Calculating clinically significant change: Applications of the Clinical Global Impressions (CGI) Scale to evaluate client outcomes in private practice

Minimal Clinically Important Difference in the Brief Assessment of Cognition in Schizophrenia-Japanese Version Composite Score: A Single-Center Preliminary Study

Background

Cognitive dysfunction is a major symptom in schizophrenia associated with social skills. It has been reported that cognitive rehabilitation can improve cognitive dysfunction. The Brief Assessment of Cognition in Schizophrenia-Japanese version (BACS-J) is often used as an outcome measure to assess the effectiveness of cognitive rehabilitation. However, the minimal clinically important difference (MCID) in the BACS-J composite score has not been reported. Therefore, we conducted this study to calculate a preliminary MCID in the BACS-J composite score and confirm the feasibility of retrospective data collection and analysis for future large-scale studies.

Methods

The medical records of patients with schizophrenia who underwent cognitive rehabilitation were retrospectively surveyed. BACS-J data were collected at the beginning and end of the cognitive rehabilitation, and Clinical Global Impression-Improvement (CGI-I) data obtained at the end of the cognitive rehabilitation were evaluated retrospectively. To calculate the MCID in the BACS-J composite score using distribution-based methods, the standard error of measurement was calculated as a characteristic of the scale itself. To calculate the MCID using anchor-based methods, the mean change in BACS-J score corresponding to "minimally improved" on the CGI-I was determined.

Results

Twenty-eight patients were included in this study, and BACS-J data were collected from all patients. The CGI-I was completed by 11 patients, 3 of whom showed "minimally improved" according to their CGI scores. Distribution-based methods applied to the data of 28 patients revealed an MCID of 0.735 for the BACS-J composite score. Anchor-based methods were ultimately not applied because the sample size was insufficient.

Conclusion

This study confirmed that CGI and BACS-J data can be collected and analyzed retrospectively. According to distribution-based methods, an increase of approximately 0.7 in the BACS-J composite score can be considered clinically meaningful. Future studies with larger sample sizes using both calculation methods could provide more accurate MCID.

Course and Outcome of Anorexia Nervosa in Adolescents from a Tertiary-level Mental Health Setting in India: A Retrospective Chart Review

Background

Anorexia nervosa is one of the least studied mental health conditions in the Indian setting. The objective of this study was to assess the course and outcome of anorexia nervosa in adolescents who had presented to a tertiary care child and adolescent psychiatry center over a period of 10 years.

Methods

The present study is a retrospective chart review of adolescents (up to the age of 18 years) with a diagnosis of anorexia nervosa, coded as F50.0 or F50.1 according to ICD 10, from 1st April 2009 to 31st March 2019. Data were extracted from the case records using standardized abstraction forms and evaluated using descriptive and nonparametric statistics.

Results

The average age at presentation and the average age at onset were 14.1 years and 13.1 years, respectively. The male-to-female ratio of the sample who got admitted was 1:9. The average duration of hospital stay was about 30 days. The duration of in-patient care and weight gain were positively correlated, with severe to extremely ill adolescents improving even in less than one month of in-patient care. Seventy per cent of the admitted adolescents followed up. The functional outcome as measured by a 'return to school' improved in 57.1% of the sample.

Conclusions

The present study highlights the collaborative multidisciplinary and individualized treatment approach employed for adolescents diagnosed with anorexia nervosa within an inpatient mental health facility in India. Adolescents who presented with more severe illness at the initial assessment, such as an early onset of symptoms and a low BMI, experienced substantial weight gain that exhibited a positive correlation with the length of their stay in the inpatient facility.

Real-world experience of using combinatorial pharmacogenomic test in children and adolescents with depression and anxiety

OBJECTIVE

To evaluate the real-world impact of using a commercially available combinatorial pharmacogenomic (CPGx) test on medication management and clinical outcomes in children and adolescents treated at a tertiary care psychiatry practice.

