CGI Scale

Attachment 5

28

Psychiatry 2007

[JULY]

The Clinical
Global
Impressions
Scale:

[REVIEW]

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, BristolMyers 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.)
ADDRESS CORRESPONDENCE TO:
Joan Busner, PhD, United Biosource Corporation, 575 E. Swedesford Rd., Suite 101, Wayne,
PA 19087; Phone: (610) 225-5982; Fax: (610) 225-5950; E-mail:
[email protected]
KEY WORDS:
Clinical Global Impressions Scale, quantification of patient outcome, tracking medication
response, research tool for clinician

[JULY]

Psychiatry 2007

29

ABSTRACT
Objective: This paper reviews
the potential value in daily clinical
practice of an easily applied
research tool, the Clinical Global
Impressions (CGI) Scale, for the
nonresearcher clinician to quantify
and track patient progress and
treatment response over time.
Method: The instrument is
described and sample patient
scenarios are provided with scoring
rationales and a practical charting
system.
Conclusion: The CGI severity
and improvement scales offer a
readily understood, practical
measurement tool that can easily
be administered by a clinician in a
busy clinical practice setting.

INTRODUCTION
The clinical reality is that most
practicing psychiatrists/clinicians
have multiple demands in busy
practices with limited time to
deliver excellent care, document
the details, track response to
interventions, and monitor and
quantify patient progress. The 10minute “med check” has become
the norm across a wide variety of
settings, dictated by large practice
pressures and insurance
reimbursement limitations. In that
timeframe, the clinician attempts
to assess, treat, and document care
for a patient population that often
presents with complex medicalpsychiatric histories, multiple
medication regimens, and
complicated diagnostic pictures.
Validated psychiatric rating
instruments are regularly employed
by clinical researchers as the
requisite basis for quantifying
serial change during the course of
clinical trials. Many of these
clinician-rated instruments require
specific ratings knowledge as well
as available time to administer
them. The obvious time constraints
of real practice restrict their utility.
Alternatively, the Clinical Global
Impressions (CGI) scale is a wellestablished research rating tool
applicable to all psychiatric
disorders that can easily be used
30

Psychiatry 2007

[JULY]

by the practicing clinician to meet
this need.
In this paper, we review the
administration of the CGI
instrument and offer several
scenarios to facilitate an
understanding of the scoring
rationale and practical value in
assessing clinical progress in a
busy clinical practice.

WHAT IS THE CGI?
The CGI was developed for use
in NIMH-sponsored clinical trials to
provide a brief, stand-alone
assessment of the clinician’s view
of the patient’s global functioning
prior to and after initiating a study
medication.1 The CGI provides an
overall clinician-determined
summary measure that takes into
account all available information,
including a knowledge of the
patient’s history, psychosocial
circumstances, symptoms,
behavior, and the impact of the
symptoms on the patient’s ability to
function.
The CGI actually comprises two
companion one-item measures
evaluating the following: (a)
severity of psychopathology from 1
to 7 and (b) change from the
initiation of treatment on a similar
seven-point scale. Subsequent to a
clinical evaluation, the CGI form
can be completed in less than a
minute by an experienced rater. In
practice, the CGI captures clinical
impressions that transcend mere
symptom checklists. It is readily
understandable and can be used
with relative ease by the nonresearcher clinician. Beyond that,
the CGI can track clinical progress
across time and has been shown to
correlate with longer, more tedious
and time consuming rating
instruments across a wide range of
psychiatric diagnoses.
In clinical research, the CGI is
administered by an experienced
clinician who is familiar with the
disease under study and the likely
progression of treatment.
Consequently, the CGI rater can
make an expert clinical global
judgment about the severity of the

