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The severity of psychiatric disorder: A replication
163
P.yvchiatry Research. 14, 163-I 73 Elseviet
The Severity Thomas Receil,ecl
of Psychiatric
E. Gift and David April
6. 1983:
Disorder:
A Replication
W. Harder
re\‘ised
r~ersion
receixxerl
Jlrne
27,
1984;
acc,epted
Augusr
23. 1984.
Abstract. A prior report documented the importance of diagnosis and psychotic symptoms as components of a global rating of severity of psychiatric disorder. The availability of 2-year followup data on 174 (807;) of the original 217 patients permits examination of the stability of components of a global rating. Menninger Health-Sickness Rating Scale (M H RS) scores again correlated with diagnosis and with psychotic symptoms; unlike the initial report, followup MHRS ratings were closely associated with a depression-neurosis factor and social role performance. .Age, race. and sex were independent of severity, while low socioeconomic status correlated with severity of illness.
Global rating, severity. assessment.
Key Words.
the utility of a global measure of severity of psychiatric illness has been recognized (Luborsky and Bachrach, 1974; Endicott et al., 1976), an empirical question arises as to which aspects of patients’ history, symptoms, and level of function are, or are not reflected in global assessments; a closely related question is the degree to which the components of a global rating are uniform across kinds of patients rated. A previous report by Gift et al. (1980), focusing on the Menninger HealthSickness Rating Scale (Luborsky, 1962; Luborsky and Bachrach. 1974). reviewed some of the methodological aspects of these empirical questions, including representative sampling, systematic collection of data, and thorough sample definition. Substantive findings of this study of first lifetime hospitalization for psychiatric illness indicated that psychotic symptoms and bizarre, disturbed behavior were more anxiety, and other nonpsychotic associated with severity than were depression, symptoms; while there was a strong relationship between severity and a psychotic, nonpsychotic dichotomy, there was little relationship between severity and more specific diagnostic categories. Severity was significantly but less closely related to certain measures of chronicity and social function. The availability of 2-year followup data on the original patient sample, collected by the researchers who assessed the patients initially. provides a valuable opportunity to explore the stability of the components of a global rating of severity of psychiatric illness. Although
Thomas
E. Gift.
W.
Harder.
to
Dr.
M.D..
Ph.D..
T.E.
Gift.
Rochester.
SY
0165-1781
85
is Associate
i\ Associate Dept.
14642.
SO3.30
of
Professorof
Profe,\or Psychiatq.
Psychiatry.
of Psychology. L!niversity
Univemityof Tufts
of
Rochester.
USA.)
c 1985
Elsevier
Science
Publishers
B.V
Rochester.
University. 300
Medford. Crittenden
Rochester. MA.
NY.
(Reprint
Blvd..
Box
David requests
R-Wing,
164 Methods As part of a larger study, the First Admission Study (Strauss et al., 1978). a representative sample (n = 217) of first inpatient admissions for functional psychiatric disorder from two catchment areas was evaluated with structured assessment interviews. The instruments used included the Psychiatric Assessment Interview (PAI) (World Health Organization, 1973). a modification of the Present State Examination (Wing et al., 1974) to record patients’symptoms and signs over the month beforeadmission. the Standard Psychiatric History Interview (Strauss et al., 1978). and a social data interview to obtain information on previous psychiatric symptoms, social role functioning, and demographic characteristics. Psychiatric history, social role function, and demographic data were also collected from case records and from patients’ relatives. For the analyses used here, symptom dimensions were generated by combining ratings of related items from the PAI. These symptom dimensions were then subjected to a factor analysis, from which four factors were derived. These factors were: a “psychosis” factor, loading heavily on delusions and hallucinations; a “neurosis” factor, loading heavily on depression, anxiety. and somatic complaints; a “retarded-bizarre” factor. and a “hyperactive-bizarre” factor (Strauss et al., 1978). Based on the information available from all sources, a DSM-/I diagnosis (American Psychiatric Association. 1968) was assigned. and the Strauss-Carpenter Prognostic Scale (Strauss and Carpenter, 1977) was used to rate duration of symptoms at the time of hospitalization. as well as several measures of social and work functioning in the month before hospitalization. Also based on the data available from all instruments, a global rating of severity of psychiatric illness was made using the Menninger Health-Sickness Rating Scale. This scale has a range of 0 (most severely disturbed) to 100 (no psychiatric disturbance). Anchor points provided with the scale include consideration of diagnostic categories. symptoms, and levels of function. The satisfactory reliability of this scale has been reported (Luborsky and Bachrach. 1974). The interviews to assess symptoms and psychiatric history were carried out by two psychiatrists and three clinical psychologists. all of whom also rated the assessment scales. All interviewers were also clinically active in treating both inpatients and outpatients with a range of modalities, including medication (for which the psychologists obtain “medical backup”). A followup evaluation by the clinician/researcher who evaluated the patient initially was carried out 2 years after the date of admission. Eighty percent of the original sample (n = 174) received a comprehensive followup assessment. A psychiatric history for the intervening 2 years was obtained along with relevant social data, a PA1 was again carried out to assess symptoms in the month before followup. and a DSM-/I diagnosis was again assigned. The patients’ clinical status was rated using the Strauss-Carpenter Level of Functicn Scale (Strauss and Carpenter, 1972). A global judgment of severity of illness was again made using the Menninger HealthSickness Rating Scale. and a second rating of overall severity of illness was made using the Global Assessment Scale (Endicott et al.. 1976). In almost all instances the same individual assessed symptoms and psychiatric history, both at admission and at followup, and made the Menninger Health-Sickness ratings both at admission and at followup. The symptom dimensions created from the followup PA1 items were subjected to a factor analysis. Two major symptom factors. the first accounting for 2170 of the variance and the second for IOqc of the variance, were derived. and varimax rotation was performed. yielding a “psychosis” factor, on which hallucinations. delusions. and other psychotic symptoms loaded heavily. and a “depression-neurosis” factor on which anxiety, depression, and other nonpsychotic symptoms loaded heavily (Table I). Each association between Health-Sickness ratings and patient characteristics reported in the prior publication is tested on the followup sample, which might thus be regarded as a replication sample. Since this is a confirmatory rather than an exploratory study. the split-half technique used in the initial report is not used here. Because the correlation between the Menninger Health-Sickness Rating Scale and the Global Assessment Scale is 0.94. data are presented only
165 Table 1. Factor analysis of symptom dimensions
at followup (n = 174)
