Mental illness has an enormous impact on health and productivity in the U.S. Twenty percent of Americans experience a mental disorder in the course of a year and 15% of the adult population receives mental health services. Within the Veterans Health Administration (VHA), 17.5% of VHA patients in FY 2001 received specialized VHA mental health services at a cost of almost $2 billion. High prevalence and cost have spurred interest in monitoring outcomes of mental health treatment, using a wide range of instruments and outcome assessment protocols. The VHA has mandated the use of a clinician-rated measure, the Global Assessment of Functioning scale (GAF) for mental health outcome assessment. However, the research literature suggests that the patient's perspective should be incorporated into outcomes monitoring systems.
The objectives of this research study were to: 1) compare the sensitivity to change (improvement over the course of mental health treatment) of three patient self-report measures to the clinician-rated Global Assessment of Functioning Scale (GAF); and 2) examine whether self-report measures provide extra explanatory power in predicting functional outcomes (employment, housing, social support, and psychiatric hospitalization). The three self-report measures selected for the study are the Veterans SF-36 (VR-36), Brief Symptom Inventory (BSI), and revised 24-item Behavior and Symptom Identification Scale (BASIS-24).
The study used a prospective, observational design. The sample included inpatients and outpatients who presented for treatment at one of two participating VISN 1 mental health facilities (Bedford and Boston/Brockton) during the specified data collection period. We recruited 449 inpatients and 896 outpatients. For outpatients, we obtained assessments at two time points: an initial assessment at entry into the study, and a final assessment approximately 3 months later. For inpatients, we obtained assessments at three time points: an initial assessment at entry into the study (within 48 hours of inpatient admission), a second assessment at discharge, and a final assessment 3 months after entry into the study. Primary and secondary data sources were used. Primary data included VR-36, BSI and BASIS-24 assessments, self-reported race/ethnicity, employment status, housing arrangements and social support. Secondary data sources were used to obtain demographic and diagnostic data, (including co-morbid psychiatric conditions), GAF ratings, and psychiatric hospitalization after study enrollment. Data analyses examined change in mental health status following treatment, correlations between change in GAF ratings with change on each of the self-report measures, analysis of clinically meaningful change to determine and compare meaningfulness of change on each measure, and multivariate regressions to examine demographic and diagnostic predictors of improvement based on self-report and clinician ratings.
At the aggregate level, psychiatric inpatients showed statistically significant change from admission to discharge and from admission to 3-month follow-up on all of the mental health self-report measures and on the GAF, with effect sizes ranging from .24 to .72 for the self-report measures. Effect size for the GAF was 2.0. Significant change occurred among inpatients for all the major diagnostic groups and for both inpatient sites. For outpatients, at the aggregate level, change from enrollment to follow-up was not consistent and not statistically significant. At the individual level, clinically meaningful improvement occurred in 31% to 65% of patients on the self-report measures and for 81% of patients on the GAF rating. Scores on all three self-report measures were moderately correlated with each other, but had little or no correlation with GAF ratings.
This study offers three important contributions. First, it provides valuable information comparing sensitivity of self-report measures with the GAF for measuring change over the course of treatment. Second, it is useful for deciding whether to incorporate a patient self-report measure into mental health outcomes monitoring efforts within the VHA at either the program or system level. Third, it provides information that can guide decision-making regarding which of three widely used self-report measures is most sensitive to measuring change over the course of treatment.
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- Schultz M, Glickman ME, Eisen SV. Predictors of decline in overall mental health, PTSD and alcohol use in OEF/OIF veterans. Comprehensive psychiatry. 2014 Oct 1; 55(7):1654-64.
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- Fasoli DR, Glickman ME, Eisen SV. Predisposing characteristics, enabling resources and need as predictors of utilization and clinical outcomes for veterans receiving mental health services. Medical care. 2010 Apr 1; 48(4):288-95.
- Chatterjee S, Rath ME, Spiro A, Eisen S, Sloan KL, Rosen AK. Gender differences in veterans health administration mental health service use: effects of age and psychiatric diagnosis. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2009 May 1; 19(3):176-84.
- Clements KM, Murphy JM, Eisen SV, Normand SL. Comparison of self-report and clinician-rated measures of psychiatric symptoms and functioning in predicting 1-year hospital readmission. Administration and policy in mental health. 2006 Sep 1; 33(5):568-77.
- Fasoli DR, Glickman ME, Seal P, Eisen SV. A Study of the Relationship between Individual Patient Factors, Utilization, and Outcomes for Veterans Receiving Mental Health Services. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
- Seal P, Glickman ME, Spiro A, Rosen AK, Rosenheck R. Do self-reported mental health measures add to GLOBAL Assessment of Functioning (GAF) ratings in predicting functional outcomes of veterans? Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
- Eisen SV, Seal P, Spiro AS, Glickman M, Rosenheck R, Herz L, Furlong P, Silva L, McCoy L. Clinically Meaningful Change in Mental Health Functioning Based on Patient Self-Report and Clinician Assessment. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 16; Arlington, VA.
Mental, Cognitive and Behavioral Disorders, Health Systems
Decision support, Patient outcomes, Screening