illness across various time points
within the context of that clinical
experience. The clinician makes a
judgment about the total picture of
the patient at each visit: the illness
severity, the patient’s level of
distress and other aspects of
impairment, and the impact of the
illness on functioning. The CGI is
rated without regard to the
clinician’s belief that any clinical
changes are or are not due to
medication and without
consideration of the etiology of the
symptoms.
Over the past 30 years, the CGI
has been shown to correlate well
with standard, well-known research
drug efficacy scales (Hamilton
Rating Scale for Depression,
Hamilton Rating Scale for Anxiety,
Positive and Negative Syndrome
Scale, Leibowitz Social Anxiety
Scale, Brief Psychiatric Rating
Scale, Scale for the Assessment of
Negative Symptoms, and others)
across a wide range of psychiatric
indications.2–6 Although some
revisions have been suggested,7–10
the standard CGI is used in
virtually all FDA-regulated and
most other CNS trials. It is an
instrument the non-researcher
clinician can adapt with ease in a
clinical setting; in fact, it is a
clinical assessment—the only
requirements for its use is that the
scoring rationale is understood and
that it is rated by a clinician who is
experienced with the disease under
study.
As noted above, the CGI has
two components—the CGI-Severity,
which rates illness severity, and the
CGI-Improvement, which rates
change from the initiation
(baseline) of treatment.
CGI-Severity (CGI-S). The
CGI-Severity (CGI-S) asks the
clinician one question:
“Considering your total clinical
experience with this particular
population, how mentally ill is the
patient at this time?” which is
rated on the following seven-point
scale: 1=normal, not at all ill;
2=borderline mentally ill; 3=mildly
ill; 4=moderately ill; 5=markedly ill;

6=severely ill; 7=among the most
extremely ill patients.
This rating is based upon
observed and reported symptoms,
behavior, and function in the past
seven days. Clearly, symptoms and
behavior can fluctuate over a week;
the score should reflect the
average severity level across the
seven days.
CGI-Improvement (CGI-I).
The CGI-Improvement (CGI-I) is
similarly simple in its format. Each
time the patient is seen after
medication has been initiated, the
clinician compares the patient’s
overall clinical condition to the one
week period just prior to the
initiation of medication use (the socalled baseline visit). The CGI-S
score obtained at the baseline
(initiation) visit serves as a good
basis for making this assessment.
Again, only the following one query
is rated on a seven-point scale:
“Compared to the patient’s
condition at admission to the
project [prior to medication
initiation], this patient’s condition
is: 1=very much improved since the
initiation of treatment; 2=much
improved; 3=minimally improved;
4=no change from baseline (the
initiation of treatment);
5=minimally worse; 6= much
worse; 7=very much worse since
the initiation of treatment.”
The CGI-I score generally tracks
with the CGI-S such that
improvement in one follows the
other. Anchors for scoring,
however, are quite different, and
the CGI-I is based upon changes
from the initiation of treatment in
contrast to changes from the
preceding week of treatment.
Consequently, the two CGI scores
can occasionally be dissociated
such that a clinician may notice
changes in the CGI-I relative to
baseline despite no recent changes
in the overall CGI severity score or
vice versa.

CAN THE CGI BE USED IN
CLINICAL PRACTICE?
For researchers, the CGI has
extraordinary utility. It is

applicable across all CNS studies,
including depression,
schizophrenia, anxiety, no matter
the population, drug, or other main
study measures. It provides a
readily recognizable and
universally known efficacy measure
that distinguishes it from the more
complex, lengthier, and sometimes
difficult to administer efficacy
scales.
For the practicing clinician, the
CGI has similar utility—it is quick
to administer, it is applicable
across all psychiatric disease states
and all medications, it tracks for
third parties (hospital or other
institution, third party payers,
pharmacy plan providers) progress
and response, and it is a metric
that documents due diligence on
the part of the clinician to measure
outcome. In some instances, the

Administration of the CGI.
Although there are no hard and
fast rules for rating the CGI,
general guidelines have evolved
over the years. Some of the more
commonly used conventions in
research, along with illustrative
scenarios, are provided.
Timeframe. The CGI is usually
rated relative to the past seven
days (including the day of the visit
up to and through the visit). In this
respect, the CGI is a statedependent measure summarizing
one week rather than a lifetime of
symptoms and behavior.
Information sources. The CGI
is designed to make use of all
information available. Thus, a
clinical interview with the patient
should be combined with any other
information available for the time
period under study (past 7 days)