Factor 1
Factor 2 Factor
Factor Depression-neurosis1 Reported
loading
restlessness
Depression Anxiety
Psychosis2
loading
0.76
Visual hallucinations
0.74
0.75
Delusions
0.73
about hallucinations
0.61
Auditory
Obsessive
symptoms
0.61
Derealization
hallucinations
0.65
0.70
Reported
belligerence
0.60
Delusions
of reference
0.54
Withdrawal
0.52
Delusions
of suspicion
0.52
Somatic
0.50
Delusions
of control
complaints
by an outside
force
0.51
1. Percent of variance accounted for: 20.9 2. Percent of variance accounted for: 9.5.
for the Health-Sickness Rating Scale. Partial followup data were available on several patients in addition to the 174. permitting a larger n for certain analyses.
Results of Health-Sickness. Health-Sickness ratings for the first patients reevaluated at the 2-year followup ranged from 6 to 85. Diagnosis. As was found initially, although the differences in mean HealthSickness ratings between diagnostic categories are quite significant, there is much overlap between diagnostic categories (Table 2). Thus, the highest Health-Sickness rating for the diagnostic group with the lowest mean score (psychotic disorders) is higher than the lowest value for the group with the highest mean Health-Sickness rating (no psychiatric diagnosis). When diagnosis is dichotomized into psychotic (schizophrenia. affective psychosis, or other psychoses) versus nonpsychotic diagnoses (situational reaction, neurosis, character disorder, or no psychiatric diagnosis), it correlates (point biserial Y 0.45,~ < 0.001) with Health-Sickness. When diagnosis is trichotomized into psychosis, nonpsychotic psychiatric disorder. and no psychiatric disorder, and these variables are used as the independent variables in a multiple regression equation with Health-Sickness as the dependent variable, the multiple r is The
Constituents
admission
q
Table 2. Health-Sickness
scores and diagnosis Health-Sickness IHS)
DSM-/I
diagnostic groups (n = 176)
No psychiatric Neurosis
diagnosis
and situational
Personality
disorder
Psychosis
, n = 32 )
in = 65) reaction
tn = 26~
in = 531
1. Analysis of variance (p < 0 05 I. 2. Scheffd’s procedure for a postenori
comparisons.
Mean1
SD
Low score
High score
Grouping by HS means2
82
7
60
95
A
63
12
37
83
B
60
14
30
96
B
51
16
22
82
C
166 0.73 and the r2 is 0.53, suggesting that over half of the variation in Health-Sickness ratings can be predicted from a knowledge of the patients’ diagnostic status. Thus, the finding, initially, that diagnosis is closely associated with Health-Sickness rating is replicated on the followup sample. Symptoms. Initially, psychotic symptoms tended to correlate with HealthSickness, but nonpsychotic symptoms did not. As shown in Table 3, psychotic symptoms again correlated with Health-Sickness ratings at followup, but in addition, many nonpsychotic symptoms were significantly correlated with Health-Sickness ratings. Also, the magnitude of the correlations of the nonpsychotic symptoms was roughly the same order as the correlations of the psychotic symptoms with HealthTable 3. Relationship of symptom dimensions and factors to Health-Sickness1 Dimensions
r
Depression
0.52
Withdrawal
0.52
Suspiciousness
0.51
Reported
0.44
restlessness
Depersonalization
0.42
Delusions of reference Other delusions
0.39
Observed
0.37
Bizarre
0.37
restlessness
behavior
0.36
Slow movement
0.35
Depressive
0.33
delusions
Oriented
0.32
Unkempt
0.30
Incongruous
affect
0.30
Other hallucinations
0.29
Auditory
hallucinations
Incomprehensible
0.29
speech
0.29
Flat affect
0.29
Obsessiveness
0.28
Delusions
0.28
of passivity
Delusions about hallucinations Labile affect
0.27
Visual hallucinations
0.26
Delusions of grandeur Slow speech
0.26
Observed
0.21
0.26
0.23
belligerence
Hypomania
0.17
Somatic
0.13
complaints
Factors Psychosis
factor
Depression-neurosis 1.
Product-moment
n = 174.
0.24 factor correlations;
0.42 results
presented if
P < 0.05.
167 Sickness. The two major factors derived at followup with Health-Sickness; the r value for the neurosis psychosis factor was 0.24. This difference in the however, did not reach statistical significance @ > Relationship
between
Health-Sickness
were both significantly correlated factor was 0.42 while that for the magnitude of these coefficients, 0.10).
and
social
role
functioning.
As
shown in Table 4. all measures of social role functioning were significantly associated with Health-Sickness ratings; thus, followup measures of social role functioning appeared to be more consistently associated with Health-Sickness than did the admission ratings of social role function. Table 4. Relationship function1
between
Health-Sickness
Social role function Quantity Quality Number Quality
Followup (n = 174)
0.22
0.30
0.25
0.32
0.29
0.31
0.41
0.32
of employment
of social
role
Admission2 (n = 217)
of work of social
and social
contacts relationships
1. Product-moment correlahons; results presented if p < 0.05. 2. Correlation coefficients underlined if replicated at admlssion
on split-halves
of sample
Demographic characteristics and Health-Sickness. Age, race, sex, marital status, and socioeconomic status were examined in relation to Health-Sickness. Age and sex were again found to be independent of Health-Sickness. Race, which was significantly associated with Health-Sickness at the initial evaluation, at followup was independent of Health-Sickness (Table 5). On the other hand, socioeconomic status, rated using the Hollingshead Two-Factor Index, which initially was independent of Health-Sickness (Table 6), at followup was correlated with Health-Sickness (r = 0.33; p < 0.01). Marital status, which initially was independent of Health-Sickness, was related to Health-Sickness at followup: Those who are single have lower Health-Sickness ratings than those who are married, with separated, widowed, or divorced in between (Table 5).
