the clinical global impressions: a widely used instrument in...
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The Clinical Global Impressions:
a widely used instrument in psychiatry
Benedetto Vitiello
Milan, November 23, 2017
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Disclosure
Benedetto Vitiello, M.D.
Professor of Child and Adolescent Neuropsychiatry,
University of Turin, Italy
o I do not have any financial conflict of interest with
the content of this presentation
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• To review the main characteristics of the Clinical Global
Impression (CGI) scales
• To discuss it strength and limitations in child psychiatry
Aims
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Clinical Global Impression Scales
Guy W. ECDEU Assessment Manual for
Psychopharmacology. Rockville, MD: US Department
of Heath, Education, and Welfare- Public Health Service Alcohol,
Drug Abuse, and Mental Health Administration, 1976.
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Of the clinician, by the clinician, for the clinician
CGI were developed as simplified global
measures
Meant to reflect the clinician’s overall
impression of a patient’s condition
As a way of quantify clinically relevant
information
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CGI-improvement scale
1 = Very much improved—a very substantial positive change
2 = Much improved—notably better with significant reduction of
symptoms, but some symptoms remain
3 = Minimally improved—slightly better with little or no clinically
meaningful reduction of symptoms. Very little change in basic clinical
status, level of care, or functional capacity
4 = No change—symptoms remain essentially unchanged
5 = Minimally worse—slightly worse but may not be clinically meaningful;
6 = Much worse—clinically significant increase in symptoms and
diminished functioning
7 = Very much worse—severe exacerbation of symptoms and loss of
functioning
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CGI -Severity
1 = Normal—not at all ill, symptoms of disorder not present
2 = Borderline mentally ill—subtle or suspected pathology
3 = Mildly ill—clearly established symptoms with minimal, if any, distress
or difficulty in social and occupational function
4 = Moderately ill—overt symptoms causing noticeable, but modest,
functional impairment or distress;
5 = Markedly ill—intrusive symptoms that distinctly impair
social/occupational function or cause intrusive levels of distress
6 = Severely ill—disruptive pathology that affects behavior and function
7 = Among the most extremely ill patients—pathology drastically
interferes in many life functions; may need hospital care
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Efficacy Index
Therapeutic effect Side effects
None Mild Mod. Severe
Marked 01 02 03 04
Moderate 05 06 07 08
Minimal 09 10 11 12
Unchanged or worse 13 14 15 16
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CGI-S and CGI-I
Good internal consistency and concurrent
validity
Correlation with symptom-specific rating
scales: 0.4-.07
Primary outcome measure in clinical trials for a
variety of conditions
– major depression, social phobia, post-traumatic
stress disorder, panic disorder, binge-eating
disorder, bipolar, etc.
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In general, good concordance between CGI and symptom rating scales
Leucht & Engel (2006) re-analyzed the
databases of four comparative effectiveness
trials of antipsychotics in adults with
schizophrenia (n=1,205)
– Similar effect sizes on BPRS and on CGI-S
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CGI-Improvement
Often dichotomized
– Very much improved (1) or much improved (2) IMPROVED
– Minimally improved (3), no change (4), or worse (5-7) NOT
IMPROVED
Forcing a clinical decision to:
– Continue treatment as effective
– Discontinue treatment as ineffective
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Risperidone( n=49) vs. placebo (n=52) for irritability in autism
RUPP Autism Group. N Engl J Med 2002;347:314-21.
Mean Scores for Irritability in the Risperidone and Placebo
Groups during the Eight-Week Trial.
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RUPP Autism Group. N Engl J Med 2002;347:314-321
Risperidone( n=49) vs. placebo (n=52) for irritability in autism
CGI-defined improvement rate— Improvement
Scale during the Eight-Week Trial.
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TADS, 2004
30
40
50
60
Baseline Week 6 Week 12
Stage I Assessments
Me
an
CD
RS
Sc
ore
- A
dju
ste
d
COMB
FLX
CBT
PBO
T A D S
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Treatment Response: Week 12
0
20
40
60
80
100
COMB FLX CBT PBO
71%
61%
43%
35%
T A D S
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Symptomatic remission (CDRS < 28)
rate at 3 months (Kennard et al. 2006)
T A D S
0
5
10
15
20
25
30
35
40
CBT PBO FLX COMB
16% 17%
23%
37%
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Level of functioning (CGAS > 70)
(Vitiello et al.
2006)
T A D S
34.6
20.2
13.5
18.7
0
5
10
15
20
25
30
35
40
COMB
(N=107)
Fluoxetine
(N=109)
CBT (N=111) Placebo
(N=112)
Per
cen
t
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CGI in clinical trials
Often used as secondary outcome measure,
together with a specific symptom rating scale
At times, combined with a specific symptom
rating scale to form a primary outcome
measure
– Responder: CGI=1 o 2 + >25% decrease in
hyperactivity scores (RUPP Network, 2005)
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Methylphenidate in preschoolers with ADHD (PATS): parallel-design clinical trial (Abikoff et al 2007)
N=114
Age 3-5 y
Dx: ADHD-combined or hyperactive type
Parallel-group design
– Methylphenidate (mean 14 mg/d) vs. placebo
Double-blind
4-weeks
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PATS parallel-design clinical trial (N=114): secondary outcomes (Abikoff et al 2007)
ES p
SWAN Total ADHD Parent (n=86) 0.43 NS
SWAN Total ADHD Teacher (n=64) 0.32 NS
ECI depression Parent (n=61) 0.55* .02
CGI-Severity (n=114) 0.73 .001
*Worse on medication
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Disease-specific modifications of the CGI
Application of anchor points to the CGI scores
The anchor points direct and limit the scoring
to the target symptoms of the specific disorder
of the study
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CGI-BP
Spearing MK, Post RM, Leverich GS, Brandt D, Nolen W.
Modification of the Clinical Global Impressions
(CGI) Scale for use in bipolar illness (BP): the
CGI-BP.
Psychiatry Res. 1997;73(3):159-71
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Improvement rate in the Treatment of Early Age Mania (TEAM) (N=279) (Geller et al., 2012)
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CGI
Strengths
Global: overall index
Transdiagnostic
Widely used
Quick to rate
Low burden on
patient’s and
clinician’s time
Convenient for use in
practical trials
Limitations
Global: lack specificity
Needs clinical expertise
and appropriate
knowledge of the
patient situation
Not explanatory