TO RATE THE CGI-S and the CGI-I, it is
important to establish the presence of
relevant symptoms, the frequency of their
occurrence over the seven-day rating
timeframe, the intensity or severity of the
symptoms, and the effect of the symptoms
on functioning in major areas of the
patient’s life—work, home, school, and
relationships.
CGI measurement can be part of
the clinical justification for offformulary medications as
medication non-response is often
as important to document as
medication response. The CGI
allows the clinician to look back
over the course of care and
identify what interventions did or
did not work. It allows even the
busiest clinician to monitor patient
progress in a consistent,
systematic manner.

from such sources as chart notes,
family members, caseworkers, unit
nurses, school teachers, for
children, or significant others.
Questions to ask. To rate the
CGI-S and the CGI-I, it is important
to establish the presence of
relevant symptoms, the frequency
of their occurrence over the sevenday rating timeframe, the intensity
or severity of the symptoms, and
the effect of the symptoms on
functioning in major areas of the
[JULY]

Psychiatry 2007

31

TABLE 1. CGI-S guidelines

1 = Normal—not at all ill, symptoms of disorder not present past seven days

2 = Borderline mentally ill—subtle or suspected pathology

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.

TABLE 2. CGI-I guidelines

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
4 = No change—symptoms remain essentially unchanged
5 = Minimally worse—slightly worse but may not be clinically meaningful; may represent very little change in basic clinical status or
functional capacity
6 = Much worse—clinically significant increase in symptoms and diminished functioning

7 = Very much worse—severe exacerbation of symptoms and loss of functioning
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,
and relationships.

CGI SCORING GUIDELINES
There are no universally accepted
scoring guidelines for the seven
anchor points; rather they were
designed to be based solely on
clinical judgment. Presented in
Tables 1 and 2 are some generically
32

Psychiatry 2007

[JULY]

applicable guidelines based on
severity and change guidelines used
in clinical research and published
for specific diseases. These
guidelines have been modified for
this paper for better applicability
across diseases. The guidelines
should be used as suggestions, not
absolutes, for scoring. Clinical
judgment and “gut” sense about the

patient may warrant scoring the
severity of illness as more or less
severe, or the change from baseline
as more or less improved, than the
suggested guidelines would indicate.

CGI SCORING EXAMPLES
Following are some clinical
scenarios that apply the typical
conventions for scoring the CGI:

CGI-S Example 1. Depression.
A 38-year-old, well-groomed,
female patient, a successful
litigation attorney, reports a onemonth unprecipitated depressive
episode that seems to be
worsening. She is currently
experiencing early morning
awakening, loss of pleasure in her
usual activities, feelings of guilt,
reduced appetite, tearfulness, and
depressed mood. She has found
herself weeping several times over
the past week, but cannot identify
a reason. She is continuing to work,
but found herself fighting back
tears at an important meeting and
believes her work may be less
sharp than it had been in the past.
No one has noticed, but she is
concerned that the depression is
worsening and may result in a
significant impact on work. She is
worried that she may lose her
“edge.” She denies suicidal
ideation. She has no previous
psychiatric history.
Suggested CGI-S Score=4
(moderately ill)
Rationale: This patient has
symptoms that are consistent with
major depressive disorder and are
beginning to affect her functioning.
She might benefit from a
medication treatment. These
elements both suggest a score no
less than a 4 (moderate). The
patient’s functioning at a very
demanding job is only affected to a
limited degree at this point; no one
has noticed and her lessened
performance does not seem
extreme. She continues to work her
normal schedule. Although
distressed, her illness has not
caused a distinct impairment of
occupational function that would
raise the score to a 5 (markedly
ill).
CGI-S Example 2.
Schizophrenia. A 34-year-old,
male patient with a diagnosis of
paranoid schizophrenia has
attended a partial hospitalization
program off and on for 12 years.
According to his caseworker, he
had been stable on his medication
regimen for the past year, but

recently stopped taking his
medication and would not cite a
reason. He attended the partial
program only one of the expected
four days this past week and this
was after the caseworker went to
his home and drove him to the
treatment facility. The caseworker
reports he has become increasingly
threatening and difficult to manage
and has been seen responding to

is not attending his day treatment
program or taking his medication.
Previously well groomed, he has
now stopped even basic elements
of self-care and hygiene. His
behavior required restraint and
may have posed a physical risk to
others. This is a patient one might
actively consider hospitalizing.
Based upon his disruptive
pathology and behavior influenced

