

Results showed that the BDI-Y had high internalconsistency (Cronbach’s alpha exceeded 0.90), pre-dictive validity, and convergent validity (correlationbetween the BDI-Y and the Children’s DepressionInventory = 0.83).47,48

Advantages. Like the BDI-II, the BDI-Y’s briefassessment and scoring time make it a convenienttool for assessing depressive symptoms on a regular

basis. In addition, the BDI-Y is written at a secondgrade reading level for easy comprehension by thisyoung age group.46 According to the test developers,certified training is not required to administer orscore the BDI-Y, which can be administered at intakeand before and after beginning antidepressant treat-ment to monitor effectiveness of the intervention.46

Limitations. Stapleton et al.47 suggested eliminat-ing repetitive items in the BDI-Y that measure iden-tical domains and reframing selected items to bemore specific to depressive symptoms. They alsoexpressed concern about negatively worded state-ments that are scored on a scale of 0–3 with thehigher score indicating greater depressive symp-toms. They suggested that statements be rewrittento include a balance of positively and negativelyworded items that could be used to compareresponse patterns across measures.47 Also, while theBDI-Y measures depressive symptoms, it does notinclude a measure of functional impairment, whichwould be helpful in determining symptom severity.

Summary. Overall, the BDI-Y is a convenient andexpedient instrument that measures depressivesymptoms throughout the acute, continuation, andmaintenance phases of treatment. Of particularbenefit is that clinicians can adjust the assessmentbased on the individual needs of the patient.Currently, the scale does not measure functionalimpairment, which could potentially limit its abilityto assess depressive symptom severity.

Center for Epidemiological Studies-Depression Scale (CES-D) and DepressionScale for Children (CES-DC)

Description. Developed at the National Institutesof Health/National Institute of Mental Health(NIMH) by Radloff in 1977,49 the Center forEpidemiological Studies-Depression Scale (CES-D)was designed as a self-report instrument to measuresymptoms of depression in adult populations. It has,however, also been used in many clinical investiga-tions of antidepressant treatment for adolescents.2

The CES-D is frequently administered to individu-als who are 14 years of age and older and is writtenat the sixth grade reading level for easy comprehen-sion.26 The CES-D takes only approximately 5 to 10minutes to administer and score.





The CES-D consists of 20 items. Respondents areasked to rate how often they have experienced cer-tain depressive symptoms in the previous 7 days.50

CES-D statements are designed to assess depres-sion symptoms including hopelessness, lethargy,insomnia/hypersomnia, and sadness.50 Each item israted on a 4-point scale ranging from 0 (never) to 3(daily). Scores on all 20 items are summed to providethe total CES-D score, which ranges from 0 (nodepressive symptoms) to 60 (most frequent/severedepressive symptoms).22 Four items are positivefeeling/cognitive statements which are reversescored to monitor for accuracy of response.2 Scoresranging from 0–15 have been categorized as mini-mal severity, from 16–23 as mild severity, and � 24as moderate/severe severity.22

In an effort to adapt the scale for a younger popu-lation, the Center for Epidemiological Studies-Depression Scale for Children (CES-DC) wasdeveloped by modifying the items to make themmore appropriate for children.2 The CES-DC isintended for use with children and adolescents rang-ing from 12 to 18 years of age.26 Similar to the CES-D, it is written at the sixth grade reading level,consists of 20 items, and takes approximately 5–10minutes to administer and score.26 The main differ-ences between the two measures are slight varia-tions in the wording of the items and in the layout ofthe items on the form.

Psychometric properties. Investigations havefound inconsistencies in the psychometric propertiesof the CES-DC. According to Poresky et al., the CES-D total score has strong internal consistency, a find-ing that has been replicated in other studies.50–52

However, data on the reliability of the CES-DC areunclear. For example, Roberts et al. found subopti-mal test-retest reliability (r = 0.61) in a studyinvolving 1,704 students from grades 9–12.51 Withregard to the concurrent validity of the CES-DC,many of the studies indicated a low correlation,ranging between 0.41 and 0.58, with other instru-ments that measure depression severity (e.g.,Hamilton Rating Scale for Depression, Children’sDepression Inventory).48,51,53