Interactions
Among
Variables
Related
between diagnosis and symptomatology, functioning were as follows.
to
Health-Sickness.
demographic
variables,
Interactions and levels of
Diagnosis and symptomatology. Diagnosis (no psychiatric diagnosis versus nonpsychotic diagnosis versus psychotic diagnosis) and the two major symptom factors were used as independent variables in a stepwise multiple regression analysis with Health-Sickness as the dependent variable. When the effect of diagnosis was controlled with this statistical technique, both of the two major symptom factors continued to make a significant (p < 0.05) contribution to Health-Sickness (Table 6). This is different than at initial assessment, when, if diagnosis was controlled, the symptom factors were not related to Health-Sickness.
Mean 41
n
Race
comparisons.
1. Analysis of variance 2. ScheffB’s procedure for a posteriori
50
34
IV
V j lowest
17
18
SD
43
50
49
51
48
Mean
17
16
15
22
18
SD
Analysis of variance. Hollingshead Two-Factor Index. Comparison of means omitted because overall analysis nonsignificant. Scheffd’s procedure for a posteriori comparisons.
93
Ill
1. 2. 3. 4.
52
II
1
10
28
I (highest)
n
6 6
20
6
14
Low score
12
6
14
6
15
Low score
Admission (p > 0.05)s
Table 6. Social class and Health-Sickness1
28
189
Black
White
Social class2
16
17
18
SD
Admission (p < 0.017)
49
101
Married
divorced,
51
47
81
35
Single
Separated,
widowed
Mean
Marital status
Low score
Admission (p > 0.05)
status, race, and Health-Sickness1
n
Table 5. Marital
79
75
80
85
72
High score
85
71
High score
79
80
85
High score
28
76
42
25
9
n
160
20
n
76
41
63
n
16
15
19
SD
22
33
24
Low score
56
65
71
68
86
Mean
67
60
Mean 24
22
Low score
96
85
High score
95
92
96
High score
16
16
17
18
8
SD
25
30
22
24
68
Low score
85
92
92
92
96
High score
Followup (p < 0.0001)
17
16
SD
Followup (p > 0.05)
70
67
61
Mean
Followup (p < 0.006)
B
AB
AB
A
A
D
D
CD
CD
C
Grouping by HS means4
B
AB
A
Grouping by HS mean@
169 Diagnosis and demographic variables. The association between HealthSickness and socioeconomic and marital status was investigated when (I) diagnosis, and (2) symptomatology, were controlled. When an analysis of covariance (ANCOVA) technique was used, with Health-Sickness as the dependent variable, marital status (single versus married versus other) as the independent variuable, and either diagnosis (no psychiatric diagnosis, nonpsychotic diagnosis, psychotic diagnosis) or the followup symptom factors as covariates, marital status was found to remain significantly associated @ < 0.05) with Health-Sickness when symptoms were controlled, but ceased to be associated with Health-Sickness when diagnosis was controlled. In a similar fashion, ANCOVA was used to examine the relationship of socioeconomic status to Health-Sickness with (I) diagnosis and (2) symptoms controlled. Socioeconomic status was found to remain significantly associated (p < 0.0 1) with Health-Sickness in both instances. Diagnosis and symptomatology with levels of functioning. Measures of work function and social function were associated with Health-Sickness even after diagnosis or the two major symptom factors were controlled using a multiple regression technique (Table 7). The addition of these levels of function and other outcome variables to the regression equation resulted in a more striking increase in the size of the r values than was the case initially; the increase in the r2 value. often interpreted as the percentage of variance in the dependent variable that can be accounted for by the independent variable set, was, of course, even more marked. Table
7. Diagnosis,
symptom
factors,
and social
role function Correlation r
Variable
with HS multiple f
0.73
Diagnosis
0.75
Diagnosis
+ psychosis
factor
Diagnosis
+ depression
Diagnosis
+ quantity
Diagnosis
+ quality
Diagnosis
+ number
Diagnosis
+ quality
Psychosis
& depression-neurosis
factors
Psychosis
& depression-neurosis
factors
+ quality
of work
0.62
Psychosis
& depression-neurosis
factor + quantity
of work
0.70
Psychosis
& depression-neurosis
factors + number
neurosis
0.75
factor
0.78
of employment
0.83
of work
0.75
of social contacts
0.75
of social relationships 0.47
0.54
of social contacts Psychosis
& depression-neurosis
factors + quality 0.57
of social relationships 1 Multtple correlation; p c 0 05 for all results
presented,
n = 174.
Discussion
The results presented here are of particular interest because they tend to confirm findings reported previously from the same sample regarding the importance of diagnosis and psychotic symptoms as components of a global rating of severity of
170 psychiatric illness. They tend also to confirm the role of certain measures of level of function as components of a global measure. On the other hand, the results point to important variation between samples in the components of a global measure of severity of psychiatric illness. Particularly in the followup sample, nonpsychotic symptoms and levels of function seem to be more important concomitants of severity than they were in the admission sample. It might be noted in this context also that these were the same patients, interviewed using the same semistructured interviews, by the same interviewers. Overall, the results presented might be seen as replicating certain findings in the previous study, particularly the association of diagnosis and psychotic symptoms with a global rating of severity of illness, but as disconfirming the hypothesis that the components of a global rating are stable over time, since in fact the role of nonpsychotic symptoms and level of function measures varied between the admission assessment and the 2-year followup assessment. It seems likely that at the time of hospitalization when patients are markedly disturbed, symptom factors such as bizarre behavior, hallucinations, delusions. and severe depression dominate the clinician’s thinking about severity of illness. At a followup point when these symptoms are much less apt to be evident, other manifestations of pathology assume a greater role in clinical judgment. An issue that always arises in considering why an expected association might not be found is the question of sufficient variation in the characteristics of interest in the sample under study. Thus, it might at first be thought that the association of neurotic symptoms with Health-Sickness at followup, but not initially, was somehow related to a lack of variability (due perhaps to everyone having an extreme level) of neurotic symptoms initially. That this is not the case, however, is attested to by the fact that a factor was derived from the initial symptom data which clearly represented a number of neurotic symptoms. The derivation of this factor with these loadings means, of course, that there was considerable variability in the sample along this dimension. The fact that the same raters who carried out the assessment initially and made the initial global ratings also assessed the patients at followup and made the followup global ratings may introduce a bias in the findings because the same raters are obviously more likely to perceive a given patient in a particular way, and conceptualize issues such as severity in a particular way. than would different raters. Thus, the findings presented here might show a closer similarity between an initial and a followup rating than would have been the case had different investigators assessed the patients and carried out the ratings at the two points. In this context, it should be noted that the data analyses for the original report had not been carried out at the time of the followup; thus, the raters were not influenced in their ratings of severity at followup by knowledge of the analyses of the admission data. On the other hand, the ratings of a given patient at followup may well have been affected by knowledge of the patient’s presentation 2 years earlier. The examination of the components of a global severity rating at hospitalization. and reexamination at a later point when patients are discharged and considerably improved, while permitting examination of the stability of rating components, does not provide an opportunity to evaluate test-retest reliability, since significant change in the subjects has occurred.
