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Brazilian Journal of Psychiatry

Print version ISSN 1516-4446On-line version ISSN 1809-452X

Rev. Bras. Psiquiatr. vol.25 no.2 São Paulo June 2003

http://dx.doi.org/10.1590/S1516-44462003000200008 

ORIGINAIS: COMUNICAÇÃO BREVE

 

Development and application of the mania rating guide (MRG)

 

Desenvolvimento e aplicação do guia para avaliação do estado maníaco (GAEM)

 

 

Flávio Shansis; Eugênio Grevet; Betina Mattevi; Marcelo Berlim; Gabriela Maldonado; Aida Santin; Marcelo Fleck; Iván Izquierdo

Departments of Biochemistry and of Psychiatric and Forensic Medicine of the Federal University of the state of Rio Grande do Sul (UFRGS). Porto Alegre, RS, Brazil

Correspondence

 

 


ABSTRACT

In this article we present the development and application of the Mania Rating Guide (MRG), a semi-structured interview. This guide was created in order to assist the filling of three mania Scales: Mania Rating Scale, Bech-Rafaelsen Mania Scale and Clinician-Administered Rating Scale for Mania. The MRG consists of twenty-one Psychopathological Dimensions, that correspond to the Items of the original Scales, and are structured in Questions. The guide was applied to fifteen manic patients admitted in the Psychiatric Unit of the Clinical Hospital of Porto Alegre. A psychiatrist interviewed them using the MRG, and the interviews were videotaped. Afterwards, three independent raters scored the Mania scales based on the films. The impression of the raters was that the MRG allows not only to easily score all the Items of the Scales but also to cover the wide spectrum of the symptomatological presentation of a manic syndrome.

Keywords: Bipolar disorder. Mania. Semi-structured interview.


RESUMO

No presente artigo, são apresentados o desenvolvimento e a aplicação de uma entrevista semi-estruturada, denominada Guia para Avaliação do Estado Maníaco (GAEM). Esse foi elaborado para auxiliar no preenchimento de três escalas de mania: Mania Rating Scale, Bech-Rafaelsen Mania Scale e Clinician-Administered Rating Scale for Mania. O GAEM é formado por vinte e uma Dimensões Psicopatológicas, que correspondem aos Itens das Escalas originais, estruturados na forma de Questões. O Guia foi aplicado em quinze pacientes bipolares em fase maníaca, admitidos na Unidade de Internação Psiquiátrica do Hospital de Clínicas de Porto Alegre. Um psiquiatra os entrevistou utilizando o GAEM, sendo que as entrevistas foram filmadas. Posteriormente, três avaliadores independentes pontuaram as Escalas de Mania a partir das filmagens. A impressão dos avaliadores foi a de que o GAEM permite não só pontuar facilmente todos os Itens das Escalas, como também abarcar o grande espectro da apresentação sintomatológica de uma síndrome maníaca.

Descritores: Entrevista semi-estruturada. Mania. Transtorno de humor bipolar.


 

 

Introduction

In the last years, several studies have shown that the collection of psychopathological data needed to the filling of the scales has its reliability increased by the application of standardized clinical interviews.1-3 Semi-structured interviews4 have proven valid for allowing satisfactory comparisons between the collected data and assuring the replication of studies by trained researchers.5 Therefore, the accuracy of clinical diagnoses determined only by non-structured interviews is questionable.6 In the psychiatric literature there are some studies about the interrater reliability of different clinical variables.6,7 Most of these studies are performed by groups of researchers who observe the same interview8 or watch a record _ usually in VCR, what artificially reduces the variable 'way of obtaining data' and therefore increases the concordance. This method, however, fails in that it disregards that different interviewers formulate different questions to collect the necessary information. (furthermore, the independence of punctuation between clinicians can be biased if the raters perceive the interviewer's clinical judgement about the patient as dependent on how he/she conducts the interview3,6). Therefore, the use of standardized instruments to the filling of the scales improves the interrater reliability.

