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The Clinical Global Impression-Schizophrenia scale: a simple instrument to

measure the diversity of symptoms present in schizophrenia

Article  in  Acta psychiatrica Scandinavica. Supplementum · February 2003

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Acta Psychiatr Scand 2003: 107 (Suppl. 416): 16–23 Copyright ª Blackwell Munksgaard 2003
Printed in UK. All rights reserved ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0065-1591

The Clinical Global Impression– –

Schizophrenia scale: a simple instrument to
measure the diversity of symptoms present
in schizophrenia
Haro JM, Kamath SA, Ochoa S, Novick D, Rele K, Fargas A, J. M. Haro1, S. A. Kamath2,
Rodrı́guez MJ, Rele R, Orta J, Kharbeng A, Araya S, Gervin M, S. Ochoa1, D. Novick3, K. Rele2,
Alonso J, Mavreas V, Lavrentzou E, Liontos N, Gregor K, Jones PB A. Fargas1, M. J. Rodr#guez1,
on behalf of the SOHO Study Group. The Clinical Global Impression– R. Rele2, J. Orta1, A. Kharbeng2,
Schizophrenia scale: a simple instrument to measure the diversity of S. Araya1, M. Gervin2, J. Alonso,
symptoms present in schizophrenia.
Acta Psychiatr Scand 2003: 107 (Suppl. 416): 16–23.
V. Mavreas4, E. Lavrentzou4,
ª Blackwell Munksgaard 2003 N. Liontos4, K. Gregor3,
P. B. Jones2 on behalf of the
Objective: To describe the development and validation of the Clinical SOHO Study Group*
1
Global Impression–Schizophrenia (CGI-SCH) scale, designed to assess Research and Development Unit, Sant Joan de
positive, negative, depressive and cognitive symptoms in Du-SSM, Sant Boi, Barcelona, Spain, 2University of
schizophrenia. Cambridge, Cambridge, UK, 3European Health Outcomes
Research, Eli Lilly and Company Limited, Windlesham,
Method: The CGI-SCH scale was adapted from the CGI scale.
Surrey, UK and 4University of Ioannina, Greece
Concurrent validity and sensitivity to change were assessed by
comparison with the Positive and Negative Symptom Severity
(PANSS) and Global Assessment of Functioning (GAF) scales. To
evaluate inter-rater reliability, all patients were assessed by two
clinicians.
Results: Symptoms were assessed in 114 patients. Correlation
coefficients between the CGI-SCH and the GAF and PANSS scores
were high (most above 0.75), and were highest for positive and negative
Key words: psychiatric status rating scales;
symptoms. Reliability was substantial (intraclass correlation psychometrics; questionnaires; schizophrenia; signs
coefficient, ICC > 0.70) in all but one dimension (depressive and symptoms
dimension, ICC ¼ 0.64).
Josep Maria Haro, Research and Development Unit,
Conclusion: The CGI-SCH scale is a valid, reliable instrument to Dr Antoni Pujades 42, E-08830-Sant Boi de L, Barcelona,
evaluate severity and treatment response in schizophrenia. Given its Spain
simplicity, brevity and clinical face validity, the scale is appropriate for Tel: +34 93 6002682; Fax: +34 93 6520051;
use in observational studies and routine clinical practice. E-mail: [email protected]

ÔfloridÕ or ÔproductiveÕ, and ÔdefectÕ or ÔdeficitÕ,

Introduction
which correspond roughly to the more up-to-date
Schizophrenia is a serious mental disorder charac- terms of positive and negative symptoms. Depres-
terized by a number of symptoms. In the past, the sion and cognitive symptoms also accompany
symptoms of schizophrenia were classified as positive and negative symptoms as psychopatho-
logical manifestations of schizophrenia. Depressed
This paper is one of a suite of papers reporting aspects of the
mood is common in individuals who suffer from
Schizophrenia Outpatient Health Outcomes (SOHO) Study. schizophrenia, often arising from the individual’s
The study and this publication were funded by Eli Lilly and appraisal of psychosis and its implications for his
Company Limited, Windlesham, Surrey, UK. or her perceived social identity, position and Ôgroup
*The SOHO Study Group is listed in the Acknowledgements fitÕ. Post-psychotic depression is associated with an
section. increased risk of suicide (1, 2). Cognitive symptoms

