GAF Scores Research Articles

Short-Term Effect of Combined ECT and Neuroleptic Therapy in Treatment-Resistant Schizophrenia

Treatment-resistant schizophrenia (TRS) is a critical public health concern. Short-term treatment with electroconvulsive therapy (ECT), combined with neuroleptics, may increase the response rate in patients with TRS, when compared with either treatment alone. We conducted an open-trial study in 59 patients with TRS with acute exacerbations, by using bilateral ECT combined with flupenthixol (dose range, 12-24 mg/day). After the first sign of clinical improvement, all patients had to pass a 3-week stabilization period during which their clinical improvement had to be sustained. The patients had to receive at least 20 ECT treatments before being considered unresponsive to ECT. Thirty-one patients were ECT responders by our criteria, 19 were non-responders, and nine were dropouts. The responder group had more male patients, paranoid type, of younger age, shorter duration of illness and duration of the current episode, less family history of schizophrenia, and higher pretreatment GAF scores. They received a lesser number of ECT treatments, a less electrical charge used, and lower doses of flupenthixol (p < 0.05). Both positive and negative symptoms improved (p < 0.05), but positive symptoms responded to a greater extent. This study supports the therapeutic efficacy of combined treatment with ECT and neuroleptic drugs. A consensus in the definition of TRS is urgently required.

What patient characteristics make therapists recommend psychodynamic psychotherapy or other treatment forms?

In order to study factors that psychodynamic therapists considered to be important for recommendation of treatment, psychiatric diagnoses (DSM-III-R Axes I and II and the GAF) as well as character traits assessed by the Karolinska Psychodynamic Profile (KAPP) were retrospectively assessed in interview case-notes of patients applying for psychodynamic psychotherapy. Recommendation of psychotherapy was predicted by the absence of a personality disorder and high GAF scores, but not by the presence of a psychiatric syndrome. The KAPP differentiated between patients with and without disorders on Axis II, but not on Axis I. Patients who were recommended psychodynamic psychotherapy were healthier on all central KAPP variables compared to those who were recommended other treatments, and they were also characterized by predominantly neurotic personality organization, with inhibition as the most prominent defence.

Costs of services for schizophrenic patients in Norway.

Estimates of the direct costs of mental health services for patients with schizophrenia are made from a registration of all patients seen during a period of 4 weeks in all treatment units serving 6 catchment areas. The estimates were based on unit costs. The total direct costs of mental health services for schizophrenic patients in Norway were estimated to be NOK 1158 million (US$ 164 million). In total, 74.3% of the costs are for long-term in-patient care, 19.7% are for acute and intermediate length in-patient care, and 6.0% are for out-patient and day care. The average costs of schizophrenic patients with a GAF score of 1-20 are almost twice those of patients with a GAF score of 21-40, and more than three times those of patients with a GAF score of 41-60.

Six-month clinical status as a predictor of 24-month clinical outcome in first-admission patients with schizophrenia.

The aim of this study was to determine whether clinical status at 6-month follow-up is a predictor of 2-year clinical status in first-admission schizophrenic patients. If short-term status is indeed a strong predictor of subsequent functioning, the relationship would support earlier initiation of aggressive interventions. An epidemiologically based sample of 162 first-admission schizophrenic patients was examined at index hospitalization and at 6- and 24-month follow-up, using a variety of diagnostic and clinical assessment instruments. Respondents were divided into three groups based on their 6-month clinical status: delusions or hallucinations present at 6-month follow-up with or without negative symptoms (n = 63); moderate to high levels of negative symptoms (but not positive symptoms) present (n = 42); neither positive nor negative symptoms present (n = 57). Differences in 24-month clinical functioning were evaluated (GAF scores, BPRS factors, role functioning, number of rehospitalizations, and illness course). No significant differences were found among the three groups on demographic characteristics, substance abuse history, or extent of treatment during the follow-up. At 24-month follow-up, respondents with positive psychotic symptoms at 6-month follow-up had the worst, and those with no positive or negative symptoms the best functioning, with the negative-symptom group intermediate on most indices. Thus, among schizophrenic patients, poor 6-month clinical status identified a patient subgroup at high risk for continued poor clinical status at 24 months, suggesting the need for earlier intensive intervention in an attempt to prevent this progression.