In the reviewed literature (MedLine from 1966 to 2001, using the keywords semi-structured interview, structured interview, mania, bipolar disorder and interview in several combinations) there was no reference to a guide for the standardized assessment of the manic state. In Brazil, however, Vilela & Loureiro9 have elaborated a semi-structured interview with guiding questions in their work of translation, adaptation and modification of the Young Mania Scale. Regarding the excellent work performed by our colleagues of the city of Ribeirão Preto we may highlight, firstly, that when that interview was published as a chapter of a book the current study was already being performed and, secondly, that our study includes two scales besides the Young Scale.

Therefore, the authors developed the Mania Rating Guide (MRG), which is a guide for a semi-structured interview of patients with bipolar disorder (BD) adapted to three mania scales: "Mania Rating Scale" (MRS),10 "Bech-Rafaelsen Mania Scale" (BRMS)11 and "Clinician-Administered Rating Scale for Mania" (CARS-M).12 This guide was essentially developed to be used in research although it can be also very useful for clinicians to interview patients with manic symptoms. The authors of this study (which is a preliminary stage of a doctorate thesis) have developed this instrument based on the need of standardizing and optimizing the data collection for the filing of the several scales used. This scale is, as far as we know, the first guide that assesses simultaneously the three scales. Therefore, the objectives of this article are: (1) to describe the methodology of development of the MRG, (2) to present the semi-structured interview and (3) to transmit the impressions of the professionals who have developed it.

 

Methods

The proposed guide (Appendix) is composed by Psychopathological Dimensions (Figure A), Items of the Mania Scales (Figure B) and Questions of the MRG (Figure C). The Items of the Mania Scales assess twenty-one Psychopathological Dimensions, out of which sixteen are objectively read to the patient and five are subjectively assessed by the interviewer. These Psychopathological Dimensions, based on the definitions of each Item of the original Scales, allow patients to demonstrate their perception about the presence or absence of symptoms and allow the clinician to quantify the severity and the degrees of intensity of the measured symptomatology.

 

 

In the process of developing the MRG, the Items of Scales related to a same Psychopathological Dimension were grouped, and Questions to investigate them were created. Therefore, for example, all Items of Scales related to the assessment of sexual interest were sequentially located. Beside the title of each Psychopathological Dimension the number of the corresponding Items in the different Scales was placed. Therefore, for example, in the Psychopathological Dimension 'Sexual Interest (MRS-3, CARS/M-10, BRMS-10)', the answers to the Items 3, 10 and 10 of the Mania Rating Scale, Clinician-Administered Rating Scale for Mania and Bech-Rafaelsen Mania Scale are respectively answered. Some of the Psychopathological Dimensions of the MRG do not have to be asked, as they are assessed based both on the objective observation during the interview (e.g., 'Observe how the patient is dressed'), and on the clinical judgement (e.g., 'Observe the level of attention of the patient').

The MRG was used in fifteen bipolar patients who were admitted in the Unit of Psychiatric Hospitalization of the Clinical Hospital of Porto Alegre (HCPA) from April to December 2000 and who respected the inclusion and exclusion criteria of this study. Patients of both genders, aged 18 to 55 years, were included. We excluded patients with a concomitant physical illness that would interfere with their mental state. All of them were interviewed by one of the authors (F.S.), who is a psychiatrist with experience in the assessment of manic patients and in the utilization of the mentioned Scales. The interviews were videotaped for further punctuation, that was performed in a joint meeting in which three psychiatrists, after watching the tapes, independently punctuated each of the three mania Scales contained in the MRG. The analysis of the concurrent validity and of the interrater reliability of these Scales will be the subject of further publications.

The project was approved by the Research Ethical Committee of the HCPA.

 

Results and Discussion

The impression of the professionals who punctuated the scales based on the videotaped semi-structured interviews was that, among the positive aspects, this interview allowed to encompass the wide spectrum of symptomatological presentation of a manic syndrome. Consequently, the clinician could obtain important information about the current situation of the disease. The MRG allowed, also, to punctuate easily all Items of the original Scales (MRS, CARS/M e BRMS).