16
 CGI-SCH validity in the SOHO study

were defined by Kraepelin in his first descriptions was to produce a simple, easy-to-administer
of dementia praecox. Taken together, these symp- instrument that could be used in observational
toms affect several areas of functioning, such as studies and routine clinical practice in schizophre-
attention, executive functioning and memory. nia. It was decided that the instrument should:
The Positive and Negative Symptom Severity
• include evaluation of positive, negative, depres-
(PANSS) scale (3) is the scale used most often
sive and cognitive symptoms;
when assessing treatment response or clinical
• be easy to understand;
severity in schizophrenia, and allows evaluation
• be quick and easy to administer;
of the symptoms of this condition. Factor analysis
• be valid and reliable; and
studies performed with the PANSS on large
• be sensitive to change.
populations of patients with schizophrenia have
identified five components in the symptomatology: The CGI-SCH scale was adapted from the CGI
positive, negative and cognitive ⁄ disorganization scale (9) and the CGI-Bipolar Patients (CGI-BP)
symptoms and two other affective dimensions scale (10). The CGI scale is a simple instrument
(4–6). The findings using the PANSS scale that evaluates the overall severity of mental disor-
have been consistent in different populations of ders. The complete CGI scale consists of three
patients (4–6). The PANSS depressive scale has different global measures designed to rate the
been shown to be a valid measure of depres- effectiveness of a particular treatment:
sive symptoms in schizophrenia when compared
(i) severity of the illness (assessment of the
with the Hamilton Rating Scale for Depression
current severity of symptoms);
(HAM-D) and the Calgary Depression Scale for
(ii) global improvement (comparison of the
Schizophrenia (7).
patient’s baseline condition to his or her
However, the PANSS (like most scales that
current condition); and
assess clinical severity) has been developed for use
(iii) efficacy index (evaluation of the patient’s
in a research environment, and while suitable for
improvement from baseline in relation to
assessing treatment response in clinical trials, is
treatment side-effects).
time-consuming to administer (typically taking 30–
45 min). Shorter, simpler and easier-to-administer The CGI has been used previously in efficacy
scales are badly needed, particularly for use in and effectiveness studies in schizophrenia (11–13),
studies of treatment effectiveness, where evaluation and has been shown to be sensitive to change:
of treatment occurs in a real practice environment. changes recorded by the CGI correlate with
In this situation rapid assessment is mandatory, as changes observed with more complex scales
a longer assessment would alter the normal course (14, 15). Nevertheless, the CGI has been criticized
of the care that is under evaluation. Quick, simple for being inconsistent and unreliable (10, 16, 17).
instruments could also be used in routine clinical Specific criticism includes the fact that the scale
practice. There is a need therefore for a simple, has asymmetric scaling, lacks standard definitions
quick and easy-to-administer scale that is suitable of illness severity and change, the change meas-
for use in observational studies and routine clinical ures are redundant and the assessment of side-
practice. effects mixed with the evaluation of treatment
The objective of this paper is to describe the change can complicate evaluation and interpret-
development and validation of the Clinical Global ation (10).
Impression–Schizophrenia (CGI-SCH) scale, a Spearing et al. modified the CGI scale to
brief assessment instrument adapted from the improve its applicability in bipolar disorder (10).
Clinical Global Impression (CGI) scale. The The CGI-BP overcomes the shortcomings of the
CGI-SCH scale is designed to assess the main CGI by eliminating the efficacy index, better
symptom dimensions in schizophrenia. defining the items, changing the anchor points
and differentiating the rating of different types of
symptoms (mania, depression and overall bipolar
Material and methods illness). The CGI-BP scale includes three categories
(severity of illness, change from preceding phase
Development of the CGI-SCH scale
and change from the worst phase of illness) and the
The CGI-SCH scale was developed for use in the evaluation of significant side-effects. Each of the
Schizophrenia Outpatient Heath Outcomes categories has a different rating for manic, depres-
(SOHO) Study (8), an observational study of the sive and global symptoms. The CGI-BP has been
outcomes of antipsychotic treatment in schizophre- used in recently conducted treatment trials in
nia. In creating the CGI-SCH scale, the objective bipolar disorder (18, 19).

