Identifying Significant Antipsychotic-Related Side Effects in Patients on a Community Psychiatric Rehabilitation Unit-A Feasibility Study of The Glasgow Antipsychotic Side-Effect Scale (GASS)

Ahmed Saeed Yahya*
Camden Islington NHS trust, UK
*Corresponding author: Ahmed Saeed Yahya, Matthew Allin BA Research Centre, Camden Islington NHS trust, London, United Kingdom
Submission: May 07, 2018; Published: November 01, 2018
Identifying Significant Antipsychotic-Related
Side Effects in Patients on a Community
Psychiatric Rehabilitation Unit-A Feasibility
Study of The Glasgow Antipsychotic Side-Effect
Scale (GASS)
Research Article
1/4Copyright © All rights are reserved by Ahmed Saeed Yahya.
Volume - 2 Issue - 1
Examines in Physical Medicine and
Rehabilitation: Open AccessC CRIMSON PUBLISHERS
Wings to the Research
ISSN 2637-7934
Abstract
Antipsychotic side-effects are common and are an important determinant of non-adherence and consequent relapse. Most rating scales for the
identification of these are lengthy and complicated. This report reviews the medical literature on the Glasgow antipsychotic side-effect scale (GASS)-a
briefandvalidatedratingscaletomeasuretheunwantedeffectsofantipsychotics.WeadministeredtheGASStofourteenin-patientsinaUnitedKingdom-
based Community Psychiatric Rehabilitation Unit. The objective was to establish the utility of the GASS in this setting and to make recommendations on
how this tool could be used in clinical practice to improve adherence to antipsychotic medication.
Keywords: GASS; Psychiatric; Community rehabilitation; Anti psychotics
Introduction
Antipsychotic side-effects are common and disabling. They
are an important determinant of non-adherence and consequent
relapse Robinson et al. [1]. The CATIE study in 2005, which
enrolled 1500 patients with Chronic Schizophrenia, showed a
high rate of treatment discontinuation (up to 74%) during the
18month period of the trial. The median time to discontinuation of
treatment was 6 months Nystazaki et al. [2]. Most rating scales for
the identification of antipsychotic side-effects are either dependent
on clinical assessment (and therefore labour intensive) or are
lengthy and detailed. Therefore, they are often not completed or
completed incorrectly. Side effect scales can be differentiated on
generalisation and structure i.e. if they are measuring specific
clusters of symptoms or a range of these. Some of the rating scales
are designed to assess for specific side effects from antipsychotic
medication. Examples of these scales include; the Barnes Akathisia
Scale which evaluates akathisia (feeling of inner restlessness
and inability to stay still). The Abnormal Involuntary Movement
Scale (AIMS) assesses for tardive dyskinesia. The Simpson Angus
rating Scale (SAS) assesses for symptoms of Parkinsonism. More
generalised screening measures include the Liverpool University
Neuroleptic Side Effect Rating Scale (LUNSERS) which consists of
51 questions. Some of the items include ‘red herring’ questions’
which can be useful for identifying patients who are over rating
their side effects Haddad et al. [3]. Scales can be differentiated
further on the basis that they are patient or clinician completed.
The Glasgow Antipsychotic Side-effect Scale (GASS; Waddell &
Taylor [4] was designed as a brief, but valid self-completion scale. It
is one of the most practical and straightforward for routine clinical
use (can be completed before outpatient appointment). It takes
five minutes to complete and contains self-explanatory questions
in simple English. It is a structured tool to measure the important
antipsychotic side effects, and there is a column on the scale to
measure the subjective level of distress/functional impairment
caused by the specific adverse effect. In this report, we summarise
the findings of a pilot evaluation of the GASS in a cohort of patients
on a Community Psychiatric rehabilitation unit.
Methods
The GASS is a 22-item scale of possible side-effects, with
symptoms rated as present ‘never’, ‘once’, ‘a few times’ and ‘every
day’ during the previous week for the first 20 symptoms, and the
other two (change in periods [women only] and weight gain) rated
over the past 3 months and as either present or absent. The scale
has a possible score range between 0 and 63. The questionnaire
form used was identical to that in the Waddell & Taylor [4] paper.
The GASS was administered on a single occasion to 14 in patients in
our Community Rehabilitation Unit. Since the study was a quality
improvement project and the data collected were routine patient
data,consentwasobtainedverballyandtherewasnoneedforethical
approval to be sought. The GASS provides sub-scores on 9 domains

Examines Phy Med Rehab Copyright © Ahmed Saeed Yahya
2/3
How to cite this article:Ahmed Saeed Yahya. Identifying SignificantAntipsychotic-Related Side Effects in Patients on a Community Psychiatric Rehabilitation
Unit-A Feasibility Study of The Glasgow Antipsychotic Side-Effect Scale (GASS). Examines Phy Med Rehab. 2(1). EPMR.000529. 2018.
