Behavioural Assessment Of Depression

The value of direct behavioural observations of motor activity in depressed people was outlined over 20 years ago by Lewinsohn and Lee (1981); they noted that simple ratings of ward behaviour correlated well with the HDRS and with the BDI (about +0.70). Tryon (1991) published a review of the measurement of activity in psychology and in medicine ('actigraphy'). He reported that actigraphy was useful in examining sleep-wake periods, and in assessing psychomotor agitation and retardation in depression. Activity levels (as measured from the wrist) changed markedly from admission to discharge, and immobility was a particularly sensitive indicator of the intensity of depression. Actigraphy has also been successfully used with outpatients. More recently, Caligiuri and Ellwanger (2000) found that 60% of depressed patients displayed abnormal psychomotor activity on a variety of tests, many of the patients showing signs similar to those found in parkinsonian disease. Changes in actigraphy have been shown to be sufficiently sensitive to detect differential responses to various antidepressant drugs, especially via early morning recordings (Stanley et al., 1999).

Alessi (2001) claims that the motor aspects of depression, in contrast to the affective aspects, have been neglected by researchers, partly because of difficulties in recording and analysing changes in motor behaviour. He suggested that recent advances in motion-capture technology will facilitate a greater focus on these aspects and broaden our understanding of a wider range of depressive phenomena.

Sobin and Hackheim (1997) provided a useful literature review of psychomotor abnormalities in depression. They reported that activity increases in bipolar patients during manic phases and decreases during depressive phases, and that 24-hour gross motor activity is higher in unipolar patients than in schizophrenic patients and bipolar patients, these differences being particularly marked during the night. Depressed patients also manifest more self-touching, less eye contact, less smiling and fewer eyebrow movements. Overall reaction times, decision times and motor-response times are all slower in depression. Sobin and Hackheim (1997) conclude that such measures are sufficiently sensitive to warrant consideration as viable objective measures of depressive states. Finally, they stress that retardation and agitation are not mutually exclusive, and that both should be measured in any comprehensive assessment of psychomotor symptoms in depression.

In the performance of psychomotor tests, significant levels of cognitive effort are also involved (such as memory). In an attempt to obtain an uncontaminated measure of motor activity, Sabbe et al. (1999) used a simple task in which cognitive demands were minimal. Depressed patients were asked to carry out 10 simple line-drawing tasks, and a range of measures were taken, such as movement time per line, pen lifts and time intervals between starting lines. Compared with healthy controls, depressed patients showed marked slowing on all tasks. Similarly, van Hoof et al. (1998) demonstrated that, whereas schizophrenic patients were characterised mainly by cognitive retardation, depressed patients were characterised by both cognitive and motor retardation.

In addition to such direct physical measures, questionnaire measures of psychomotor activity have also been developed. The CORE system (a sign-based method of rating psy-chomotor disturbances) has been shown to be helpful in distinguishing melancholia from other types of depression (Parker et al., 2000), and in the prediction of response to electroconvulsive therapy (ECT) (Hickie et al., 1996). However, its content validity has been questioned (Sobin et al., 1998). The Motor Agitation and Retardation Scale (Sobin et al., 1998) has been shown to distinguish clearly between normals and depressed inpatients; and scores on the Depressive Retardation Rating Scale (Lemelin & Baruch, 1998) are associated with global attentional deficits in major depression. Finally, the Saltpetre Retardation Rating Scale correlates with depression severity and with prognosis, and is sensitive to change (Dantchev & Widloecher, 1998).

Speech Patterns and Depression

Lewinsohn and Lee (1981) described a method of coding and monitoring the verbal interactions of depressed people in their own homes and during group therapy, using time-sampling methodology. More recently, Hale et al. (1997) recorded verbal interactions between depressed people and others, including their partners. During speech, patients displayed more movements (such as self-touching), and fewer head nods and shakes. However, the value of such measures of verbal interaction in monitoring changes in level of depression remains to be demonstrated.

Measurement of formal speech characteristics appears to be more promising. Early work by Szabadi et al. (1976) demonstrated that speech pause time was lengthened in depression. More recently, Vanger et al. (1992) found that overall speech activity decreased and silences increased, in line with the level of depression, and with the emotional salience of the discussion topic. Kuny and Stassen (1993) observed speech patterns and measured voice sound characteristics in 30 recovering depressives, on seven occasions throughout their hospital stay. Several of their measures were closely related to the time course of recovery, such as voice timbre, loudness and variability of loudness. These associations were clear in about two-thirds of their sample, but not in the remaining third (mainly those with poor or variable recovery). These results were replicated in a later study, using the HDRS to assess severity; in addition, they reported a marked relationship between early signs of recovery and later outcome (Stassen et al., 1998). Sobin and Hackheim (1997) listed a number of speech and voice characteristics related to depression, including low voice amplitude, decreased monitoring and correction of speech, and reduced speaking time.

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