Psychiatric Symptom Assessment Scale Research Articles

Geriatric patients improve as much as younger patients from hospitalization on general psychiatric units.

To determine whether geriatric patients aged 65 and older on general adult psychiatric units improve as much as younger patients, over what duration their improvement occurs, and their risk of readmission. Cohort study. Inpatient psychiatric unit of an urban, university-affiliated, county hospital from January 1993 through August 1999. A total of 5,929 inpatients. Standardized, routine assessments by attending psychiatrists included the Psychiatric Symptom Assessment Scale (PSAS) on admission and discharge. Discharge scores, length of stay (LOS), and risk of readmission within 1 year were modeled for the groups using multiple regression analyses. Geriatric patients constituted 5% (n=299) of the 5,929 admissions. In multivariate analysis, geriatric status was not associated with discharge PSAS scores. Median LOS was longer for geriatric patients (16 days) than younger patients (10 days, P<.001), especially in older women (14 days) and geriatric patients with mild medical illness severity (13 days vs 11 days in those with moderate-to-severe medical illness). Geriatric patients were as likely to be readmitted within 1 year of discharge as younger patients. Geriatric patients on general inpatient psychiatry units improved as much as younger patients. Their longer LOS was associated with milder medical illness severity. There may be a role for more specialized care of elderly women or geriatric patients with mild to moderate medical illness to improve the efficiency of their care.

Transfer of care between physician teams does not affect length of stay or symptomatic improvement in hospitalized psychiatric patients

To determine if the length of stay, discharge against medical advice (AMA) or psychiatric symptom severity differs when patients are treated by a single team of physicians versus transfer to a second team all cases ( N=1304) admitted to the high intensity psychiatric unit then transferred to a lower intensity unit of a single hospital over 39 months were reviewed. A modified version of the Psychiatric Symptom Assessment Scale (PSAS) was completed on admission and discharge. Statistical analyses including linear and logistic regressions were performed. We found that the length of stay (mean ±SD) was 18.7±10.9 days for transferred patients ( N=871) and 18.3± 10.6 days for those cared for by only one team ( P=.507). Discharge PSAS scores (11.8±9.4 for transferred patients and 14.2±10.4 for those who kept their physicians), were not different between groups after adjustment for severity on admission. Discharges against medical advice were not different between the groups ( P=.207). Although the previous internal medicine literature and single psychiatric study describe a longer length of stay for those patients transferred between physicians, this study shows no differences in terms of length of stay, severity on discharge or AMA discharge rate.

Neuroleptic withdrawal in treatment-resistant patients with schizophrenia: tardive dyskinesia is not associated with supersensitive psychosis

The objective of this retrospective study was to determine whether tardive dyskinesia (TD) represents a risk factor for supersensitive psychosis (SS) by assessing the effect of medication withdrawal on ratings of psychopathology for 30 days following discontinuation of antipsychotic medication in patients with and without TD. The subjects were 101 treatment-resistant patients with schizophrenia who had been admitted to the inpatient service of Neuroscience Research Hospital (NRH), National Institute of Mental Health, between 1982 and 1994 to undergo studies involving discontinuation of antipsychotic medication. Patients were rated independently on a daily basis on the 22-item Psychiatric Symptom Assessment Scale (PSAS), an extended version of the Brief Psychiatric Rating Scale (BPRS). The overall frequency of TD was 35.6%. Tardive dyskinesia patients were older ( p<0.0006) and had suffered from schizophrenia for a longer time ( p<0.003) than No-TD patients. Repeated measure ANOVA revealed a “time” effect for all subgroups studied. The interaction TD×time, however, was not statistically significant for any of the clusters. Within-group analysis revealed significant differences against baseline for measures of positive symptoms, negative symptoms and abnormal involuntary movements in the No-TD group 3 and 4 weeks after antipsychotic withdrawal. In the TD group, however, the changes were observed only at 4 weeks following antipsychotic discontinuation in just two of the positive symptoms cluster. Between-group analyses revealed that, at baseline, the Mannerisms cluster (abnormal involuntary movements) was significantly higher in the TD group ( p<0.05). No significant differences were observed between any of the remaining clusters at baseline or at different times following drug withdrawal. In conclusion, the relationship between SS and TD could not be confirmed in a cohort of patients with treatment-resistant schizophrenia. In the present study, patients with no TD seemed to deteriorate faster than patients with TD in terms of psychopathology and abnormal involuntary movements. It is possible that both group of patients may undergo supersensitive receptor changes, and that these changes may be more pronounced but potentially reversible in the group without TD.

