Scandinavian Journal of Primary Health Care

ISSN: 0281-3432 (Print) 1502-7724 (Online) Journal homepage: http://www.tandfonline.com/loi/ipri20

Monitoring improvement using a patient-rated

depression scale during treatment with anti-
depressants in general practice. A validation study
on the Goldberg Depression Scale

Jørgen Holm, Liselotte Holm, Per Bech

To cite this article: Jørgen Holm, Liselotte Holm, Per Bech (2001) Monitoring improvement using
a patient-rated depression scale during treatment with anti-depressants in general practice. A
validation study on the Goldberg Depression Scale, Scandinavian Journal of Primary Health Care,
19:4, 263-266, DOI: 10.1080/02813430152706819

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Monitoring improvement using a patient-rated
depression scale during treatment with
anti-depressants in general practice
A ×alidation study on the Goldberg Depression Scale
Jørgen Holm1, Liselotte Holm 2 and Per Bech3
1
General Practice and 2Psychological Practice, Svendborg and 3Psychiatric Research Unit, Department of
Psychiatry, Frederiksborg General Hospital, Hillerød, Denmark.
Scand J Prim Health Care 2001;19:263– 266. ISSN 0281-3432
ObjectiØe – To perform a pilot study on the value of the Goldberg
Depression Scale as an instrument for monitoring improvement in
depressed patients treated with anti-depressants in general practice.
Design – A comparative study using simultaneous ratings on the
observer-based 17-item Hamilton Depression Scale and the patient-
rated Goldberg Depression Scale.
Setting – General practice.
Patients – Twenty-one patients meeting the ICD-10 criteria of a
moderate depressive episode were assessed at the time of inclusion
and through three follow-up visits.
Main outcome measures – Scores on the Goldberg Depression Scale
compared to the Hamilton Depression Scale.
Results – An acceptable internal and external validity of the Gold-
General practitioners (GPs) are currently under criti-
cism for inefŽ ciency in the detection and treatment of
the majority of depressed patients (1,2). In this re-
gard, it may indeed seem strange that, in everyday
practice, so little effort is made to monitor the state
of patients during treatment. Few doctors would like
to do without tools when dealing with asthma.
There are a number of depression rating scales
available today, the Hamilton Depression Scale
(HAM-D) (3) probably being the best known and the
gold standard in research studies. HAM-D is an
observer-rated scale and requires some instruction in
its use. It has been shown, however, that even experi-
enced psychiatrists demonstrate considerable inter-
observer variation performing a HAM-D score on
one and the same patient (4). There are also validated
patient-rated scales available, such as the Zung De-
pression Scale (5) and Beck’s Depression Inventory
(6), but these have been used as research tools rather
than for clinical purposes, and neither has been
adopted by general practice to any signiŽ cant extent.
In the 1990s, the development of new question-
naires was concerned, on the one hand, with content
validity covering the DSM-IV dimension of major
depression (7) and, on the other, with being as pa-
ORIGINAL PAPER
berg Depression Scale was demonstrated. The Loevinger co-
efŽ cient varied from 0.25 at the time of diagnosis to 0.57, 0.65 and
0.69 by visits two, three and four. Factor analysis identiŽ ed only one
general factor explaining 50% or more of the variants, except at visit
1. When the Goldberg Depression Scale was correlated to the
Hamilton Depression Scales, a coefŽ cient of 0.74 was obtained
(p B0.001).
Conclusion – This pilot study indicates that the Goldberg Depression
Scale is suitable for monitoring improvement in depressed patients
treated in general practice. Further studies are recommended.
Key words: depression, rating scales, primary health care.
Jørgen Holm, General Practice, Klosterplads 9, DK-5700 SØ end-