CLINICAL JUDGMENT AND “GUT” SENSE
about the patient may warrant scoring the
severity of illness as more or less severe,
or the change from baseline as more or
less improved, than the suggested
guidelines would indicate.
auditory hallucinations, including
taking cover behind furniture in
attempts to hide from “enemies.” In
the past week, he obeyed a
command hallucination to “go
after” a fellow patient, but was
physically circumvented from
harming the patient by three staff
members, who physically
restrained him. The caseworker
reported that although the patient
was passively cooperative about
coming to today’s visit, he did not
speak with her at all during the
trip. In the office, he is guarded
and suspicious. He mumbles under
his breath, but refuses to elaborate
as to what he has said or to whom
it was directed. Twice he makes a
fist and raises his arm
threateningly in the direction of
the psychiatrist, but then puts his
hand back in his lap. He appears
disheveled and is ungroomed; he
has not changed his clothing over
the past week, which his
caseworker reports is a new
behavior for him.
Suggested CGI-S score=6
(severely ill)
Rationale: The patient’s
functioning is clearly affected by
his symptoms to the extent that he

by symptoms (hallucinations), a
CGI-S score of 6 (severely ill) is
warranted. This patient did attend
his day treatment program one day
and did willingly accompany the
caseworker to his visit with the
psychiatrist, suggesting a
somewhat lessened level of severity
than a 7 would imply.
CGI-I Example 1. Anxiety. A
patient who has been in treatment
and receiving an SSRI for an
anxiety disorder for four months
comes in for a medication check.
The patient’s CGI-S at the visit at
which SSRI medication was
initiated (“baseline” visit, to use
clinical trial terminology) was 4
(moderate). At today’s visit, the
patient reports that the anxiety
symptoms have decreased
considerably. The patient is now
able to sleep 7 to 8 hours each
night, with no initial insomnia. This
represents a significant change
from baseline, at which time the
patient spent 2 to 3 hours each
night trying to fall asleep, with a
nightly total of 4 to 5 hours of fitful
sleep. The patient reports having
this week felt excessively anxious
about running out of gas and about
a burglar entering the house. The
[JULY]

Psychiatry 2007

33

PATIENT A. Treatment management sample (CGI) tracking table
PATIENT A. Treatment management
supplemental chart notes

Patient: Joe Smith, age 38
Diagnoses: major depression and generalized anxiety disorder
VISIT/DATE

SYMPTOMS

1

2

3

4

5

TOLERABILITY

ACTION

1/7/07

Depression
and anxiety

N/A (no meds)

SSRI
initiated
[name and
dose]

2/7/07

Depression
and anxiety

Slight
headache one
evening, now
resolved

No problems

4/7/07

Minimal
improvemen
t in both
depression
and anxiety
relative to
Visit 1

No problems

5/7/07

Virtually
symptom
free for
depression
and anxiety

Daytime
sleepiness

Psychiatry 2007

[JULY]

5

N/A (no
meds)

5

4

Raise dose
[name and
new dose]

6

5

maintain
dose

3

3

Switch from
am to hs
dosing

2

1

[name and
dose]

estimated time spent engaged in
these anxious thoughts was less
than one hour per day, compared to
an estimated 3 to 4 hours per day
at baseline. The patient drove over
a bridge this week, which was
described as somewhat difficult and
fear-provoking, but manageable. At
baseline, the subject was wholly
avoidant of bridges, which caused
him to drive 30 minutes out of his
way each day to get to work.
Suggested CGI-I score=2 (much
improved)
Rationale: The patient’s clinical
status has clearly changed in the
direction of improvement. For a
CGI-I score of 3 (minimally
improved), the level of change
would not be sufficient to make an
appreciable difference to the
34