Limitations. While the CES-D and CES-DC arequick assessment tools for assessing depressivesymptoms that have been present over the past week,this short assessment time is inconsistent with the

time frame for the DSM-IV-TR MDD diagnostic crite-ria.22,25 In addition to the weak psychometric proper-ties of the CES-D and CES-DC, these instrumentsmainly focus on the emotional domain of depressionand only track symptom frequency.2 Brooks andKutcher cautioned that the CES-D and CES-DC havepoor reliability, are insensitive to change in symp-toms, and do not comprehensively assess depressivesymptomatology.2 Although these instruments can beused in clinical or research practice to monitordepressive symptom frequency, caution is recom-mended in their use and interpretation due to thereported limitations in their psychometric properties.

Summary. The current versions of the CES-D andCES-DC have significant limitations. Specifically,the scales have weak psychometric strength andthey do not accurately track or assess severity ofdepressive symptoms.

Children’s Depression Inventory (CDI)

Description. The Children’s Depression Inventory(CDI) is the most commonly used, cited, and investi-gated self-report measures of depressive symptoma-tology for use with children and adolescents.48,54

Kovacs created this widely used measure in 1975(with a manual for it published in 1992) as a modi-fied version of the BDI for use with children andadolescents.48,55

The CDI is used with children and adolescentsbetween 7 and 17 years of age; it is written on thefirst grade reading level and takes approximately10–15 minutes to administer and score.26,56 Sup-porting parent self-reports for the CDI are alsoavailable. The 27 items measure cognitive, affective,and behavioral depressive symptoms.56 Each CDIitem includes three statements that describe symp-toms of depression and the child is instructed tochoose which statement best describes his or herfeelings over the previous 2 weeks.57,58 Items arerated on a 3-point scale that ranges from 0 to 2, withthe possible total score ranging from 0 to 54.58

Kovacs suggested that a total score of 13 points orgreater is a reliable cut-off for indicating the pres-ence of clinically significant depression.48 However,Smucker et al.59 and Larsson and Melin60 suggestedthat a total score of 19 or greater is an appropriatecut-off for discriminating between the presence andabsence of clinically significant depression. In a

study designed to examine the appropriate CDI cut-off score using receiver-operating characteristics(ROC) analysis, Timbremont et al. found that totalscores of both 13 and 19 were equally and adequate-ly sensitive in predicting a probable diagnosis ofdepressive disorder.61 Their study suggested that atotal score of 16 provided the optimal balancebetween sensitivity and specificity.61

Psychometric properties. In addition to being themost commonly used depression rating inventory forchildren and adolescents, the CDI also has the largestamount of available normative data.54 Multiple inves-tigations have documented its high test-retest relia-bility, strong internal consistency (coefficient alphas >0.80), and strong ability to discriminate betweenhealthy subjects and depressed patients.2,55,56,58,62–70

The concurrent validity of the CDI is sound, withscores correlating well with other child depressionself-reports such as the Reynolds AdolescentDepression Scale (correlation of 0.73) and the Depres-sion Self-Rating Scale (correlation of 0.81).2,71

According to Twenge and Nolen-Hoeksema, CDIscores correlate moderately with depression ratingscores of psychiatrists and can discriminate betweenmood and other psychiatric disorders.58 They cau-tioned, however, that the CDI does not effectively dif-ferentiate between depressive and anxioussymptoms.58 Brooks and Kutcher reported that theCDI is more sensitive to change than both theChildren’s Depression Rating Scale-Revised and theReynolds Child Depression Scale when these instru-ments are used with children who are 9 to 12 years ofage.2

Advantages. The CDI is quick and easy to adminis-ter and score and allows for broad comparison acrossdifferent age groups (individuals 7 to 17 years of age).The minimal time and effort it takes for children tocomplete this measure minimizes the possibility thathighly depressed children will not respond.72 Anotheradvantage of the CDI is that a reliable and valid par-ent version is available,55,62,73 which can provide addi-tional information and insight into a child’sdepressive symptoms from an alternative source.

Summary. The CDI is one of the most reliable meas-ures for assessing and tracking depressive symptoma-tology in children and adolescents, largely due to itsapplicability to a large age group, its quick adminis-

tration time that minimizes the likelihood of falsereporting, and its inclusion of supplemental informa-tion from caregivers (e.g., parents).