borg, Denmark. E-mail: jorgenholm@dadlnet.dk
tient-friendly as possible in ensuring a high degree of
applicability in the general practice setting.
The Goldberg Depression Scale (GDS) (8) was the
questionnaire selected as being patient-friendly by the
general practitioner involved in this study. The objec-
tive of this pilot study has been to investigate the
value of the Goldberg Depression Scale as an instru-
ment for monitoring the improvement of depressed
patients treated in general practice.
METHODS
Nine general practitioners were recruited (through
advertising) as clinical investigators and received
training in the use of HAM-D.
Scales
The Goldberg Depression Scale. The GDS is an
18-item self-rating scale (Fig. 1), with each item rated
on a 0 – 5 point Likert scale. The total score can
therefore range from 0 (complete absence of depres-
sive symptoms) to 90 (most severe depression). The
GDS was translated into Danish by the authors and
back-translated into American English. This back-
translated version was accepted by Goldberg himself.
Scand J Prim Health Care 2001; 19
264 J. Holm et al.
The Hamilton Depression Scale. The 17-item ver-
sion of the HAM-D followed the original version (3),
but has been further improved. This Danish version
was endorsed by Hamilton himself (9) and has been
used in several Danish and Scandinavian trials
(10,11). The score range of this scale is from 0 (no
depressive symptoms) to 52 (most severe depression);
the cut-off score for major depression is 18, while full
remission is a score of 7 or lower (9).
Patients
Patients fulŽ lling the ICD-10 criteria of an at least
moderate depressive episode demanding medical
treatment were included. They were assessed by GDS
and HAM-D at inclusion and over the course of
three follow-up visits. The doctors were blinded to
the GDS scores. Exclusion criteria were conditions
precluding the patients from handling a self-rating
questionnaire, e.g. dementia or visual impairment. A
total of around 20 patients was found sufŽ cient for
testing the validity of the GDS in this pilot study.
Statistical analysis
Reliability. For interview-based scales such as the
HAM-D, inter-rater reliability is important, and so to
ensure doctor capability in using the HAM-D, a
WHO videotaped interview was used to measure
inter-rater reliability (12). The WHO interview has an
ofŽ cially accepted score of 21.09 2.3.
Fig. 1. The Goldberg Depression Scale – original version.
Scand J Prim Health Care 2001; 19
For questionnaires like the GDS, the test –retest
reliability is often discussed but rarely used. Thus, the
test – retest analysis has to rely on a very stable condi-
tion of the patient between test and retest. In this
pilot study of the acute therapy of depressive patients
the situation was not suited for a test –retest
examination.
Validity. The validity of a scale covers both inter-
nal and external validity. Internal validity covers the
extent to which the total score is a sufŽ cient statistic.
Factor analysis has been used to measure the internal
consistency of the GDS. Thus, an overall, general
factor is indicative of internal validity. The factor
analysis is extremely sensitive to the dispersion of
scale scores in the population investigated (13,14).
The Loevinger coefŽ cient of homogeneity is a test of
uni-dimensionality, i.e. of the summed total score
being a sufŽ cient or adequate statistic. CoefŽ cients of
0.30 or higher indicate homogeneity or uni-dimen-
sionality. The GDS has been compared to the HAM-
D for Loevinger coefŽ cients.
An essential aspect of external validity is respon-
siveness. This is the ability of a scale to measure
improvement in patients during a period of treat-
ment. In the acute therapy of major depression a
response is deŽ ned as a 50% (or more) reduction of
the baseline scores at endpoint. The GDS has been
compared to the HAM-D in this way in relation to its
 Monitoring impro×ement with a patient-rated depression scale 265