DOI: 10.31031/EPMR.2018.02.000529
Volume - 2 Issue - 1
of possible side effects: sedation and central nervous system;
cardiovascular; extrapyramidal; anticholinergic; gastro-intestinal;
Genito-urinary; diabetes-indication; hyperprolactinaemia
indicators and weight gain.
Results
Thirteen out of a total of 14 patients agreed to complete the
study. Of the 13 who completed the form, all but one filled the form
in its entirety. One patient left out the score for one item (weight
gain) 7 were female and 6 were male. Their age ranged between 32
and 65 years (Mean 42.9). All 13 patients who completed the form
had a diagnosis of a Treatment Refractory Psychosis. Nine of these
patients were taking Clozapine as an Anti- Psychotic medication.
The GASS total scores ranged between 1 and 57. Five patients had
GASS scores in the ‘Severe’ range, four had ‘Moderate’ side-effects
and four reported only having ‘Mild’ side-effects (Table 1). The
most frequent side effects experienced were in the Central Nervous
System and diabetes risk indicator domains. Genito-urinary
symptoms and hyperprolactinaemia indicators were relatively
infrequent as were anticholinergic symptoms (Table 2).
Table 1: GASS score summary.
Pa-
tient
num-
ber
Gen-
der
Age
To-
tal
Catego-
ry
Mild/
mod/
severe
CNS
Total
01-
Feb
CNS
Mean
(2)
CVS
To-
tal
03-
Apr
CVS
Mean-
2
EPS
Total
05-Oct
EPS
Mean-
6
Anti-
chol
Total
Nov-
13
Anti-
chol
Mean
-3
GI
14
GU
15
Dia-
be-
tes
16
Pro-
lactin
Tot
17-
20/21
Pro-
lactin
Mean-
3
Weight
Gain 22
1 M 54 43 Severe 6 3 5 2.5 12 2 2 0.67 2 2 3 8 2.67 3
2 M 38 3 Mild 2 1 0 0 0 0 0 0 0 0 0 0 0 0
3 F 41 13
Moder-
ate
2 1 0 0 3 0.5 0 0 0 0 2 0 0 3
4 F 65 36 Severe 6 3 1 0.5 14 2.33 8 2.67 3 0 3 0 0 0
5 F 43 57 Severe 6 3 6 3 18 3 9 3 3 0 3 9 2.25 3
6 M 37 23
Moder-
ate
5 2.5 5 2.5 5 0.83 3 1 0 0 2 0 0 3
7 M 35 31 Severe 5 2.5 2 1 8 1.33 2 0.67 3 0 3 2 0.67 3
8 F 34 25
Moder-
ate
3 1.5 3 1.5 12 2 2 0.67 2 0 3 3 0.75 3
9 F 52 37 Severe 5 2.5 5 2.5 16 2.67 5 1.67 0 1 2 3 0.75 MV
10 M 32 1 Mild 1 0.5 0 0 0 0 0 0 0 0 0 0 0 0
11 M 43 5 Mild 1 0.5 0 0 4 0.67 0 0 0 0 0 0 0 0
12 F 40 16
Moder-
ate
3 1.5 2 1 5 0.83 2 0.67 1 0 1 0 0 0
13 F 44 12 Mild 3 1.5 0 0 6 1 0 0 0 0 3 0 0 0
Table 2: Range and mean scores per domain.
Mean Score Range
CNS 2.54 0.5-3
CVS 1.12 0-3
EPS 1.32 0-3
Anticholinergic 0.85 0-3
GI 1.08 0-3
GU 0.23 0-2
Diabetes risk indicator 1.92 0-3
Hyperprolactinaemia indicator 0.55 0-2.67
Weight gain 1.5 0-3
CNS: Central Nervous System; CVS: Cardiovascular; EPS:
Extrapyramidal; Antichol: Anticholinergic; GI: Gastro-
intestinal; GU: Genito-Urinary; MV: Missing Value
Discussion
The response rate in this pilot study was high (only 1 person
declined out of 14) and almost all participants completed the GASS
form it its entirety. The scale only took about 5 minutes for each
participant to complete and the scoring and summarizing process
was also straight forward. A much higher proportion of participants
(69%) reported significant (moderate or severe) side-effects than
the out-patients in the original Waddell & Taylor [4] paper (24%).
