Translation, adaptation and reliability study of the Scale to Assess Unawareness of Mental Disorder - SUMD

Tradução, adaptação e estudo de confiabilidade da Escala para Avaliar a Ausência da Noção do Transtorno Mental - SUMD

BRIEF REPORT

Translation, adaptation and reliability study of the Scale to Assess Unawareness of Mental Disorder - SUMD

Tradução, adaptação e estudo de confiabilidade da Escala para Avaliar a Ausência da Noção do Transtorno Mental - SUMD

Nina Fiss^I; Ana Cristina Chaves^{I, II}

^IPaulista Medical School of the Universidade Federal de São Paulo (Federal University of São Paulo, UNIFESP/EPM)

^IIProgram of Schizophrenia at the Department of Psychiatry of UNIFESP/EPM

^{Correspondence}

ABSTRACT

INTRODUCTION: Previous studies have suggested that lack of insight into mental disorder can be an important predicting factor involving the course of psychotic disorders mainly regarding compliance with treatment. The Scale to Assess Unawareness of Mental Disorder-SUMD is a semi-structured open interview that evaluates global insight, insight into illness and insight into symptoms. The SUMD has shown good reliability and validity and has demonstrated certain advantages over previous measures of insight, suggesting the usefulness of a multidimensional view of this complex concept.

OBJECTIVE: The aim of this study is to translate, adapt and test the reliability of the SUMD in schizophrenic patients.

METHODS: This study involved 35 schizophrenic patients according to the DSM-IV criteria, who where under treatment in the Schizophrenia Program of the Federal University of São Paulo. Two independent examiners conducted the reliability study simultaneously.

RESULTS: The results demonstrated that the SUMD achieved a good intraclass reliability coefficients between investigators - ICC ranged from 0.55 to 0.97 - for the general items to assess awareness of mental disorder and 0.56 to 0.98 - for the symptoms items.

DISCUSSION: These coefficients were similar to those found by the researchers who developed this scale. The SUMD scale has proven to be easily applied and may be deemed an useful instrument with good psychometrics capacities in researches involving schizophrenic subjects.

Keywords: Schizophrenia/diagnosis; Psychotic disorders/diagnosis; Awareness; Psychiatric status rating scales; Reproducibility of results; Mental Status Schedule

RESUMO

INTRODUÇÃO: Estudos sugerem que a falta de insight para a doença mental pode ser um fator preditivo de mau prognóstico no curso dos transtornos psicóticos, principalmente em relação à adesão ao tratamento. A Escala para Avaliar a Ausência de Noção do Transtorno Mental - SUMD é uma entrevista aberta semi-estruturada que avalia o insight global do paciente, para a doença e para seus sintomas. A SUMD tem demonstrado boa confiabilidade e validade devido a sua característica multidimensional e, também, apresentado vantagens em relação a outros instrumentos que avaliam o insight.

OBJETIVO: O objetivo deste estudo foi traduzir, adaptar e testar a confiabilidade da SUMD em pacientes com esquizofrenia.

MÉTODOS: Foram avaliados 35 pacientes com diagnóstico de esquizofrenia pelo DSM-IV, do Programa de Esquizofrenia da UNIFESP/EPM, através da SUMD, por dois entrevistadores independentes.

RESULTADOS: Os resultados do estudo de confiabilidade demonstraram que a SUMD apresentou bons coeficientes de confiabilidade intraclasse entre os investigadores, com coeficientes variando entre 0,55 e 0,97 para os itens gerais e de 0,56 a 0,98 para os itens de sintomas específicos.

DISCUSSÃO: Estes coeficientes foram similares aos encontrados pelos investigadores que desenvolveram a escala. A SUMD mostrou ser de fácil aplicação, demonstrando ser um instrumento útil e com boas propriedades psicométricas na avaliação do insight em pacientes com esquizofrenia em nosso meio.

Descritores: Esquizofrenia/diagnóstico; Transtornos psicóticos/diagnóstico; Conscientização; Escalas de graduação psiquiátrica; Psicometria; Reprodutibilidade de resultados; Entrevista psiquiátrica padronizada

Introduction

The awareness of illness and of its symptoms as perceived by the schizophrenic patient and its influence in the compliance with treatment and in the clinical outcome has been the subject of several studies in the last decade.¹ Many of these studies verified that the lack of insight is a prevalent characteristic in schizophrenia and is frequently associated with a bad prognostic. More recently, Amador et al² has found a rate of 60% of schizophrenic patients who had moderate to severe lack of awareness about mental disorders.¹

In a review about the concept of insight, Marková, Berrios³ stated that it is common for investigations to be focused only on one or two components of insight. The concern to define insight into illness as a multidimensional construct which comprises several phenomena, is more recent.^1,4-5

In order to test this hypothesis Amador et al² have developed a multidimensional scale, Scale to Assess Unawareness of Mental Disorder (SUMD). This instrument assesses the insight or the awareness of patients regarding their illness and the assignments given to the disease and its symptoms. Six items of the SUMD assess the general awareness of the illness and sixteen assess the awareness of specific symptoms.¹

The aims of our study were to translate and adapt the English version of SUMD into Portuguese and test the reliability of this version in our society among schizophrenic patients.

