Professional Documents
Culture Documents
The Clinical
[REVIEW]
Global
Impressions
Scale:
Applying a Research
Tool in Clinical Practice
by JOAN BUSNER, PhD; and STEVEN D. TARGUM, MD
AUTHOR AFFILIATION:
Dr. Busner is Clinical Associate Professor of Psychiatry, Penn State College of Medicine, and
Clinical Manager, United BioSource Corporation, Wayne, Pennsylvania; Dr. Targum is
Consultant to Massachusetts General Hospital, Department of Psychiatry, Boston,
Massachusetts
DISCLOSURE:
Dr. Busner has received grant support, served on the speaker bureau, or served as a
consultant for the following pharmaceutical companies: Eli Lilly, Glaxo SmithKline, Bristol-
Myers Squibb, Forest, Shire, and Merck. She is an employee of United BioSource
Corporation; Dr. Targum is a consultant to the department of psychiatry at Massachusetts
General Hospital, and has been a paid consultant to BrainCells Inc., Memory
Pharmaceuticals, Prana Biotechnology, Epix Pharmaceuticals, Dynogen pharmaceuticals,
Nupathe, United Biosource Corporation, and Johnson and Johnson PRD within the past
year, and is an executive-in-residence at Oxford BioScience Partners (Boston, Mass.)
KEY WORDS:
Clinical Global Impressions Scale, quantification of patient outcome, tracking medication
response, research tool for clinician
1 = Normal—not at all ill, symptoms of disorder not present past seven days
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; symptom level may warrant medication
5 = Markedly ill—intrusive symptoms that distinctly impair social/occupational function or cause intrusive levels of distress
6 = Severely ill—disruptive pathology, behavior and function are frequently influenced by symptoms, may require assistance from others
7 = Among the most extremely ill patients—pathology drastically interferes in many life functions; may be hospitalized
Adapted from Kay SR. Positive and negative symptoms in schizophrenia: Assessment and research. Clin Exp Psychiatry Monograph No 5.
Brunner/Mazel, 1991.
1 = Very much improved—nearly all better; good level of functioning; minimal symptoms; represents a very substantial change
2 = Much improved—notably better with significant reduction of symptoms; increase in the level of functioning but some symptoms
remain
3 = Minimally improved—slightly better with little or no clinically meaningful reduction of symptoms. Represents very little change in
basic clinical status, level of care, or functional capacity
5 = Minimally worse—slightly worse but may not be clinically meaningful; may represent very little change in basic clinical status or
functional capacity
Adapted from Spearing MK, Post RM, Leverich GS, et al. Modification of the Clinical Global Impressions (CGI) Scale for use in bipolar
illness (BP): the CGI-BP.Psychiatry Res 1997;73(3):159–71.
patient’s life—work, home, school, applicable guidelines based on patient may warrant scoring the
and relationships. severity and change guidelines used severity of illness as more or less
in clinical research and published severe, or the change from baseline
CGI SCORING GUIDELINES for specific diseases. These as more or less improved, than the
There are no universally accepted guidelines have been modified for suggested guidelines would indicate.
scoring guidelines for the seven this paper for better applicability
anchor points; rather they were across diseases. The guidelines CGI SCORING EXAMPLES
designed to be based solely on should be used as suggestions, not Following are some clinical
clinical judgment. Presented in absolutes, for scoring. Clinical scenarios that apply the typical
Tables 1 and 2 are some generically judgment and “gut” sense about the conventions for scoring the CGI:
SSRI
Depression initiated N/A (no Visit #: 1
1 1/7/07 N/A (no meds) 5 Date: January 7, 2007
and anxiety [name and meds)
dose] CGI-S = 5
Predominant symptoms: Depression and
anxiety
Slight Raise dose Tolerability? N/A medication to begin this
Depression headache one evening
2 2/7/07 5 4
and anxiety evening, now Medication? SSRI initiated (name and
[name and
resolved dose)
new dose]
Switch to Visit #: 2
Depression different Date: February 7, 2007
same; SSRI CGI-S=5 (markedly ill), CGI-I=4 (no
3 3/7/07 anxiety has No problems 6 5 change)
significantly Predominant symptoms: depression and
[name and
worsened anxiety
dose]
Tolerability? slight headache one evening
that resolved on own
Minimal
Medication? SSRI raised by 20mg
improvemen
t in both Visit#: 3
maintain
4 4/7/07 depression No problems 3 3 Date: March 7, 2007
dose
and anxiety CGI-S= 6 (severely ill), CGI-I=5 (minimally
relative to worse) (remember this is always in compari-
Visit 1 son to the CGI-S that was done prior to
medication--thus, this is in comparison to
Virtually the CGI-S of 5 at Visit 1)
symptom Switch from Predominant symptoms: Depression stayed
Daytime
5 5/7/07 free for am to hs 2 1 the same; anxiety has worsened
sleepiness
depression dosing Tolerability? No problems
and anxiety Medication: Switch of medication to second
SSRI [name, dose] due to lack of efficacy for
anxiety (CGI-I has worsened despite dose