Among the difficulties reported by the raters we may mention the obtainment of objective answers when the patient had a manic syndrome of greater severity, due to the own features of the disorder. We also noted a greater difficulty to answer to questions who depended on the subjective judgement of the observer (e.g., 'bizarre clothing'). However, this aspect is more related to the inherent difficulties of any assessment involving the interviewer's subjectivity than to the Guide proper. Besides, patients with some degree of cognitive impairment also presented difficulties in the understanding of the formulated questions. However, many of these difficulties are also found in any psychiatric interview, especially with manic patients, as it is always difficult to perform structured or semi-structured interviews with highly disorganized patients. These are the methodological questions yet to be resolved.

 

Conclusion

MRG allows the psychiatrist to encompass the great majority of the psychopathological aspects of a manic syndrome, facilitating, thus, the correct filling of the three Scales used in this study. Lastly, we aimed that with this practice the professionals increase their capabilities to perform the clinical interviews in general _ be them semi-structured or not.

 

References

1. Fleck MPA, Chaves MLF, Guelfi J-D, Poirier M-F, Lôo H. Aplicação da versão em português de um guia para entrevista semi-estruturada adaptada a quatro escalas de depressão. J Bras Psiq 1997;46(6):339-45.         [ Links ]

2. Williams JBW. A structured interview guide for the Hamilton depression rating scale. Arch Gen Psychiatry 1988;45(8):742-7.         [ Links ]

3. Endicott J, Spitzer RL. A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1978;35:837-44.         [ Links ]

4. Spitzer RL, Fleiss JL, Burdock EI, Hardesty AS. The mental status schedule: rationale, reliability and validity. Compr Psychiatry 1964;5:384-95.         [ Links ]

5. Ravindran AV, Welburn K, Copeland JRM. Semi-structured depression scale sensitive to change with treatment for use in the elderly. Brit J Psychiatry 1994;164:522-7.         [ Links ]

6. Steiner JL, Tebes JK, Sledge WH, Walker ML. A comparison of the structured clinical interview for DSM-III-R and clinical diagnoses. J Nerv Ment Dis 1995;183:365-9.         [ Links ]

7. Ziegler VE, Meyer DA, Rosen SH, Biggs JT. Reliability of video taped Hamilton ratings. Biol Psychiatry 1978;13:119-22.         [ Links ]

8. Endicott J, Cohen J, Nee J, Fleiss J, Sarantakos S. Hamilton depression rating scale: extracted from regular and change versions of the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1981;38:98-103.         [ Links ]

9. Vilela JA, Loureiro SR. Escala de avaliação de mania de Young _ estudo das qualidades psicométricas da versão brasileira. In: Gorenstein C, Andrade L, Zuardi A, editores. Escalas de avaliação clínica em psiquiatria e psicofarmacologia. São Paulo: Lemos; 2000. p. 113-23.         [ Links ]

10. Young RC, Biggs TJ, ZieglerVE, et al. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133:429-35.         [ Links ]

11. Bech P, Bolwig TG, Kramp P, et al. The Bech-Rafaelsen mania scale and the Hamilton depression scale. Acta Psychiatr Scand 1979;59:420-30.         [ Links ]

12. Altman EG, Hedeker DR, Janicak PG, et al. The clinician-administered rating scale for mania (CARS-M): development, reliability, and validity. Biol Psychiatry 1994;36:124-34.         [ Links ]

 

 

Correspondence
Flávio Shansis
Av. Taquara, 586/606
90460-210 Porto Alegre, RS, Brazil

Received on 29/5/2001. Reviewed on 30/9/2002. Approved on 11/12/2002. Sponsoring Agencies that supported the study: FAPERGS and PROPESQ-UFRGS.

