Global Assessment Of Functioning Ratings Research Articles

Validity of the self-rated 36-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 as a measure of functioning in Swedish psychiatric outpatients

Purpose The aim of this study was to investigate concurrent validity of the Swedish self-rated 36-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 by comparison with professional Global Assessment of Functioning (GAF) ratings in psychiatric outpatients. Material and methods A cross-sectional convenience sample of 444 patients was recruited from their regular psychiatric outpatient settings. The patients filled out the WHODAS 2.0; their clinicians provided clinical information and performed GAF ratings blinded to the patients’ assessments. Analyses of correlations, variance components, and ROC curves were performed to investigate the validity of the WHODAS 2.0 through comparison with the GAF. The variance component analyses included working status, psychosocial problems, number of diagnostic groups, and remission status. GAF ratings were separated as total (GAF-T), symptoms (GAF-S), and functioning (GAF-F). Results There was significant correlation (p < 0.001) between WHODAS 2.0 total and domain scores and GAF-S, GAF-F, and GAF-T ratings. The correlations varied from r = 0.29 to r = 0.48, with the highest being between GAF-F rating and WHODAS 2.0 total score. Repeating the analyses for separate diagnostic groups replicated the findings, though not for psychotic, substance-related, and eating disorders. The WHODAS 2.0 showed good ability to distinguish impaired functioning below a fixed GAF-T cut-off of 70 (area under the curve: 0.74–0.78). The explained variance was lower for the WHODAS 2.0 than for the GAF (38.9% vs. 59.2%). Conclusions Concurrent validity was found when comparing the Swedish self-administered 36-item version of WHODAS 2.0 with the expert-rated GAF in psychiatric outpatients.

Does a web-based feedback training program result in improved reliability in clinicians' ratings of the Global Assessment of Functioning (GAF) Scale?

The Global Assessment of Functioning (GAF) Scale is used in routine clinical practice and research to estimate symptom and functional severity and longitudinal change. Concerns about poor interrater reliability have been raised, and the present study evaluated the effect of a Web-based GAF training program designed to improve interrater reliability in routine clinical practice. Clinicians rated up to 20 vignettes online, and received deviation scores as immediate feedback (i.e., own scores compared with expert raters) after each rating. Growth curves of absolute SD scores across the vignettes were modeled. A linear mixed effects model, using the clinician's deviation scores from expert raters as the dependent variable, indicated an improvement in reliability during training. Moderation by content of scale (symptoms; functioning), scale range (average; extreme), previous experience with GAF rating, profession, and postgraduate training were assessed. Training reduced deviation scores for inexperienced GAF raters, for individuals in clinical professions other than nursing and medicine, and for individuals with no postgraduate specialization. In addition, training was most beneficial for cases with average severity of symptoms compared with cases with extreme severity. The results support the use of Web-based training with feedback routines as a means to improve the reliability of GAF ratings performed by clinicians in mental health practice. These results especially pertain to clinicians in mental health practice who do not have a masters or doctoral degree.

Equipercentile linking of scales measuring functioning and symptoms: Examining the GAF, SOFAS, CGI-S, and PANSS

The Global Assessment of Functioning (GAF) and the Social and Occupational Functioning Assessment Scale (SOFAS) are rating scales commonly used to assess the level of functioning in patients with schizophrenia. To understand the correspondence of scores between GAF and SOFAS, and what they mean from a clinical point of view, we examined the linkage of (a) GAF with SOFAS total scores, (b) GAF with Clinical Global Impressions Scale (CGI) and Positive and Negative Syndrome Scale (PANSS), and (c) SOFAS with CGI and PANSS. We used the equipercentile linking method to identify corresponding scores of simultaneous GAF, SOFAS, PANSS and CGI ratings in 1208 patients from a naturalistic European cohort study. Data were collected at baseline and at months 6, 12, 18 and 24. GAF and SOFAS total scores were found to be practically exchangeable. Both scales had strong negative correlations with CGI and PANSS; the linkage also suggested the presence of slight impairment in functioning even when patients are free from symptoms. These findings are important for the comparison of scores when different rating scales are used. We present a detailed conversion table in an online supplement.

