The Brief Psychiatric Rating Scale. Dimension of schizophrenia--reliability and construct validity

Fatores associados à qualidade de vida de pacientes com esquizofrenia

OBJETIVO: O tratamento de portadores de transtornos mentais graves e crônicos tem experimentado grandes mudanças no Brasil, com uma crescente valorização de tratamentos de base comunitária. Estes pacientes passam, concomitantemente, a receber um tratamento que valoriza antes a sua reinserção social e melhora das condições de vida, do que a mera abolição de seus sintomas principais. Assim, torna-se fundamental a avaliação da qualidade de vida dos pacientes vivendo na comunidade. MÉTODO: Uma revisão bibliográfica foi realizada com o objetivo de descrever a distribuição dos fatores sociodemográficos e clínicos que influenciam a qualidade de vida de indivíduos com esquizofrenia. RESULTADOS: Foram selecionados 25 estudos, a maior parte de países europeus. A maioria foi realizada na década de 90. Quase todos os estudos eram seccionais, e a maior parte avaliou amostras de indivíduos vivendo na comunidade. Os fatores sociodemográficos, excetuando a renda mensal, não se mostraram associados à qualidade de vida. Contudo, alguns estudos encontraram associações entre gênero, idade, estado civil e escolaridade com a qualidade de vida. Os sintomas depressivos e ansiosos se mostraram associados a uma pior qualidade de vida em diversos estudos. Observou-se associação similar quanto aos sintomas negativos e positivos da esquizofrenia, mas sem a mesma consistência. CONCLUSÕES: Os estudos não foram consistentes quanto à associação entre fatores sociodemográficos e clínicos e qualidade de vida de pacientes com esquizofrenia. É possível que essa heterogeneidade de achados seja decorrente tanto de aspectos vinculados à doença quanto ao desenho desses estudos, pouco adequados à investigação de associações causais.

Suicidality in bipolar I disorder

People with bipolar disorder are at high suicide risk. The literature suggests that suicidality is predicted by higher symptom severity and less use of pharmacological agents, but few studies have examined the joint contributions of these variables. The present study examines the conjoint contribution of symptom severity and pharmacological treatment to suicidal ideation and behavior among participants with bipolar disorder. The model was able to account for 53% of the variance in suicidality scores. Depression, mixed state, and hopelessness were significantly associated with suicidality. All other variables were nonsignificant once symptom severity had been controlled. Implications for future research are described.

Aripiprazole in schizophrenia with cocaine dependence: a pilot study

The debilitation of schizophrenia (SCHZ) worsens markedly with comorbid cocaine dependence (CD) and alcohol abuse. To date, no medications have conclusively demonstrated effects against both SCHZ and CD (SCHZ + CD) simultaneously. Because of its dopamine-modulating properties, we hypothesized that aripiprazole would alleviate cocaine craving in patients with SCHZ + CD. We conducted a prospective, 8-week, open-label trial in poorly compliant SCHZ + CD subjects. Each received aripiprazole as their sole neuroleptic agent at a maximum dose of 15 mg/d. The Brief Psychiatric Rating Scale (BPRS) and the Brief Substance Craving Scale (BSCS) measured psychosis and subjective cocaine and alcohol cravings. Urine tests for cocaine provided data on actual use. Of 10 male subjects entered, 6 (60%) completed the 8-week trial. In those cases, positive urine tests dropped significantly (P < 0.001) after 2 weeks, when aripiprazole had reached steady state. Mean cocaine craving scores declined significantly (P = 0.026) as did mean alcohol craving scores (P = 0.006). Declining psychosis scores were associated with declining cocaine craving (r = 0.87, P < 0.01) and alcohol craving (r = 0.88, P < 0.01), respectively. This experience suggests possible aripiprazole effects in lowering both desire for and the use of cocaine in comorbid SCHZ subjects. These data suggest double-blind, randomized, comparison study in this severely ill, comorbid patient group.

The InterSePT scale for suicidal thinking reliability and validity

BACKGROUND

The InterSePT Scale for Suicidal Thinking (ISST) is a 12-item instrument for the assessment of current suicidal ideation in patients with schizophrenia and schizoaffective disorders. We report the psychometric characteristics of this new scale based on two studies.

METHOD

In Study 1, 22 inpatients with schizophrenia and schizoaffective disorders, who had recently attempted suicide or engaged in suicidal ideation, were rated by three trained independent raters to examine interrater reliability. In Study 2, a total of 980 patients with schizophrenia or schizoaffective disorder with a history of suicidal ideation in the past 36 months were enrolled in a 2-year industry-sponsored suicide prevention study. At baseline, these patients were administered the ISST and the Clinical Global Impression Scale for Severity of Suicidality (CGI-SS) by the Principal Investigator (PI) and by a blinded rater (BR), who also administered the Positive and Negative Symptom Scale (PANSS), the Calgary Depression Scale (CDS), and the Scale of Functioning (SOF). Indices of internal reliability, construct and discriminant validity were examined.