Methods

1) The studied group had 35 outpatients (20 males and 15 females), with mean age of 29.7 years(SD = 10.6), who met criteria for diagnosis of schizophrenia (DSM-IV⁶), seen at the Schizophrenia Program (PROESQ) of the Department of Psychiatry/ UNIFESP-EPM. The sample aimed to include patients with variability both in the time of disease as in the severity of impairment.

2) Translation and adaptation of the SUMD into Portuguese and back-translation into English.

There were no difficulties in the adaptation of the scale into the current culture, as the SUMD seeks to investigate symptoms present in the main psychiatric diagnostic criteria. The back-translation of the Brazilian version of the SUMD from Portuguese into English was performed by a professional who mastered both languages and was acquainted with the mental health field, but who had not had any previous contact with the scale.

3) Study on the reliability of the scale

All participants signed the informed consent. Two independent researchers who have alternated in the conduction of the interviews accomplished the assessment of patients. The scale has a training manual which was used by the researchers, who at the time of the interview had a professional formation between 8 and 11 years.

The test used to assess the reliability between observers was the Intraclass Correlation Coefficient. The statistical program used was the SPSS (version 8.0).

Results

The sample had 35 patients, being 20 (57.1%) males and 15 (42.9%) females. Mean age of patients was 29.69 years (SD 10.64), and the age of onset was 22.63 years (SD 8.32). Mean schooling was 9.54 years (SD 3.33) and the time of disease was 7.12 years (SD 8.4). The reliability rate of the general items had a mean variation between 0.55 and 0.97 (Table 1). The reliability rate of the current symptoms had a mean variation between 0.71 and 0.99.

Discussion

Currently, the SUMD is the most used scale to assess awareness of illness in mental disorders and according to Kemp, David it may be considered as the most comprehensive and adequate one to assess the several aspects of awareness of illness among schizophrenic patients.⁷ All the items of the general subscale (Table 1) had high rates of Intraclass Correlation Coefficients (ICC), which were similar to those of the study by Amador et al.²

The Brazilian version of the SUMD showed being easily applicable on schizophrenic patients (DSM-IV). The time of assessment was short, and there is no need of special training to apply it, but the interviewer has to be acquainted with the psychiatric symptomatology.

The Brazilian version of the SUMD had a good psychometric performance and may be considered as a useful instrument to assess the awareness of illness among patients with schizophrenia and related disorders in our society.

Submitted: 22 April 2003

Accepted: 4 February 2004

Financing: None

Conflict of interests: None

Original version accepted in Portuguese

Study based on the Thesis presented in June 2001 to obtain the M.Sc. Degree in Mental Health at the Department of Psychiatry of UNIFESP/EPM.

• 1. Amador XF, Strauss DH, Yale SA, Flaum MM, Edincott J, Gorman JM. Assessment of insight in psychosis. Am J Psychiatry. 1993;150(6):873-9.
• ²
  2. Manual de diagnóstico e estatística de transtornos mentais DSM-IV. 4ª ed Traduzido por Batista D. Porto Alegre: Artes Médicas Sul; 1995.
• 3. Amador XF, Strauss DH, Yale SA, Gorman JM. Awareness of illness in schizophrenia. Schizophr Bull. 1991;17(1):113-32.
• 4. Markova IS, Berrios GE. Insight in clinical psychiatry revisited. Compr Psychiatry. 1995;36(5):367-76.
• 5. Schwartz RC, Cohen BN, Grubaugh A. Does insight affect long-term inpatient treatment outcome in chronic schizophrenia? Compr Psychiatry. 1997;38(5):283-8.
• 6. Schwartz RC. The relationship between insight, illness and treatment outcome in schizophrenia. Psych Q. 1998;69(1):1-22.
• 7. Kemp R, David A. Psychosis: insight and compliance. Forensic Psychiatry. 1995;8:357-61.

Correspondence to

Nina Fiss

Rua Angeline Mafei Vita, 725, apto. 111

01455-070 São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  21 Nov 2005
• Date of issue
  June 2005

History

• Accepted
  04 Feb 2004
• Received
  22 Apr 2003