P03-57 - Negative symptoms and functioning in first episode psychosis and chronic schizophrenia

IntroductionCourse and outcome in schizophrenia are heterogeneous. Numerous studies have shown an association between the presence of negative symptoms and psychosocial and occupational functioning of patients.ObjectivesTo analyse the prevalence of negative symptoms in the course of illness in first episode psychosis and chronic schizophrenia and to establish its relation with the functional outcome.Methods43 patients with a first-episode psychosis (FEP) from our area were compared with 43 chronic schizophrenic patients and 43 normal controls from a parallel area. They were matched one on one for age, gender and years of education. All subjects were compared regarding psychopathology and functional outcome terms. Patients were examined with Positive and Negative Syndrome Scale (PANSS) for clinical symptom. Longitudinal functionality was prospectively assessed with the Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) rating scales.ResultsWe found significant differences between FEP and chronic patients in negative symptom severity (t = -4.97, p&lt; 0.001) and global assessment of functioning (t = 7.58, p&lt; 0.001). There was no statistically significant difference between the two groups in PANSS positive and general components or Clinical Global Impression. Negative symptom severity was associated with poorer GAF ratings in first episode psychosis and chronic schizophrenia.ConclusionsNegative symptoms appear to be persistent. In our study negative symptom severity was associated with social and functional impairment, defined as Global Assessment of Functioning Scale score of less than or equal to 60.

The MIRECC Version of the Global Assessment of Functioning Scale: Reliability and Validity

This study examined the reliability and convergent, discriminant, and predictive validity of the Mental Illness Research, Education, and Clinical Center (MIRECC) version of the Global Assessment of Functioning (GAF) scale. The MIRECC GAF measures occupational functioning, social functioning, and symptom severity on three subscales. MIRECC GAF ratings were obtained for 398 individuals with schizophrenia or schizoaffective disorder who were receiving treatment at three Veterans Affairs mental health clinics. Assessments were completed by using the Positive and Negative Syndrome Scale and the Quality of Life Interview at baseline and nine months later. All three MIRECC GAF subscales exhibited very high levels of reliability. The occupational and symptom subscales showed good convergent and discriminant validity. The social subscale was related to measures of social functioning and, to a greater degree, symptom severity. The occupational and social subscales significantly predicted their respective domains at the nine-month follow-up. The symptom subscale predicted negative symptoms at follow-up; however, it did not predict positive symptoms or cognitive disorientation. Instead, the social subscale was predictive of cognitive disorientation at follow-up. When the standard GAF was routinely administered by clinicians, scores demonstrated little validity. The three MIRECC GAF subscales can be scored reliably, and they have good concurrent and predictive validity. Further work is needed on brief measures of patient functioning, especially measures of social functioning.