Again at followup, as at the initial assessment, the Health-Sickness ratings were found to be independent of age and sex. Although initially Health-Sickness ratings were associated with race, this relationship did not obtain when either diagnosis or psychotic symptomatology was controlled; at followup, Health-Sickness ratings were found to be independent of race. On the other hand, both socioeconomic status and marital status were found to be associated with Health-Sickness, even when symptomatology was controlled. Methodologically, the independence of Health-Sickness and demographic variables found initially might well be viewed positively by researchers. inasmuch as it suggested that users of this rating scale might largely avoid questions of prejudice, or bias, inherent in the instrument (Baldwin et al., 1975; Wilkinson, 1975). The situation at followup is not so clear cut. It must be noted in this context that global severity ratings were made by researchers who were simultaneously systematically collecting data of a variety of sorts. Use of the Menninger scale in a clinical setting or in a situation where other areas are the foci of research attention might result in a different set of weightings of components. Viewed as substantive findings, the association of a global measure of severity of psychiatric illness with socioeconomic status and marital status is of some interest. The association of low levels of psychiatric illness with high socioeconomic status might be regarded as consistent with a number of findings of earlier workers who examined psychiatric populations (Hollingshead and Redlich, 1958) and used survey techniques (Warheit et al., 1975) to investigate community samples. The finding that married individuals tend to show a lesser degree of psychiatric illness than those who are single is also in accord with findings from a number of prior studies. Findings from the present study also resemble those from prior studies in that a number of explanations. or models, are consistent with these data (Gove, 1972). A possible explanation for the fluctuating relationship of severity of illness with race and socioeconomic status is that initially a sample was composed of whites who showed a spectrum of severity of illness, ranging from the most disturbed to those who may have been admitted to the hospital electively; blacks, on the other hand, tended to be grouped at the more severely disturbed end, because blacks who were less disturbed were less likely to be admitted to the hospital. This phenomenon may have reflected, among other things, a mistrust of the University Hospital, or at least a feeling of discomfort, on the part of black patients and their families exceeding that of their white counterparts. At followup, when severe symptoms had resolved for almost all patients in the sample, race therefore seemed not to be associated with severity of illness. By the same token, at followup, when such variables as work and social functioning began to be more associated with Health-Sickness, socioeconomic status began to show an association with severity of illness that reflected, in turn, the association between socioeconomic status and level of work and social adjustment (Markey et al., 1976). Luborsky and Bachrach in their 1974 publication reviewing experience accumulated at that time with the Menninger Health-Sickness Rating Scale made the point that taking a mean of several composite criteria provides a more reliable measure than does a single rating. Epstein (1980) makes a similar point, noting that ratings, or
172 determinations, averaged across settings will have a general validity not shared by a determination made with respect to one specific setting. The data presented here would suggest that, in fact, global ratings of severity of illness using the Menninger Health-Sickness Rating Scale may reflect several sorts of symptomatology, diagnoses, and aspects of both work and social functioning, suggesting that such global measures would have a robustness not found with more specific, or more narrowly formulated, measures (e.g., a specific scoring system for the Rorschach). However, the position of Luborsky, Bachrach, and Epstein is taken with respect to a rating composed of explicitly defined components. The changes over time in the components of the Menninger Health-Sickness rating presented here suggest that a weaker claim is to be made with respect to composite ratings that reflect more loosely defined components, such as are represented by the anchor points provided with the Menninger scale.
References Psychiatric Association. DSM-II: Diagnoslic and Statistical Manual qf Mental 2nd ed. APA. Washington, DC (1968). Baldwin, B., Floyd, H., and McSeveney, D. Status inconsistency and psychiatricdiagnosis: A structural approach to labeling theory. Journal of Health and Social Behavior, 16,257 (I 975). Endicott, J., Spitzer. R., Fleiss, J., and Cohen. J. The Global Assessment Scale. Archives a/ American Disorders.
General
Psychiatry,
33, 766 (1976).
Epstein, S. The stability of behavior: Ps_vchologisr,
Il. Implications
for psychological
research.
Americ,an
35, 790 (1980).
Gift, T.E., Strauss, J.S., and Harder, D.W. The severity of psychiatric disorder. Ps_vchiatr>, 3, 3 I ( 1980). Gift, T.E., Strauss, J.S., Harder, D.W.. Kokes, R.F.. and Ritzier. B.A. Established chronicity of psychotic symptoms in first-admission schizophrenic patients. American Journal qf Psychiatry, 138, 779 ( I98 I). Gove, W.R. The relationship between sex roles, marital status and mental illness. Social Forces, 51, 34 (1972). Hollingshead. A.. and Redlich, R. Social Class and Mental Illness. John Wiley&Sons. New York (I 958). Luborsky. L. Clinicians’ judgment of mental health. Archives of General Ps_vchiarrj,, 7,407 Research,
(1962).
Luborsky. Archives
L., and Bachrach,
qf General
Psychiatry.
