DEPRESSION AND ANXIETY 31:533–538 (2014)

Research ArticleTHE REMISSION FROM DEPRESSION QUESTIONNAIRE

AS AN OUTCOME MEASURE IN THE TREATMENTOF DEPRESSION

Mark Zimmerman, M.D.,∗ Jennifer H. Martinez, B.A., Naureen Attiullah, M.D., Michael Friedman, M.D.,Cristina Toba, M.D., and Daniela A. Boerescu, M.D.

Background: The Remission from Depression Questionnaire (RDQ) assessesmultiple domains considered by depressed patients to be relevant to the constructof remission. The present study is the first to examine the validity of the RDQas an outcome measure. Methods: One hundred fifty-three depressed patientswho presented for treatment, or who were in ongoing treatment and had theirmedication changed, were evaluated at baseline and at 4-month follow-up. Inaddition to the RDQ, the patients completed the Quick Inventory of DepressiveSymptomatology (QIDS), and they were rated on 17-item Hamilton RatingScale for Depression (HAMD). Results: The patients showed significant levels ofimprovement from baseline to 4 months on each scale. The effect size of the RDQtotal score was similar to the effect sizes of the HAMD and QIDS. Both the RDQand QIDS were significantly associated with patients’ self-reported remissionstatus. However, the RDQ remained significantly associated with remission statusafter controlling for QIDS scores, whereas the QIDS was not associated withremission status after controlling for RDQ scores. Discussion: The RDQ isas sensitive to change as purely symptom-based scales such as the QIDS andHAMD. Moreover, the RDQ accounts for variation in patients’ self-perceivedremission status after controlling for QIDS scores, but the reverse was not true.The RDQ allows clinicians and researchers to gain a broader perspective ofdepressed patients’ status than purely symptom measures, and is more consistentwith a biopsychosocial approach toward the treatment of depression. Depressionand Anxiety 31:533–538, 2014. C© 2013 Wiley Periodicals, Inc.

Key words: depression, remission; Hamilton Rating Scale for Depression;Remission from Depression Questionnaire; Quick Inventory of DepressiveSymptomatology

The American Psychiatric Association’s guidelines forthe treatment of major depressive disorder (MDD) indi-cate that achieving remission should be viewed as the pri-

Department of Psychiatry and Human Behavior, , Brown Med-ical School and the Department of Psychiatry, Rhode IslandHospital, Providence, Rhode, Island

Funding/support: Eli Lilly USA, LLC.

∗Correspondence to: Dr. Mark Zimmerman, Department of Psychi-atry and Human Behavior, Brown Medical School and the Depart-ment of Psychiatry, Rhode Island Hospital, 146 West River Street,Providence, RI 02904. E-mail: mzimmerman@lifespan.org

mary goal of treatment.[1] This recommendation stemsfrom studies that have consistently demonstrated thatcompared to patients who are in remission, patients whohave responded to treatment but failed to achieve symp-tomatic remission continue to experience more psy-chosocial impairment and have a higher likelihood ofrecurrence of a full depressive syndrome.[2–7]

Received for publication 12 February 2013; Revised 25 June 2013;Accepted 2 August 2013

DOI 10.1002/da.22178Published online 02 October 2013 in Wiley Online Library(wileyonlinelibrary.com).

C© 2013 Wiley Periodicals, Inc.

534 Zimmerman et al.

How to best define remission has received recent at-tention. Ideally, remission would be defined biologicallybased on the normalization of underlying pathophys-iological dysfunction.[8] However, currently there areno valid biological state markers of MDD that are use-ful in monitoring the course of the disease. In the ab-sence of such biological measures, remission is definedphenomenologically.

During the past decade our research group has un-dertaken a series of studies examining how to define re-mission from depression. While remission is typicallydefined as a score below a cutoff value on a standardizedscale such as the Hamilton Rating Scale for Depression(HAMD),[9] we found in a survey of depressed patientsreceiving ongoing treatment that the presence of fea-tures of positive mental health, a return to one’s usualself, and a return to one’s usual level of functioning weremore frequently considered important in defining remis-sion than a resolution of depressive symptoms.[10] Theseresults raised concerns that researchers’ approach towarddefining remission did not adequately reflect depressedpatients’ perspective of the concept.