METHODS

A retrospective cohort study using our prospectively maintained database of patients undergoing CPGx testing was performed. Only patients with clinical data at the time of ordering CPGx test (pre-baseline), potential medication change visit (baseline) and 8-weeks follow-up (post-baseline) visit were included. Clinical Global Impression (CGI) scores for each visit were calculated. Appropriate statistical analysis, including one-sample t-test, paired t-test and Chi-square test was performed.

RESULTS

Based on the inclusion criteria, 281 (75.9%) of the 370 patients with CPGx testing were included. Their mean age was 15.8 ± 4.5 years (111 females; 39.5%). The average number of medications significantly increased to 2.4 ± 1.2 on the post-baseline visit [t(280) = 8.34, p < 0.001). Medications were added in 123 (43.7%), replaced in 92 (32.7%) patients and remained unchanged in rest. There was no significant association between medication-related adverse effects and psychotropic medication change group (p = 0.27). The study population showed a significant improvement (p < 0.001) in the CGI severity, efficacy, and global improvement indices.

CONCLUSION

In our experience of using CPGx test in a large cohort of children and adolescents during routine clinical practice, three-quarter of them underwent medication change. Additionally, we noted an improvement in clinical outcomes without impacting adverse effects. While the role of clinical judgement in medication changes in our cohort is likely, CPGx may supplement clinical decision making. However, the best use and benefit of CPGx in routine clinical practice needs further investigation.

Reliable change and the reliable change index: still useful after all these years?

In 1984 Jacobson and colleagues introduced the concept of reliable change, viz the amount of change on a measure that an individual needed to show to determine that it exceeded the extent of change likely due to measurement error alone. Establishing reliable change was a pre-requisite for determining clinical significance. This paper summarizes the rationale for determining reliable change as providing an individual-focused, idiographic alternative to the dominant nomothetic approach to clinical outcome research based on group mean data and statistical significance. The conventional computational steps for calculating an individual’s standardized difference (reliable change) score and the minimum raw change score on the measure (a reliable change index) required to classify individuals as reliably positively changed, indeterminate, or reliably deteriorated are described. Two methods for graphically representing reliable change are presented, and a range of possible uses in both research and practice settings are summarized. A number of issues and debates concerning the calculation of reliable change are reviewed. It is concluded that the concept of reliable change remains useful for both cognitive behavioural researchers and practitioners, but that there are options regarding methods of computation. In any use of reliable change, the rationale for selecting among method options and the exact computations used need clear and careful description so that we can continuously judge the utility and appropriateness of the use of reliable change and enhance its value to the field.

Key learning aims

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High Intensity Interval training (HIIT) for people with severe mental illness: A systematic review & meta-analysis of intervention studies- considering diverse approaches for mental and physical recovery

There is a mortality gap of 15 to 20 years for people with severe mental illness (SMI - psychotic spectrum, bipolar, major depressive disorders). Modifiable risk factors include inactivity and low cardiorespiratory fitness (CRF). Exercise can improve mental and physical outcomes; optimal type and intensity of exercise for people with SMI has yet to be determined. High Intensity Interval training (HIIT) is an exercise with distinct cardio-metabolic advantages in other disease populations compared to traditional moderate intensity continuous training (MCT). We investigated the feasibility and efficacy of HIIT for people with SMI. Major electronic databases were searched, identifying HIIT studies for adults experiencing SMI.Data on feasibility, safety, study design, sample characteristics, and physical and psychological outcomes were extracted and systematically reviewed. Meta-analyses were conducted within group, pre and post HIIT interventions, and between group, to compare HIIT with control conditions. Nine articles were identified including three pre/post studies, one non randomised and five randomised trials, (366 participants, 45.1% female). HIIT appears as feasible as MCT, with few safety concerns. Following HIIT, there was a moderate improvement in CRF and depression. There was no difference between HIIT and MCT for adherence or CRF.HIIT improved depression more than MCT.