17
Haro et al.

Table 1. The CGI-SCH scale

I. Severity of illness
Considering your total clinical experience with patients with schizophrenia, how severely ill has the patient been during the last week?
Normal, Minimally Mildly Moderately Markedly Severely Among the most
not ill ill ill ill ill ill severely ill

1. Positive symptoms 1 2 3 4 5 6 7
(e.g. hallucinations, delusions or bizarre behaviour)
2. Negative symptoms 1 2 3 4 5 6 7
(e.g. affective flattening, avolition or anhedonia)
3. Depressive symptoms 1 2 3 4 5 67
(e.g. sadness, depressed mood or hopelessness)
4. Cognitive symptoms 1 2 3 4 5 6 7
(e.g. impaired attention, concentration or memory)
5. Overall severity 1 2 3 4 5 6 7

II. Degree of change

Compared to the previous evaluation*, how much has the patient changed? Rate improvement whether or not, in your judgement, is due entirely to treatment?
Very much Much Minimally No Minimally Much Very much
improved improved improved change worse worse worse N ⁄A

1. Positive symptoms 1 2 3 4 5 6 7 9
(e.g. hallucinations, delusions or bizarre behaviour)
2. Negative symptoms 1 2 3 4 5 6 7 9
(e.g. affective flattening, avolition or anhedonia)
3. Depressive symptoms 1 2 3 4 5 6 7 9
(e.g. sadness, depressed mood or hopelessness)
4. Cognitive symptoms 1 2 3 4 5 6 7 9
(e.g. impaired attention, concentration or memory)
5. Overall severity 1 2 3 4 5 6 7 9

*In treatment trials with several evaluation points, use 'Compared to the phase immediately preceding this treatment trial' instead of 'Compared to the previous evaluation'.

Based on the CGI and CGI-BP, the CGI-SCH this index combines two diverse constructs, it is
was developed for use with patients with schizo- difficult to rate and probably not particularly
phrenia. The CGI-SCH is simpler than the CGI reliable. The efficacy index has been deleted from
and the CGI-BP scales as it consists of only two the CGI-SCH and it is suggested that the evalu-
categories; severity of illness and degree of change ation of side-effects should be undertaken with
(Table 1). The severity of illness category evalu- specific scales.
ates the situation during the week previous to the The meaning of each of the ratings of the CGI-
assessment, while the degree of change category SCH is similar to the PANSS dimensions (positive,
evaluates the change from the previous evaluation negative, depressive and cognitive ⁄ disorganiza-
(or from the phase preceding the treatment trial). tion). The term ÔCGI-SCH cognitive symptomsÕ is
Each category contains five different ratings used instead of ÔCGI-SCH cognitive ⁄ disorganiza-
(positive, negative, depressive, cognitive and tionÕ, as cognitive symptoms is a term with which
global) that are evaluated using a seven-point psychiatrists are more likely to be familiar and the
ordinal scale. To help understanding, a short scale was designed for use by psychiatrists working
definition of each symptom is included in the in clinical practice rather than a research environ-
instrument, and the instruction manual contains a ment.
more detailed definition of each dimension. Com- A brief user manual was developed to accom-
pared with the CGI instrument, several important pany the CGI-SCH (available from the authors).
changes have been introduced. The scaling of Following development of the CGI-SCH scale and
ratings has been modified to achieve more con- the user manual, a process of cognitive debriefing
sistent intervals and time domains have been was undertaken to test if the instrument was
clarified. For example, the CGI instrument asks understood as it was intended.
for the state of the patient Ôat this timeÕ, while the The CGI-SCH was developed in English. The
CGI-SCH asks for the state of the patient Ôduring original English version was converted to Spanish
the last weekÕ. The CGI efficacy index rates the using standard translation–backtranslation proce-
improvement due to pharmacological treatment dures, including expert panels, cognitive debriefing
and relates this to the presence of side effects. As and pilot testing.

