Agreement in psychiatric assessment

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

Evaluation of the routine clinical use of the Brief Psychiatric Rating Scale (BPRS) and the Abnormal Involuntary Movement Scale (AIMS)

OBJECTIVE

To evaluate the routine clinical use of the Brief Psychiatric Rating Scale (BPRS) (in psychiatrists' monthly notes) and the Abnormal Involuntary Movement Scale (AIMS) (done at admission and annually) in a state hospital.

METHODS

Two residents and a medical student were trained in the use of the BPRS and the AIMS. These "key raters" then rated 21 patients before and 28 patients after the ward psychiatrists had one retraining session on the BPRS. These raters' results were compared with the ward psychiatrists' results before and after the BPRS retraining as well as with the ward psychiatrists' annual AIMS ratings.

RESULTS

The key raters had high correlations among themselves (0.85 for total BPRS and a mean of 0.83 for individual BPRS items), but the correlations with the ward psychiatrists' ratings were very low (0.17 for total BPRS and a mean of 0.37 for individual BPRS items), and those correlations improved only slightly after the retraining of the ward psychiatrists (0.33 for total BPRS and a mean of 0.41 for individual BPRS items). Ward psychiatrists both missed tardive dyskinesia and labelled parkinsonism as tardive dyskinesia.

CONCLUSIONS

The BPRS and AIMS are useful, practical rating scales, but if they are to be used routinely in clinical care, users must be regularly trained and retrained and rating performance evaluated. (Journal of Psychiatric Practice 2011;17:300-303).

The measurement of psychotic acuity by nursing staff

Accurate evaluation of patients' psychotic state is essential to decrease psychotic symptoms and protect the patient and others. The aim of this paper is to conduct a literature review in order to access the utility, reliability and validity of current rating scales that are purported to measure psychotic acuity of inpatient population. A search of a number of electronic databases was undertaken to retrieve potential articles that focus on the measurement of acute psychosis. We identified some conceptual and theoretical problems when using a scale that is monitoring the progress of discharge and assesses the outcome of treatments. The findings revealed a difficulty in finding a commonly agreed definition of acute psychosis and a problem of obtaining frequent measures, and the frequency of measurement and fluctuation in psychosis. The most dominant scales in assessing psychosis were reviewed: the Global Assessment of Functioning Scale, the Brief Psychiatric Rating Scale and the Positive and Negative Symptom Scale. Several issues related to the scales' inter-rater reliability and construct validity remain unexplored. None of these scales addressed the conceptual and theoretical problems that we identified. A new scale that will measure acuity of symptoms in inpatient settings needs to be created.

Olanzapine versus haloperidol in schizoaffective disorder, bipolar type

BACKGROUND

The present analysis was performed on data from a subsample of patients with schizoaffective disorder, bipolar type, who participated in a multicenter, double-blind study comparing olanzapine to haloperidol.

METHODS

Patients with schizoaffective disorder bipolar type, characterized as currently manic, mixed, depressed, or euthymic, were assessed weekly for 6 weeks during treatment with either olanzapine or haloperidol. Manic symptoms were measured using the sum of six items of the BPRS, and depressive symptoms were assessed using the Montgomery-Asberg Depression Rating Scale. In addition, cognitive functioning was measured using the sum of seven items from the PANSS. Repeated measures analyses were performed using random coefficients regression of the serial measurement of manic, cognitive, and depressive symptoms.

RESULTS

A significant treatment difference was detected overall, indicating that olanzapine was significantly more effective than haloperidol in reducing symptoms of depression and improving patients' cognitive symptoms. The superiority of olanzapine over haloperidol in the reduction of manic symptoms did not reach statistical significance (P=.052). The greatest improvement in both manic and cognitive symptoms was seen in the olanzapine-treated 'currently manic' subgroup, and least improvement in the haloperidol-treated 'euthymic' subgroup. Depressive symptoms were most improved in the olanzapine-treated 'depressed' subgroup, and least improved in the corresponding haloperidol subgroup.

CONCLUSIONS

Overall, olanzapine was superior to haloperidol with respect to thymoleptic effects in patients with schizoaffective disorder, bipolar type.

New subscales for an anchored version of the Brief Psychiatric Rating Scale: construction, reliability, and validity in acute psychiatric admissions

Attending psychiatrists completed an anchored version of the 18-item Brief Psychiatric Rating Scale (BPRS-A) based on admission and evaluation information on a total of 2,921 adult patients treated at 1 public sector acute psychiatric teaching hospital. Exploratory factor analysis was applied to a 6-month sample to construct 4 nonoverlapping subscales: Resistance, Positive Symptoms, Negative Symptoms, and Psychological Discomfort. Confirmatory factor analysis compared these new subscales to 3 other published subscale models using a second 6-month sample. Internal consistency, rater influence, and interrater agreement were estimated in separate studies. Discriminant validity was explored by comparison of diagnosis-based samples. Application of the BPRS-A as a debriefing instrument in the study of symptomatic change and the multiple challenges inherent in psychometric study of such a rating scale in realistic hospital practice are discussed.