 

 

This study is part of the doctorate thesis of Flávio Shansis in course in the Federal University of the state of Rio Grande do Sul.

 

 

Appendix

Mania Rating Guide (MRG)

Abbreviation of the original scales

• MRS _ Mania Rating Scale

• CARS/M _ Clinician-Administered Rating Scale for Mania

• BRMS _ Bech-Rafaelsen Mania Scale

1. MOOD (MRS-1, CARS/M-2, BRMS-6)

• How has your mood been in the last two weeks?

• Have there been moments in the last weeks in which you have felt too well, cheerful or happy? If yes, please give an example.

• Does this differ from your regular mood? How long does it last?

• Have you felt or do you feel more excited or happier than other people?

• This excitement was or is disproportional to the circumstances? If yes, please give an example.

• Have you been or are you more euphoric or more optimistic than usual? If yes, please give an example.

• Have you felt or are you feeling exhausted for being so excited?

• Have you had any laughter outburst in an inappropriate moment? If yes, please give an example.

• Have you become more playful than usual? If yes, please give an example.

2. ENERGY (MRS-2, CARS/M-9)

• How has your energy been for doing things in the last two weeks?

• Have you had more energy than usual to do things?

• Have you been more active than usual or had the feeling that 'you could 'function' all day without being tired?

• Do you feel or have you felt less tired than usual?

• Does it interfere with you daily activities? If yes, please give an example.

• Do you feel more agitated than usual?

3. ACTIVITY (MRS-2, CARS/M-3, BRMS-1)

• Have you been more active in the last two weeks?

• Have you been moving more than usual?

• Have you been gesticulating more than usual?

• Have there been moments in which you cannot remain sitting?

• Have there been moments in which you have to keep moving or walking uninterruptedly?

• Do you become tired of moving or walking so much?

• Has someone had to hold you to make you stop moving and/or walking?

4. SEXUAL INTEREST(MRS-3, CARS/M-10, BRMS-10)

• How has your sexual interest been in the last two weeks?

• Have you been thinking or speaking more than usual about sex?

• Have you had more sexual relationships than usual?

• Have you had more sexual partners than usual?

5. NEED OF SPLEEPING (MRS-4, CARS/M-8, BRMS-9)

• How has your sleep been in the last two weeks?

• How much time do you usually need to sleep?

• Have you had to sleep less than usual to feel rested?

• How many less hours have you needed/do you need to sleep? (Convert in percentage).

• How has your sleep been in the last three nights?

6. IRRITABILITY (MRS-5, CARS/M-2, BRMS-5)

• How is your relationship with other people?

• Have you felt more irritable or upset than usual? If yes, please give an example.

• Have you lost your temper or been more impatient than usual? If yes, please give an example.

• Have you been more upset with other people than usual? If yes, please give an example.

• Are there some subjects that when spoken irritate or upset you? If yes, please give an example.

• Have you reached to the point of throwing objects far away or damaging things? If yes, please give an example.

• Have you been more involved in arguments or fights than usual?

• Have you reached the point of physically aggressing someone? If yes, please why?

7. SPEECH (MRS-6, CARS/M-4, BRMS-2)

• Have you been more talkative than usual?

• Do you feel that sometimes you cannot stop talking?

• Do you think you have been talking or talk more than usual?

• People say that it has been more difficult to talk with you than usual? What is the reason?

• Subjective: Observe the patient's speech: whether he/she can be interrupted or not and/or whether he/she 'dominates' or not the conversation.

8. THOUGHT/FLIGHT OF IDEAS (MRS-7, CARS/M-5, BRMS-3)

• Have you felt upset for having many thoughts in your mind at the same time?

• Have you had episodes in which your thoughts were much more rapid than usual (i.e. 'mental confusion')?

• Have these very fast thoughts (i.e., mental confusion) interfered with your daily activities? If yes, please give an example.

• Do you have difficulties in completing a thought?