18
 CGI-SCH validity in the SOHO study

Patients Statistical analysis

The study was conducted in three centres: Sant Concurrent validity (a type of construct validity) is
Joan de Déu-Serveis de Salut Mental in Barce- the capacity of an instrument to agree with other
lona, Spain, the University of Cambridge in the constructs that coexist with the one assessed by
UK and the University of Ioannina in Greece. the test. Concurrent validity of the CGI-SCH scale
The study sample was designed to include a was assessed by analysing the agreement between
broad representation of patients with schizophre- the CGI-SCH ratings with the PANSS (positive,
nia, including in-patients and outpatients, as well negative, depressive, cognitive ⁄ disorganization
as patients experiencing an acute episode and and global scores), and the GAF. The CGI-SCH
those in a stable condition. Patients were recruit- severity of illness (CGI-SCH SI) score for positive
ed from three acute in-patient units and three symptoms was compared with the PANSS positive
outpatient services. The heterogeneity of this score, for example, and the CGI-SCH SI score for
patient sample reflects the expectation that the depressive symptoms was compared with the
CGI-SCH will be used in both in-patient and PANSS depressive score. Pearson correlation
outpatient settings. Patients with a diagnosis of coefficients were used to analyse the association.
schizophrenia (according to IDC-10 or DSM-IV The PANSS scores were calculated using the
criteria), receiving psychiatric treatment, aged following items (4, 23):
18 years or older, and who gave informed consent
• positive (delusions, hallucinatory behaviour,
for participation were included. No exclusion
grandiosity, suspiciousness, unusual thought
criteria were applied.
content, lack of judgment and insight);
• negative (blunted affect, emotional withdrawal,
Methods poor rapport, passive ⁄ apathetic social with-
drawal, lack of spontaneity and flow of conver-
The objectives of the evaluation were to determine
sation, motor retardation, active social
the concurrent validity, inter-rater reliability and
avoidance, disturbance of volition);
sensitivity to change of the CGI-SCH scale. A
• depressive (anxiety, guilt feelings, depression);
battery of instruments were administered to the
and
patients, including a sociodemographic and clinical
• cognitive ⁄ disorganization (poor attention, con-
questionnaire, the CGI-SCH scales, the PANSS
ceptual disorganization, difficulty in abstract
(3, 20) and the Global Assessment of Functioning
thinking, disorientation).
Scale (GAF) (21, 22).
Out-patients included in the study were rated by Sensitivity to change was analysed by calculat-
two clinicians (one of whom was usually the ing the effect size of the change of the CGI-SCH,
treating psychiatrist) using the battery of instru- the PANSS and the GAF ratings from admission
ments. One of the clinicians conducted the inter- to discharge. The effect size was calculated by
view and both clinicians completed the four dividing the mean change in the scale by the
questionnaires independently. Only the severity of standard deviation. Sensitivity to change of the
illness (and not the degree of change) part of the CGI-SCH scale was also evaluated by comparing
CGI-SCH was completed for outpatients, as there the change in the CGI-SCH scale with the change
was no follow-up assessment. In-patients were in the PANSS and the GAF scales. As with the
evaluated twice. The first evaluation took place validity assessment, each of the CGI-SCH ratings
during the first days after admission (this evalua- was compared to the rating in the other scales
tion was equivalent to the evaluation of out- that measured the same construct. Pearson corre-
patients), and the second evaluation was conducted lation coefficients were used to analyse this
at discharge by one of the clinicians. The second association.
evaluation included the same instruments, except CGI-SCH degree of change (CGI-SCH DC)
that both categories of the CGI-SCH scales ratings measure the change of the severity of the
(severity of illness and degree of change) were disorder between two time-points (e.g. from the
rated. The order of administration of the ques- initiation of treatment to the assessment of its
tionnaires was the same in all cases and was effectiveness). The CGI-SCH DC ratings at dis-
sociodemographic and clinical questionnaire, CGI- charge were compared to the change in the CGI-
SCH, PANSS and GAF. SCH SI ratings from admission to discharge.
The study protocol was approved by the ethics Pearson correlation coefficients were used to ana-
committees of the participating institutions. lyse the agreement.

