Journal of Psychiatric Research 93 (2017) 59e63

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Journal of Psychiatric Research

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Measuring anxiety in depressed patients: A comparison of the

Hamilton anxiety rating scale and the DSM-5 Anxious Distress
Specifier Interview
Mark Zimmerman, M.D *, Jacob Martin, B.A, Heather Clark, B. S, Patrick McGonigal, B.A,
Lauren Harris, B.A., Carolina Guzman Holst, B.S.
From the Department of Psychiatry and Human Behavior, Brown Medical School, The Department of Psychiatry, Rhode Island Hospital, Providence, United
States

a r t i c l e i n f o a b s t r a c t

Article history: DSM-5 included criteria for an anxious distress specifier for major depressive disorder (MDD). In the
Received 4 April 2017 present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS)
Received in revised form project we examined whether a measure of the specifier, the DSM-5 Anxious Distress Specifier Interview
25 May 2017
(DADSI), was as valid as the Hamilton Anxiety Scale (HAMA) as a measure of the severity of anxiety in
Accepted 26 May 2017
depressed patients. Two hundred three psychiatric patients with MDD were interviewed by trained
diagnostic raters who administered the Structured Clinical Interview for DSM-IV (SCID) supplemented
Keywords:
with questions to rate the DADSI, HAMA, and Hamilton Depression Rating Scale (HAMD). The patients
Depression
Anxiety
completed self-report measures of depression, anxiety, and irritability. Sensitivity to change was
DSM-5 Anxious Distress Specifier Interview examined in 30 patients. The DADSI and HAMA were significantly correlated (r ¼ 0.60, p < 0.001). Both
Hamilton Anxiety Scale the DADSI and HAMA were more highly correlated with measures of anxiety than with measures of the
other symptom domains. The HAMD was significantly more highly correlated with the HAMA than with
the DADSI. For each anxiety disorder, patients with the disorder scored significantly higher on both the
DADSI and HAMA than did patients with no current anxiety disorder. A large effect size of treatment was
found for both measures (DADSI: d ¼ 1.48; HAMA: d ¼ 1.37). Both the DADSI and HAMA were valid
measures of anxiety severity in depressed patients, though the HAMA was more highly confounded with
measures of depression than the DADSI. The DADSI is briefer than the HAMA, and may be more feasible
to use in clinical practice.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction (0 ¼ absent, no symptoms; 1 ¼ mild, occurs irregularly and for

The Hamilton Rating Scale for Anxiety (HAMA) (Hamilton, 1959)
is the most commonly used clinician-rated measure of anxiety in
treatment studies of depression (Ionescu et al., 2014). The HAMA
was published more than 50 years ago. As one of the first reliable
and valid interviewer-administered instruments assessing the
severity of anxiety, it is not surprising that it has become the
standard in the field.
The 14 items of the HAMA are rated from 0 to 4 with general
guidelines provided for distinguishing the gradations of severity
* Corresponding author. 146 West River Street, Providence, RI 02904, United
States.
E-mail address: mzimmerman@lifespan.org (M. Zimmerman).
short periods of time; 2 ¼ moderate, occurs more constantly and of
longer duration, requiring considerable effort on part of patient to
cope with it; 3 ¼ severe, continuous and dominates patient's life;
4 ¼ very severe, incapacitating.) The items incorporate groups of
symptoms (e.g., autonomic symptoms; respiratory symptoms,
fears) rather than specific, single, symptoms.
Although the HAMA is a reliable and valid measure of the
severity of anxiety in depressed patients, at least 5 problems with
the scale have been described through the years. First, the scale
includes items assessing depression. One of the items on the scale is
labeled depressed mood, which includes an assessment of low
mood, loss of pleasure or interest in activities, early morning
awakening, and diurnal variation of mood. The components of
other HAMA items also incorporate features of depression (e.g., loss
of libido as part of the genitourinary symptoms item; easily moved

