The clinical global impression scale and the influence of patient or staff perspective on outcome

BACKGROUND: Since its first publication, the Clinical Global Impression Scale (CGI) has become one of the most widely used assessment instruments in psychiatry. Although some conflicting data has been presented, studies investigating the CGI's validity have only rarely been conducted so far. It is unclear whether the improvement index CGI-I or a difference score of the severity index CGI-S (dif) is more valid in depicting clinical change. The current study examined the validity of these two measures and investigated whether therapists' CGI ratings correspond to the view the patients themselves have on their condition. METHODS: Thirty-one inpatients of a German psychotherapeutic hospital suffering from a major depressive disorder (age M = 45.3, SD = 17.2; 58.1% women) participated. Patients filled in the Beck Depression Inventory (BDI). CGI-S and CGI-I were rated from three perspectives: the treating therapist (THER), the team of therapists involved in the patient's treatment (TEAM), and the patient (PAT). BDI and CGI-S were filled in at admission and discharge, CGI-I at discharge only. Data was analysed using effect sizes, Spearman's ρ and intra-class correlations (ICC). RESULTS: Effect sizes between CGI-I and CGI-S (dif) ratings were large for all three perspectives with substantially higher change scores on CGI-I than on CGI-S (dif). BDI (dif) correlated moderately with PAT ratings, but did not correlate significantly with TEAM or THER ratings. Congruence between CGI-ratings from the three perspectives was low for CGI-S (dif) (ICC = .37; Confidence Interval CI .15 to .59; F(30,60) = 2.77, p < .001; mean ρ = 0.36) and moderate for CGI-I (ICC = .65 (CI .47 to .80; F(30,60) = 6.61, p < .001; mean ρ = 0.59). CONCLUSIONS: Results do not suggest a definite recommendation for whether CGI-I or CGI-S (dif) should be used since no strong evidence for the validity of neither of them could be found. As congruence between CGI ratings from patients' and staff's perspective was not convincing it cannot be assumed that CGI THER or TEAM ratings fully represent the view of the patient on the severity of his impairment. Thus, we advocate for the incorporation of multiple self- and clinician-reported scales into the design of clinical trials in addition to CGI in order to gain further insight into CGI's relation to the patients' perspective.