RESULTS

The intraclass correlation coefficient (ICC) for the total ISST score for the 22 subjects in Study 1 was 0.90 and mean weighted item kappa coefficients ranged from 0.66 to 0.92. In Study 2, internal reliability (Cronbach alpha) was high, ranging from 0.86 to 0.89 for the individual items, and the overall Cronbach alpha coefficient for all items was 0.88. The ISST (PI) total score was highly correlated with the CGI-SS by the blind rater (r = 0.61, p < 0.0001). ISST total scores significantly differentiated the different levels of CGI-SS (F = 519.2; p < 0.0001). Results of construct and discriminant validity analyses are also presented.

CONCLUSION

The ISST is a reliable and valid instrument for the assessment of current suicidal thinking in patients with schizophrenia and schizoaffective disorder by both clinicians and researchers.

Personality and self-variables: important determinants of subjective quality of life in schizophrenia out-patients

OBJECTIVE

To investigate factors determining severely mentally ill patients' self-rated quality of life. The study hypothesized that objective life circumstances, personality, self-variables, and psychopathology would be determinants of quality of life.

METHOD

A total of 117 individuals with schizophrenia and related disorders were investigated. Structural equation modelling was used to: 1). investigate if one or more subfactors best described the covariance within each potential determinant and quality of life, 2). explore the relations between all variables and factors extracted in step 1.

RESULTS

A multi-factorial model indicated that a self-factor and two psychopathology factors worked as mediators of self-rated quality of life, in turn composed of an internal and an external aspect. Personality dimensions and objective life circumstances accounted directly or indirectly for substantial parts of quality of life.

CONCLUSION

The relative importance of individual characteristics and objective indices was shown. Trait-like properties, such as the self-factor and personality, explained most of the variation in self-rated quality of life.

Factor structure of Bech's version of the Brief Psychiatric Rating Scale in Brazilian patients

The objective of the present study was to evaluate the factor structure of Bech's version of the Brief Psychiatric Rating Scale (BPRS), translated into Portuguese. The BPRS was administered to a heterogeneous group of psychiatric inpatients (N = 98) and outpatients (N = 62) in a University Hospital. Each patient was evaluated from one to eight times. The interval between consecutive interviews was one week for the inpatients and one month for the outpatients. The results were submitted to factorial analysis. The internal consistency of the total scale and of each factor was also estimated. Factorial analysis followed by normalized orthogonal rotation (Varimax) yielded four factors: Withdrawal-Retardation, Thinking Disorder, Anxious-Depression and Activation. Internal consistency measured by Cronbach's alpha coefficient ranged from 0.766 to 0.879. The data show that the factor structure of the present instrument is similar to that of the American version of the BPRS which contains 18 items, except for the absence of the fifth factor of the latter scale, Hostile-Suspiciousness.

The relationship of personality dimensions as measured by the temperament and character inventory and quality of life in individuals with schizophrenia or schizoaffective disorder living in the community

The influence of personality factors on the appraisal of subjective quality of life in individuals with schizophrenia or schizoaffective disorder is not much investigated. The present study examined this relationship in a sample of 104 patients living in the community. The temperament and character inventory was used to assess personality and the Lancashire quality of life profile was used to assess quality of life. The results showed that lower levels of harm avoidance and higher levels of self-directedness were significantly correlated to a better subjective quality of life. Regression analyses controlling for psychopathology revealed that a higher level of self-directedness was significantly associated with a better subjective quality in all aspects measured and explained the variance in the latter in the range of 4-12%. It is concluded that personality factors are involved in severely mentally ill individuals' assessment of their quality of life and should be accounted for in evaluations of quality of life assessments. The strength and directions of this influence require further studies.

The relationship of personality dimensions as measured by the temperament and character inventory and quality of life in individuals with schizophrenia or schizoaffective disorder living in the community

The influence of personality factors on the appraisal of subjective quality of life in individuals with schizophrenia or schizoaffective disorder is not much investigated. The present study examined this relationship in a sample of 104 patients living in the community. The temperament and character inventory was used to assess personality and the Lancashire quality of life profile was used to assess quality of life. The results showed that lower levels of harm avoidance and higher levels of self-directedness were significantly correlated to a better subjective quality of life. Regression analyses controlling for psychopathology revealed that a higher level of self-directedness was significantly associated with a better subjective quality in all aspects measured and explained the variance in the latter in the range of 4-12%. It is concluded that personality factors are involved in severely mentally ill individuals' assessment of their quality of life and should be accounted for in evaluations of quality of life assessments. The strength and directions of this influence require further studies.

A structured interview guide increases Brief Psychiatric Rating Scale reliability in raters with low clinical experience

OBJECTIVE

To assess the beneficial impact of a structured interview on the reliability of BPRS ratings in raters with low clinical experience.

METHOD

Each patient was rated once a week in two separate interviews, conducted on the same day. The first interview was conducted by a rater with low clinical experience (recruited from a group of five residents in psychiatry and one clinical psychologist in training). All second interviews were conducted by the same highly experienced psychiatrist.

RESULTS

The number of items with full agreement between observers increased with the use of SIG. The value of intraclass correlation coefficients for individual items and the total score also increased, approaching reported studies with experienced raters.