Children’s Depression Rating Scale (CDRS)

Description. The Children’s Depression Rating Scale(CDRS) was first created in 1979 by Poznanski et al.74

The current revised version (CDRS-R) was publishedby Poznanski and Mokros in 1996.34 The CDRS-R is aclinician-rated instrument used to measure the sever-ity of depression in children 6 to 12 years of age.23 TheCDRS-R is administered in the form of a clinical inter-view with the child and parent(s) (it is recommendedthat child and parent[s] be interviewed separately),after which the clinician synthesizes all informationto determine a summary score for each of the 17items.9,75 Since the CDRS-R is administered in inter-view format, the clinician can collect information frommultiple informants (e.g. parents, teachers, and/orother caregivers).2 Depending on how many individu-als are available to interview, the CDRS-R can takefrom 15 to 30 minutes or longer to administer andscore.2

The CDRS-R consists of 17 items: the first 14 itemsmeasure impairment in schoolwork, difficulty havingfun, social withdrawal, sleep disturbance, appetitedisturbance, fatigue, preoccupation with physicalcomplaints, irritability, guilt, low self-esteem,depressed feelings, morbid ideation, suicidal ideation,and excessive weeping.2 The last 3 items are scoredbased on clinician observation of facial affect, listlessspeech, and hypoactivity.2 The first 14 items arescored on a Likert-type scale of 1–7, while the last 3items are scored on a scale of 1–5, with lower scoresindicating the absence of the symptom.16,76 Possibletotal scores range from 17–113; previous research hasindicated that a score of 40 or greater is congruentwith a diagnosis of depression.76–78

Psychometric properties. According to Poznanskiand Mokros, the CDRS-R has good internal consis-tency (alpha coefficient = 0.85), interrater reliability(r = 0.92), and test-retest reliability (r = 0.78).34

Subsequent research has supported these findings.In 2004, the TADS used the CDRS-R as a primaryoutcome measure and found the intraclass correla-tion coefficient at baseline and during stage 1 oftreatment (fluoxetine and/or CBT) was 0.95, indicat-ing excellent interrater reliability.6



Brooks and Kutcher reported that the CDRS-Rhas suitable face validity as the items query depres-sion symptoms specifically related to the diagnosisof MDD in the DSM-IV.2 Likewise, the CDRS-Rmeasures cognitive, somatic, affective, and psy-chomotor symptoms without bias for any singlesymptom category.2 Concurrent and criterion valid-ity were demonstrated in a study by Shain et al.,who found that the CDRS-R correlated stronglywith the Hamilton Rating Scale for Depression(HRSD; r = 0.92).79 Shain et al. also found that theCDRS-R, when administered biweekly, was able todistinguish between acutely depressed and chroni-cally depressed patients.80

The CDRS-R has been successfully used to meas-ure sensitivity to treatment effects in three majorstudies: The Treatment of SSRI-Resistant Depres-sion in Adolescents (TORDIA) study in 2008,5 theTreatment for Adolescents with Depression Study(TADS) in 2003,6 and a double-blind, randomized,controlled trial of fluoxetine in children and adoles-cents with depression published in 1997.81

Advantages. An advantage of using the CDRS-R isthe ability to integrate information from multiplesources (e.g., child, parent, teacher, alternate care-givers). In addition, as shown in research studies,the CDRS-R is an effective tool for measuring treat-ment effects and changes in the frequency and/orintensity of depressive symptoms. The arrangementof the CDRS-R is also useful in developing a rapportbetween the clinician and child, since the less inva-sive questions are placed at the beginning of theinterview, while questions concerning suicidal andmorbid ideation are placed near the end of themeasure.

Limitations. While being able to collect informa-tion from multiple sources is helpful in understand-ing the patient’s depressive symptoms, if parentreport and child report are dissimilar, clinical judg-ment must be used in assigning the final scores;this could reduce reliability and consistency amongdifferent raters. Interviewing parent(s) and childseparately also causes administration time to belonger than for self-reports. Another concern is thatthe CDRS-R may produce false-positive findings inchildren who have comorbid chronic illnesses (e.g.,sickle cell anemia) due to the number of somaticsymptoms included on the scale.77

Summary. The CDRS-R was not designed to serve asa diagnostic tool, but it is valuable and convenient formeasuring depressive symptoms over time. TheCDRS-R is the most commonly used depression sever-ity measure in clinical investigations, thus substanti-ating its clinical applicability and utility. Theinclusion of reports from multiple sources (i.e., chil-dren, parents, clinicians, teachers) increases the accu-racy and effectiveness of the scale to assess severity ofdepressive symptoms.