9. GRANDIOSITY (MRS-8, CARS/M-7, BRMS-7)

• Have you felt more confident about yourself than usual? To what degree (discrete, mild, moderate, etc.)?

• Have you felt that you were a particularly important person or that you had special powers, beyond-normal knowledge or capabilities? If yes, please give an example.

• Is there any special mission or purpose for your life. If yes, which one?

• Do you have any special relationship with Good? If yes, which one?

• Have you heard/seen things that only you have heard/seen? If yes, please give an example.

• Have you been or are you more suspicious of other people than usual? If yes, please give an example.

• Do you have the feeling that the things around you are related to you? If yes, please give an example.

• Do you have the feeling of being controlled by someone or by any force? If yes, please give an example.

10. INSIGHT (MRS-11, CARS/M-15)

• Do you think your behavior is different than usual?

• Do you think you are ill?

• Do you think you need treatment?

11. JUDGEMENT (CARS/M-10)

• When you were feeling euphoric or irritable, have you done things that caused trouble for you and your family? If yes, please give an example.

• Have you spent money without assessing the consequences of that? If yes, please give an example.

• Have you been involved in 'rave parties' or in great parties? If yes, please give an example.

• Have you taken on tasks and/or responsibilities for which you were not qualified? If yes, please give an example.

• Have you taken attitudes connected or been involved in risk situations? If yes, please give an example.

• Have you made more phone calls than usual?

12. DISTRACTIBILITY (MRS-7, CARS/M-6)

• Have you been more inattentive than usual?

• This inattentiveness bothers your conversations and/or interfere with your daily activities?

• Do you manage to finish your activities?

• Subjective: Observe the level of attention of the patient.

13. WORK (BRMS-11)

• Have you been able to work in the last two weeks?

• How is your motivation to work?

• How is your performance at work?

• Have you been relating with your working colleagues as usual?

• Have you 'lost' your temper ('your mind') at work?

• In case the patient is not currently working: Do you think you could come back to work whenever you were in better conditions?

• In case the patient be weekly assessed: In the last week have you resumed your work as you usually did? Have you had difficulties to resume them for being too inattentive or because you motivation was oscillating too much? Have you been absent from your work very often? Have you been fired from your work for some time? Have you stopped working for being hospitalized?

• In case the patient be hospitalized: Have you managed to participate in recreational activities?

14. DELUSIONS (CARS/M-12)

• Have you felt as if you were being controlled by an external force or power? If yes, please give an example.

• Have you felt as if people on the radio or TV were talking to you, about you or communicating with you in a special way? If yes, please give an example.

• Have you had any (other) strange or unusual belief or idea?

• Have these beliefs anyhow interfered with your functioning?

15. HALLUCINATONS (CARS/M-13)

• Have you heard sounds or voices when there was no one near you? If yes, please give an example.

• Have you had visions or felt some odors that other people did not perceive? If yes, please give an example.

• Have you had some (other) strange or unusual perceptions?

• Have these experiences anyhow interfered with your functioning?

16. ORIENTATION (CARS/M-14)

• Have you recently had problems to remember who you were, dates or current events?

• Do you know what the current day of the week, month, year and the name of this place are?

17. AGRESSIVE BEHAVIOR (MRS-9, CARS/M-2)

• Subjective: Observe in the patient signs of irritation and/or aggressive behavior.

18. APPEARENCE (MRS-10)

• Subjective: Observe how the patient is dressed (i.e., how is his/her general appearance) and if his/her clothes are adequate to the circumstances.

19. VOICE VOLUME (BRMS-4)

• Subjective: Observe the patient's voice volume.

20. CONTACT (BRMS-8)

• Subjective: Observe if the patient has an intrusive, questioning, dominating and/or controlling behavior and whether these behaviors are or not pertinent to the context.

21. THOUGHT (CARS/M-11)

• Subjective: Observe the patient's capability of understanding, incoherence, loosening of associations, neologisms, illogical thought. We are not punctuating here the flight of ideas.

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