Characteristics of Psychotic Patients With Foreign Accent Syndrome

Characteristics of Psychotic Patients With Foreign Accent Syndrome

Psychosocial Functioning of Medicaid Recipients With Major Depression

Back to table of contents Previous article Next article LettersFull AccessLettersSteven C. Marcus Ph.D.Mark Olfson M.D., M.P.H.Steven C. Marcus Ph.D.Search for more papers by this authorMark Olfson M.D., M.P.H.Search for more papers by this authorPublished Online:1 Jul 2006https://doi.org/10.1176/ps.2006.57.7.1046AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Psychosocial Functioning of Medicaid Recipients With Major DepressionTo the Editor: Confounding of treatment selection by illness severity threatens many nonexperimental observational research designs that use administrative data to study mood disorders ( 1 , 2 ). In a study of antidepressants and suicide, for example, if depressed patients who receive antidepressants are more severely ill than ostensibly similar depressed patients who do not receive antidepressants, an observed association between antidepressant treatment and suicide may simply reflect this underlying selection bias. Because measures of illness severity are not routinely available in administrative data sets, it is unclear whether or to what extent this bias exists. We sought to evaluate whether psychosocial functioning differs among patients with major depressive disorder on the basis of their use of antidepressant medications or psychotherapy. We merged a 1993-1994 Medicaid claims database containing patient diagnostic and service use data with a community-tracking database that includes a clinician-administered Global Assessment of Functioning (GAF) ( 3 ) rating. During this period, there was a low level of managed care penetration and a high level of data completeness. Patients selected had received a diagnosis of major depressive disorder ( ICD-9 codes 296.2 or 296.3) that was preceded by a period of at least 60 days without antidepressant treatment and had also received a GAF rating within 60 days preceding the first noted diagnosis of major depressive disorder. Filled prescriptions for antidepressant medications were noted in the 60 days after the diagnosis of major depression. A similar algorithm was used to examine GAF ratings and use of psychotherapy. A total of 472 patients were identified for the antidepressant analysis; 159 (34 percent) had filled a prescription for an antidepressant in the 60 days after the diagnosis of major depressive disorder. The mean±SD GAF score of the group that initiated antidepressant medications (49.6±13.1) did not significantly differ from that of the group that did not initiate antidepressants (50.1±11.7). The GAF score of the 341 patients who received psychotherapy (50.3±12.2) was similar to that of the 175 patients who did not receive psychotherapy (49.7±12.0). The findings stratified by age (six to 20 years and 21 years and older) directly mirrored the overall findings for both antidepressant and psychotherapy use.Under these conditions, neither initiation of antidepressant medication nor psychotherapy treatment was significantly related to illness severity as measured by a clinician-administered GAF. The study's limitations include relatively small samples, a concern that clinician-administered GAF ratings are only weakly related to function and outcome ( 4 ), an absence of documented standardization of the GAF ratings, and temporal delays between the GAF ratings and treatment. Within the context of these limitations, the similarities in mean GAF ratings for these groups may help to reduce concern over confounding of treatment initiation and illness severity. Dr. Marcus is affiliated with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia. Dr. Olfson is with the Department of Psychiatry, College of Physicians and Surgeons of Columbia University and the New York State Psychiatric Institute, New York.

Pulmonary Artery Catheterization in Acute Coronary Syndromes: Insights From the GUSTO IIb and GUSTO III Trials

The Global Assessment of Functioning (GAF) and the Social and Occupational Functioning Assessment Scale (SOFAS) are rating scales commonly used to assess the level of functioning in patients with schizophrenia. To understand the correspondence of scores between GAF and SOFAS, and what they mean from a clinical point of view, we examined the linkage of (a) GAF with SOFAS total scores, (b) GAF with Clinical Global Impressions Scale (CGI) and Positive and Negative Syndrome Scale (PANSS), and (c) SOFAS with CGI and PANSS. We used the equipercentile linking method to identify corresponding scores of simultaneous GAF, SOFAS, PANSS and CGI ratings in 1208 patients from a naturalistic European cohort study. Data were collected at baseline and at months 6, 12, 18 and 24. GAF and SOFAS total scores were found to be practically exchangeable. Both scales had strong negative correlations with CGI and PANSS; the linkage also suggested the presence of slight impairment in functioning even when patients are free from symptoms. These findings are important for the comparison of scores when different rating scales are used. We present a detailed conversion table in an online supplement.

Special Section on the GAF: Continuity of Care and Clinical Outcomes in a National Health System