Depression Self-Rating Scale (DSRS)

Description. Developed by Birleson in 1981, theDepression Self-Rating Scale (DSRS) is an 18-iteminstrument designed to measure the cognitive, affec-tive, and behavioral symptoms of depression in chil-dren 7 to 13 years of age.82 The DSRS listsstatements concerning depressive symptoms, andrespondents are instructed to answer each state-ment with “most of the time,” “sometimes,” or “never”as applicable for the past week.83 Since statementsare worded both positively (“ I look forward to thingsas much as I used to”) and negatively (“I feel like cry-ing”) the responses are scored in the direction ofdepressed mood on a scale of 0, 1, or 2.83 The totalscore, which is derived by adding the score for eachitem, ranges from 0 to 36.84 A cut-off score of 13 hasbeen found to distinguish between depressed andnon-depressed children.84 This short self-report scaletakes approximately 10 minutes to administer andscore.

Psychometric properties. Little research has beenconducted on the psychometric properties of theDSRS.83 However, the two major studies thatexplored the reliability and validity of the DSRSfound that it was psychometrically sound.71,77

Birleson et al. reported good reliability with a test-retest correlation of 0.80 and internal consistency(split-half reliability) correlation of 0.86.84 Theresearch of Asarnow and Carlson produced findingscomparable to those of Birleson et al.71,84 Both stud-ies found that the DSRS had sound validity sincethe total score was able to discriminate betweenchildren diagnosed with depressive disorders andthose without depressive disorders. The DSRS wasalso strongly correlated with the CDI, and signifi-cant specificity was reported at 82% and fair sensi-tivity at 67%.71



Advantages. The brevity and simple format of theDSRS places fewer cognitive demands on the childcompared with other self-report measures, which isan advantage when working with younger and/orcognitively impaired populations.71,85 In addition,the DSRS uses language that is more appropriatefor a younger population compared with the wordingused in other self-reports. Examples of items include“I get tummy aches” and “ I like to go out to play.”83

Limitations. While the validity and reliability ofthe DSRS have been documented in two major stud-ies,82,84 confirmation of these findings and addition-al research on this scale are limited. Most of theresearch on the DSRS was completed more than 20years ago and used the DSM-III86 as a diagnostictool. Additional up-to-date research is needed to val-idate the scale with the revised DSM-IV criteria.

Summary. There is limited support for the utility ofthe DSRS to adequately measure depressive symp-toms and severity; additional research is thereforewarranted to investigate its psychometric proper-ties. Also, the inclusion of language appropriate foryounger children may limit its utility in older chil-dren and adolescents.71

Mood and Feeling Questionnaire (MFQ)

Description. The Mood and Feeling Questionnaire(MFQ) is a self-report measure created by Angoldand Costello in 1987 to detect DSM-III-R depressionin children and adolescents 6 to 17 years of age.23,87

The MFQ consists of 30 to 35 statements (versionsdiffer slightly) that address all of the depressivesymptoms listed in the DSM-III-R criteria88 as wellas clinically relevant symptoms of loneliness andself-perception.2 Respondents are asked to respond“true,” “sometimes,” or “not true” to each statementfor the period covering the previous 2 weeks.2 Thisextended instrument takes approximately 10 to 15minutes to complete, although a shortened versionis available. Scores are based on a scale from 0 (nottrue) to 2 (true), and total scores for the MFQ rangefrom 0 to 64 for the 32-statement version. A cutoffscore of 27 has produced the highest sensitivity andspecificity rates (78% each).89

The short version of the MFQ (SMFQ) was devel-oped by Angold et al.90 It consists of 13 items fromthe original longer version that were found to have

the best discriminating power and internal consis-tency.2,90 The SMFQ is scored on the same scale asthe MFQ with a range of 0 to 26. A cutoff score of 6yielded 80% sensitivity and 81% specificity in astudy conducted by Katon et al.90,91 Cliniciansshould note that, while the SMFQ is useful forquickly assessing depressive symptoms, it does notassess suicidal ideation.2