Table I. Factor analysis and Loevinger coefŽ cient of homogeneity at the four visits.

Visit 1 Visit 2 Visit 3 Visit 4

Loevinger co-efŽ cient of homogeneity 0.25 0.57 0.65 0.69

No. of factors with an eigenvalue greater than 1 6 4 4 3
First factor General General General General
Explained variance 28.8% 55.0% 61.7% 66.6%
Second factor Bipolar Bipolar Bipolar Bipolar
Explained variance 15.0% 10.6% 8.3% 10.6%
Scree plot number of factors 3 1 1 1

responsiveness and a correlation coefŽ cient was cal- patients (62%) had a reduction of 50% or more on
culated by use of the Spearman rank-order method. the baseline scores at endpoint. On the GDS, 12 of
the 21 (57%) patients had a reduction of 50% or
more. The difference in responsiveness between 62%
RESULTS and 57% was statistically insigniŽ cant. The correla-
Twenty-four patients were included; 3 dropped out tion of the total GDS and HAM-D scores was 0.74
before completing all four visits, thus leaving 21 (p B 0.001).
patients (5 men) ranging in age from 28 to 69 years
(mean 43 years).
The investigator’s inter-rater reliability in using DISCUSSION
HAM-D was adequate with a mean score of 22.2 and Statement of principal Ž ndings
a standard deviation of 2.7 (absolute values 17– 25). In this study, we identiŽ ed one factor with fairly high
Loevinger coefŽ cients of homogeneity through visits
Internal ×alidity two to four (the dispersion at visit one being too
The internal validity of the GDS was acceptable. small for testing homogeneity). This, combined with
Table I gives the Loevinger coefŽ cient of homogene- the Ž nding of high correlation coefŽ cients versus
ity as well as the results of the factor analysis at the HAM-D showing an acceptable external validity, in-
four visits. At visit one (baseline), the Loevinger dicates that the GDS is a uni-dimensional scale for
coefŽ cient was below 0.40, and six factors were iden- measuring the degree of improvement in depressive
tiŽ ed. However, the Ž rst factor was a general one, i.e. states treated in general practice.
all items had positive loadings. The second factor was
bipolar and the scree plot identiŽ ed three factors.
In contrast, the next three visits had accepted
Loevinger coefŽ cients and the scree plot identiŽ ed
only one general factor explaining 50% of the vari-
ance. This re ects the difference between visit one Table II. Rank order of items. At the top, the most inclusive
milder items. At the bottom the most severe items. In paren-
and the other visits in terms of dispersion of the theses the original number as shown in Fig. 1.
Goldberg Scale. Before treatment (visit one) the pa-
tients had a similar level of depression. During the Fatigue (9)
treatment period (visits two to four) the dispersion Great effort to do things (10)
was greater as the patients responded more heteroge- DifŽ culty making decisions (5)
Sad and unhappy (7)
neously. The result indicates that the 18 items on the Disturbed sleep (14)
scale have a valid rank order and structure. Table II Do things slowly (1)
gives the rank order. The items of fatigue, sadness, Lost interest in things (6)
disturbed sleep and lack of interests are the most Pleasure gone out of life (4)
inclusive items, i.e. are present even in mild degrees of DifŽ culty concentrating (3)
Depressed even when good things happen (17)
depression. These items are listed in the ICD-10 as Feeling trapped (16)
the most inclusive items. Among the most exclusive Future seems hopeless (2)
items are hopelessness, feelings of guilt and thoughts Feeling agitated (8)
of suicide. Feeling lifeless (13)
Weight changes (18)
Feeling like a failure (12)
External ×alidity Feeling guilty (11)
The corresponding mean scores on the two scales are Suicidal thoughts (15)
given in Table III. On the HAM-D, 13 of the 21

Scand J Prim Health Care 2001; 19

266 J. Holm et al.
Table III. Mean scores at the various visits.
Visit no. Interval (days) HAM-D GDS
1 21 56
11 (7–22)
2 14 45
11 (6–25)
3 12 35
13 (3–20)
4 8 26
Strengths and weaknesses of the study
Tools such as rating scales should be tested in the
context of their intended use, as in fact in this study.
However, the recruitment of investigators through
advertising implies a bias of presumed special interest
in psychiatry. This would be a major problem had the
HAM-D been the scale under validation, but in this
situation it merely provides fair condition to the tested
self-rating scale. Although our patient material is large
enough to produce fairly signiŽ cant test results, we still
feel that only limited conclusions should be drawn.
Other studies on self -rating scales
To our knowledge, no other studies have been pub-
lished on the GDS. The demonstrated statistical values
against HAM-D in analysing internal and external
validity, and the rank order of items found in this
study, are similar to those produced in the validation
studies of other accepted self-rating scales (15).
Meaning of the study
This pilot study indicates that the GDS may be a valid
self-rating scale for monitoring improvement in de-
pressed patients treated in general practice. Modern
self-rating scales can serve as documentation for the
course of treatment, thus meeting the increasing legal
demands on the GP dealing with psychiatric patients.
Eliminating the inter-observer variation, such scales do
have advantages over observer-rated scales when refer-
ring the patient or during shared care treatment.
Unanswered questions and further research
This study was not designed to investigate the possible
use of the GDS as a diagnostic tool or its potential as
a screening instrument in detecting depression. The
ICD-10 criteria for depression have been formulated
very clearly and should not be questioned as the basis
of the diagnosis. We do, however, suggest further
studies of the GDS in a larger population: 1) to conŽ rm
the Ž ndings in this study, 2) to investigate patients’ and
doctors’ choices in comparing the GDS with HAM-D
for monitoring purposes, and 3) to evaluate the poten-
tial of the GDS as a screening tool.
Scand J Prim Health Care 2001; 19
ACKNOWLEDGEMENTS
We thank the investigating general practitioners: Jan
Harder, Peter Lindegaard, Bente Lützen, Anne-Marie
Munck, Kim Rønhof, Erik Schaumburg (deceased),
Ida Zacho, Jørn Fisch-Thomsen (the ninth investigator
was author JH). Also, we thank Ove Aaskoven,
Tolstrup Data, for carrying out the statistical analysis.
The study received Ž nancial support from the Council
of Quality Development in the County of Funen.
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