Patient satisfaction in a comprehensive sectorized psychiatric service: Study of a 1-year-treated incidence cohort

As part of The Nordic Comparative Study on Sectorized Psychiatry, an investigation of the quality of care in terms of patient satisfaction was performed in one of the seven participating centers, the Department of Psychiatry, Skellefteå, Sweden. The main study used a 1-year-treated incidence cohort, and all patients with 3 or more outpatient visits were included in the present sample?in total, 216 patients. The response rate was 55% (n=119). A rather thorough dropout analysis showed that severity of disorder or several social characteristics did not distinguish responders from non-responders. It is therefore assumed that the results are fairly representative of the included sample. The associations between levels of patient satisfaction and patient background characteristics, treatment and service characteristics, and the patient's initial expectations of treatment were examined. There was a high overall satisfaction with services. Satisfaction with information procedures and the perceived coinfluence in the treatment planning showed more negative results. Diagnosis, GAF score at index contact, various patient social characteristics, or initial level of expectations was not associated with the level of satisfaction with services. It is concluded that patient satisfaction studies using standardized measures are an important part of the quality assurance work of a comprehensive psychiatric service.

Lamotrigine as a promising approach to borderline personality: an open case series without concurrent DSM-IV major mood disorder

Background: Borderline personality disorder (BPD) has long defied definitive treatment. Such failure is reflected in repeated suicidal crises, often associated with dysphoric symptoms of a chronic fluctuating nature, whose labile intermittent character does suggest a subthreshold bipolar depressive mixed state. For all these reasons, we hypothesized that the anticonvulsant lamotrigine, touted to be a mood stabilizer with antidepressant properties, might be uniquely beneficial for these patients. Methods: From a base rate of about 300 patients in a community mental health center, we identified eight patients meeting seven or more of the DSM-IV criteria for BPD without concurrent major mood disorders. All patients presented with history of severe suicidal behavior, hostile depression and/or labile moods, stimulant and alcohol abuse, as well as multiple unprotected sexual encounters; one patient was actually HIV positive. All had failed previous trials with different antidepressants and mood stabilizers. All current medications were gradually withdrawn – and when necessary – patients kept on a low dose of a conventional neuroleptics for a few weeks, while lamotrigine was being gradually introduced in 25-mg weekly increments until the patient responded (up to 300 mg/day maximum). Results: Consistent with previous work by us and others, bipolar family history could be documented in three of eight BPD patients, and worsening on antidepressants in four of eight, providing indirect support to our conceptualization of BPD as a bipolar variant. One patient developed a rash on 25 mg and was dropped from the lamotrigine trial, while another patient was noncompliant. Three who failed lamotrigine, subsequently responded, respectively, to sertraline, lithium–thioridazine combination, and valproate. The remaining three patients showed a robust response to lamotrigine, ranging from 75 to 300 mg/day: their functioning jumped from a mean baseline DSM-IV GAF score in the 40’s to the 80’s during 3–4 months. Among all responders impulsive sexual, drug-taking and suicidal behaviors disappeared and no longer met the criteria for BPD. At an average follow-up of 1 year, they no longer meet criteria for BPD. Limitations: Open uncontrolled results on a small number of patients in a tertiary care center may not generalize to BPD patients at large. Conclusions: Overall, the BPD response to pharmacotherapy in the present case series was 75%. The fact that five of six pharmacotherapy responders required mood stabilizers, argues against the prevalent view that the depressions of borderline patients belong to unipolarity. Of BPD patients who completed the trial, 50% achieved sustained remission from their personality disorder with lamotrigine monotherapy. The dramatic nature of the response in patients refractory to all previous medication trials and maintenance of a robust response over 1 year, argue against a placebo effect. Controlled systematic investigation of lamotrigine in BPD is indicated.

Placement Predictors of Geropsychiatric Inpatients

This retrospective study examined all admissions from home to the Houston Veterans Affairs Medical Center geropsychiatric inpatient unit during a 20-month period. Mini-Mental State Examination, Brief Psychiatric Rating Scale, Hamilton Rating Scale for Depression, Cohen-Mansfield Agitation Inventory, and Global Assessment of Functioning were administered on admission and discharge. We found that patients admitted with a diagnosis of dementia were at high risk of placement in a nursing home (94% of cases), particularly those demented patients with more severe, refractory psychiatric and cognitive impairment. Discharge GAF scores appeared to be an important predictor of discharge status for all patients.

Outcome of psychiatric hospitalization for very low-functioning demented patients.

The authors determined the outcome of geropsychiatric hospitalization for 73 very low-functioning demented patients (GAF score < 21). General psychiatric symptoms, depression, and agitation decreased significantly, and mean GAF scores increased significantly, with no significant change in cognitive function. Psychiatric hospitalization can meaningfully improve function and quality of life even in this very impaired population. Despite these improvements many patients are discharged to more restrictive settings.

