New Clinician/Patient Tools being Developed for Prospective Monitoring

By Prof. Nina Schooler
Prelapse Magazine
, No. 2, September 1995

Prof. Nina R. Schooler, Western Psychiatric Institute and Clinic, Pittsburgh and Prof. Wolfgang Fleischhacker, Universitätsklinik für Psychiatrie, Innsbruck are working on a new Prelapse tool

As described by Prof. Kane, the definition of relapse is multidimensional and the prevention of relapse - realization of the Prelapse concept - requires detailed knowledge of the individual patient and the "essential ingredient" of clinical judgment We are developing a new clinical tool that will help the clinician to observe the patient and exercise good clinical judgement.

For a tool to be most useful to clinicians it must be very patient-specific and relatively easy to use. The goal is to record information each time the patient is seen that can be readily reviewed to see whether there are changes in the patient's clinical condition even relatively small changes that may
suggest to the clinician that a dosage increase, medication change or increased monitoring should be considered. Specifically, we are designing a clinical tool that will allow the clinician to assess the four factors that Prof. Kane includes in his definition of relapse.

The tool will be called "Prospective Monitoring - Clinician" and, reflecting the importance of family members in the entire Prelapse concept, we plan to develop a parallel tool for the use of patients and their family members.

The goal
By paying close attention to the patient longitudinally and prospectively we may be able to avert the disruptive effects of psychotic symptom exacerbation, relapse and rehospitalization. Four related areas need to be monitored:

1. The patient's overall clinical status
2. Target symptoms of the illness for the patient
3. Non-specific symptoms that may be early warning signs
4. Social and functional disability

Clinical judgments
We ask the doctor or the clinician who is following the patient most closely this question: "In your clinical judgment, how severely ill is the patient at this time?" The options are: Not at all; minimally: mildly; moderately; markedly; severely; among the most severely ill patients.

Each of these options has a numerical value ranging from "O" for "not at all" to "6" for among the most severely ill patients" and these options are presented along a horizontal line as a "Visual Analogue Scale", so that the clinician can make a tick-mark anywhere along the line to indicate how severely ill the patient is.

We also ask for a second clinical judgment: "How much has the patient changed since the last visit?" The options are: Very much improved; much improved; minimally improved; no change; minimally worse; much worse; very much worse.

The same numerical score range is used and the same Visual Analogue Scale. This is an important measure because it alerts clinicians to think about relatively subtle changes that may be taking place.

The target symptoms
Equally important is the identification of significant symptoms for the patient that are the main focus of treatment and to evaluate these symptoms at each visit. It is the tailoring of target symptoms to the individual patient rather than using the ready-made scales for evaluating symptoms that we think will make this tool valuable for clinicians. These are also measured using the Visual Analogue Scale.

Non-specific symptoms
Non-specific symptoms such as sleep disturbance, irritability, difficulty concentrating and restlessness may serve as early warning signs of impending relapse. So we also ask the clinician to identity such signs for each patient and to monitor them as well.

Social and functional disability
Last of all we will assess disability using a comparable format.

This is not yet a completed tool and we invite readers of Prelapse to offer their suggestions for features that would be useful in prospective monitoring of patients in order to avert relapse.

Reprinted with permission.

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