As part of the Rhode Island Methods to Improve Di-agnostic Assessment and Services (MIDAS) project, wedeveloped the Remission from Depression Question-naire (RDQ) to capture a broader array of domains con-sidered by patients to be relevant to the construct ofremission.[11,12] The first study of the RDQ comparedits acceptability to the acceptability of a symptom-basedmeasure—the Quick Inventory of Depressive Symp-tomatology (QIDS).[13] We selected the QIDS for com-parison because it was one of the primary outcome mea-sures used in the STAR*D study.[14] We found that thepatients considered the multifactorial RDQ a more accu-rate indicator of their goals of treatment than the QIDS.

In a second study, we examined the psychometric per-formance of the RDQ. The RDQ demonstrated excel-lent internal consistency and test–retest reliability.[11]

Both the RDQ and QIDS were significantly associatedwith patients’ self-reported remission status. However,the RDQ remained significantly associated with remis-sion status after controlling for QIDS scores whereasthe QIDS was not associated with remission status aftercontrolling for RDQ scores.

In the present study from the MIDAS project, we ex-amined the validity of the RDQ as an outcome measure.We examined whether each of the subscales of the RDQwas sensitive to change, and compared the scale as a mea-sure of outcome to the QIDS and HAMD in depressedpatients treated in routine clinical practice.

METHODSA convenience sample of 153 patients diagnosed with DSM-IV ma-

jor depressive disorder who presented for treatment to the Rhode Is-land Hospital Department of Psychiatry outpatient practice (n = 78), orwho were in ongoing treatment and had their medication changed dueto lack of efficacy (n = 75), were evaluated at baseline and at 4-monthfollow-up. The mean interval between the baseline and follow-up eval-

uations was 16.4 weeks (SD = 4.2 weeks). Not all available patientsparticipated in the study due to the lack of availability of raters or thetreating psychiatrist did not refer the patient to the study. Approxi-mately half of the patients were diagnosed with MDD based on theStructured Clinical Interview for DSM-IV (SCID),[15] whereas theother patients were diagnosed on the basis of an unstructured clini-cal interview. The sample included 42 (27.5%) men and 111 (72.5%)women who ranged in age from 18 to 79 years (M = 43.7, SD = 13.6).The Rhode Island Hospital institutional review committee approvedthe research protocol, and all patients provided informed, writtenconsent.

The RDQ assesses symptoms of depression as well as other vari-ables reported by patients as relevant to determining remission. Theconstructs assessed by the RDQ were based on a literature review, oursurvey of depressed patients’ ratings of the importance of 16 factors indetermining remission,[10] and two focus groups with depressed pa-tients in ongoing treatment. The discussion of the focus groups wastranscribed, and a list of potential items for the RDQ was constructed.The list of items was sent to the focus group participants who rated theitems’ understandability, redundancy, and relevance to the constructof remission. The first draft of the RDQ consisted of 77 items. Thepool of 77 items was reduced to 41 items after initial pilot testing. Theitems are grouped into 7 domains: symptoms of depression (13 items),other symptoms that are often present in depressed patients such asanxiety and irritability (5 items), features of positive mental health (11items), coping ability (3 items), functioning (3 items), life satisfaction(3 items), and a general sense of wellbeing (3 items). The items referto the prior week, and are rated on a 3-point rating scale (not at all orrarely true; sometimes true; often or almost always true). The items arescored 0, 1, and 2 with higher item values reflecting greater pathology.Thus, for symptom items (e.g. “I felt guilty”) a rating of often or al-most always true was scored as 2, whereas for the positive mental healthitems (e.g. “I felt confident”) a rating of not at all or rarely true wasscored as 2. The reliability of the RDQ was studied in 274 depressedoutpatients. The scale had excellent internal consistency (Cronbach’sα = .97 for the total scale and above .80 for each of the seven subscales)and test–retest reliability (total scale r = .85, and above .60 for eachsubscale).[11]

In addition to the RDQ, the patients completed the QIDS, a reli-able and valid self-report measure of the DSM-IV symptom criteriaof MDD.[13] Each item of the QIDS is scored from 0 to 3, and thetotal score ranges from 0 to 27 because only the highest score is usedfrom items that are components of a single DSM-IV criterion. For ex-ample, only the highest value of the insomnia and hypersomnia itemscontributes to the total score. The QIDS has demonstrated high levelsof reliability and has been shown to be sensitive to change in severalcontrolled studies.