H. Factors
influencing
clinicians’judgments
of mental health.
31, 292 (1974).
Markey, J.. Miles, D., and Rushing, W. The relation between social class and functional status: A new look at the drift hypothesis. Journal af Health and Social Behavior, 17, 194 (1976).
Strauss, J.S., and Carpenter, W.T.. Jr. The prediction of outcome in schizophrenia: 1. Characteristics of outcome. Archives af General Psychiatry. 27, 739 (1972). Strauss, J.S., and Carpenter, W.T., Jr. Prediction of outcome in schizophrenia: Ill. Five-year outcome and its predictors. Archives af General Psychiatry, 34, 159 (1977). Strauss. J.S., Kokes. R.F.. Ritzler, B.A., Harder, D.W., and VanOrd. A. Patterns of disorder in first admission psychiatric patients. Journalof Nervous and Menral Disease, 116,61 I (1978). Warheit. G.J.. Holzer, C.E., and Arey. S.A. Race and mental illness: An epidemiological update. Journal of Health and Social Behavior, 15,243 (1975). Wilkinson, G. Patient audience social status and the social construction of psychiatric disorders: Toward a differential frame of reference hypothesis. Journal yf Health and Social Behavior.
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173
Wing, J., Cooper, J., and Sartorius, N. Measurement and Classification of Psvchiatric, Symptoms: An Instruction Manual ,for the PSE and CA TEGO Program. Cambridge University Press, New York (1974). World Health Organization. The International Pilot Studvof’Schizophrenia. Vol. I. WHO, Geneva (1973).
P.yvchiatry Research. 14, 163-I 73 Elseviet
The Severity Thomas Receil,ecl
of Psychiatric
E. Gift and David April
6. 1983:
Disorder:
A Replication
W. Harder
re\‘ised
r~ersion
receixxerl
Jlrne
27,
1984;
acc,epted
Augusr
23. 1984.
Abstract. A prior report documented the importance of diagnosis and psychotic symptoms as components of a global rating of severity of psychiatric disorder. The availability of 2-year followup data on 174 (807;) of the original 217 patients permits examination of the stability of components of a global rating. Menninger Health-Sickness Rating Scale (M H RS) scores again correlated with diagnosis and with psychotic symptoms; unlike the initial report, followup MHRS ratings were closely associated with a depression-neurosis factor and social role performance. .Age, race. and sex were independent of severity, while low socioeconomic status correlated with severity of illness.
Global rating, severity. assessment.
Key Words.
the utility of a global measure of severity of psychiatric illness has been recognized (Luborsky and Bachrach, 1974; Endicott et al., 1976), an empirical question arises as to which aspects of patients’ history, symptoms, and level of function are, or are not reflected in global assessments; a closely related question is the degree to which the components of a global rating are uniform across kinds of patients rated. A previous report by Gift et al. (1980), focusing on the Menninger HealthSickness Rating Scale (Luborsky, 1962; Luborsky and Bachrach. 1974). reviewed some of the methodological aspects of these empirical questions, including representative sampling, systematic collection of data, and thorough sample definition. Substantive findings of this study of first lifetime hospitalization for psychiatric illness indicated that psychotic symptoms and bizarre, disturbed behavior were more anxiety, and other nonpsychotic associated with severity than were depression, symptoms; while there was a strong relationship between severity and a psychotic, nonpsychotic dichotomy, there was little relationship between severity and more specific diagnostic categories. Severity was significantly but less closely related to certain measures of chronicity and social function. The availability of 2-year followup data on the original patient sample, collected by the researchers who assessed the patients initially. provides a valuable opportunity to explore the stability of the components of a global rating of severity of psychiatric illness. Although
Thomas
E. Gift.
W.
Harder.
to
Dr.
M.D..
Ph.D..
T.E.
Gift.
Rochester.
SY
0165-1781
85
is Associate
i\ Associate Dept.
14642.
SO3.30
of
Professorof
Profe,\or Psychiatq.
Psychiatry.
of Psychology. L!niversity
Univemityof Tufts
of
Rochester.
USA.)
c 1985
Elsevier
Science
Publishers
B.V
Rochester.
University. 300
Medford. Crittenden
Rochester. MA.
NY.
(Reprint
Blvd..
Box
David requests
R-Wing,
164 Methods As part of a larger study, the First Admission Study (Strauss et al., 1978). a representative sample (n = 217) of first inpatient admissions for functional psychiatric disorder from two catchment areas was evaluated with structured assessment interviews. The instruments used included the Psychiatric Assessment Interview (PAI) (World Health Organization, 1973). a modification of the Present State Examination (Wing et al., 1974) to record patients’symptoms and signs over the month beforeadmission. the Standard Psychiatric History Interview (Strauss et al., 1978). and a social data interview to obtain information on previous psychiatric symptoms, social role functioning, and demographic characteristics. Psychiatric history, social role function, and demographic data were also collected from case records and from patients’ relatives. For the analyses used here, symptom dimensions were generated by combining ratings of related items from the PAI. These symptom dimensions were then subjected to a factor analysis, from which four factors were derived. These factors were: a “psychosis” factor, loading heavily on delusions and hallucinations; a “neurosis” factor, loading heavily on depression, anxiety. and somatic complaints; a “retarded-bizarre” factor. and a “hyperactive-bizarre” factor (Strauss et al., 1978). Based on the information available from all sources, a DSM-/I diagnosis (American Psychiatric Association. 1968) was assigned. and the Strauss-Carpenter Prognostic Scale (Strauss and Carpenter, 1977) was used to rate duration of symptoms at the time of hospitalization. as well as several measures of social and work functioning in the month before hospitalization. Also based on the data available from all instruments, a global rating of severity of psychiatric illness was made using the Menninger Health-Sickness Rating Scale. This scale has a range of 0 (most severely disturbed) to 100 (no psychiatric disturbance). Anchor points provided with the scale include consideration of diagnostic categories. symptoms, and levels of function. The satisfactory reliability of this scale has been reported (Luborsky and Bachrach. 