Psychometric properties. Sound reliability for theMFQ was established in studies by Wood et al.89 andCostello et al.92 using intraclass correlation coeffi-cients (ICCs), with results of 0.78 and 0.75, respec-tively. Wood et al. also found strong internalconsistency with an alpha coefficient of 0.94.89

Angold et al. reported that the MFQ had a moderatecorrelation with the CDI (r = 0.67),90 while Wood etal. determined that the MFQ has moderate diagnos-tic accuracy (area under the curve = 0.82).89

Research on the SMFQ has indicated that it hasreliability and validity similar to the longform.23,90,91 While it is psychometrically sound, theSMFQ does have a bias toward affective and cogni-tive symptoms and does not assess changes inweight, appetite, disturbances of sleep, or suicidalideation.2

The MFQ has only been used in a small number oftreatment studies with mixed results; thus its sensi-tivity to change cannot be accurately measured atthis time.2 In addition, the validity of the SMFQ asa measure for use in epidemiological studies has notbeen adequately assessed.2

Summary. Although preliminary evidence suggeststhat the MFQ has good psychometric properties, fur-ther research is needed to confirm its effectiveness inassessing depressive symptom severity and trackingit across time. The SMFQ does not provide a compre-hensive assessment of depressive symptoms andwould benefit from the inclusion of additional items.

Quick Inventory of DepressiveSymptomatology (QIDS)

Description. The 16-item Quick Inventory ofDepressive Symptomatology (QIDS) was derived byRush et al. from the longer 30-item Inventory ofDepressive Symptomatology (IDS).33,93,94 The QIDSis available as a self-report (QIDS-SR16), parentreport (QIDS-P16), and clinician semi-structured



interview (QIDS-C16). The QIDS-SR16 and QIDS-P16 each take approximately 5 to 10 minutes to com-plete.33 The QIDS-C16 semi-structured interviewtakes approximately 15 to 20 minutes to complete,as clinicians must first obtain the child and parentscores, and then complete a summary/clinician score.Symptoms are to be rated based on patient experi-ences from the previous week.33 The 16-item QIDS isscored by converting individual items into the nineDSM-IV symptom criterion domains, which are: 1)sad mood; 2) concentration; 3) self-criticism; 4) suici-dal ideation; 5) interest; 6) energy/fatigue; 7) sleepdisturbance; 8) decrease/increase in appetite/weight;and 9) psychomotor agitation/retardation.33 Eachsymptom is scored on a scale of 0 to 3, with higherscores indicating greater symptom severity.86 Thetotal score can range from 0 to 27.33

Psychometric properties. Several studies havedocumented the sound psychometric properties ofthe QIDS-SR16 and QIDS-C16.28,33,77,95–97 A studyby Rush et al. found high internal consistency(Cronbach’s alpha = 0.86) and item-total correla-tions (> 0.60) for the QIDS-SR16.33 In addition,total scores on the QIDS-SR16 were highly corre-lated with the IDS-SR30 (0.96) and the HamiltonRating Scale for Depression (0.81). This study alsoestablished that the QIDS-SR16 was sensitive tochanges in symptoms and severity when using acutoff score of 6 (79% sensitivity and 81% specifici-ty). These results have been reproduced in a subse-quent study by Rush et al.28 and in a study byTrivedi et al.97 Trivedi et al. tested the psychomet-ric properties of the QIDS-C16 and found internalconsistencies ranging from 0.81 to 0.94 (Cronbach’salpha) in patients with both depression and bipolardisorder.97 QIDS-C16 total scores were highly cor-related (0.82) with a diagnosis of MDD in patientsat exit and were found to be sensitive to changes insymptoms.97 The studies by Rush et al. and Trivediet al. were both conducted with adult populations(individuals who were 18 to 75 years of age).28,33,97