http://dx.doi.org/10.1016/j.jpsychires.2017.05.014
0022-3956/© 2017 Elsevier Ltd. All rights reserved.
60 M. Zimmerman et al. / Journal of Psychiatric Research 93 (2017) 59e63
to tears as part of the tension item). It is therefore not surprising
that the HAMA has been criticized for failing to adequately distin-
guish depression and anxiety (Maier et al., 1988; Porter et al., 2017;
Riskind et al., 1987). The inclusion of symptoms of depression on
the HAMA confounds the interpretation of studies examining the
efficacy of treatments for depression on anxiety.
A second problem with the HAMA is that each of the items on
the scale includes multiple symptoms. For example, the tension
item incorporates the assessment of feelings of tension, fatigability,
startle response, being moved to tears easily, trembling, feelings of
restlessness, and inability to relax. The anxious mood item includes
worries, anticipation of the worst, fearful anticipation, and irrita-
bility. To examine a treatment's effects on each of these individual
constructs, it would be necessary to have separate ratings of them.
Because the HAMA item ratings are complex, covering multiple
symptoms, a third potential problem with the scale is that some
symptoms can be rated on multiple items. For example, Hamilton's
description for rating the depression item includes early waking,
which could also be rated on the insomnia item. It is likely that
there is variability amongst raters, particularly raters at different
sites, in how insomnia is rated (i.e., on both items, only on the
insomnia item, or only on the depression item). The same could be
said for the rating of fatigue and restlessness, both of which are
listed on multiple items.
Because half of the items on the HAMA assess somatic symp-
toms of anxiety, a fourth criticism of the scale has been that it is
sometimes difficult to determine if the ratings reflect symptoms of
anxiety or side effects of medication (Bruss et al., 1994; Maier et al.,
1988).
And fifth, the general guidelines in rating the graded levels of
severity have been criticized as being open to interpretation and
rating variance (Bruss et al., 1994). To improve reliability and
facilitate standardization of measurement across studies, semi-
structured interviews and rating manuals have been developed
(Bech, 2011; Bruss et al., 1994; Shear et al., 2001). However, these
guidelines differ in the ways they define the severity levels.
In recognition of the clinical significance of anxious features in
depressed patients, DSM-5 included criteria for an anxious distress
specifier for major depressive disorder (MDD) (American
Psychiatric Association, 2013). A measure of anxiety severity
based on the DSM-5 specifier offers several potential advantages
over the HAMA. First is its brevityd the DSM-5 specifier includes
only 5 items versus the 14 items of the HAMA. It would therefore
take much less time (and thus less cost) to administer. In fact,
perhaps a measure of the DSM-5 criteria would be considered brief
enough to administer in routine clinical practice.
Second, the DSM-5 criteria reflect single symptoms whereas
each HAMA item represents a group of symptoms. Thus, the
simpler structure of the DSM-5 criteria could improve reliability,
reduce rater variability across settings, and reduce administration
effort. And third, a measure of the DSM-5 specifier would not be
confounded by symptoms of depression.
We recently validated a semi-structured interview to assess the
criteria of the DSM-5 anxious distress specifierdthe DSM-5
Anxious Distress Interview (DADSI) (Zimmerman et al., 2017). In
our initial validation study, we found that the DADSI was signifi-
cantly, albeit moderately, correlated with the HAMA. While the
DADSI was initially developed as a measure of the MDD anxious
distress specifier subtyping, the goal of the present study was to
determine whether the DADSI was equivalent to the HAMA as a
measure of general anxiety severity in patients with MDD.
Accordingly, in the present report from the Rhode Island Methods
to Improve Diagnostic Assessment and Services (MIDAS) project,
we tested the hypothesis that the DADSI was as valid as the HAMA
as a general anxiety severity measure in depressed patients.
Because of the inclusion of depressive symptoms on the HAMA, we
further hypothesized that the DADSI would be less highly corre-
lated with measures of depression than the HAMA.
2. Methods
The study was conducted in the Rhode Island Hospital Depart-
ment of Psychiatry partial hospital program, a 5-day per week
intensive treatment program. Patients meet with a psychiatrist and
therapist daily, and attend 4 groups per day. The average length of
stay is 7.5 days (SD ¼ 4.8).
Two hundred and three patients with current DSM-IV/DSM-5