CONCLUSION

These results suggest that the use of SIG reduces variability of information gathering in reliability testing of BPRS with less experienced raters.

Interrater reliability of the Brief Psychiatric Rating Scale used at a community-based inpatient crisis stabilization unit

In 1993, the State of Georgia passed a law reforming the mental health system to include more consumers of services and their families on local boards, to provide services in the community, and to measure and report the outcomes of these services. As mental health services expanded in the community, it became necessary to extend the use of reliable and valid instruments appropriate to a brief treatment setting. This field study investigates the usefulness of the Brief Psychiatric Rating Scale (BPRS) using paired ratings to measure the level of psychiatric symptoms of clients treated in an urban community inpatient crisis stabilization unit. Interrater agreement for all paired assessments exceeded .85 comparing favorably with previous studies reported in the literature. The BPRS was found to be a useful and efficient instrument in this community setting.

Neuropsychological correlates of positive vs. negative schizophrenic symptomatology

This study attempts to further the validity of the subtype hypothesis in schizophrenia by testing the relationship of neuropsychological functions in schizophrenics with predominantly positive vs. negative symptoms. The Brief Psychiatric Rating Scale (BPRS) was used to parse schizophrenics into positive and negative symptom groups, while a neuropsychological test battery was administered to both types of patients. The results indicate that positive schizophrenic symptomatology is related to frontal executive tasks, whereas negative schizophrenic symptomatology is related to mental tracking tasks that require motoric and dexterous manipulation. However, the absence of non-overlapping symptomatic and neuropsychological functioning groups raises the possibility that a three or more factor model may be more reasonable for reflecting the variety of symptom and neuropsychological patterns in patients, rather than the two-type positive vs. negative dichotomy. The results further the hypothesis that schizophrenia is not a single disease entity.

Dimensions of the Brief Psychiatric Rating Scale: an examination of stability during haloperidol treatment

The purpose of the study was to investigate invariance of the factor structure of the Brief Psychiatric Rating Scale (BPRS) during haloperidol treatment. Data were collected in a placebo-controlled, double-blind, crossover treatment study examining the relationship between haloperidol plasma level and clinical outcome. Subjects were 173 acutely exacerbated, newly admitted patients with a diagnosis of schizophrenia or schizoaffective disorder. Exploratory (EFA) and confirmatory (CFA) factor analyses were performed at four time points: (1) last day of the preplacebo period; (2) last day of the placebo period; (3) end of the first treatment week; and (4) end of the treatment period. EFAs demonstrated (1) good reproducibility of commonly used BPRS factors at the preplacebo time point, (2) substantial changes in the factor structure during the placebo period, and (3) a reemergence of the initial (preplacebo) factor structure for most of the factors during haloperidol treatment. CFAs showed that traditional clinical factors were correlated with each other at all time points and that there were substantial changes in correlation among these factors over time. Our results suggest that longitudinal applications of traditional BPRS subscales should take factorial stability over time into consideration. Since many clinical trials use placebo data as a standard for longitudinal comparisons, further psychometric investigation is necessary to increase construct reliability and temporal stability.

Agreement in psychiatric assessment

In 103 schizophrenic patients we investigated the extent of practice needed in the use of the Brief Psychiatric Rating Scale (BPRS) to enable its reliability to be assessed. The agreement level of the 7 raters was analysed. Generally, the lowest mean agreement found was for the negative symptoms of the BPRS schizophrenia subscale. A high degree of agreement was attained both for the positive symptoms of the BPRS schizophrenia subscale and for the symptoms of the depression--and of the mania subscale. The degree of disagreement observed was due to both individual differences in assessment ability and the rating procedure. These results indicate that it is necessary to state the degree of agreement achieved in studies in which several raters are taking part.

Diagnostic and classification systems with special emphasis on the Minicompendium

With the introduction of major tranquillizers more than three decades ago symptom rating scales were soon accepted as the method of evaluating their clinical effects. The Mini-compendium is a collection of rating scales for measuring outcome of antianxiety drugs, antidepressants, antimanics, and anti-psychotics. The scales have been selected by their "cash values", i.e. the scales most frequently used for the respective dimensions. These scales have been further developed in terms of strict item definitions. The simple sum of the individual scale items has been considered as a sufficient statistic if they fulfilled latent structure analysis of shared phenomenology.

The use of case vignettes in studies of interrater reliability of psychiatric target syndromes and diagnoses. A comparison of ICD-8, ICD-10 and DSM-III

This study is part of the ICD-10 field trials in which the use of case vignettes for interrater agreement has been examined. From our electronic database of 880 consecutively admitted inpatients we selected 24 cases that were transcribed to vignettes covering the first 5 ICD-10 target syndrome of dementia, substance use disorders, schizophrenia, mood and anxiety disorders. ICD-10 was compared with ICD-8 and DSM-III. The results showed that all 3 standard classification systems obtained an acceptable interrater agreement. Among the diagnoses, depressive disorders gave rise to most disagreement between the raters. Discrepancies between the methods of measuring interrater agreement were found when intraclass reliability was compared with consensus calculations for the individual patient.