Less research on these scales has been done withchild and adolescent populations. In one recentstudy, Gray et al. evaluated the psychometric prop-erties of the QIDS-SR16 in children who were 7 to13 years of age.77 They found high internal consis-tency (alpha coefficient of 0.85) and a good correla-tion with the CDRS-R (r = 0.76). Nevertheless,these investigators suggested that further research

is needed with this measure in child and adolescentpopulations.77

Advantages. The QIDS is one of few measures forwhich a self-report, parent report, and clinicianreport are available in the public domain. Anotheradvantage is the new technology available foradministering the QIDS, which involves an interac-tive voice response (IVR) version. Studies using theIVR system to administer the QIDS in adult popu-lations have found excellent psychometric proper-ties. Moore et al. used a self-rated IVR version of theQIDS (QIDS-IVR) in an adolescent population whowere 12 to 17 years of age.96 Respondents usedspeaker-independent voice recognition, whichrecords spoken responses of “yes,” “no,” and wholenumbers.96 Results from this adolescent popula-tion also yielded evidence for internal consistency,reliability, and convergent validity.96 This novelmethod of self-report administration allows forfaster, easier collection of symptom information.More research is needed on use of the QIDS inchild and adolescent populations, on the parentform of the QIDS, and on the new IVR administra-tion method.

Summary. The main advantages of the QIDS arethat it is available in the public domain, it is quickand easy to administer, and it is available in multi-ple versions and languages, enabling a comprehen-sive assessment of depressive symptomatology.Further research is warranted to determine theeffectiveness of the QIDS in assessing childhoodand adolescent depression.

Reynolds Child/Adolescent DepressionScales (RCDS/RADS)

Description. Reynolds created the ReynoldsAdolescent Depression Scale (RADS) in 1987, andthe scale was subsequently adapted for use withchildren (RCDS) in 1989.40,98,99 The second editionof the RADS was released in 2002 with an expand-ed age range and re-standardization.100,101 Both theRCDS and RADS are 30-item self-report question-naires that assess the incidence and severity ofdepressive symptoms.102 The RCDS was developedfor children in grades 3–6 (approximately 7–12years of age), while the RADS measures depressivesymptoms in adolescents 11 to 20 years of age.41



Both questionnaires take approximately 5 to 10minutes to complete and score.2

Each item in the questionnaires is a statement towhich the patient responds with one of four choices:“almost never,” “hardly ever,” “sometimes,” or “mostof the time.” Scores are based on a four-point scale (1= almost never, 2 = hardly ever, 3 = sometimes, and4 = most of the time).41 Statements are presented inthe present tense in order to elicit the current statusof the patient.2 Both forms of this measure aredesigned to assess cognitive, somatic, psychomotor,and interpersonal symptoms.2 While the RCDS/RADS assesses the symptoms of depression, severalitems included are uncharacteristic of depression(e.g., “I feel happy”), in order to keep the patient’sattention and serve as a check for appropriateresponses.2 The RCDS/RADS is scored by reversingthe 7 positively worded items and then summing theratings on all 30 items to compute a score between30 and 120.41 Reynolds determined that a total cut-off score of 77 or higher discriminates severity asso-ciated with clinical depression.40

Psychometric properties. The RCDS and RADShave been extensively evaluated in both clinical andnonclinical populations.40–42,79,99,103 In all instances,the RCDS/RADS was found to have a reliability coef-ficient of 0.80 or higher, internal consistency alphasbetween 0.91 and 0.94, and strong test-retest relia-bility (rs > 0.60).2 Strong validity has also been estab-lished. Two independent studies found correlationsbetween the RADS and the Hamilton Rating Scalefor Depression of 0.73 and 0.83.40,41 In addition, a cor-relation of 0.77 has been found between the RADSand the CDRS, 0.87 between the RADS and the CDI,and 0.84 between the RADS and the BDI-II.41,79

Reynolds et al. supported the RCDS as a valid meas-ure of childhood depression.42 Reynolds and Coatsalso successfully used the RADS to detect changes insymptoms and severity after treatment.103

Advantages. In addition to considerable researchsupporting the sound psychometric properties of theRCDS/RADS, the RCDS and RADS have the advan-tage of being designed for use in school settings(with a manual providing administration instruc-tions for teachers). While this makes group adminis-tration easier, it might not be as viable in clinicalsettings. In addition, since two scales are availableto be administered to subjects who range in age from

7 to 20 years, this instrument has the advantage ofbeing able to track symptoms longitudinally.