MDD presenting for an intake evaluation at the Rhode Island
Hospital Department of Psychiatry partial hospital program were
interviewed by a trained diagnostic rater who administered the
Structured Clinical Interview for DSM-IV (SCID) (First et al., 1997).
The SCID was supplemented with questions from the Schedule for
Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer,
1978) assessing the severity of symptoms and psychosocial func-
tioning during the week prior to the evaluation as well as a lifetime
history of suicide attempts. Of relevance to the current study, all
patients were evaluated on the SADS items assessing psychic
anxiety, depressed mood, and irritability. Additional questions
were included to rate the items on the 17-item Hamilton Depres-
sion Rating Scale (HAMD) (Hamilton, 1960) and the HAMA
(Hamilton, 1959). A subsample was re-interviewed on the day of
discharge. Details regarding interviewer training and diagnostic
reliability are available in other publications from the MIDAS
project, which have documented high reliability in diagnosing
anxiety and mood disorders (Zimmerman and Mattia, 1999). The
Rhode Island Hospital institutional review committee approved the
research protocol, and all patients provided informed, written
consent.
The DADSI assesses the 5 symptoms of the anxious distress
specifier (feeling keyed up or tense, feeling restless, difficulty
concentrating because of worry, fear that something awful might
happen, and feeling that one might lose control). The probes of the
DADSI inquire about symptom presence and severity for the past
week and also determine if the symptom is present for the majority
of the depressive episode. Item severity for the past week is rated
from 0 to 4. Total scale scores range from 0 to 20. The DADSI
interview was integrated into the SCID and completed immediately
after the MDD section.
The patients completed the Clinically Useful Depression
Outcome Scale (CUDOS) (Zimmerman et al., 2008a), the Clinically
Useful Anxiety Outcome Scale (CUXOS) (Zimmerman et al., 2010),
the Clinically Useful Anger Outcome Scale (CUANGOS)
(Zimmerman, in preparation) and the Remission from Depression
Questionnaire (Zimmerman et al., 2013). The self-report scales
were usually completed prior to the diagnostic interview. The rat-
ings on the DADSI were made blind to the results of the self-report
scales.
The CUDOS contains items assessing all of the DSM-IV inclusion
criteria for MDD (Zimmerman et al., 2008a). The respondent is
instructed to rate the 16 symptom items on a 5-point ordinal scale
indicating “how well the item describes you during the past week,
including today” (0 ¼ not at all true/0 days; 1 ¼ rarely true/1e2
days; 2 ¼ sometimes true/3e4 days; 3 ¼ usually true/5e6 days;
4 ¼ almost always true/every day). Compound DSM-IV symptom
criteria referring to more than one construct (e.g. problems
concentrating or making decisions; insomnia or hypersomnia)
were subdivided into their respective components and a CUDOS
item was written for each component. Total scores range from 0 to
64. In the present study the internal consistency of the CUDOS was
0.75.
 M. Zimmerman et al. / Journal of Psychiatric Research 93 (2017) 59e63
The CUXOS is a general measure of psychic and somatic anxiety
rather than a disorder specific scale. The respondent is instructed to
rate the 20 CUXOS items on a 5-point ordinal scale indicating “how
well the item describes you during the past week, including today”
(0 ¼ not at all true; 1 ¼ rarely true; 2 ¼ sometimes true; 3 ¼ usually
true; 4 ¼ almost always true). Total scores range from 0 to 80. In the
present study the internal consistency of the CUXOS was 0.90.
In contrast to most measures of depression that assess only
symptom presence during the past week or two, the 41-item RDQ
assesses a broader array of features reported by patients as relevant
to determining remission. The domains covered on the RDQ were
based on a literature review, our previous study of depressed pa-
tients' ratings of the relative importance of 16 factors in deter-
mining remission (Zimmerman et al., 2006), and two focus groups
with depressed patients. The domains assessed were: symptoms of
depression, other symptoms that are often present in depressed
patients such as anxiety and irritability, features of positive mental
health, coping ability, functioning, life satisfaction, and a general
sense of well-being. The items refer to the prior week, and are rated
on a 3-point rating scale (not at all or rarely true; sometimes true;
often or almost always true). The items are scored 0, 1, and 2 with
higher item values reflecting greater pathology. In a study of 274
depressed outpatients, the RDQ demonstrated excellent internal