1974). The interviews to assess symptoms and psychiatric history were carried out by two psychiatrists and three clinical psychologists. all of whom also rated the assessment scales. All interviewers were also clinically active in treating both inpatients and outpatients with a range of modalities, including medication (for which the psychologists obtain “medical backup”). A followup evaluation by the clinician/researcher who evaluated the patient initially was carried out 2 years after the date of admission. Eighty percent of the original sample (n = 174) received a comprehensive followup assessment. A psychiatric history for the intervening 2 years was obtained along with relevant social data, a PA1 was again carried out to assess symptoms in the month before followup. and a DSM-/I diagnosis was again assigned. The patients’ clinical status was rated using the Strauss-Carpenter Level of Functicn Scale (Strauss and Carpenter, 1972). A global judgment of severity of illness was again made using the Menninger HealthSickness Rating Scale. and a second rating of overall severity of illness was made using the Global Assessment Scale (Endicott et al.. 1976). In almost all instances the same individual assessed symptoms and psychiatric history, both at admission and at followup, and made the Menninger Health-Sickness ratings both at admission and at followup. The symptom dimensions created from the followup PA1 items were subjected to a factor analysis. Two major symptom factors. the first accounting for 2170 of the variance and the second for IOqc of the variance, were derived. and varimax rotation was performed. yielding a “psychosis” factor, on which hallucinations. delusions. and other psychotic symptoms loaded heavily. and a “depression-neurosis” factor on which anxiety, depression, and other nonpsychotic symptoms loaded heavily (Table I). Each association between Health-Sickness ratings and patient characteristics reported in the prior publication is tested on the followup sample, which might thus be regarded as a replication sample. Since this is a confirmatory rather than an exploratory study. the split-half technique used in the initial report is not used here. Because the correlation between the Menninger Health-Sickness Rating Scale and the Global Assessment Scale is 0.94. data are presented only
165 Table 1. Factor analysis of symptom dimensions
at followup (n = 174)
Factor 1
Factor 2 Factor
Factor Depression-neurosis1 Reported
loading
restlessness
Depression Anxiety
Psychosis2
loading
0.76
Visual hallucinations
0.74
0.75
Delusions
0.73
about hallucinations
0.61
Auditory
Obsessive
symptoms
0.61
Derealization
hallucinations
0.65
0.70
Reported
belligerence
0.60
Delusions
of reference
0.54
Withdrawal
0.52
Delusions
of suspicion
0.52
Somatic
0.50
Delusions
of control
complaints
by an outside
force
0.51
1. Percent of variance accounted for: 20.9 2. Percent of variance accounted for: 9.5.
for the Health-Sickness Rating Scale. Partial followup data were available on several patients in addition to the 174. permitting a larger n for certain analyses.
Results of Health-Sickness. Health-Sickness ratings for the first patients reevaluated at the 2-year followup ranged from 6 to 85. Diagnosis. As was found initially, although the differences in mean HealthSickness ratings between diagnostic categories are quite significant, there is much overlap between diagnostic categories (Table 2). Thus, the highest Health-Sickness rating for the diagnostic group with the lowest mean score (psychotic disorders) is higher than the lowest value for the group with the highest mean Health-Sickness rating (no psychiatric diagnosis). When diagnosis is dichotomized into psychotic (schizophrenia. affective psychosis, or other psychoses) versus nonpsychotic diagnoses (situational reaction, neurosis, character disorder, or no psychiatric diagnosis), it correlates (point biserial Y 0.45,~ < 0.001) with Health-Sickness. When diagnosis is trichotomized into psychosis, nonpsychotic psychiatric disorder. and no psychiatric disorder, and these variables are used as the independent variables in a multiple regression equation with Health-Sickness as the dependent variable, the multiple r is The
Constituents
admission
q
Table 2. Health-Sickness
scores and diagnosis Health-Sickness IHS)
DSM-/I
diagnostic groups (n = 176)
No psychiatric Neurosis
diagnosis
and situational
Personality
disorder
Psychosis
, n = 32 )
in = 65) reaction
tn = 26~
in = 531
1. Analysis of variance (p < 0 05 I. 2. Scheffd’s procedure for a postenori
comparisons.
Mean1
SD
Low score
High score
Grouping by HS means2
82
7
60
95
A
63
12
37
83
B
60
14
30
96
B
51
16
22
82
C
166 0.73 and the r2 is 0.53, suggesting that over half of the variation in Health-Sickness ratings can be predicted from a knowledge of the patients’ diagnostic status. Thus, the finding, initially, that diagnosis is closely associated with Health-Sickness rating is replicated on the followup sample. Symptoms. Initially, psychotic symptoms tended to correlate with HealthSickness, but nonpsychotic symptoms did not. As shown in Table 3, psychotic symptoms again correlated with Health-Sickness ratings at followup, but in addition, many nonpsychotic symptoms were significantly correlated with Health-Sickness ratings. Also, the magnitude of the correlations of the nonpsychotic symptoms was roughly the same order as the correlations of the psychotic symptoms with HealthTable 3. Relationship of symptom dimensions and factors to Health-Sickness1 Dimensions
r
Depression
0.52
Withdrawal
0.52
Suspiciousness
0.51
Reported
0.44
restlessness
Depersonalization
0.42
Delusions of reference Other delusions
0.39
Observed
0.37
Bizarre
0.37
restlessness
behavior
0.36
Slow movement
0.35
Depressive
0.33
delusions
Oriented
0.32
Unkempt
0.30
Incongruous
affect
0.30
Other hallucinations
0.29
Auditory
hallucinations
Incomprehensible
0.29
speech
0.29
Flat affect
0.29
Obsessiveness
0.28
Delusions
0.28
of passivity
Delusions about hallucinations Labile affect
0.27
Visual hallucinations
0.26
Delusions of grandeur Slow speech
0.26
Observed
0.21
0.26
0.23
belligerence
Hypomania
0.17
Somatic
0.13
complaints
Factors Psychosis
factor
Depression-neurosis 1.
Product-moment
n = 174.
0.24 factor correlations;
0.42 results
presented if
P < 0.05.