Long-term morbidity associated with delayed treatment of first admission schizophrenic patients: a re-analysis of the Camarillo State Hospital data

The authors examined data from a follow-up study of first admission schizophrenic patients treated with and without antipsychotic medications, who were discharged from the hospital within 6 months. It was predicted that patients who did not require antipsychotic medications for discharge would have a more favourable long-term outcome. The subjects were part of the Camarillo State Hospital study conducted by May and colleagues in the late 1950s and early 1960s. Patients had been randomly assigned to treatment with and without antipsychotic medications. The number of rehospitalization days and total prescribed chlorpromazine equivalents were calculated for each patient for the 2 years following discharge. In order to assess patients' continuing ability to function, 11 patients from each group who met DSM-IV criteria for schizophrenia were matched for age, educational status at first admission, race, and gender; their Global Assessment of Functioning Scale (GAF) score was estimated across a period of 6-7 years following discharge. During the second year following discharge, patients initially treated with antipsychotic medications required fewer rehospitalization days than the initially non-medicated patients. Furthermore, 6-7 years following initial discharge, those patients initially treated with medications were functioning at a higher level, as measured by GAF scores, than patients not initially treated with antipsychotic medications. The results of this study suggest that, at least for this subgroup of patients, early treatment with antipsychotic medications both decreases the immediate morbidity associated with schizophrenia, and prevents detrimental changes possibly related to prolonged untreated psychosis.

Impact of shorter lengths of stay on status at discharge in bipolar mania.

This study assesses the impact of shortening the inpatient length of stay on status at discharge in patients with mania. The authors performed a chart review on 131 patients with discharge diagnoses of bipolar disorder, current episode manic type, admitted to the private attending service at Colorado Psychiatric Hospital between 1985 and 1995. In 1990, a new program (the alternatives program) that provides a continuum of acute care services and shorter inpatient lengths of stay was instituted. Retrospectively assessed GAF, CGI, treatment outcome rating scores, and length of stay (LOS) were compared for the prealternatives (1985-1989), early alternatives (1990-1992), and recent alternatives (1993-1995) program treatment eras. A progressive decrease in inpatient LOS, duration of the acute care episodes, and total service utilization was seen across eras. Despite the more recent shortening in LOS, no significant differences were seen in GAF and treatment outcome rating scores at discharge. GAF and treatment outcome rating scores on hospital days 3 and 7, however, suggested that patients were improving more rapidly in the more recent eras. Inpatient LOS and duration of the acute care episodes have significantly decreased over the last 10 years, but patients appear no more ill at discharge. The authors postulate that changes in psychopharmacologic practice and the inpatient treatment model may have facilitated the more rapid clinical improvement seen in the more recent eras. The authors caution that we need prospective studies that include postdischarge follow-up to assess further the impact of shorter inpatient stays on the posthospital course of manic patients.

Urgent need for a Need Assessment Scale in monitoring social support: A validation study on the Swedish version of the Camberwell Assessment of Need

Ericson BG, Hansson J-H, Teike T. Urgent need for a Need Assessment Scale in monitoring social support. A validation study on the Swedish version of the Camberwell Assessment of Need. Nord J Psychiatry 1997;51:173–182. Oslo. ISSN 0803–9488.In the aftermath of the desinstitutionalion process the social needs of patients with severe mental illness have been put on the agenda both for policy makers and professional groups working in this field. To be able to develop carefully designed monitoring systems to attend to this group of patients, there is an urgent need for assessment tools in this work. The Camberwell Assessment of Need is a form for a comprehensive assessment of the needs of people with a severe mental illness. The content and construct validity of the Swedish CAN version was tried out on a group of 45 patients from the Department of Psychiatric Rehabilitation at the County Hospital of Jönköping, Sweden, using in interviews a survey of need areas, the GAF functioning scale, and a quality of life scale (QLS-100). The overall result shows a rather weak correlation between assessment made by the GAF scale and assessment by key workers with the CAN. However, when the data are broken down, some interesting correspondences are found. Using the chi-square test the need areas accommodation, self-care, and daytime activities correspond with high and low GAF score, respectively. Somewhat surprisingly, the QLS-100 scores and the patient scores of the CAN show an even poorer correspondence. We interpret this as showing that where the QLS-100 invites to judgements on a desired quality of life, CAN judgements are more directed toward assessing factual circumstances in the individual's everyday lie. We advocate further validity and reliability studies, since continuous changes in the support systems call for careful reasoning in addressing the difficult question of the relation between support and need

Routine evaluation of mental health: reliable information or worthless "guesstimates'?