CGI-I

Switch to
different
SSRI

Depression
same;
anxiety has
significantly
worsened

3/7/07

CGI-S

patient’s clinical status, level of
distress, or functioning. This
patient is now experiencing a
significant nightly improvement in
sleep, a reduction in time spent
engaged in worry, and is driving
over bridges allowing him to cut 60
minutes round trip off his daily
commute. These improvements in
distress level, symptom severity,
and functional ability suggest an
improvement score better than 3
because of his noticeable clinical
improvement and better
functioning. Nonetheless, the
patient is still symptomatic; he
endures the drive over the bridge
with distress and still experiences
anxious ruminations each day.
Consequently, a rating of 2, much
improved, rather than 1, very much

Patient: Joe Smith, age 38
Diagnoses: major depression and
generalized anxiety disorder
Visit #: 1
Date: January 7, 2007
CGI-S = 5
Predominant symptoms: Depression and
anxiety
Tolerability? N/A medication to begin this
evening
Medication? SSRI initiated (name and
dose)
Visit #: 2
Date: February 7, 2007
CGI-S=5 (markedly ill), CGI-I=4 (no
change)
Predominant symptoms: depression and
anxiety
Tolerability? slight headache one evening
that resolved on own
Medication? SSRI raised by 20mg
Visit#: 3
Date: March 7, 2007
CGI-S= 6 (severely ill), CGI-I=5 (minimally
worse) (remember this is always in comparison to the CGI-S that was done prior to
medication--thus, this is in comparison to
the CGI-S of 5 at Visit 1)
Predominant symptoms: Depression stayed
the same; anxiety has worsened
Tolerability? No problems
Medication: Switch of medication to second
SSRI [name, dose] due to lack of efficacy for
anxiety (CGI-I has worsened despite dose
increase and adequate length of time)
Visit #: 4
Date: April 7, 2007
CGI-S= 3 (mildly ill) CGI-I=3 (minimally
improved)
Predominant symptoms: Depression and
anxiety have both improved to a minimal
degree relative to baseline
Tolerability? No problems
Medication: SSRI #2 maintained at current
dose
Visit #: 5
Date: May 7, 2007
CGI-S=2 (borderline ill) CGI-I=1 (very
much improved)
Predominant symptoms: Both depression
and anxiety have improved dramatically
Tolerability? daytime sleepiness
Medication: SSRI #2 maintained at current
dose; switched from am to hs dosing

PATIENT B. Treatment management sample (CGI) tracking table

PATIENT B. Treatment management
supplemental chart notes

Patient: Mary Jones, age 9
Diagnosis: attention deficit hyperactivity disorder
VISIT/DATE

SYMPTOMS

1

5/22/06

Inattention
and
hyperactivity
home and
school

5/29/06

2

3

4

6/5/06

7/7/06

TOLERABILITY

ACTION

CGI-S

CGI-I

N/A (no meds)

Initiate
stimulant
[name,
dose]

4

N/A (no
meds)

Inattention
and
hyperactivity
have
lessened a
bit at home;
still
prominent at
school

No problems

Dose raised
[name,
dose]

3

3

One
episode
fidgetiness
at school
(minor);
otherwise
no
symptoms
at school or
home

Eating less per
parent; onepound weight
loss since last
visit

No
symptoms
noted

No problems

improved, best captures this
patient’s improvement relative to
his baseline state.
CGI-I Example 2. Anxiety.
The anxious patient in the previous
example (CGI-I Example 1) returns
one month later. He reports that he
is now afraid of leaving his house
without accompaniment. This is a
new development for him. He is
anxious and worried all day long.
He called work and told them he
had the flu. In reality, he was afraid
to leave his house. He has only left
the house three times this week,
including his visit to the clinic
today, all accompanied by his wife.
He felt panicky on all three
occasions. Although he denies any

Maintain
dose; parent
to provide
breakfast
prior to
dosing

Maintain
dose;
continue to
dose after
breakfast

2

1

1

1

lightheadedness or other symptoms
suggesting impending syncope, he
reports worrying constantly about
“passing out” in front of a moving
car or bus. He is fearful that he will
forget the name of a well-known
friend or relative should they call
him on the phone. He is sleeping
only 1 to 2 hours a night. His wife
reports that she has “never seen
him so bad.” He cries in the
interview and admits he has
considered “ending it all” to make
the pain go away.
Suggested CGI-I score=7 (very
much worse)
Rationale. The patient has
clearly worsened relative to his
baseline condition. The patient has