consistency, with a Cronbach's a of 0.97 for the total scale and
above 0.80 for each of the 7 subscales. The test-retest reliability of
the total scale was 0.85 and above 0.60 for each subscale
(Zimmerman et al., 2013).
The 13-item CUANGOS is a general measure of irritability and
aggression. The rating instructions are the same as the CUXOS. Total
scores range from 0 to 52. In the present study the internal con-
sistency of the CUANGOS was 0.92.
The joint-interview inter-rater reliability of the DADSI and
HAMA was examined in 25 subjects (Zimmerman et al., 2017). The
reliability of both scales was high (intraclass correlation of 0.93 for
DADSI and 0.94 for HAMA).
2.1. Data analyses
We examined convergent and discriminant validity (Campbell
and Fiske, 1959) by examining the correlations of the DADSI and
HAMA, respectively, with measures of anxiety (CUXOS, SADS psy-
chic and somatic anxiety) and nonanxious symptoms (CUDOS,
CUANGOS, HAMD, SADS depressed mood, SADS irritability). We
compared the correlations with the DADSI and HAMA by calcu-
lating the difference between the Fisher z transformations of the
correlation coefficients and dividing the difference by the standard
error (Steiger, 1980).
Table 1
Discriminant and convergent validity of the DSM-5 Anxious Distress Specifier Interview (DADSI) and Hamilton Anxiety Rating Scale (HAMA) scores.
Measures Correlation with DADSI, ra
Measures of Anxiety Symptoms
SADS psychic anxiety 0.55
SADS somatic anxiety 0.50
Clinically Useful Anxiety Outcome Scalec 0.51
Measure of Nonanxious Symptoms
17-item Hamilton Depression Rating Scale 0.49
SADS depressed mood 0.29
SADS irritability 0.15
Clinically Useful Depression Outcome Scalec 0.32
Clinically Useful Anger Outcome Scalec 0.30
SADS indicates Schedule for Affective Disorders and Schizophrenia.
a
All correlation coefficients are significant at p <. 01 except for SADS irritability item (p < .05).
b
All correlation coefficients are significant at p <. 01 except for SADS irritability item (n.s.).
c
Missing data on the self-report scales reduced sample size to 176.
61
We used t-tests to determine whether DADSI and HAMA scores
were significantly higher in patients with specific anxiety disorders
compared to patients without an anxiety disorder. We used Lev-
ene's test for Equality of Variances to examine homogeneity of
variance of the two samples, and when significant used separate
variance estimates with adjusted degrees of freedom. We examined
the correlation between the DADSI and HAMA and various indices
of psychosocial morbidity, and compared the magnitude of these
correlations. Finally, paired t-tests were used to examine sensitivity
to change in 30 patients. We also examined the correlation be-
tween the change in DADSI and change in HAMA scores and
computed the Cohen's d for both measures.
3. Results
3.1. Demographic characteristics
The 203 patients in the study included 51 (25.1%) men, 148
(72.9%) women, and 4 (2.0%) transgender patients who ranged in
age from 18 to 77 years (mean ¼ 36.1, SD ¼ 14.2). About one-fifth of
the subjects were married (21.2%, n ¼ 43); the remainder were
single (46.3%, n ¼ 94), divorced (11.8%, n ¼ 24), separated (4.4%,
n ¼ 9), widowed (2.5%, n ¼ 5), or living with someone as if in a
marital relationship (13.8%, n ¼ 28). The educational level achieved
by the subjects was: 6.4% (n ¼ 13) did not graduate high school,
19.7% (n ¼ 40) graduated high school or achieved equivalency,
39.4% (n ¼ 80) completed some college, and 34.5% (n ¼ 70) grad-
uated college. The racial composition of the sample was 73.4%
(n ¼ 149) white, 4.9% (n ¼ 10) black, 10.8% (n ¼ 22) Hispanic, 2.0%
(n ¼ 4) Asian, and 8.9% (n ¼ 18) from another or a combination of
the above racial backgrounds.
3.2. Discriminant and convergent validity
The DADSI and HAMA were significantly correlated (r ¼ 0.60,
p < 0.001). The data in Table 1 shows that both the DADSI and
HAMA were more highly correlated with measures of anxiety
(DADSI mean r ¼ 0.52; HAMA mean r ¼ 0.55) than with measures of
the other symptom domains (DADSI mean r ¼ 0.31; HAMA mean
r ¼ 0.31). The HAMD was significantly more highly correlated with
the HAMA than with the DADSI. In fact, the HAMA shared twice as
much variance with the HAMD (48%) than did the DADSI (24%).
3.3. Association with psychiatric diagnosis
Patients with any DSM-5 anxiety disorder scored significantly
higher than patients with no current anxiety disorder on both the
Correlation with HAMA, rb Difference in Correlations
0.50 z ¼ 1.0, p ¼ 0.33
0.62 z ¼ 2.4, p ¼ 0.16
0.53 z ¼ 0.4, p ¼ 0.72
0.69 z ¼ 4.2, p < 0.001
0.38 z ¼ 1.5, p ¼ 0.13
0.10 z ¼ 0.8, p ¼ 0.42
0.23 z ¼ 1.4, p ¼ 0.16
0.19 z ¼ 0.2, p ¼ 0.09
62 M. Zimmerman et al. / Journal of Psychiatric Research 93 (2017) 59e63

