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Abstract
Objectives. There is a need for an observation scale for assessment and monitoring of acutely psychotic patients. Milestones based on such ratings should be defined, similar to the PANSS-based Remission criteria. FAST-O is such an instrument (11 items and a CGI rating). Methods. Reliability, validity and factor structure were analyzed in four separate studies–most importantly in one study of 33 chronic forensic in-patients rated concurrently by three independent raters, and another study of 91 Psychiatric Intensive Care Units patients and 20 newly admitted forensic patients, rated twice, each time by two independent raters. Results. The factor structure was simple, two factors and an orphan item (Depression). Reliability was adequate on item (>0.75) as well as scale (>0.85) level. There was no bias related to the rater's professional background. The instrument was sensitive to change. Percentile-based algorithms allow characterization of patients and groups. Tentative treatment milestones are defined; a clinical state “half-way” between the acute state and remission. Conclusions. FAST-O is a reliable, valid and easy to implement observation scale for patients with a psychotic illness, which can be used without bias by all staff.
Acknowledgements
The project was initiated some years ago by Birgit Ekholm, working for AstraZeneca, and Eva Lindström. They created the first version of FAST-O and ran the first rating study. Sten Levander came on-board shortly after initiation, as clinician and researcher, and has been responsible for the statistical analysis. Eva Tuninger is the Swedish clinician involved in the AfterCare project, which supplies reference data. The other members of the AfterCare team, lead by Sheilagh Hodgins, is gratefully acknowledged for their contribution. Eva Lindström headed the 5-year study, which also supplies reference data. AstraZeneca has supported the project in all phases. Specifically, Birgit Ekholm and Eva Dencker Vansvik should be acknowledged. Most patients were medicated at the time of the studies, but the selection of drugs for treatment was at the clinician's discretion and not recorded in the data base.
Statement of Interest
Thomas Koernig is an employee at AstraZeneca. Sten Levander and Eva Lindström have received honorarium from a number of pharmaceutical companies, including AstraZeneca. The study has not been supported by any other sponsor than AstraZeneca.
Appendix: FAST-O Rating Scale
The scale
The FAST-O scale (construction and properties) is described in the word document FAST-O, which can be downloaded from the www.eurocog.eu home page. The assessment is based on observation of the patient during the last 24 hours in situations in which FAST item problems are manifest. The instrument comprises eleven FAST-O items and a CGI rating.
Item definitions
The first six items are part of the NOSIE scale, the remaining ones are PECC/PANSS items. Finally a CGI assessment is done. For each of the items there are definitions of what the item denotes, and anchor points. Each item is assessed on a scale from 0 to 4; higher values signal more problems.
Sometimes there is insufficient information to assess an item. Then mark the item as Not enough information. For some items this option is missing–if the patient is observed it is always possible to rate the item.
Dressing
0: Adequate in the context, neat
1: Same but less neat
2: Deviant dressing but neat
3: Deviant dressing, dirty, falling apart
4: Completely inadequate dressing
Personal hygiene, self-care, neatness
0: Normal hygien, clothes, nails etc. OK
1: Certain shortcomings, hair wash, nails long/dirty
2: Significant shortcomings, dirty, unfresh
3: Substantial shortcomings, greasy, smells
4: Seriously deviant personal neatness
X: Not enough information
Table manners
0: Normal table manners
1: Certain shortcomings,
2: Significant shortcomings, unpleasant
3: Substantial shortcomings, others leave the table
4: Completely disorganized or no food intake
Speech
0: Normal speech, good timing, mutuality
1: Certain shortcomings
2: Significant shortcomings, poor mutuality
3: Substantial shortcomings, difficult to understand
4: Incoherent speech or mute
Social interest for environment and persons
Participates, takes initiatives.