Psychometric properties and utility of the problem severity summary for adults with serious mental illness.

The authors studied the psychometric properties and utility of the Problem Severity Summary (PSS), a 13-item instrument that assesses symptom severity and functioning among adults with severe and persistent mental illness. Case managers rated the PSS among more than 1,000 adults with severe and persistent mental illness who were receiving services at either mainstream community mental health centers or specialty community mental health centers (serving various minority groups) in one county in Washington State. A subsample of clients was used to assess the concurrent validity of the PSS with the Psychiatric Symptom Assessment Scale. Interrater reliability was adequate for ten of the 13 PSS items. Four meaningful factors were derived, each with adequate internal consistency: community functioning, negative social behavior, affective distress, and psychotic disturbance. The PSS demonstrated adequate concurrent and predictive validity. Sensitivity of the PSS factors to change showed that scores on three of the four scales changed significantly over one year. Discriminant validity indicated that the PSS is generally unbiased in terms of demographic characteristics. The PSS is a brief, easily administered instrument that shows psychometric promise for use in clinical contexts, such as treatment planning, concurrent review of care, and guidance for level-of-care decisions, as well as for quality management purposes.

Effects of smoking during antipsychotic withdrawal in patients with chronic schizophrenia

A number of studies have shown that patients with schizophrenia smoke more than other psychiatric patients and more than the general population. Also, medicated schizophrenics who smoke present more positive symptoms of schizophrenia than non-smokers. The objective of the present study was to assess the effect of smoking on ratings of psychopathology for 30 days following discontinuation of antipsychotic medication. The subjects were 101 treatment-resistant patients with schizophrenia who had been admitted to the inpatient service of Neuroscience Research Hospital (NRH), National Institute of Mental Health, between 1982 and 1994 to undergo studies involving discontinuation of antipsychotic medication. Patients were rated independently on a daily basis on the 22-item Psychiatric Symptom Assessment Scale (PSAS), an extended version of the Brief Psychiatric Rating Scale (BPRS). At baseline, ratings for Verbal Positive, Paranoia and Loss of Function were higher in smokers ( n=65) than non-smokers ( n=36), but a statistically significant difference was observed only for the Verbal Positive cluster. Analysis by gender revealed that male non-smokers had the lowest psychopathology ratings at baseline. There were no differences in Anxiety/depression, Behavior Positive, Deficit Symptoms or Mannerisms (a measure for abnormal involuntary movements). Following medication discontinuation, repeated-measure analysis demonstrated a ‘time’ effect for all the variables studied and a ‘group’ (smokers vs. non-smokers) effect for Verbal Positive, Paranoia, and Loss of Function. Post-hoc comparisons at individual time points showed significantly higher ratings for smokers at week 1 for Paranoia. No differences were observed at later time points. In conclusion, at baseline, smokers had more positive symptoms and were apparently more functionally impaired than non-smokers. This difference was no longer evident after a 30 day medication discontinuation period.