Table 2
Total scores on the DSM-5 Anxious Distress Specifier Interview (DADSI) and Hamilton Anxiety Rating Scale (HAMA) in depressed patients with and without a current DSM-IV
anxiety disorder.

Current Anxiety Disorder N DADSI total t valuea p level HAMA total t valuea p level

Mean SD Mean SD

Panic Disorder 51 13.1 4.0 5.39 <0.001 32.1 7.8 6.29 <0.001
Generalized Anxiety Disorder 115 12.7 3.9 5.76 <0.001 29.7 8.0 5.34 <0.001
Social Phobia 78 11.7 4.1 4.13 <0.001 28.7 8.2 4.32 <0.001
Specific Phobia 18 12.7 4.6 3.46 0.001 31.4 9.3 4.13 <0.001
Generalized Anxiety Disorder, Panic, Agoraphobia, Social Phobia, Specific Phobia 153 12.0 4.2 4.78 <0.001 29.3 8.3 5.07 <0.001
Any Anxiety Disorderb 161 11.9 4.2 4.73 <0.001 29.1 8.4 4.84 <0.001
No Anxiety Disorder 42 8.5 4.2 e e 22.2 7.3 e e
a
DADSI and HAMA scores were compared between each anxiety disorder and the no anxiety disorder group.
b
Includes panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and other
specified and unspecified anxiety disorders.

DADSI and HAMA (Table 2). We examined DADSI and HAMA scores
in patients with each of the individual disorders. The comparison
group in each of these analyses was the 42 patients without a
current anxiety disorder. The data in Table 2 shows that for each
anxiety disorder, patients with the disorder scored significantly
higher than patients with no current anxiety disorder. The total
number of anxiety disorders was significantly correlated with both
the DADSI (r ¼ 0.39, p < 0.001) and HAMA (r ¼ 0.39, p < 0.001).
3.4. Association with indicators of psychosocial morbidity
Both the DADSI and HAMA were significantly, albeit modestly,
correlated with the SADS rating of functioning in the past week,
though only the HAMA was significantly correlated with the RDQ
psychosocial functioning subscale (Table 3). Only the DADSI was
significantly correlated with a lifetime history of suicide attempts
and the CUDOS suicidal ideation item, though these correlations
were not significantly higher than the HAMA correlations and the
correlations were modest in magnitude. None of the differences in
the correlations between the HAMA and DADSI and the indicators
of psychosocial morbidity were significant.
3.5. Sensitivity to change
Thirty patients were reevaluated at discharge, at least one week
after the initial evaluation (mean ¼ 11.1 days, SD ¼ 4.4, range 7e23
days). The change in DADSI scores was significantly correlated with
a change in HAMA scores (r ¼ 0.67, p < 0.001). The scores on both
the DADSI and HAMA were significantly lower at follow-up
compared to baseline (DADSI: 6.0 ± 5.0 vs. 12.4 ± 3.5, paired
t ¼ 7.64, p < 0.001; HAMA: 15.6 ± 10.1 vs. 27.8 ± 7.5, paired t ¼ 6.80,
p < 0.001). A large effect size of treatment was found for both
measures (DADSI: d ¼ 1.48; HAMA: d ¼ 1.37).
4. Discussion
Both the HAMA and DADSI were significantly correlated with
other measures of anxiety, more highly correlated with other
measures of anxiety than with measures of depression and irrita-
bility, achieved higher scores in patients with comorbid anxiety
disorders than in patients without an anxiety disorder, significantly
correlated with functional impairment, and were sensitive to
change. Thus, both scales were valid measures of anxiety severity in
depressed patients. An advantage of the DADSI over the HAMA as a
measure of anxiety among patients with MDD is that it is briefer
and less confounded with measures of depression.
The correlation with the HAMD, the most commonly used
depression scale used in placebo-controlled studies of antidepres-
sants (Zimmerman et al., 2016), was greater with the HAMA than
with the DADSI. This is not surprising because one of the items on
the HAMA is explicitly an item assessing depressed mood and other
features of depression, and other items on the HAMA include as-
sessments of symptoms that are characteristic of depression. When
a measure of anxiety is partially confounded with items assessing
depression, it makes it more difficult to interpret treatment studies
of depression examining the efficacy of treatment on symptoms of
anxiety. The results of the present study suggest that a measure of
the DSM-5 anxious distress specifier may be a less confounded
assessment of anxiety in antidepressant treatment studies.
Our group has previously stated that we believe that stan-
dardized scales should be routinely used to measure outcome when
treating psychiatric disorders (Zimmerman et al., 2008b). In fact,
we believe that this should be the standard of care. If the standard
of care is to change in the future, and scales are to be incorporated
into clinical practice, then it will be necessary to consider feasibility
issues as much as the psychometric properties of the measures. We
have developed a series of clinically useful self-administered scales