Continuity of care is widely viewed as a key quality indicator for outpatient mental health care. However, few studies have been conducted of the relationship between continuity of care and client outcomes. This study examined the relationship between measures of three aspects of continuity of care (regularity of care, continuity of treatment across organizational boundaries, and intensity of treatment) and the Global Assessment of Functioning (GAF), a single-item mental health status measure, in a national health care system. Three analytic samples were derived from a nationwide Department of Veterans Affairs administrative data set: patients with at least one inpatient GAF rating and a later outpatient GAF rating (N=8,334) and two groups who had at least two outpatient GAF ratings, one group that was beginning a new episode of treatment (N=49,946) and a second group in ongoing treatment (N=123,371). Hierarchical linear modeling was used to control for potential site-level autocorrelation and to adjust for differences in diagnostic status, sociodemographic characteristics, baseline GAF score, and the length of time between GAF ratings. Several positive and significant relationships were found for discharged inpatients and new outpatients. However, only a few of these relationships could be confidently said to be clinically meaningful. Specifically, among discharged inpatients, for every additional month in which an outpatient visit occurred over a six-month period, there was a .69 increase in the GAF change score for a total increase of 4.1 points. Among new outpatients the equivalent values were smaller, at .3 and 1.8. In contrast with the findings for discharged inpatients and new outpatients, high intensity of care was negatively associated with GAF change scores for continuing outpatients. In contrast with several earlier studies, this study showed positive and statistically significant associations between several continuity-of-care measures and client outcomes. These relationships were observed only in transitional treatment situations, that is, after hospital discharge and at the beginning an episode of outpatient care, situations in which continuity of care may be especially important. However, although positive and statistically significant, the magnitude of these effects may not have been clinically meaningful.

Brief Reports: A Comparison of the Aberrant Behavior Checklist and the GAF Among Adults With Mental Retardation and Mental Illness

Psychiatric assessment among individuals with a diagnosis of both mental retardation and mental illness presents a clinical challenge. This retrospective study compared two rating scales--the Aberrant Behavior Checklist (ABC) and the Global Assessment of Functioning (GAF)--to determine the scales' utility in a partial hospital setting. Although ABC and GAF ratings were weakly correlated, the ABC revealed symptom patterns consistent with recognizable features of psychiatric syndromes and differential improvement in symptoms within and between diagnostic subgroups. The ABC provided a more useful measure of treatment response than the GAF in this patient population.

Global Assessment of Functioning ratings and the allocation and outcomes of mental health services.

The Global Assessment of Functioning (GAF) is an integral part of the standard multiaxial psychiatric diagnostic system. The purpose of including the GAF in DSM-IV as a tool for axis V assessment is to enable clinicians to obtain information about global functioning to supplement existing data about symptoms and diagnoses and to help predict the allocation and outcomes of mental health treatment. The purpose of this study was to examine the value of the GAF as part of a systemwide program for monitoring the allocation and outcomes of mental health care services. Clinicians used the GAF to assess global functioning among 9,854 patients with psychiatric or substance use disorders, or both, who were already participating in an outcomes monitoring program of the Department of Veterans Affairs. A longitudinal prospective follow-up design was used. Patients' clinical diagnoses and symptoms were stronger predictors of GAF ratings than was their social or occupational functioning. GAF-rated impairment was associated with the provision of inpatient or residential care and outpatient psychiatric care, but patients with greater levels of impairment did not receive more treatment. GAF ratings were only minimally associated with treatment outcomes. No robust associations were found between GAF ratings and outcomes as assessed by clinician interview or by patients' self-report at follow-up. Including GAF ratings in a program for predicting the allocation and outcomes of mental health care is of questionable value. Research is needed to determine whether systematic training and ongoing validity checks would enhance the contribution of the GAF in monitoring service use and outcomes.

Global assessment of functioning (GAF) ratings: determinants and role as predictors of one-year treatment outcomes.

To assess the adequacy of global ratings of patients' psychosocial functioning, which are an integral part of the current system for obtaining multidimensional psychiatric diagnoses and are embodied by the Global Assessment of Functioning (GAF) Scale as AXIS V of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994). We identified a sample of 1,688 patients with substance use disorders, many of whom also had psychiatric disorders; examined the determinants of GAF ratings; and focused on how well these ratings predicted patients' one-year symptom and psychosocial functioning outcomes. Patients' clinical diagnoses and psychiatric symptoms were stronger predictors of GAF ratings than was their social and occupational functioning. Moreover, GAF ratings were only minimally associated with patients' one-year psychological, social, and occupational functioning outcomes. These findings raise serious questions about the conceptual and clinical value of the current standard method of assessing psychiatric and substance abuse patients' global functioning.