19
Haro et al.

Inter-rater reliability was assessed by comparing total scores, respectively (Pearson correlation
the ratings of each of the CGI-SCH dimensions coefficients ranging from 0.75 to 0.86). Moderate
made by the two clinicians for the same patient, agreement was found between the CGI-SCH
analysed using intraclass correlation coefficients depressive score and the PANSS depressive dimen-
(ICC) (24). ICC values range from 0 to 1; values of sion and the CGI-SCH global score and the GAF
0.7 and over are considered to indicate Ôsubstantial scale (Pearson correlation coefficients of 0.60 and
agreementÕ and values of 0.5–0.7 are considered to 0.67, respectively). As symptom dimensions are not
indicate Ômoderate agreementÕ (25). As the GAF totally independent, correlations between the CGI-
scale can have up to 100 possible scores, inter-rater SCH SI scales and the other scales that assessed
reliability was calculated by grouping the scores symptoms not directly related to the symptoms
into 5-point intervals. being evaluated in that CGI-SCH dimension were
also present. However, as expected, the values of
the Pearson correlation coefficients were low
Results
(values ranging from 0.02 to 0.37), except for the
A total of 114 patients were included in the cognitive and negative dimensions, where correla-
study; 50 patients from Spain (24 in-patients and tion coefficients were around 0.5. Scales that assess
26 out-patients), 34 from the United Kingdom (19 global symptomatology or functioning (CGI-SCH
in-patients and 15 out-patients) and 30 from global score, PANSS total and GAF) were corre-
Greece (eight in-patients and 22 out-patients). lated to symptom dimensions, as global symptoms
The proportion of men was 66.7%, 82.8% and include the individual dimensions.
69.7% for Spain, United Kingdom and Greece, Sensitivity to change was analysed by assessing the
respectively. Mean age was 38.7 years (SD 10.2), effect size of the change in ratings during admission
37.0 years (SD 11.6) and 33.9 years (SD 10.6) for (Table 4). The effect sizes for CGI-SCH SI positive
Spain, United Kingdom and Greece, respectively. and global scores were higher than for negative,
Patient sociodemographic and clinical characteris- depressive and cognitive symptoms, and similar to
tics are outlined in Table 2. those for the PANSS positive, total and GAF scores.
Correlation coefficients for the ratings in the Hospital admission to in-patient units is usually
CGI-SCH SI scales and the PANSS, and GAF caused by an increase in positive symptoms and its
scores are shown in Table 3. Values in bold are improvement is the main objective of treatment. The
correlations that compare the CGI-SCH SI scales effect sizes of the PANSS depressive and cogni-
with the corresponding assessment in the other tive ⁄ disorganization scores were higher than the
instruments. CGI-SCH SI ratings for positive, CGI-SCH SI depressive and cognitive ratings.
negative, cognitive symptoms and overall severity The Pearson correlation coefficients of the
showed substantial agreement with the PANSS change in CGI-SCH SI scores with the corres-
positive, negative, cognitive ⁄ disorganization and ponding PANSS dimension and GAF score (CGI-
SCH SI positive with PANSS positive score,
CGI-SCH SI negative with PANSS negative
Table 2. Patient sociodemographic and clinical characteristics
score, etc.) ranged from 0.62 (P < 0.001) for
Characteristic depressive symptoms to 0.70 (P < 0.001) for
positive symptoms (data not shown). The correla-
Setting
In-patient (%) 44.7 tion coefficients between the change in CGI-SCH
Outpatient (%) 55.3 SI scores and the CGI-SCH degree of change
Gender (% male) 69.7 scores ranged from 0.63 (depressive symptoms) to
Mean (SD) age (years) 36.9 (10.8)
Mean (SD) age at first treatment contact (years) 24.1 (6.6)
0.75 (cognitive symptoms).
Housing Inter-rater reliability was substantial for the
Independent residence (%) 31.3 CGI-SCH SI positive, negative, cognitive and
Residence as dependent family member (%) 43.7 global scores (ICC ranged from 0.73 to 0.82) and
Supervised residence (%) 20.5
Homeless (%) 3.6
moderate for the depressive scores (ICC ¼ 0.64)
Other (%) 0.9 (Table 5). Inter-rater reliability was slightly higher
Mean (SD) PANSS score for the PANSS and GAF instruments than for the
Global 70.5 (22.4) CGI-SCH scores.
Positive 18.2 (7.7)
Negative 20.0 (9.1)
Depressive 6.3 (2.5)
Discussion
Cognitive 8.8 (4.1)
Mean (SD) GAF score 44.2 (19.9) The CGI-SCH scale is a brief assessment instru-
Number of patients 114
ment designed to evaluate positive, negative,

20
 CGI-SCH validity in the SOHO study

Table 3. Concurrent validity: correlation coefficients for the CGI-SCH severity of illness scales and PANSS and GAF scores

CGI-SCI CGI-SCH CGI-SCH CGI-SCH CGI-SCH PANSS PANSS PANSS PANSS PANSS
Scale positive negative depressive cognitive global positive negative depressive cognitive total