Routine evaluation of mental health care systems necessitates a quick assessment of progress and outcome. This study was designed to determine the value of the GAF-scale in such applications. We allowed 104 raters from six therapeutic centres to rate five clinical case-vignettes. Interrater reliability was almost equal for raters within different professional categories. The highest and the lowest scores for each of the case-vignettes differed by between 39 and 45 points. The raters' biases ranged from -23 to +30 points, and random deviations were between 1 and 20 points. Systematic differences between centres were up to 6 points. Our main finding is that the reliability of GAF scores in routine settings proved unsatisfactory with entrained raters.

Self-image and personality traits in gender identity disorders: an empirical study.

Self-image and personality traits, measured by SASB and SCID screen respectively, were compared between transsexuals, patients diagnosed as Gender Identity Disorders of Adolescence and Adulthood, Non-transsexual Type (GIDAANT), and normal controls. Transsexual and GIDAANT patients differed significantly in both their self-image and personality traits. While both the transsexuals' and controls' self-images were positive with self-love, the GIDAANT patients had a negative self-image. On the SCID screen, the GIDAANT group fulfilled 39.8% of all axis II criteria; transsexuals fulfilled 28.6% versus 17.1% for the control group. Mean GAF scores (axis V) were 62, 70, and 83, respectively. For all patients a more negative self-image was significantly related to lower social functioning according to GAF and to more personality pathology according to SCID screen. The prevalence of additional clinical axis I and II disorders was about twice as high among GIDAANT patients as among transsexuals. Although the two conditions are closely related, we found more differences than similarities in the studied aspects and a clear tendency that the GIDAANT patients had more psychopathology overall. Although the transsexuals also differed significantly in some aspects from the controls, they showed less personality pathology and they had a normal self-image. Negative self-image, high degree of fulfilled axis II criteria, and low GAF scores seem to be corresponding factors and in this study clearly differentiate transsexuals from GIDAANT patients.

Axis V--Global Assessment of Functioning Scale. Evaluation of a self-report version.

The present study examines a self-report version of the Global Assessment of Functioning Scale according to Axis V (GAF self-report). The sample (n = 73) was a psychiatric outpatient population from a catchment area clinic. Patients with psychotic and organic mental disorders were not included. The diagnostic distribution on Axis I was similar to the findings from previous studies. Axis II disorders were identified among 47%, of whom a majority also had a concomitant Axis I disorder. The mean GAF expert score was 66.5 (range: 48-86). High complexity and severity of disorders and a high number of fulfilled Axis II criteria were significantly associated with low GAF scores. Independent expert ratings on GAF were correlated with the GAF self-report overall at r = 0.62, varying from 0.45 to 0.91 between different diagnostic groups. In general, the patients scored themselves lower (mean: -4.4 units) than expert ratings. Patients with depressive symptoms from an adjustment disorder or mood disorder were most prone to underestimation. Women also tended to score themselves lower than experts did. Conclusively, the GAF self-report turned out to be a valid and reliable unidimensional instrument measuring psychological, social and occupational functioning. The GAF is easy to handle, and with a self-report version as a complement, Axis V could be more frequently used in future clinical practice and research.

Social adjustment, coping style, and clinical course among DSM‐III‐R community unipolar depressives

AbstractThe study describes social adjustment and coping style among three DSM‐III‐R unipolar depression diagnostic groups (pure dystbymia, double depression, and pure major depression). The primary goal was to determine if these variables would discriminate between the groups. Also studied were the clinical course features of the unipolar groups. Data from 106 nontreatntent, community‐recruited subjects participating in a DSM‐IV mood disorders field trial at Virginia Commonwealth University were used for this study. Results indicated no differences in social adjustment and coping style among the pure dysthymia, double depression, and major depression groups. One exception was the significantly higher GAF scores among the pure dysthymia group. Clinical course differences were found between the two combined dysthymia groups (pure dysthymics and double depressives) when compared to the major depressive group. Dysthymics reported an earlier age of onset and a higher prevalence of insidious onset. Major depressives were able to pinpoint exacerbating stressors precipitating syndromal episodes. Depression 2:36–42 (1994). © 1994 Wiley‐Liss, Inc.

Recollections of Parental Behavior and Axis II Cluster Diagnosis

A group of psychiatric outpatients was classified according to whether they met criteria for an Axis II DSM-III-R diagnosis in the A, B, or C clusters. The subjects were also administered the Parental Bonding Index (PBI), which measures recollections of parental care and overprotection during childhood. PBI scores were able to differentiate patients in the three clusters and a comparison group of patients without a specific Axis II diagnosis, but were not predictors of GAF scores. GAF scores were lower in the more disturbed personality clusters.