The HAMD is the most commonly used clinician-rated outcomescale in depression treatment studies. The original rating form in-cluded 21 items, though Hamilton[9] indicated that only the first 17items should contribute to the total scale score because one of the lastfour items represented depressive type rather than depression severity(diurnal mood variation), and three other items did not occur with suf-ficient frequency (derealization, paranoia, and obsessional symptoms).Nine of the 17 items are rated from 0 to 4 whereas eight items arerated 0 to 2, thus the maximum score is 52. The HAMD ratings weremade blind to the responses to the self-report questionnaires, whichwere completed on the same day.

At the follow-up evaluation the patients also filled out a form thatincluded a question regarding the patient’s perception of whether theywere currently in remission from depression (“Do you consider your-self to be in remission from your depression?” 0 = yes, 1 = no). Theterm remission was not defined for the patients; thus, they were left toanswer the question based on their personal conceptualization of theconcept.

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Research Article: The Remission from Depression Questionnaire 535

TABLE 1. Scores at baseline and 4 month follow-up and effect sizes on the 17-item Hamilton Depression Rating Scale,Quick Inventory for Depressive Symptomatology, and Remission from Depression Questionnaire in 153 depressedoutpatients

Baseline 4 Month Follow-upMeasure Mean SD Mean SD t value Effect size (95% C.I)

Quick Inventory of Depressive Symptomatology 15.8 4.4 10.2 5.8 12.5a 1.09 (0.89, 1.29)17-item Hamilton Depression Rating Scale 19.6 5.6 11.8 8.3 13.4a 1.10 (0.90, 1.30)Remission from Depression Questionnaire total 54.4 12.2 36.6 20.7 10.8a 1.05 (0.85, 1.25)Remission from Depression Questionnaire subscales

Depression symptoms 14.9 4.3 9.1 6.1 11.2a 1.10 (0.90, 1.10)Other symptoms 6.6 2.7 4.5 3.2 8.0a 0.71 (0.53, 0.89)Coping ability 4.0 1.6 2.9 1.9 6.2a 0.63 (0.45, 0.81)Positive mental health 16.1 4.7 11.2 6.6 8.8a 0.86 (0.67, 1.05)Functioning 3.6 1.6 2.5 1.9 6.2a 0.63 (0.45, 0.81)Life satisfaction 4.6 1.6 3.3 2.3 7.3a 0.66 (0.48, 0.84)General sense of wellbeing 4.9 1.4 3.1 2.2 8.6a 0.98 (0.78, 1.18)

aP < .001

DATA ANALYSESFor each scale, we used paired t-tests to compare follow-up scores

to baseline values. We computed the effect size (Cohen’s d) on eachof the measures, as well as the RDQ subscales. An effect size of .2was considered small, .5 medium, and .8 large.[16] Confidence inter-vals were computed for the effect sizes using the Exploratory Softwarefor Confidence Intervals.[17] Nonoverlapping 95% confidence inter-vals were considered significantly different. Pearson correlations werecomputed between the change in HAM-D scores and change in theRDQ total and subscale scores. We used independent sample t-teststo determine whether RDQ subscale scores were significantly higherin patients who were and were not in remission. Remission was de-fined according to scores on the HAMD and patients’ self-evaluationof remission status. Levene’s test for Equality of Variances was usedto examine homogeneity of variance of the two samples, and whenthis test was significant separate variance estimates were used with ad-justed degrees of freedom. In these analyses we used two definitionsof remission: HAMD ≤ 7 and patients’ self-report of remission sta-tus. In addition, we computed partial correlations between the RDQand QIDS with each remission definition while controlling for scoreson the other scale. In computing correlations with remission status,remission was assigned a value of 1 and nonremission was coded 0.Thus, correlation coefficients with the QIDS and RDQ had a negativevalence.

RESULTSOn each scale, the patients showed significant levels

of improvement from baseline to follow-up (Table 1).A large effect size was found for the RDQ total scalescore, and this was similar to the large effect size basedon the HAMD and QIDS (Table 1). There was variabil-ity amongst the RDQ subscales in their effect size. Thecoping and functioning subscales had significantly lowereffect sizes than the depressionsymptoms subscale.

For each of the RDQ subscales, the change in scoresfrom baseline to 4 months was significantly correlatedwith change in scores on the HAMD (Table 2). Thechange in the coping and functioning subscales had thelowest correlations with the change in HAMD scores.

TABLE 2. Correlation between the changes in scores onthe Hamilton Depression Rating Scale (HAMD) and theRemission from Depression Questionnaire total andsubscale scores in 153 depressed outpatients

Correlation withRDQ subscale HAMDa

Total score .68Depression symptoms .59Other symptoms .55Coping ability .35Positive mental health .60Functioning .47Life satisfaction .52General sense of wellbeing .57

aAll correlation coefficients are significant at the P < .001 level.