A Phase II Double-Blind, Placebo-Controlled, Efficacy and Safety Study of SPN-812 (Extended-Release Viloxazine) in Children With ADHD

Objective: The objective of this study is to evaluate efficacy and safety of SPN-812 (extended-release viloxazine) for ADHD in children aged 6 to 12 years. Method: In an 8-week study, 222 participants were randomized to placebo or SPN-812 100, 200, 300, or 400 mg/day. Measurements included ADHD Rating Scale (RS)-IV total score and Clinical Global Impression-Severity (CGI-S) and Clinical Global Impression-Improvement (CGI-I) scores. Safety assessments included laboratory and electrocardiogram (ECG) measurements, suicidality monitoring (Columbia-Suicide Severity Rating Scale), and adverse event (AE) reporting. Results: Significant improvements in ADHD-RS-IV total score were observed for 200, 300, and 400 mg dose groups versus placebo (p < .05; effect size [ES] = 0.547, 0.596, and 0.623). CGI-I score for the 300 mg group and CGI-S score for all SPN-812 groups except for 100 mg improved significantly (p < .05) versus placebo. The most frequent AEs (≥15%) were somnolence, headache, and decreased appetite. Conclusion: SPN-812 significantly reduced the severity of ADHD symptoms and was well tolerated. The efficacy and safety of SPN-812 are being investigated in Phase III trials.

Practice Guidelines for the Assessment of Clinically Significant Treatment Outcomes in the Children's Mental Health System

The use of program evaluation to monitor client change and improve intervention effectiveness is gaining increasing importance in the mental health field. However, there is a lack of literature available in community-based clinics for those who desire to evaluate the effectiveness of services. Through this article the authors review the literature on the best methods to assess clinically significant treatment outcomes in community-based children's mental health services. The strengths and weaknesses of commonly recommended methods of evaluating change are discussed (i.e., reliable change index, percentage of improvement, normative comparisons, and effect size) using a dataset from a community-based parenting program (N = 308).

Anxiety sensitivity and impairment: evidence for a direct association and partial mediation by subclinical anxiety symptoms

BACKGROUND

Mounting evidence suggests that specific psychological risk factors increase the likelihood for the development of anxiety psychopathology. Anxiety sensitivity (AS), the fear of the consequences of anxiety, is one such risk factor. However, very little is known about the consequences of having elevated AS prior to the development of diagnosable psychopathology. We hypothesized that elevated AS may create impairment among premorbid individuals. The aims of the present study were twofold. The first aim was to examine whether having elevated AS would be predictive of impairment in a nonclinical sample. The second aim was to examine whether subclinical anxiety symptoms would partially mediate the association between AS and impairment in daily life.

METHOD

These aims were examined in two studies utilizing samples of individuals with elevated levels of AS. Study 1 (N=387) and Study 2 (N=79) were comprised of participants with elevated AS. Participants completed a battery of questionnaires and a diagnostic interview to assess for risk status. Only participants without an anxiety disorder were eligible to participate in the study to ensure that they were in the premorbid stage.

RESULTS

In Study 1, there was a direct effect of AS on impairment. Additionally, there was evidence for anxiety symptoms acting as a partial mediator in the relation between AS and impairment. Study 2 revealed the same pattern of results, with AS having a significant direct effect on impairment that was partially mediated by anxiety symptoms.

LIMITATIONS

The samples utilized in the present sample were primarily Caucasian females, thereby potentially limiting the generalizability of these findings.

CONCLUSIONS

This study provides evidence that a premorbid risk factor is associated with impairment before the actual development of an anxiety disorder. Implications of the present investigation and future directions are discussed.

Clinical and reliable change in an Australian residential substance use program using the Addiction Severity Index

Although the Addiction Severity Index (ASI) is one of the most frequently used measures in alcohol and other drug research, it has rarely been used to assess clinical and reliable change. This study assessed clients' clinical and reliable change at The Salvation Army residential substance abuse treatment centers in Australia. A total of 296 clients completed ASI interviews on admission to treatment and 3 months after discharge from treatment. Clients demonstrated significant improvement on all seven ASI composites. The range of reliable change for each ASI composite varied from 30% to 70%. More than two-thirds of clients experienced clinically significant improvement for alcohol and drug problems. Psychiatric distress was clinically reduced in 44% of clients. This research indicates that residential substance abuse treatment can make important differences in client's lives at a clinical and functional level. However, the research highlights the challenge of effectively targeting psychiatric comorbidity within alcohol and other drug abuse populations.