This is unsurprising in view of the severity and chronicity of
mental illness in our cohort reflected by their need for a psychiatric
rehabilitation care pathway. In keeping with this, 9/13 (69%) of
our participants were prescribed more than one psychotropic.
In the Waddell & Taylor [4] outpatient cohort, only 28% were on
more than one psychotropic. The fact that diabetes risk indicators
were frequently reported is significant, given the high prevalence
of diabetes among service users with psychosis. Relatively low
scores for hyperprolactinaemia indicators are consistent with

3/3
How to cite this article:Ahmed Saeed Yahya. Identifying SignificantAntipsychotic-Related Side Effects in Patients on a Community Psychiatric Rehabilitation
Unit-A Feasibility Study of The Glasgow Antipsychotic Side-Effect Scale (GASS). Examines Phy Med Rehab. 2(1). EPMR.000529. 2018.
DOI: 10.31031/EPMR.2018.02.000529
Examines Phy Med Rehab Copyright © Ahmed Saeed Yahya
Volume -2 Issue - 1
more frequent use of prolactin-sparing (second generation)
antipsychotics-particularly clozapine-in this patient group. We
conclude that the GASS is a satisfactory instrument for identifying
significant antipsychotic side-effects in a rehabilitation unit setting.
Limitations
GASS does not collect information about constipation-a
common unwanted effect of the antipsychotic clozapine, which
is commonly used in treatment refractory psychosis. Our results
may therefore represent an under-estimate of the true range and
prevalence of antipsychotic side effects in this patient group.
Recommendations
We recommend that patients in long term rehabilitation
units should complete the GASS every 3 months, and that total
GASS scores within the moderate/severe range should trigger
a medication review. Collaborative practice with service users
will aid future medication adherence and thus have the potential
to make a significant contribution to relapse prevention Cleary
et al. [5]. Training in the use of GASS should be made available to
clinicians in the Multi-Disciplinary Team (including nurses, OTs,
support workers and medical staff) - particularly in teams who care
for patients who have treatment-refractory psychosis. We thought
it would be helpful to put the item scores (0, 1, 2, 3) onto the GASS
scoring sheets to facilitate score totalling. Future research should
focus on how the scale can be utilised as a clinical tool to improve
real-world outcomes Hynes et al. [6].
Acknowledgement
We thank the Whittington Health Library, at Whittington NHS
Trust for their support with Literature searching. We are also
grateful for the administrative support received from the Audit and
Medical Records departments at Camden & Islington NHS Trust.
References
1. Robinson DG, Woerner MG, Alvir JM, Hinrichsen GA, Lieberman JA, et
al. (2002) Predictors of medication discontinuation by patients with
first-episode schizophrenia and schizo-affective disorder. Schizophrenia
Research 57(2-3): 209-219.
2. Nystazaki M, Tsapakis EM, Hadjulis M, Alevizopoulos G (2014) Validation
of the glasgow antipsychotic side-effect scale (GASS) in Greece. Journal
of Psychology & Clinical Psychiatry 1(4): 1-6.
3. Haddad P, Fleischhacker WW, Moller HJ (2014) SMARTS (Systematic
monitoring of Adverse events Related to treatments): The development
of a pragmatic patient-completed checklist to antipsychotic drug side
effects. Therapeutic Advances in Psychopharmacology 4(1): 15-21.
4. Waddell L, Taylor M (2008) A new self-rating scale for detecting
atypical or second-generation antipsychotic side-effects. Journal of
Psychopharmacology 22(3): 238-243.
5. Cleary A, Walsh F, Connolly H, Hays V, Dowling M, et al. (2012) Monitoring
and documentation of side effects from depot antipsychotic medication:
an interdisciplinary audit of practice in a regional mental health service.
Journal of Psychiatric and Mental Health Nursing 19(5): 395-401.
6. Hynes C, Keating D, Williams S, Madigan K, Clarke M, et al. (2015)
Glasgow antipsychotic side-effects scale for clozapine-development
and validation of a clozapine-specific side-effects scale. Schizophrenia
Research 168(1-2): 505-513.
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Identifying Significant Antipsychotic-Related Side Effects in Patients on a Community Psychiatric Rehabilitation Unit-A Feasibility Study of The Glasgow Antipsychotic Side-Effect Scale (GASS)

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Identifying Significant Antipsychotic-Related Side Effects in Patients on a Community Psychiatric Rehabilitation Unit-A Feasibility Study of The Glasgow Antipsychotic Side-Effect Scale (GASS)