Six patients did not indicate whether they consideredthemselves to be in remission. Of the remaining 147 pa-tients, slightly less than 40% considered themselves tobe in remission at the time of the 4-month evaluation(38.1%, n = 56). The majority of the patients (60.7%)who considered themselves to be in remission also scoredin the remission range on the HAMD. The remitted pa-tients scored significantly lower on each of the RDQ sub-scales than the patients who did not consider themselvesto be in remission (Table 3). QIDS scores were also sig-nificantly lower in the remitters than the nonremitters(7.1 ± 5.2 vs. 12.2 ± 5.3, t = 5.6, 145 df, P < .001). TheQIDS was significantly correlated with self-reported re-mission status (r = −.42, P < .001); however, the partialcorrelation between the QIDS and self-reported remis-sion status, controlling for total RDQ scores, was notsignificant (r = .08, n.s.). RDQ total scores were sig-nificantly lower in remitters than nonremitters (24.4 ±19.0 vs. 44.5 ± 18.7, t = 6.28, 144 df, P < .001), and thecorrelation with remission status was −.46 (P < .001).In contrast to the finding for the QIDS, the partial cor-relation between the RDQ and self-reported remission

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TABLE 3. RDQ subscale scores in depressed patients who were and were not in remission according to patients’self-assessment of remission status

Remitters (n = 56) Nonremitters (n = 90)RDQ subscale Mean SD Mean SD t value

Total score 24.4 19.0 44.5 18.7 6.3a

Depression symptoms 6.3 6.2 11.0 5.5 4.9a

Other symptoms 3.3 3.2 5.3 3.0 3.7a

Coping ability 2.3 2.0 3.4 1.7 3.7a

Positive mental health 7.4 6.4 13.6 5.8 6.1a

Functioning 1.6 1.8 3.2 1.8 5.0a

Life satisfaction 1.9 2.2 4.0 2.0 5.9a

General sense of wellbeing 1.7 1.9 4.1 2.0 7.3a

aP < .001

status, controlling for QIDS scores, was significant (r =−.21, P < .01).

Slightly more than one-third of the patients scored 7and below on the 17-item HAMD and were thereforeconsidered to be in remission (35.3%, n = 54). The ma-jority of the HAMD remitters (64.2%) also consideredthemselves to be in remission. The patients who werein remission scored significantly lower on each RDQsubscale than the patients who were not in remission(Table 4). RDQ total scores were significantly lower inremitters than nonremitters (18.1 ± 15.1 vs. 47.4 ± 15.6,t = 11.2, 150 df, P < .001), and the correlation with re-mission status was −.67 (P < .001). The partial corre-lation between the RDQ and HAM-D remission status,controlling for QIDS scores, was −.27 (P < .001). QIDSscores were also significantly lower in remitters thannonremitters (5.0 ± 2.8 vs. 13.1 ± 4.9, t = 12.8, 150.4df, P < .001), and the correlation was −.67 (P <.001).The partial correlation between the QIDS and HAM-Dremission status, controlling for total RDQ score, wassignificant (r = −.27, P < .001).

DISCUSSIONIn studies of the efficacy and effectiveness of treat-

ing depression, remission has been defined in symptomterms only. Specifically, remission has been defined ac-

cording to scores falling below a cutoff on symptomseverity scales such as the HAMD. This narrow approachtoward defining remission is at variance with patients’broader conceptualization of multiple factors that theyconsider to be important in determining remission fromdepression. Previous research from the MIDAS projectfound that depressed patients consider return to normalfunctioning, quality of life, the presence of positive as-pects of mental wellbeing, and ability to cope with stress,in addition to symptom resolution, as critically impor-tant in determining whether a depressive episode was inremission.[10] Consistent with the hypothesis that remis-sion entailed more than the absence of depressive symp-toms, in another report from the MIDAS project wefound that ratings of symptom severity, functional im-pairment from depression, and quality of life were eachsignificantly and independently associated with patients’subjectively perceived remission status.[18]

These studies suggested the value in developing anew outcome measure that broadly evaluated the do-mains that depressed patients considered important indetermining remission. The present study is the firstone to examine whether the RDQ can be used as ameasure of change. Previously, we established that pa-tients considered the multifactorial RDQ to be a moreaccurate indicator of their goals of treatment than apurely symptom measure.[12] In the second study ofthe RDQ in depressed patients who were in ongoing

