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Outcome in psychiatric outpatient services: reliability, validity and outcome based on routine assessments with the GAF scale
Umeå University, Faculty of Social Sciences, Psychology.
Umeå University, Faculty of Social Sciences, Psychology.
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The general aim of the studies presented in this thesis is to investigate the possibility of using clinical data to measure outcomes in psychiatric outpatient services. The specific aims are to investigate whether routine clinical assessments and ratings are reliable and have adequate validity, and then to use these data to calculate treatment outcomes and explore factors that affect these outcomes.

The main result shows that ratings of global mental health made by clinicians in routine clinical work can be used to evaluate treatment outcomes in outpatient settings. The clinicians responsible for diagnosing and assessing patients used the GAF scale with satisfactory reliability (ICC1,1 = 0.81) and fair interrater reliability (overall kappa = 0.53) when categorizing main diagnostic groups of the DSM-IV axis I. The GAF scale can thus be used to assess global mental health and to monitor outcomes in clinical settings. However, a GAF culture bias was observed. This bias can probably be corrected with feedback and training.

Psychiatric treatment in outpatient settings had a generally positive effect on patients’ global mental heath (ES = 0.65). The overall result when clinical significance methodology was used showed that 28.1% of the patients had recovered and a further 6.6% showed reliable improvement. Patients being treated with psychotherapeutically influenced methods showed a considerably better effect (ES = 1.00). There is a dose of sessions effect that is particularly marked for short treatment episodes. Thirteen sessions are required for 50% of the patients to show reliable improvement. The strongest influence on treatment outcome was whether the termination of a patient’s treatment was planned or unplanned.

In conclusion: Clinical databases can be used to study the outcome of psychiatric services provided they a) include a large number of subjects representing an intention-to-treat perspective; b) the instruments used are clinically relevant and reliable; c) the raters contributing to the data base are motivated to decrease attrition; d) the database includes extensive data to allow for control of confounding factors; and e) data are collected at critical occasions in treatment, such as at the start of treatment and at discharge from treatment, making it possible to focus on effects. Psychiatric outpatient treatment has a positive effect, but considerable improvements may be possible with more stringent use of psychotherapeutic methods, sufficient doses of sessions, and planned terminations. However, the progress of treatment is also affected by such factors as pre-treatment severity and diagnoses.

Place, publisher, year, edition, pages
Umeå: Psykologi , 2007. , 71 p.
Keyword [en]
reliability, validity, outcome, effectiveness, clinical, significance, GAF scale, DSM-IV, outpatients, psychiatry, dose response, services
National Category
Psychology
Identifiers
URN: urn:nbn:se:umu:diva-968ISBN: 91-7264-240-8 (print)OAI: oai:DiVA.org:umu-968DiVA: diva2:145230
Public defence
2007-02-02, Hörsal E, Humanisthuset, Umeå universitet, Umeå, 09:00
Opponent
Supervisors
Available from: 2007-01-11 Created: 2007-01-11Bibliographically approved
List of papers
1. Relationship between the global assessment of functioning and other DSM axes in routine clinical work
Open this publication in new window or tab >>Relationship between the global assessment of functioning and other DSM axes in routine clinical work
2005 (English)In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 56, no 4, 439-443 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The aim of this study was to investigate the validity of theGlobal Assessment of Functioning (GAF) when routinely used in clinicalwork by focusing on the relations between the GAF, other axes in theDSM system, and some demographic variables conceptually derived ontheoretical and clinical grounds.

Methods: A clinical database containingdata for 5,538 patients assessed by 181 raters as a part of routinepractice in psychiatric outpatient settings in Sweden was used. A hierarchicallinear regression model and a variance component model wereused to analyze the data. Regression models were also used to determinehow the relation between the GAF and axis I depends on the selectionof diagnostic groups in the sample.