167 Sickness. The two major factors derived at followup with Health-Sickness; the r value for the neurosis psychosis factor was 0.24. This difference in the however, did not reach statistical significance @ > Relationship
between
Health-Sickness
were both significantly correlated factor was 0.42 while that for the magnitude of these coefficients, 0.10).
and
social
role
functioning.
As
shown in Table 4. all measures of social role functioning were significantly associated with Health-Sickness ratings; thus, followup measures of social role functioning appeared to be more consistently associated with Health-Sickness than did the admission ratings of social role function. Table 4. Relationship function1
between
Health-Sickness
Social role function Quantity Quality Number Quality
Followup (n = 174)
0.22
0.30
0.25
0.32
0.29
0.31
0.41
0.32
of employment
of social
role
Admission2 (n = 217)
of work of social
and social
contacts relationships
1. Product-moment correlahons; results presented if p < 0.05. 2. Correlation coefficients underlined if replicated at admlssion
on split-halves
of sample
Demographic characteristics and Health-Sickness. Age, race, sex, marital status, and socioeconomic status were examined in relation to Health-Sickness. Age and sex were again found to be independent of Health-Sickness. Race, which was significantly associated with Health-Sickness at the initial evaluation, at followup was independent of Health-Sickness (Table 5). On the other hand, socioeconomic status, rated using the Hollingshead Two-Factor Index, which initially was independent of Health-Sickness (Table 6), at followup was correlated with Health-Sickness (r = 0.33; p < 0.01). Marital status, which initially was independent of Health-Sickness, was related to Health-Sickness at followup: Those who are single have lower Health-Sickness ratings than those who are married, with separated, widowed, or divorced in between (Table 5).
Interactions
Among
Variables
Related
between diagnosis and symptomatology, functioning were as follows.
to
Health-Sickness.
demographic
variables,
Interactions and levels of
Diagnosis and symptomatology. Diagnosis (no psychiatric diagnosis versus nonpsychotic diagnosis versus psychotic diagnosis) and the two major symptom factors were used as independent variables in a stepwise multiple regression analysis with Health-Sickness as the dependent variable. When the effect of diagnosis was controlled with this statistical technique, both of the two major symptom factors continued to make a significant (p < 0.05) contribution to Health-Sickness (Table 6). This is different than at initial assessment, when, if diagnosis was controlled, the symptom factors were not related to Health-Sickness.
Mean 41
n
Race
comparisons.
1. Analysis of variance 2. ScheffB’s procedure for a posteriori
50
34
IV
V j lowest
17
18
SD
43
50
49
51
48
Mean
17
16
15
22
18
SD
Analysis of variance. Hollingshead Two-Factor Index. Comparison of means omitted because overall analysis nonsignificant. Scheffd’s procedure for a posteriori comparisons.
93
Ill
1. 2. 3. 4.
52
II
1
10
28
I (highest)
n
6 6
20
6
14
Low score
12
6
14
6
15
Low score
Admission (p > 0.05)s
Table 6. Social class and Health-Sickness1
28
189
Black
White
Social class2
16
17
18
SD
Admission (p < 0.017)
49
101
Married
divorced,
51
47
81
35
Single
Separated,
widowed
Mean
Marital status
Low score
Admission (p > 0.05)
status, race, and Health-Sickness1
n
Table 5. Marital
79
75
80
85
72
High score
85
71
High score
79
80
85
High score
28
76
42
25
9
n
160
20
n
76
41
63
n
16
15
19
SD
22
33
24
Low score
56
65
71
68
86
Mean
67
60
Mean 24
22
Low score
96
85
High score
95
92
96
High score
16
16
17
18
8
SD
25
30
22
24
68
Low score
85
92
92
92
96
High score
Followup (p < 0.0001)
17
16
SD
Followup (p > 0.05)
70
67
61
Mean
Followup (p < 0.006)
B
AB
AB
A
A
D
D
CD
CD
C
Grouping by HS means4
B
AB
A
Grouping by HS mean@
169 Diagnosis and demographic variables. The association between HealthSickness and socioeconomic and marital status was investigated when (I) diagnosis, and (2) symptomatology, were controlled. When an analysis of covariance (ANCOVA) technique was used, with Health-Sickness as the dependent variable, marital status (single versus married versus other) as the independent variuable, and either diagnosis (no psychiatric diagnosis, nonpsychotic diagnosis, psychotic diagnosis) or the followup symptom factors as covariates, marital status was found to remain significantly associated @ < 0.05) with Health-Sickness when symptoms were controlled, but ceased to be associated with Health-Sickness when diagnosis was controlled. In a similar fashion, ANCOVA was used to examine the relationship of socioeconomic status to Health-Sickness with (I) diagnosis and (2) symptoms controlled. Socioeconomic status was found to remain significantly associated (p < 0.0 1) with Health-Sickness in both instances. Diagnosis and symptomatology with levels of functioning. Measures of work function and social function were associated with Health-Sickness even after diagnosis or the two major symptom factors were controlled using a multiple regression technique (Table 7). The addition of these levels of function and other outcome variables to the regression equation resulted in a more striking increase in the size of the r values than was the case initially; the increase in the r2 value. often interpreted as the percentage of variance in the dependent variable that can be accounted for by the independent variable set, was, of course, even more marked. Table
7. Diagnosis,
symptom
factors,
and social
role function Correlation r
Variable
with HS multiple f
0.73
Diagnosis
0.75
Diagnosis
+ psychosis
factor
Diagnosis
+ depression
Diagnosis
+ quantity
Diagnosis
+ quality
Diagnosis
+ number
Diagnosis
+ quality
Psychosis
& depression-neurosis
factors
Psychosis
& depression-neurosis
factors
+ quality
of work
0.62
Psychosis
& depression-neurosis
factor + quantity
of work
0.70
Psychosis
& depression-neurosis
factors + number
neurosis
0.75
factor
0.78
of employment
0.83
of work
0.75
of social contacts
0.75
of social relationships 0.47
0.54
of social contacts Psychosis
& depression-neurosis
factors + quality 0.57
of social relationships 1 Multtple correlation; p c 0 05 for all results
presented,
n = 174.