0: Normal interest
1: Certain shortcomings
2: Significant shortcomings, rejects contacts
3: Substantial shortcomings, autistic tendencies
4: Complete lack of interest, autistic
The following items are observational ones from the Hamilton Depression scale (H1: Depression and H3: Suicidality), equivalent to the PANSS G6 item (Depression) and five other PECC/PANSS items (the Excitation/Aggression subscale). The PECC/PANSS 1–7 format is compressed to the FAST 0–4 format according to the rule 1–2 = 0; 3 = 1; 4 = 2; 5 = 3; 6–7 = 4.
Depression, suicidality
The patient is crying, says s/he is a bad person, expresses guilt feelings, life is meaningless.
0: None of this or so mild that it is within the normal range considering the context.
1: Depression/dysphoria to a certain extent, but less than 25% of the time and with no effect on thinking, functions and behaviour. Nothing that indicates suicide risk.
2: Depression/dysphoric, but less than 50% of the time, some effects on thinking, functioning and behaviour. Not suicidal.
3: Apparently depressed/dysphoric, more than 50% of the time, clear effects on thinking, functions and behaviour. Suicide risk cannot be excluded.
4: Evident depression most of the time, immensely affecting function/behaviour, and/or substantial risk of suicide.
X: Not enough information
Hostility
Verbally/non-verbally expressed rage. Feelings of being maltreated, sarcasms, use of foul
language and “dirty” words.
0: None of this or so mild that it is within the normal range considering the context.
1: Mild increase of hostility with sarcastic remarks, irritability, interprets communication negatively, marks words.
2: Moderate increase with sarcastic remarks, negative comments and so on, clear effects on social interactions.
3: Apparent and repeated expressions of hostility with substantial negative effects on social interactions.
4: High level of irritability, accusations, verbal threats, hostile gestures, socially unacceptable.
Excitation
Either hyperactivity with an increase of motor activity, vigilance, scanning of the environment, or substantial mood swings which are inappropriate in relation to the context.
0: None of this or so mild that it is within the normal range considering the context.
1: Mild increase in motor functions, talkative, scans the environment and reacts to even the slightest stimuli. Alternatively, mild increase of mood-swings, no eruptions.
2: Moderate but a clear increase, alternatively, clear and inappropriate mood-swings, temporary but limited eruptions.
3: Apparent increase of symptoms in these areas that has substantial negative effects on social interactions, affective eruptions which are clearly out of context.
4: Substantial hyperactivity, which makes it difficult for the patient to find peace during more than a few minutes. Clear negative effects on ADL-functions, some incoherence.
Tension
The rating is based on verbal information regarding anxiety and the level of bodily manifestations of tension that can be observed (posture, muscular tension, tremor, breathing pattern, psychogenic sweating, other autonomic manifestations).
0: None of this or so mild that it is within the normal range considering the context.
1: Mild increase of tension.
2: Moderate increase, voices distress.
3: Clear increase in tension which affects behaviour negatively.
4: Highly tensed, cannot focus, occupied to the border of incoherence.
X: Not enough information
Cooperation
Lacking will/ability to cooperate. Active refusal to do what others want/expect, combined with distrust, defensive stance, refusal to accept authority and staff.
0: None of this or so mild that it is within the normal range considering the context.
1: Seems distrusting and negative, bitter and sarcastic, but not to the extent that it affects social interactions other than marginally.
2: As score 1 but with some negative impact on social interactions. Temporarily refuses to comply with normal social obligations, particularly vs. staff.
3: Same problem but now demonstratively uncooperative, repeated refusal to comply with normal social duties and rules, regardless of context.
4: Uncooperativeness is a consistent and dominant problem for the patient’s social interactions.
Control of impulses and affects
Disturbed regulation of action control, either by external stimuli (“temptations” or over-reactions to changes in the environment), or behaviour is inappropriately affected by sudden and unwarranted affects.
0: None of this or so mild that it is within the normal range considering the context.
1: Some increase of unpredictability, e.g., can be upset, argue, use foul language when confronted/corrected. Alternatively, acts on the spur of the moment but can apologize later.
2: Apparent increase of unpredictability, but still able to understand after some time, acknowledge her/his mistake and regret what happened–but with overall negative social consequences.