Summary. The RCDS/RADS is quick to administerand score, and it can be used in children between theages of 7 and 20, thus enabling longitudinal assess-ment of depressive symptoms. Empirical evidencesupports the use of the RCDS/RADS in both clinicaland nonclinical populations, as well as in-group set-tings, thus making it a viable option for use in aca-demic and other large group settings.

Summary of Findings

Table 1 summarizes information on the nine meas-ures reviewed in this article. As described in thisreview, most of the commonly used child and ado-lescent depression rating scales have sound psycho-metric properties and are useful indicators ofdepression severity and changes in outcome withtreatment. For example, with the exception of theCES-D and the DSRS, the reliability and validity ofthe other rating scales discussed here are empiri-cally supported.2,82 These findings support thepotential utility of these measures in the assess-ment of children and adolescents with MDD. Theutility of depression rating scales, particularly theCDI and the CDRS-R, is also supported by thescales’ ability to track symptom severity over thecourse of antidepressant treatment.8,34,52 For exam-ple, the TADS study suggested that depression rat-ing scales could be easily integrated into researchand clinical practice and, importantly, that theycould be used with multiple clinical populations. Ofimportance for both research and clinical practice,many of the instruments for rating depressionseverity have parallel forms for both children andparents, are easy to administer and score withoutthe need for specialized training, and can be incor-porated into general practice without increasingtime burden.

Even though earlier research has focused onexamining the strengths and benefits of depressionseverity rating scales, little attention has been paidto their potential use to advance measurement-based care in the clinical arena. We have a numberof short- and long-term suggestions to help guide cli-nicians in implementing measurement-based care.

In the short term, we suggest that clinicians con-sider using a combination of self-rated and clini-



cian-rated scales in order to assess symptom sever-ity and change across treatment. To maximize thebenefit of these measures and minimize increasedtime burden, clinicians should choose those depres-sion severity instruments that provide coverage forthe symptomatology most appropriate for the par-ticular clinical population they treat. A sensiblechoice may be to use a depression rating instrumentfor which parallel forms are available, such as theQIDS or the CDRS. For example, the QIDS is avail-able as a self-report, parent-report, and cliniciansemi-structured interview.33 Similar to the QIDS,the CDRS-R includes a self-report and clinicianreport of depressive symptomatology. Thus, both ofthese measures facilitate the integration of reportsfrom multiple sources.2 However, for the clinician-rated versions, the training and time required toadminister the scale could limit its feasibility foruse in clinical settings.9,75

In the long-term, education and training pro-grams are needed to increase clinicians’ awarenessof the importance and benefits of using availabledepression severity rating scales as a means ofimplementing measurement-based care. At present,there is a significant gap between research and clin-ical practice that limits the translation of importantresearch findings into clinical therapeutic practice.Measurement-based care can enhance the success-ful implementation of evidence-based guidelinesbased on research studies (e.g., TADS) in real worldsettings. Continued efforts are needed in both theresearch and clinical arenas to ensure that optimaltreatment regimens are put into practice for chil-dren and adolescents with severe depression.

Clinical Vignette

A 16-year-old male presented for an initial evalua-tion after a recent emergency department visit for asuicide attempt. He reported profound hopelessnessand social withdrawal over the past 5 months afterhis parents divorced and he started attending a newschool. Other depressive symptoms included dailyirritability, difficulty falling asleep every night, a 15-pound weight loss, regular headaches, fatigue, andproblems concentrating. His mother related that hispersonality had changed drastically over the pastyear. For example, although he had previouslyexcelled academically, he was now showing behaviorproblems at school and his teachers were concerned