estimated time spent engaged in patient’s clinical status, level of increase and adequate length of time)
these anxious thoughts was less distress, or functioning. This
than one hour per day, compared to patient is now experiencing a Visit #: 4
an estimated 3 to 4 hours per day significant nightly improvement in Date: April 7, 2007
at baseline. The patient drove over sleep, a reduction in time spent CGI-S= 3 (mildly ill) CGI-I=3 (minimally
a bridge this week, which was engaged in worry, and is driving improved)
described as somewhat difficult and over bridges allowing him to cut 60 Predominant symptoms: Depression and
anxiety have both improved to a minimal
fear-provoking, but manageable. At minutes round trip off his daily
degree relative to baseline
baseline, the subject was wholly commute. These improvements in
Tolerability? No problems
avoidant of bridges, which caused distress level, symptom severity, Medication: SSRI #2 maintained at current
him to drive 30 minutes out of his and functional ability suggest an dose
way each day to get to work. improvement score better than 3
Suggested CGI-I score=2 (much because of his noticeable clinical Visit #: 5
improved) improvement and better Date: May 7, 2007
Rationale: The patient’s clinical functioning. Nonetheless, the CGI-S=2 (borderline ill) CGI-I=1 (very
status has clearly changed in the patient is still symptomatic; he much improved)
direction of improvement. For a endures the drive over the bridge Predominant symptoms: Both depression
and anxiety have improved dramatically
CGI-I score of 3 (minimally with distress and still experiences
Tolerability? daytime sleepiness
improved), the level of change anxious ruminations each day. Medication: SSRI #2 maintained at current
would not be sufficient to make an Consequently, a rating of 2, much dose; switched from am to hs dosing
appreciable difference to the improved, rather than 1, very much
Inattention Visit #: 1
Initiate
and Date: May 22, 2006
stimulant N/A (no
1 5/22/06 hyperactivity N/A (no meds) 4 CGI-S = 4 (moderately ill) CGI-I/Not
[name, meds)
home and Applicable (first visit)
dose]
school Predominant symptoms: inattention and
hyperactivity at home and school
Inattention Tolerability? N/A medication to begin
and tomorrow
hyperactivity Medication? Stimulant initiated (name and
have Dose raised dose)
2 5/29/06 lessened a No problems [name, 3 3
bit at home; dose]
still
prominent at Visit #: 2
school Date: May 29, 2006
CGI-S=3 (mildly ill), CGI-I=3 (minimal
improvement)
One
Predominant symptoms: inattention and
episode
hyperactivity; both have lessened some-
fidgetiness Maintain
Eating less per what at home, per parent, though still
at school dose; parent
parent; one- quite noticeable at school
(minor); to provide
3 6/5/06 pound weight 2 1 Tolerability? no problems
otherwise breakfast
loss since last Medication? stimulant dose raised
no prior to
visit
symptoms dosing
at school or
home Visit#: 3
Date: June 5, 2006
Maintain CGI-S= 2 (minimally ill), CGI-I=1 (very
No dose; much improved)
4 7/7/06 symptoms No problems continue to 1 1 Predominant symptoms: teacher reported
noted dose after 1 episode of "fidgetiness" during math les-
breakfast son (25 minute duration). Otherwise, no
symptoms noted at school. Parent
reports home hyperactivity and inattention
symptoms have both been dramatically
improved, best captures this lightheadedness or other symptoms
improved throughout the week.
patient’s improvement relative to suggesting impending syncope, he Tolerability? Eating less per parent; has
his baseline state. reports worrying constantly about lost 1 pound in past week.
CGI-I Example 2. Anxiety. “passing out” in front of a moving Medication: Maintain current dose;
The anxious patient in the previous car or bus. He is fearful that he will instruct parent to dose after large break-
example (CGI-I Example 1) returns forget the name of a well-known fast.
one month later. He reports that he friend or relative should they call
is now afraid of leaving his house him on the phone. He is sleeping Visit #: 4
without accompaniment. This is a only 1 to 2 hours a night. His wife Date: July 7, 2006
CGI-S=1 (normal, not at all ill); CGI-I=1
new development for him. He is reports that she has “never seen
(very much improved)
anxious and worried all day long. him so bad.” He cries in the Predominant symptoms: No symptoms of
He called work and told them he interview and admits he has ADHD evident this week across multiple
had the flu. In reality, he was afraid considered “ending it all” to make settings.
to leave his house. He has only left the pain go away. Tolerability? No problems. Child's weight
the house three times this week, Suggested CGI-I score=7 (very is maintained, and parent reports child's
including his visit to the clinic much worse) eating has normalized.
today, all accompanied by his wife. Rationale. The patient has Medication: Stimulant maintained at cur-
He felt panicky on all three clearly worsened relative to his rent dose. Breakfast prior to dosing will
continue.
occasions. Although he denies any baseline condition. The patient has