CGI-SCH SI negative 0.27c

CGI-SCH SI depressive 0.18b 0.14a
CGI-SCH SI cognitive 0.27c 0.51c 0.02
CGI-SCH SI global 0.73c 0.61c 0.16a 0.49c
PANSS positive 0.86c 0.30c 0.02 0.34c 0.73c
PANSS negative 0.25c 0.80c 0.16b 0.52c 0.54c 0.34c
PANSS depressive 0.26c 0.04 0.61c 0.02 0.22c 0.16b 0.10
PANSS cognitive 0.37c 0.51c 0.05 0.78c 0.54c 0.47c 0.59c 0.15a
PANSS total 0.64c 0.61c 0.14a 0.62c 0.75c 0.78c 0.75c 0.32c 0.797c
GAF )0.55c )0.51c )0.108 )0.51c )0.67c )0.60c )0.47c )0.13a )0.534c )0.66c
SI, severity of illness.
a
P < 0.05; bP < 0.01; cP < 0.001.

Table 4. Analysis of sensitivity to change: effect size of the change in CGI-SCH, except for the depressive score (CGI-SCH depres-
PANSS and GAF scores from admission to discharge in in-patients sive rating ICC was 0.64 compared with 0.80 in the
Scale Effect size
PANSS depressive dimension). The association of
the CGI-SCH scales with the PANSS dimension
CGI-SCI SI positive 0.81 ratings measured with the Pearson correlation
CGI-SCH SI negative 0.14
CGI-SCH SI depressive 0.31
coefficient was high for all of the ratings, except,
CGI-SCH SI cognitive 0.25 again, for the depressive symptoms (Pearson cor-
CGI-SCH global 0.79 relation coefficient of 0.6, indicating a moderate
PANSS positive 0.93 relationship).
PANSS negative 0.24
PANSS depressive 0.49
The CGI-SCH global rating correlation with the
PANSS cognitive 0.50 PANSS total and GAF scores was apparently
PANSS total 0.80 lower than that for the positive, negative and
GAF 0.90 cognitive scores (Pearson correlation coefficients of
0.75 and 0.67 for the correlation with the PANSS
total and GAF scores, respectively, compared with
Table 5. Inter-rater reliability analysis: ICC of the evaluations of the two clinicians 0.86, 0.80 and 0.78, for the positive, negative and
and the battery of instruments cognitive scores, respectively). However, it should
Scale ICC be remembered that the PANSS global, GAF and
CGI-SCH global rating do not measure the same
CGI-SCI SI positive 0.82 constructs. The CGI-SCH global score assesses
CGI-SCH SI negative 0.73
CGI-SCH SI depressive 0.64 global severity of the disorder, including both
CGI-SCH SI cognitive 0.77 symptoms and interference with functioning. The
CGI-SCH global 0.75 PANSS total score only evaluates symptoms and
PANSS positive 0.88
not interference, and the GAF scale is made up of
PANSS negative 0.77
PANSS depressive 0.80 two independent scales (severity of symptoms
PANSS cognitive 0.85 and interference) and the final rating is the lowest
PANSS total 0.87 of both. The correlation between the GAF and
GAF 0.87
PANSS total scores was 0.66.
Some correlation exists between the intensity of
the symptoms in different dimensions. For exam-
depressive, cognitive symptoms and overall sever- ple, the CGI-SCH negative symptoms score is
ity in schizophrenia. The scale aims to translate related to the CGI-SCH cognitive score. Clinical
clinical judgement into ratings that reflect the sense dictates that patients with more negative
diversity of symptoms present in schizophrenia. symptoms are also likely to score higher in terms
The ratings are based on clinical judgement and the of cognitive symptoms. The correlation between
assessment is not time consuming to administer. depressive, positive and negative symptoms has
Overall, the psychometric properties of the CGI- also been found by other authors (26–28).
SCH scale were good. CGI-SCH inter-rater reli- Sensitivity to change for the CGI-SCH scale was
ability measured with the ICC was similar to the similar to sensitivity to change for the PANSS and
PANSS dimension score ICC in most ratings, GAF, except for the depressive dimension, where

21
Haro et al.

sensitivity to change was lower for the CGI-SCH UK; (UK) Martin Knapp, London School of Economics,
depressive score. Centre for the Economics of Mental Health, Institute of
Psychiatry, London, UK.
When considering these findings, it should be
remembered that the design of the study tried to
mimic routine clinical practice. The rating of the References
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