Table 3
Correlations between DSM-5 Anxious Distress Specifier Interview (DADSI) scores and Hamilton. Anxiety Rating Scale (HAMA) scores and indices of psychosocial morbidity.

Morbidity Indicator Correlation with DADSI Correlation with HAMA Difference in Correlations

Past week functioninga 0.24* 0.33* z ¼ 1.5; p ¼ 0.13

Suicidal ideationa 0.12 0.01 z ¼ 1.7; p ¼ 0.08
Lifetime suicide attemptsa 0.15* 0.09 z ¼ 1.0; p ¼ 0.34
RDQ Coping Abilityb 0.11 0.13 z ¼ 0.3; p ¼ 0.77
RDQ Positive Mental Healthb 0.10 0.17* z ¼ 1.0; p ¼ 0.31
RDQ Functioningb 0.10 0.23* z ¼ 1.9; p ¼ 0.06
RDQ Life Satisfactionb 0.03 0.07 z ¼ 0.6; p ¼ 0.56
RDQ General Well-beingb 0.16* 0.17* z ¼ 0.1; p ¼ 0.89
CUDOS Suicide Item 0.16* 0.05 z ¼ 1.6; p ¼ 0.10

RDQ indicates Remission from Depression Questionnaire; CUDOS, Clinically Useful Depression Outcome Scale.
*p < 0.05.
a
Items from the Schedule for Affective Disorders and Schizophrenia.
b
Subscales from the Remission from Depression Questionnaire.
 M. Zimmerman et al. / Journal of Psychiatric Research 93 (2017) 59e63
for use in research and clinical practice. Ideally, self-administered
scales would be complemented with clinician-administered rat-
ing scales. The brevity of the DSM-5 specifier may facilitate its use
in clinical practice.
While we would expect the DADSI to require less administrative
time than the HAMA, we did not systematically record the time to
administer each of these scales. We could not time the scale
administration because the ratings on the clinician scales were not
independent of each other. That is, the same rater completed the
DADSI, the HAMA, the HAMD, and the SADS items. It would be
preferable to have independent interviewers complete the clinician
rating scales though this is not practical in an integrated clinical
research setting in which the interview is conducted primarily for
clinical purposes, and the use of the information for research pur-
poses is a secondary goal.
The present study was conducted in a single clinical practice in
which the majority of the patients were white, female, and had
health insurance. Replication in samples with different de-
mographic characteristics is warranted. It will also be important to
replicate these findings in an outpatient sample.
Potential conflicts of interest
None.
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