The long-term effects of placebo in patients with chronic schizophrenia

Background: It has been hypothesized that placebo periods may increase long-term morbidity for patients with schizophrenia. In this study, the long-term effect of a placebo period was evaluated in a group of relatively treatment-refractory patients with chronic schizophrenia. Methods: This retrospective study examined behavioral rating scores for 127 patients with chronic schizophrenia who were placed in a double-blind placebo study on the inpatient units of the National Institute of Mental Health Neuropsychiatric Research Hospital. Patients were rated daily with the Psychiatric Symptom Assessment Scale (PSAS), an extended and anchored version of the Brief Psychiatric Rating Scale (BPRS). At the end of the placebo phase, most patients were placed on haloperidol. Pre-placebo baseline PSAS ratings were compared with, first, discharge ratings and second, post-placebo ratings. To determine expected variability in the course of illness, patients in the placebo group were compared with patients hospitalized during the same time period, but who did not enter the placebo study. Results: By discharge, ratings for placebo patients had returned to baseline. Post-placebo ratings were quite variable. Although many of the placebo patients had returned to baseline by day 3 of the post-placebo phase, others had not returned to baseline by post-placebo day 42. PSAS Total Scores for patients who left the study early were no different at baseline, placebo, or through post-placebo day 35 compared with patients who completed the study. Conclusions: The results indicate that given a sufficiently lengthy recovery period, patients with chronic schizophrenia who go through a placebo phase return to baseline, but that the speed with which they attain that recovery is highly variable. Biol Psychiatry 1999;46:1092–1105

OUTCOMES OF PSYCHIATRIC HOSPITALIZATIONS: GERIATRIC VS. YOUNGER PATIENTS

Objective: To determine whether outcomes for geriatric (65 yrs) inpatients were worse than for younger patients treated in the same units. Methods: All inpatient psychiatry admissions in a 75-bed inpatient psychiatric unit of an urban, university affiliated, county hospital from January 1993 through June 1997 were reviewed. Standardized, routine assessments by attending psychiatrists include the Psychiatric Symptom Assessment Scale (PSAS), a 23-item instrument similar to the Brief Psychiatric Rating Scale, on admission and discharge. Discharge scores and length of stay were compared between the groups in multivariable analysis of variance models adjusting for admission score, gender, race, severity of medical illness, substance abuse, involuntary hold status, and diagnosis. Results: 187 (5%) of the 3,541 admissions were for geriatric patients. Mean (±SD) PSAS scores on admission were 34.8±16.0 in geriatric patients vs. 33.4±14.6 in younger patients, (P=0.2). In the multivariable analysis, geriatric status was not significantly associated with discharge score. Geriatric patients were found to have significantly longer adjusted lengths of stay, mean 18 vs. 14 days, especially for depressed patients, mean 19 vs.12 days (P<0.001). Conclusion: Although clinical outcomes are comparable between age groups, geriatric patients stay significantly longer. There may be a role for more specialized care of depressed geriatric patients if it can achieve equal or greater improvement over a shorter length of stay. P82

The impact of seclusion on the treatment outcomes of psychotic in-patients.

The controversial practice of seclusion for the treatment of the acutely emotionally ill continues despite a lack of proven effectiveness. This retrospective cohort study examined the impact of seclusion alone and in combination with other important patient-centred treatment variables (medications), disease severity variables, psycho-social and demographic variables that best predicted outcome (as defined by length of hospital stay and reduced pathology at discharge) for a group of consecutively admitted psychotic in-patients. Comparisons of baseline and outcome measures for secluded and non-secluded cohorts were made via t-test analysis, and patient-related variables were entered as groups for stepwise regression analysis to determine those factors that could best predict outcome. Data were collected via a comprehensive chart review of 85 patients with psychosis, who were consecutively admitted over an 8-month period to a psychiatric in-patient unit of a general community hospital in southern Ontario, Canada. Bigelow's Psychiatric Symptom Assessment Scale (PSAS) was applied to the chart admission and discharge data to determine both initial pathology scores and pathology change scores. Investigator-developed global rating scales measured the early pharmacological and psycho-social variables of interest. Although seclusion itself did not appear to be associated with any more or less improvement in mental status at discharge, seclusion was associated with a 12-day increase in length of hospital stay, raising additional questions about its therapeutic effectiveness. Early medication response together with seclusion predicted 16% of the total variance of length of hospital stay (P = 0.0011) while baseline pathology, being married and being employed together predicted 66% of reduced pathology at discharge (P = 0. 00001). Secluded subjects experienced an earlier age of illness onset, were employed or full-time students, exhibited poorer attitude towards hospital, were more likely to be substance or drug abusers, received greater doses of chlorpromazine-equivalent medications, and had longer lengths of hospital stay than their non-secluded cohorts. Two predictive regression equations were formulated on the basis of these results. This study has raised several questions for further prospective investigation, has validated previous findings in the literature, and has produced new findings that may be of interest to administrators and clinicians providing quality care to this high-risk population.

Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital.

The study examined predictors of discharge against medical advice (AMA) and outcomes of psychiatric patients with AMA discharges, as measured by poorer symptom ratings at discharge and higher rates of rehospitalization. A total of 195 patients discharged AMA from general hospital psychiatric units were compared retrospectively with 2,230 regularly discharged patients. AMA status was defined as signing out against medical advice, being absent without leave, or being administratively discharged. All patients received standardized assessments within 24 hours of admission and at discharge. Demographic characteristics, psychiatric history, DSA-IV psychiatric and substance use diagnoses, and scores on an expanded 32-item version of the Psychiatric Symptom Assessment Scale were compared. The groups did not differ in primary psychiatric diagnoses. Patients discharged AMA were significantly less likely to be Caucasian or to be functionally impaired due to physical illness. They were more likely to live alone, have a substance use diagnosis, use more psychoactive substances, and have more previous hospitalizations. Patients discharged AMA had significantly shorter lengths of stay, higher rehospitalization rates, and more severe symptoms at discharge, even when length of stay was taken into account. The differences between the groups in male gender and young age were better accounted for by a greater likelihood of substance abuse in these groups. The results suggest a profile of patients who may be discharged AMA. Such patients have worse outcomes and are more likely to be high utilizers of inpatient resources. Aggressive identification of patients likely to be discharged AMA and early discharge planning for appropriate outpatient treatment are recommended.

Psychiatric symptoms in a community-based medically ill population.

Twenty-five home health nurses used the Psychiatric Symptom Assessment Scale to assess the prevalence of psychiatric symptoms in a convenience sample of 176 medically ill clients in their caseloads. Psychiatric symptoms were observed in 74% of the clients, with somatic concerns, anxiety statements, depressive mood, tension, and helpless/hopeless statements being the most prevalent symptoms. Although most symptoms were rated as mild or moderate, several clients had severe symptoms. Implications for nursing care are discussed.

Pros-Methylimidazoleacetic Acid in Cerebrospinal Fluid of Patients with Chronic Schizophrenia: Relationships to Ratings of Symptoms, Ventricular Brain Ratios, and Rates of Urine Excretion

Concentrations of pros-methylimidazoleacetic acid (p-MIAA) were measured in cerebrospinal fluid of 30 patients with chronic schizophrenia. Levels of p-MIAA correlated negatively with mean scores of the Psychiatric Symptom Assessment Scale for positive symptoms (r = -0.48), but not negative symptoms, and with ventricular brain ratios (r = -0.48). Patients with abnormal ventricular enlargements had much lower concentrations of p-MIAA than those with normal ventricles. These results suggest that processes that reduce accumulation of p-MIAA in CSF may be associated with increased severity of symptoms among patients with chronic schizophrenia.