3: Substantial unpredictability but still some relation vs. triggers in the environment. This has lead to substantial problems vs. social interactions.
4: The patient displays repeated episodes of unwarranted impulsive or affective eruptions which are completely inadequate in regard to context. This has had serious consequences for social interactions.
Clinical Global Impression
The seven-level rating is based on the level of symptoms, and the consequences for social interactions, and not, like for GAF, the general functioning level. Thus it should be conceived of as a split GAF rating with focus on symptoms.
1: No symptoms or signs of a psychiatric disorder
2: Borderline case between health and illness
3: Light degree of illness
4: Moderate degree of illness
5: Evidently ill
6: Seriously ill
7: Extremely ill, completely dysfunctional
X: Not enough information
Scale definitions
The FAST-O scores should be considered on item level (11 items) or as subscale scores. The first five items are denoted NOSIE items and this subscale refers to everyday social functions. The Depression item is not part of a subscale–it should be kept on item level. Items 7–11 refer to behaviour which reflects excitation and aggression, directly or indirectly, and forms the E/A subscale. The CGI rating is a global index of the degree of illness and should be considered on item level.
Algorithms – general information
FAST-O scores can be expressed on item level and subscale level, as scores and sumscores. It is pointless to sum all scores to a total score because the two subscales, and the Depression item, are uncorrelated, and the variability is different for different items (items with a large variability will be dominant contributors to the sumscore).
A more intuitive way (than scores and sumscores) is to express these measures as percentiles, relative a norm population. Percentiles have the advantage of being on interval measurement level, like a temperature scale. The difference between two percentile scores have an absolute meaning – going from 55 to 45 is as large an improvement as going from 80 to 70. The critical point is to select the appropriate reference population. Several sets of percentile scores are provided, with a range of patients representing very ill, chronic, forensic inpatients, to well managed general psychiatry out-patients in a stable phase since 5 years. For some of the materials, NOSIE subscale data are not available. The data-base will be updated continuously when new study material becomes available. Percentile scores can be calculated on the EuroCog homepage (www.eurocog.eu).
By comparing the scores of an actual patient with the appropriate reference group, important information can be extracted concerning which problem that is most urgent to address by the clinician. Since percentile scores are directly comparable it is also possible to measure improvement (or worsening) during monitoring. For example: a patient lives in sheltered housing and usually scores 5 on the NOSIE subscale, 0 on Depression and 2 on Excitation/ Aggression. According to the percentile table for chronic forensic patients, his actual percentile scores (calculated as the midpoint of a range) are 55 (46–64), 20 (0–40) and 44 (39–49). He is slightly more ill with respect to social functions and slightly less ill for Excitation/Aggression than a typical forensic inpatient. Maybe he should become inpatient. By consulting the table for acutely admitted forensic patients, who have been regarded as needing to become inpatients, we can see that the percentile values are clearly better than for most of these patients (around 20), and more similar to the percentiles after two weeks of inpatient treatment–speaking against re-admission of a short duration.
Another example concerns a newly admitted PICU patient. At admission she has percentile values around 50 for all indices. Two weeks later she should have improved substantially and reached the symptom level typical of patients who improve by treatment. However, she scores still high on Depression and Excitation/Aggression – i.e. the clinician must rethink the current approach because it does not work, and specifically, high percentile scores on these specific points may signal suicide risk.
Scores, whether expressed numerically or as percentiles, do aid the clinician's decision-making, but in a relative way. Milestone criteria are absolute. Either a patient has passed the milestone or not, and when s(he has done it, treatment should enter a new phase 0. The FAST-O milestone reference data refer to the percentage of the comparison group patients who have failed to reach the Milestones. This provides some realism to the ambitions relative patients. Some have not, and will likely never reach a specific milestone. Then, this patient may need more support than the average patient in order to uphold an acceptable quality of life.
As an example, a percentile table for patients recently admitted (within 48 h) to five Swedish Psychiatric Intensive Care units is provided.