regarding his current academic progress. The patientand his mother related that he had been treated withan unspecified psychotropic medication severalmonths ago but had only taken it briefly because itwas not covered by their insurance plan and “did notseem to help much.” He had also talked to a schoolcounselor twice in the past year. The patient had nosignificant medical history. He had a positive familyhistory of psychiatric illness; his biological father hada history of major depressive disorder and alco-holism, two paternal aunts had been treated fordepression, and his maternal grandmother had beenhospitalized for depression and treated with a courseof electroconvulsive therapy. The psychiatrist com-pleted a comprehensive evaluation over the course oftwo sessions. The evaluation included a detaileddiagnostic interview with the patient and his mother,collateral information from the school counselor, anda telephone interview with the patient’s biologicalfather. This clinician had prior experience and train-ing with the Children’s Depression Rating Scale-Revised (CDRS-R) and thus chose this tool as ameans of collecting objective data regarding thepatient’s depressive symptoms while building rap-port during the interviews. The patient and his moth-er also completed self-report measures of depressivesymptomatology, the Quick Inventory For DepressiveSymptoms (QIDS-SR16 and QIDS-P16), at each visit.The psychiatrist explained to the patient and hismother that the use of these depression severityinstruments provided an objective means to measurethe patient’s depressive symptoms and trackprogress, “in much the same way that you have yourblood pressure and temperature checked in a doctor’soffice.” The CDRS-R and the QIDS-SR16 scores werein the severe range at the two initial evaluation vis-its. After reviewing all information, the patient wasdiagnosed with major depressive disorder, recurrent,severe without psychotic features. After an extensivediscussion and informed consent process, fluoxetine(10 mg/day) was initiated, with the dose subsequent-ly increased to 20 mg/day. A course of CBT was alsoinitiated, which included family sessions. Thepatient’s depressive symptoms and response to themedication and CBT were carefully monitored ateach visit. After several weeks, his symptomsresolved and the CDRS-R and QIDS scoresdecreased. He began making new friends at schooland excelled academically. The patient and his fami-ly noted that they had initially been skeptical about





Tabl

e 1.

Dep

ress

ion

rat

ing

scal

es

Inst

rum

ent

Bec

k D

epre

ssio

nIn

vent

ory-

II

(BD

I-II

)37

Bec

k D

epre

ssio

nIn

vent

ory

for

Yout

h (B

DI-

Y)45

Cen

ter

for

Epi

de-

mio

logi

cal S

tudi

es-

Dep

ress

ion

Scal

e(C

ES-

D),

For

child

ren:

CE

S-D

C)49

Chi

ldre

n’s

Dep

ress

ion

Inve

ntor

y (C

DI)

48

Chi

ldre

n’s

Dep

ress

ion

Rat

ing

Scal

e-R

evis

ed(C

DR

S-R

)34

Dep

ress

ion

Self-

Rat

ing

Scal

e(D

SRS)

82

Sca

lefo

rmat

Self-

repo

rt

Self-

repo

rt

Self-

repo

rt

Self-

repo

rt

Clin

icia

n-ra

ted

Self-

repo

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thor

(s)

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t A.S

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Age

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7–18

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12–1

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DC

)

7–17

6–12

7–13

Ass

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tim

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5–10

min

.

5–10

min

.

5–10

min

.

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5 m

in.

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in.

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.

# of

it

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21 20 20 27 17 18

Sym

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“filling out forms all the time” but latercame to appreciate this psychiatrist’sapproach as “no other mental healthprofessionals had been so careful in thepast or taken the time to ask about allof these symptoms.” The patientacknowledged that completing the self-report form at each visit helped him tobetter understand and monitor his ownsymptoms of depression, making thedepression less of a mystery and some-thing over which he had more control.

Directions for Future Research

Earlier research supporting the efficacyand benefits of using depression ratingscales and the currently limited use ofmeasurement-based care in clinicalpractice indicate that further researchis needed to address the use of meas-urement-based care in clinical practice.For example, studies need to be done toinvestigate the current use of measure-ment-based care in childhood and ado-lescent depression, namely which scalesare being used and whether their relia-bility and validity are empirically sup-ported. In addition, longitudinal studiesassessing the utility and benefit of rat-ing scales in tracking symptom severityover the course of treatment will con-tribute significantly to their ecologicalvalidity.

Conclusion

This review suggests that there isstrong empirical evidence supportingthe utility and benefit of depression rat-ing scales in documenting depressionseverity in children and adolescentswith MDD. As the number of childrenand adolescents diagnosed with depres-sion and the prevalence of relapseincrease, there is a great need to moreeffectively disseminate knowledge ofmeasurement-based care in order tooptimize treatment for children andadolescents with depression.1,4,21–23



Tabl

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A Systematic Overview of Measurement-Based Care in the Treatment of Childhood and Adolescent...

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