A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania

There are no rapid-acting intramuscular formulations of atypical antipsychotics available for quickly calming an agitated patient with bipolar disorder. In this study, 201 agitated patients with bipolar mania were randomly assigned to receive one to three injections of the atypical antipsychotic olanzapine (10 mg, first two injections; 5 mg, third injection), the benzodiazepine lorazepam (2 mg, first two injections; 1 mg, third injection), or placebo (placebo, first two injections; olanzapine, 10 mg, third injection) within a 24-hour period. Agitation was measured at baseline, every 30 minutes for the first 2 hours, and at 24 hours after the first injection using the Positive and Negative Syndrome Scale-Excited Component subscale and two additional agitation scales. At 2 hours after the first injection, patients treated with olanzapine showed a significantly greater reduction in scores on all agitation scales compared with patients treated with either placebo or lorazepam. At 24 hours after the first injection, olanzapine remained statistically superior to placebo in reducing agitation in patients with acute mania, whereas patients treated with lorazepam were not significantly different from those treated with placebo or olanzapine. Furthermore, no significant differences among the three treatment groups were observed in safety measures, including treatment-emergent extrapyramidal symptoms, the incidence of acute dystonia, or QTc interval changes. These findings suggest that intramuscular olanzapine is a safe and effective treatment for reducing acute agitation in patients with bipolar mania.

Evaluation of standardized rater training for the Positive and Negative Syndrome Scale (PANSS)

The Positive and Negative Syndrome Scale (PANSS) is employed increasingly for the evaluation of therapeutic outcome in studies on schizophrenia. Rater training is important to improve the concordance and accuracy of ratings; however, there are no established guidelines for carrying out such training. We conducted rater training, under clinical conditions, of psychiatrists and clinical psychologists who were rather unfamiliar with the PANSS. Based on videotapes of PANSS interviews, all participants were trained during five successive standardized weekly sessions. The results were analyzed with respect to conventional criteria of concordance with standard expert ratings and interrater reliability. The main objective was to evaluate the number of training sessions which are necessary and sufficient to achieve acceptable PANSS rating results. Additionally, differences in training outcome for positive, negative and general psychopathological symptoms and between subgroups of different clinical and PANSS experience were considered. After three weekly sessions, satisfactory concordance of about 80% of clinicians on the PANSS total scale was obtained. However, in comparison with the positive and general psychopathological subscales, the PANSS negative-symptom subscale yielded somewhat less satisfactory results, with about 70% of the raters achieving sufficient accuracy. Intraclass correlations corroborated these findings. No substantial differences in training outcome were found between subgroups of different clinical and PANSS experience. We conclude that at least three standardized PANSS training sessions are recommended to obtain satisfactory accuracy of ratings.

Improvement of inter-rater reliability of PANSS items and subscales by a standardized rater training

The present evaluation focused on the inter-rater reliability of single items and subscales of the Positive and Negative Syndrome Scale (PANSS) before and after a standardized rater training. The results of two independent studies comprising n=23 (study I) and n=12 (study II) psychiatrists and videotaped interviews with schizophrenic patients were analysed. Chance-corrected coefficients of rating agreement with expert standards (weighted kappa) were computed for single items and subscales of the PANSS. The results clearly demonstrate the importance of rater trainings. After three training sessions, 90% of the PANSS items reached an acceptable level of reliability (kappa(w)>0.40) in both evaluated studies, and for 80% of the PANSS items values of kappa(w)>0.60 were achieved.

Improving the usefulness of the Karolinska Psychodynamic Profile in research: proposals from a reliability study

The interrater reliability of data obtained by use of the Karolinska Psychodynamic Profile (KAPP) was tested among 60 women seeking treatment for drinking problems. The first rater had a psychodynamic background but was minimally trained rating the KAPP subscales and performing KAPP interviews. Independent, blind ratings of audiotaped interviews by an experienced KAPP rater revealed that 8 of the subscales obtained satisfactory reliability, whereas 6 subscales showed unsatisfactory reliability. Furthermore, data for one subscale (normopathy) showed a zero correlation between raters, probably due to the novelty of the construct. Additionally 3 subscales related to bodily aspects were of little clinical significance among the present study group. Our data were compared with data from previous KAPP reliability studies, and the reasons for similarities and discrepancies of results are discussed.