Patient: Mary Jones, age 9
Diagnosis: attention deficit hyperactivity
disorder

Visit #: 1
Date: May 22, 2006
CGI-S = 4 (moderately ill) CGI-I/Not
Applicable (first visit)
Predominant symptoms: inattention and
hyperactivity at home and school
Tolerability? N/A medication to begin
tomorrow
Medication? Stimulant initiated (name and
dose)

Visit #: 2
Date: May 29, 2006
CGI-S=3 (mildly ill), CGI-I=3 (minimal
improvement)
Predominant symptoms: inattention and
hyperactivity; both have lessened somewhat at home, per parent, though still
quite noticeable at school
Tolerability? no problems
Medication? stimulant dose raised

Visit#: 3
Date: June 5, 2006
CGI-S= 2 (minimally ill), CGI-I=1 (very
much improved)
Predominant symptoms: teacher reported
1 episode of "fidgetiness" during math lesson (25 minute duration). Otherwise, no
symptoms noted at school. Parent
reports home hyperactivity and inattention
symptoms have both been dramatically
improved throughout the week.
Tolerability? Eating less per parent; has
lost 1 pound in past week.
Medication: Maintain current dose;
instruct parent to dose after large breakfast.
Visit #: 4
Date: July 7, 2006
CGI-S=1 (normal, not at all ill); CGI-I=1
(very much improved)
Predominant symptoms: No symptoms of
ADHD evident this week across multiple
settings.
Tolerability? No problems. Child's weight
is maintained, and parent reports child's
eating has normalized.
Medication: Stimulant maintained at current dose. Breakfast prior to dosing will
continue.

[JULY]

Psychiatry 2007

35

stopped going to work and is barely
leaving his home. His worries are
almost constant, clearly excessive,
and are virtually all-consuming.
The worries have become less
reality-based and are a source of
almost unendurable mental
distress. He is barely sleeping. The

CGI is the tool of the clinician. For
the clinician, the questions are
always the severity of the overall
condition and whether the patient’s
overall condition is improving,
worsening, or staying the same.
Therefore, an adaptation of the
instrument we suggest the clinician

...AN ADAPTATION OF THE INSTRUMENT
we suggest the clinician adopt is to score
the CGI as the entire picture (overall
assessment) within the past week
encompassing all targeted symptoms and
conditions.
patient finds his situation painful to
the point of entertaining suicidal
thoughts. Overall, the patient’s
level of symptoms, frequency of
symptoms, and its effect on his
functioning are far above a CGI-I of
5, (minimally worse), or even 6,
much worse. His clinical status,
relative to baseline, reflects a
severe exacerbation of symptoms
with a loss of functioning
suggesting a CGI-I score of 7 (very
much worse). As the ultimate
decision-maker, the clinician rater
decides if the patient rates a 6 or a
7. What is most important is that
ratings are consistent across time
and across patients.

QUESTIONS, ISSUES AND TIPS
What if I’m treating the
patient for more than one
condition? How should I
complete the CGI?
In most clinical trials, the drug
under study is being evaluated for
one primary condition (for
example, depression or generalized
anxiety disorder). In those
situations, the CGI is typically
rated relevant only to that
condition. In clinical care, in
contrast, the physician may be
treating several conditions at once.
Outside of the research setting the
36

Psychiatry 2007

[JULY]

adopt is to score the CGI as the
entire picture (overall assessment)
within the past week encompassing
all targeted symptoms and
conditions. Maintaining
supplemental short notes of the
areas that have responded best or
that still need attention will be very
helpful in guiding treatment
decisions. The CGI charting system
presented here is designed to
provide a place to track the issue of
multiple targeted symptoms.
What if the patient has a side
effect from the medication?
Should that be reflected on the
CGI?
Earlier versions of the CGI
included a place for determining
the risk benefit ratio of side effects
to symptom relief. Current versions
do not, and the CGI rating should
not incorporate side effects. The
CGI charting system presented
here is designed to provide a place
to note any dose-limiting or
otherwise important side effects.
How would I use the CGI to
help manage treatment?
Although there are many
possible systems a clinician might
use to track CGI scores, a simple
charting system that tracks visits
with limited, concise amounts of
supporting clinical data may be