Histamine metabolites in cerebrospinal fluid of patients with chronic schizophrenia: their relationships to levels of other aminergic transmitters and ratings of symptoms

Levels of the histamine metabolites, tele-methylhistamine (t-MH) and tele-methylimidazoleacetic acid (t-MIAA), and metabolites of other aminergic transmitters and of norepinephrine were measured in cerebrospinal fluid of 36 inpatients with chronic schizophrenia and eight controls. The mean t-MH level from controls was nearly identical to the levels seen previously in healthy volunteers. Compared with controls, the mean level of t-MH in the schizophrenic patients was 2.6-fold higher ( p=0.006); 21 of the patients had levels exceeding the range of controls. There was no significant difference ( p>0.05) in levels of other analytes, although the levels of t-MH correlated significantly with those of t-MIAA, homovanillic acid, 3,4-dihydroxyphenylacetic acid, norepinephrine, 3-methoxy-4-hydroxyphenylglycol and 5-hydroxyindoleacetic acid. The difference in levels of t-MH were not attributable to medication, since those taking ( n=10) or withdrawn from ( n=26) neuroleptic drugs had nearly the same mean levels of t-MH; each group had higher levels than controls (ANOVA: p<0.05). Patients with or without tardive dyskinesia showed no significant differences in means of any analyte. Only levels of t-MH among those with schizophrenia correlated with positive symptom scores on the Psychiatric Symptom Assessment Scale ( r s =0.45, p<0.02). The elevated levels of t-MH in cerebrospinal fluid, which represent histamine that was released and metabolized, suggest increased central histaminergic activity in patients with chronic schizophrenia.

A multidimensional approach to analysis of cerebrospinal fluid biogenic amines in schizophrenia: II. Correlations with psychopathology

As part of a multidimensional study of cerebrospinal fluid biogenic amine metabolites in schizophrenia, the relationship between neurochemical measures and psychopathology assessed using the Psychiatric Symptom Assessment Scale (PSAS) was analyzed. In a group of 20 unmedicated patients, 3,4-dihydroxyphenylacetic acid (DOPAC) was a predictor of symptom severity in a stepwise multiple regression model. Values of 3-hydroxykynurenine and metanephrine in the unmedicated state predicted clinical response in a stepwise multiple regression model, as measured by improvement in PSAS mean item score following 6 weeks on a standard dose of neuroleptic. In a subgroup of 14 patients in whom both off- and on-medication concentrations of cerebrospinal fluid biogenic amines and metabolites were measured, change in 3-hydroxykynurenine predicted clinical outcome in a multiple regression model. These findings point toward the need to examine the role of the kynurenine pathway of tryptophan metabolism in the pathophysiology of schizophrenia.

A clinical trial of nifedipine in schizophrenia and tardive dyskinesia

Effects of the dihydropyridine calcium channel inhibitor nifedipine on chronic schizophrenia and tardive dyskinesia were studied in an 8-week double-blind crossover trial. Four of the ten patients had tardive dyskinesia, and three of these were not receiving neuroleptics. No effects on symptoms of chronic schizophrenia were found using Psychiatric Symptom Assessment Scale ratings. In the four patients with tardive dyskinesia, an average improvement in total abnormal Involuntary Movement Scale scores of 57% was observed. These data suggest that dihydropyridine calcium channel inhibitors may be effective in the treatment of tardive dyskinesia in schizophrenic patients.

Haloperidol and Reduced Haloperidol Concentrations and Psychiatric Ratings in Schizophrenic Patients Treated with Ascorbic Acid

Recent reports have suggested an augmentation by ascorbic acid of haloperidol treatment of schizophrenic patients. This study was designed to examine whether pharmacokinetic interactions between ascorbic acid and haloperidol occur in this population. Eight male inpatients diagnosed as having chronic schizophrenia by DSM-III-R criteria and stabilized on a fixed dose of haloperidol were given oral doses of ascorbic acid, 4.5 grams daily, for 2 weeks in an open trial. Serum concentrations of haloperidol and is metabolite, reduced haloperidol, were measured by high performance liquid chromatography. Psychiatric symptoms were monitored using the Psychiatric Symptom Assessment Scale performed by nursing staff blind to the haloperidol status but not to the ascorbic acid dosage. The addition of ascorbic acid was not associated with any change in psychopathology in this group of patients, nor was there any apparent pharmacokinetic interaction with haloperidol.