TABLE 4. RDQ subscale scores in depressed patients who were and were not in remission according to the HamiltonDepression Scale

Remitters (n = 54) Nonremitters (n = 98)RDQ subscale Mean SD Mean SD t value

Total score 18.1 15.1 47.4 15.6 11.2a

Depression symptoms 4.0 4.3 12.1 5.0 10.4a

Other symptoms 2.1 2.4 5.9 2.7 8.8a

Coping ability 1.9 1.9 3.6 1.6 5.7a

Positive mental health 6.0 5.6 14.2 5.2 9.1a

Functioning 1.3 1.5 3.3 1.8 6.8a

Life satisfaction 1.5 1.9 4.3 1.8 8.8a

General sense of wellbeing 1.3 1.7 4.2 1.8 9.8a

aP < .001

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Research Article: The Remission from Depression Questionnaire 537

treatment, we found that the scale had excellent psycho-metric properties.[11]

In the present study we found that the RDQ was assensitive to change as the QIDS and HAMD. The ef-fect size of each of the scales was nearly identical. How-ever, among the RDQ subscales there was variability inthe effect sizes, and the coping and functioning subscaleshad lower effect sizes than the depression symptoms sub-scale, and changes in these subscales were the least highlycorrelated with changes in HAMD scores. One inter-pretation of this finding is that these dimensions changemore slowly than other facets of depression and the max-imal benefit of treatment had not yet been achieved by4 months. Alternatively, it is possible that these dimen-sions are more resistant to improvement, that they mighthave improved as much as they are going to, and theless robust changes reflect a less complete, albeit moreaccurate, level of improvement.

Recently, other researchers have also advocated abroader conceptualization of remission. Nease et al.[19]

developed a five-item measure (the Remission Evalua-tion and Mood Inventory Tool (REMIT) to assess otherfactors beyond depressive symptoms that characterizeremission in the primary care setting. They viewed theirmeasure as an adjunct to measures of depressive symp-toms in order to more fully evaluate the effectivenessof treatment. Consistent with other research from ourgroup[18] they found a substantial level of discordancebetween scores on a measure of depressive symptomsand the REMIT.

A limitation of the current study was that it was basedin a large, general adult outpatient private practice set-ting in which patients had health insurance. Replica-tion in samples with other demographic characteris-tics is warranted. Future studies should examine if allconstructs assessed by the RDQ are independently as-sociated with remission. At this stage of the scale’s de-velopment we considered it premature to examine thisissue and eliminate some of the RDQ’s subscales. Ourstudies of the RDQ have thus far focused on outpa-tients with major depressive disorder. Additional studyof the measure in patients with bipolar depression, andminor depression, are warranted. In the present study,we did not collect information on the patients’ educa-tion level, ethnicity, socioeconomic status, and employ-ment status. Future research should examine the impactof these factors on the psychometrics of the RDQ andwhether they impact on the scale’s performance as anoutcome measure. Also, we did not evaluate diagnos-tic comorbidity and how this might differentially impactupon an outcome measure assessing only symptoms ver-sus a broader-based scale.

A single question was used to evaluate the patient’sself-perception of remission status. In asking this ques-tion the term remission was not defined. It is thereforepossible that patients varied in their conceptualizationsof this construct. Perhaps some did not even know whatit meant. However, this would have introduced errorvariance, and would not account for predicted differ-

ences in symptom levels and functioning between pa-tients who answered this question in the affirmative andnegative.[20,21] Lack of understanding of the term re-mission is also unlikely to be responsible for the RDQ’ssignificant association with patients’ self-reported remis-sion status after controlling for QIDS scores whereas theQIDS was not similarly associated after controlling forRDQ scores.

In conclusion, the present study demonstrated thatthe RDQ is as sensitive to change as purely symptom-based scales such as the QIDS and HAMD. Moreover,this is the second study to demonstrate that the mul-tidimensional RDQ was associated with patients’ self-perception of their remission status after controllingfor the QIDS scores but the QIDS was not associatedwith self-perceived remission after controlling for RDQscores. The RDQ allows clinicians and researchers togain a broader perspective of depressed patients’ statusthan symptom measures, and is more consistent with abiopsychosocial approach toward the treatment of de-pression, and therefore is a potentially useful addition tothe compendium of scales used to evaluate outcome intreating depression.