most useful. In this way, at a
glance, the clinician is able to see
the entire course of the patient’s
treatment. Obviously, the clinician
is free to track and chart any other
areas of interest. The chart is
presented in tabular form with
sample supplemental chart notes.
The tables should be used as a
guide for setting up a template with
abbreviated information (see
Patients A and B Sample Tables
and Chart Notes). The chart notes
may be used to supplement the
table. Complete the chart notes and
table at the end of each patient
visit and then move them up to the
next visit so they remain a current
running log.
Discussion of Patient A. For
the case described in Treatment
Management Patient A, the CGI
chart can be used to track progress
over time. By scanning the last 2
columns, it is apparent that this
patient has improved from an initial
severity of 5 (markedly ill) to a
severity of 1 (normal, not at all ill)
over the course of treatment. The
patient’s improvement level on
various interventions ranged from 5
(minimally worsened from visit 1)
to 1 (very much improved) by the
final treatment date shown. Details
of the visits can be fleshed out in
the accompanying chart notes
format, as well as, of course, by
traditional chart notes.
Discussion of Patient B. The
case described in Treatment
Management Patient B also
illustrates the utility of the CGI
chart in tracking treatment
progress over time. The patient’s
global assessment changes from a
CGI-S of 4 (moderate) at Visit 1 to
a CGI-S of 1 (normal, not at all ill)
by Visit 4. Her CGI-I is rated as a 1
(very much improved) by Visit 3
although there are still some
residual symptoms (subtle
pathology). Her medication course,
including tolerability issues and
changes to doses, as well as other
interventions (e.g., dosing after
food) are also documented. Details
of the visits can be fleshed out in
the accompanying brief chart notes

format, as well as, of course, by
traditional chart notes.
At the patient’s next visit, the
CGI tracking table and notes will be
ready for quick perusal by the
clinician.

8.

CONCLUSIONS
The CGI can be a useful, easily
adopted tool for the practicing
clinician. It is a brief,
understandable quantification
method that can facilitate
treatment over time.

REFERENCES
1.

2.

3.

4.

5.

6.

7.

Guy W (ed). ECDEU Assessment
Manual for
Psychopharmacology. Rockville,
MD: US Department of Heath,
Education, and Welfare Public
Health Service Alcohol, Drug
Abuse, and Mental Health
Administration, 1976.
Bandelow B, Baldwin DS, Dolberg
OT, et al. What is the threshold
for symptomatic response and
remission for major depressive
disorder, panic disorder, social
anxiety disorder, and generalized
anxiety disorder? J Clin
Psychiatry 2006;67:1428–34.
Leucht S, Kane JM, Kissling W, et
al. Clinical implications of brief
psychiatric rating scale scores. Br
J Psychiatry 2005;187:366–71.
Leucht S, Engel RR. The relative
sensitivity of the Clinical Global
Impressions Scale in the Brief
Psychiatric Rating Scale in
antipsychotic drug trials.
Neuropsychopharmacology
2006;31:406–12.
Spielmans GI, McFall JP. A
comparative meta-analysis of
Clinical Global Impressions
change in antidepressant trials. J
Nerv Ment Dis 2006;194:845–52.
Zaider TI, Heimberg RG, Fresco
DM, et al. Evaluation of the
Clinical Global Impression Scale
among individuals with social
anxiety disorder. Psychol Med
2003;33:611–22.
Beneke M, Rasmus W. Clinical
Global Impressions (ECDEU) :
Some critical comments.
Pharmacopsychiatry

9.

10.

1992;25:171–6.
Haro JM, Kamath SA, Ochoa S, et
al. The Clinical Global
Impression-Schizophrenia Scale:
A simple instrument to measure
the diversity of symptoms
present in schizophrenia. Acta
Psychiatr Scand 2003;107(suppl
416):16–23.
Kadouri A, Corruble E, Falissard
B. The improved Clinical Global
Impression Scale (iCGI):
Development and validation in
depression. BMC Psychiatry
2007;7:7.
Spearing M, 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;73:159–71.

[JULY]

Psychiatry 2007

37