Discussion
The results presented here are of particular interest because they tend to confirm findings reported previously from the same sample regarding the importance of diagnosis and psychotic symptoms as components of a global rating of severity of
170 psychiatric illness. They tend also to confirm the role of certain measures of level of function as components of a global measure. On the other hand, the results point to important variation between samples in the components of a global measure of severity of psychiatric illness. Particularly in the followup sample, nonpsychotic symptoms and levels of function seem to be more important concomitants of severity than they were in the admission sample. It might be noted in this context also that these were the same patients, interviewed using the same semistructured interviews, by the same interviewers. Overall, the results presented might be seen as replicating certain findings in the previous study, particularly the association of diagnosis and psychotic symptoms with a global rating of severity of illness, but as disconfirming the hypothesis that the components of a global rating are stable over time, since in fact the role of nonpsychotic symptoms and level of function measures varied between the admission assessment and the 2-year followup assessment. It seems likely that at the time of hospitalization when patients are markedly disturbed, symptom factors such as bizarre behavior, hallucinations, delusions. and severe depression dominate the clinician’s thinking about severity of illness. At a followup point when these symptoms are much less apt to be evident, other manifestations of pathology assume a greater role in clinical judgment. An issue that always arises in considering why an expected association might not be found is the question of sufficient variation in the characteristics of interest in the sample under study. Thus, it might at first be thought that the association of neurotic symptoms with Health-Sickness at followup, but not initially, was somehow related to a lack of variability (due perhaps to everyone having an extreme level) of neurotic symptoms initially. That this is not the case, however, is attested to by the fact that a factor was derived from the initial symptom data which clearly represented a number of neurotic symptoms. The derivation of this factor with these loadings means, of course, that there was considerable variability in the sample along this dimension. The fact that the same raters who carried out the assessment initially and made the initial global ratings also assessed the patients at followup and made the followup global ratings may introduce a bias in the findings because the same raters are obviously more likely to perceive a given patient in a particular way, and conceptualize issues such as severity in a particular way. than would different raters. Thus, the findings presented here might show a closer similarity between an initial and a followup rating than would have been the case had different investigators assessed the patients and carried out the ratings at the two points. In this context, it should be noted that the data analyses for the original report had not been carried out at the time of the followup; thus, the raters were not influenced in their ratings of severity at followup by knowledge of the analyses of the admission data. On the other hand, the ratings of a given patient at followup may well have been affected by knowledge of the patient’s presentation 2 years earlier. The examination of the components of a global severity rating at hospitalization. and reexamination at a later point when patients are discharged and considerably improved, while permitting examination of the stability of rating components, does not provide an opportunity to evaluate test-retest reliability, since significant change in the subjects has occurred.
Again at followup, as at the initial assessment, the Health-Sickness ratings were found to be independent of age and sex. Although initially Health-Sickness ratings were associated with race, this relationship did not obtain when either diagnosis or psychotic symptomatology was controlled; at followup, Health-Sickness ratings were found to be independent of race. On the other hand, both socioeconomic status and marital status were found to be associated with Health-Sickness, even when symptomatology was controlled. Methodologically, the independence of Health-Sickness and demographic variables found initially might well be viewed positively by researchers. inasmuch as it suggested that users of this rating scale might largely avoid questions of prejudice, or bias, inherent in the instrument (Baldwin et al., 1975; Wilkinson, 1975). The situation at followup is not so clear cut. It must be noted in this context that global severity ratings were made by researchers who were simultaneously systematically collecting data of a variety of sorts. Use of the Menninger scale in a clinical setting or in a situation where other areas are the foci of research attention might result in a different set of weightings of components. Viewed as substantive findings, the association of a global measure of severity of psychiatric illness with socioeconomic status and marital status is of some interest. The association of low levels of psychiatric illness with high socioeconomic status might be regarded as consistent with a number of findings of earlier workers who examined psychiatric populations (Hollingshead and Redlich, 1958) and used survey techniques (Warheit et al., 1975) to investigate community samples. The finding that married individuals tend to show a lesser degree of psychiatric illness than those who are single is also in accord with findings from a number of prior studies. Findings from the present study also resemble those from prior studies in that a number of explanations. or models, are consistent with these data (Gove, 1972). A possible explanation for the fluctuating relationship of severity of illness with race and socioeconomic status is that initially a sample was composed of whites who showed a spectrum of severity of illness, ranging from the most disturbed to those who may have been admitted to the hospital electively; blacks, on the other hand, tended to be grouped at the more severely disturbed end, because blacks who were less disturbed were less likely to be admitted to the hospital. This phenomenon may have reflected, among other things, a mistrust of the University Hospital, or at least a feeling of discomfort, on the part of black patients and their families exceeding that of their white counterparts. At followup, when severe symptoms had resolved for almost all patients in the sample, race therefore seemed not to be associated with severity of illness. By the same token, at followup, when such variables as work and social functioning began to be more associated with Health-Sickness, socioeconomic status began to show an association with severity of illness that reflected, in turn, the association between socioeconomic status and level of work and social adjustment (Markey et al., 1976). Luborsky and Bachrach in their 1974 publication reviewing experience accumulated at that time with the Menninger Health-Sickness Rating Scale made the point that taking a mean of several composite criteria provides a more reliable measure than does a single rating. Epstein (1980) makes a similar point, noting that ratings, or
172 determinations, averaged across settings will have a general validity not shared by a determination made with respect to one specific setting. The data presented here would suggest that, in fact, global ratings of severity of illness using the Menninger Health-Sickness Rating Scale may reflect several sorts of symptomatology, diagnoses, and aspects of both work and social functioning, suggesting that such global measures would have a robustness not found with more specific, or more narrowly formulated, measures (e.g., a specific scoring system for the Rorschach). However, the position of Luborsky, Bachrach, and Epstein is taken with respect to a rating composed of explicitly defined components. The changes over time in the components of the Menninger Health-Sickness rating presented here suggest that a weaker claim is to be made with respect to composite ratings that reflect more loosely defined components, such as are represented by the anchor points provided with the Menninger scale.
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