Results: Seventeen percentof the systematic variance in GAF scores was explained by diagnosticdifferences as defined on DSM-IV axis I, and 5.1 percent was explainedby psychosocial and environmental problems as measured on DSM-IVaxis IV. Unexpectedly, the site of the investigation explained another 3.6percent of the variance.

Conclusions: The GAF can be used as a comprehensivemeasure of global mental health in routine clinical work forassessment and for outcome management.

Place, publisher, year, edition, pages
Washington: American Psychiatric Association, 2005
Identifiers
urn:nbn:se:umu:diva-5640 (URN)
Available from: 2007-01-11 Created: 2007-01-11 Last updated: 2017-12-14Bibliographically approved
2. Reliability of global assessment of functioning ratings made by clinical psychiatric staff
Open this publication in new window or tab >>Reliability of global assessment of functioning ratings made by clinical psychiatric staff
2005 (English)In: Psychiatric Services, ISSN 1075-2730, E-ISSN 1557-9700, Vol. 56, no 4, 434-438 p.Article in journal (Refereed) Published
Abstract [en]

Objective: In the Swedish psychiatric care system, systematic follow-upof clinical work with patients is becoming a part of regular service, anda number of care providers are using the Global Assessment of Functioning(GAF) to measure outcomes. This study investigated the reliabilityof the GAF and analyzed certain factors that affect measurementerrors when the scale is used by regular psychiatric staff.

Methods: Eighty-one raters from various psychiatric outpatient clinics ratedeight case vignettes. Interrater reliability was assessed by using intraclasscorrelation coefficients (ICCs), and factors associated with reliabilitywere analyzed by using raters’ unique residual values.

Results: The results showed that staff who are responsible for assessing firsttimepatients at outpatient psychiatric clinics and making diagnoses areusing the GAF with satisfactory reliability (ICC1,1=.81). The factors associatedwith reliability were raters’ subjective attitude toward the GAF and motivation to use the scale and other measurement instruments inpsychiatry.

Conclusions: GAF ratings made by an individual rater can beused to measure changes and outcomes at the group level. However, themeasurement error is too large for assessment of change for an individualpatient, in which case it might be necessary to use several raters. If raters are positively inclined to use rating instruments, measurementerrors are minimized and reliability is maximized.

Place, publisher, year, edition, pages
Washington, D.C.: American Psychiatric Association, 2005
Identifiers
urn:nbn:se:umu:diva-5641 (URN)
Available from: 2007-01-11 Created: 2007-01-11 Last updated: 2017-12-14Bibliographically approved
3. Diagnostic reliability of DSM-IV axis I in clinical practice
Open this publication in new window or tab >>Diagnostic reliability of DSM-IV axis I in clinical practice
(English)Manuscript (Other academic)
Identifiers
urn:nbn:se:umu:diva-5642 (URN)
Available from: 2007-01-11 Created: 2007-01-11 Last updated: 2011-01-25Bibliographically approved
4. Culture bias in clinical use of the GAF scale
Open this publication in new window or tab >>Culture bias in clinical use of the GAF scale
(English)Manuscript (Other academic)
Identifiers
urn:nbn:se:umu:diva-5643 (URN)
Available from: 2007-01-11 Created: 2007-01-11 Last updated: 2011-01-25Bibliographically approved
5. Treatment effects in psychiatric outpatient services
Open this publication in new window or tab >>Treatment effects in psychiatric outpatient services
Manuscript (Other academic)
Identifiers
urn:nbn:se:umu:diva-5644 (URN)
Available from: 2007-01-11 Created: 2007-01-11 Last updated: 2010-01-13Bibliographically approved
6. The dose of sessions effects in psychiatric outpatient services
Open this publication in new window or tab >>The dose of sessions effects in psychiatric outpatient services
(English)Manuscript (Other academic)
Identifiers
urn:nbn:se:umu:diva-5645 (URN)
Available from: 2007-01-11 Created: 2007-01-11 Last updated: 2011-01-25Bibliographically approved

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