REFERENCES1. American Psychiatric Association. Practice Guideline for the

Treatment of Patients With Major Depressive Disorder. Wash-ington, DC: American Psychiatric Association; 2010.

2. Faravelli C, Ambonetti A, Pallanti S, Pazzagli A. Depressive re-lapses and incomplete recovery from index episode. Am J Psychi-atry 1986;143:888–891.

3. Judd L, Paulus M, Schettler P, et al. Does incomplete recoveryfrom first lifetime major depressive episode herald a chronic courseof illness? Am J Psychiatry 2000;157:1501–1504.

4. Judd LL, Akiskal HS, Maser JD, et al. Major depressive dis-order: a prospective study of residual subthreshold depressivesymptoms as predictor of rapid relapse. J Affect Disord 1998;50:97–108.

5. Paykel ES, Ramana R, Cooper Z, Hayhurst H, Kerr J, Barocka A.Residual symptoms after partial remission: an important outcomein depression. Psychol Med 1995;25:1171–1180.

6. Thase ME, Simons AD, McGeary J, et al. Relapse after cognitivebehavior therapy of depression: Potential implications for longercourses of treatment. Am J Psychiatry 1992;149:1046–1052.

7. Simons A, Murphy G, Levine J, Wetzel R. Cognitive therapy andpharmacotherapy for depression. Sustained improvement overone year. Arch Gen Psychiatry 1986;43:43–48.

8. Keller M. Past, present, and future directions for defining optimaltreatment outcome in depression. JAMA 2003;289:3152–3160.

9. Hamilton M. A rating scale for depression. J Neurol NeurosurgPsychiatry 1960;23:56–62.

10. Zimmerman M, McGlinchey J, Posternak M, Friedman M, At-tiullah N, Boerescu D. How should remission from depressionbe defined? The depressed patient’s perspective. Am J Psychiatry2006;163:148–150.

11. Zimmerman M, Martinez J, Attiullah N, et al. A new type of scalefor determining remission from depression: The Remission fromDepression Questionnaire. J Psychiatr Res 2013;47:78–82.

12. Zimmerman M, Galione J, Attiullah N, et al. Depressed pa-tients perspectives of two measures of outcome: The QuickInventory of Depressive Symptomatology (QIDS) and the

Depression and Anxiety

538 Zimmerman et al.

Remission from Depression Questionnaire (RDQ). Ann Clin Psy-chiatry 2011;23:208–212.

13. Rush A, Trivedi M, Ibrahim H, et al. The 16-Item Quick In-ventory of Depressive Symptomatology (QIDS), clinician rating(QIDS-C), and self-report (QIDS-SR): a psychometric evalua-tion in patients with chronic major depression. Biol Psychiatry2003;54:573–583.

14. Trivedi M, Rush A, Wisniewski S, et al. Evaluation of outcomeswith citalopram for depression using measurement-based carein STAR*D implications for clinical practice. Am J Psychiatry2006;163:28–40.

15. First MB, Spitzer RL, Gibbon M, Williams JBW. StructuredClinical Interview for DSM-IV Axis I Disorders – Patientedition (SCID-I/P, version 2.0). New York, NY: BiometricsResearch Department, New York State Psychiatric Institute;1995.

16. Cohen J. Statistical Power Analysis for the Behavioral Sci-ences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates;1988.

17. Cumming G. Understanding The New Statistics: Effect Sizes,Confidence Intervals, and Meta-Analysis. New York, NY: Rout-ledge; 2012.

18. Zimmerman M, McGlinchey JB, Posternak M, Friedman M,Boerescu D, Attiullah N. Remission in depressed patients:more than just symptom resolution. J Psychiatr Res 2008;42:797–801.

19. Nease DJ, Aikens JE, Klinkman MS, Kroenke K, Sen A. Towarda more comprehensive assessment of depression remission: theRemission Evaluation and Mood Inventory Tool (REMIT). GenHosp Psychiatry 2011;33:279–286.

20. Zimmerman M, Martinez J, Attiullah N, et al. Why do some de-pressed outpatients who are in remission according to the Hamil-ton Depression Rating Scale not consider themselves to be inremission? J Clin Psychiatry 2012;73:790–795.

21. Zimmerman M, Martinez J, Attiullah N, et al. Further evidencethat the cutoff to define remission on the 17-item HamiltonDepression Rating Scale should be lowered. Depress Anxiety2012;29:159–165.

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