Highlights
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• The Transdiagnostic Global Impression – Psychopathology scale (TGI-P) assesses and visualizes severity across 10 transdiagnostic psychiatric symptom domains.
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• Both patient and informant versions of the TGI-P scale were completed in under 5 min by most participants, with high ratings for clarity and ease of use.
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• The new TGI-P versions enable multi-informant assessment and were preferred over other tools by most participants, highlighting their potential to enhance collaborative and measurement-based care.
Introduction
Measurement-based care (MBC), the continuous administration of validated rating scales in everyday practice [Reference McIntyre1, Reference Dunlop, Gray and Rapaport2], is a cornerstone of effective psychiatric practice [Reference Dunlop, Gray and Rapaport2–Reference Maj, Stein, Parker, Zimmerman, Fava and De Hert5]. MBC has been shown to improve consistency, appropriateness, quality, and cost effectiveness of treatment in depression [Reference Maj, Stein, Parker, Zimmerman, Fava and De Hert5, Reference McIntyre, Lee and Mansur6]. Nevertheless, the use of measurement-based devices in clinical settings in uncommon, contributing to heterogeneity of care and reducing the likelihood of optimized outcomes [Reference Correll, Kishimoto, Nielsen and Kane7–Reference Hatfield and Ogles9]. To help address this gap, the Transdiagnostic Global Impression – Psychopathology (TGI-P) scale was developed as the first detailed and multidimensional transdiagnostic symptom scale in psychiatry, assessing 10 core symptom domains (positive, negative, manic, depressive, hostility, self-harm, addiction, cognitive, anxiety and sleep symptoms) using a simple 1–7 severity rating, modelled on the Clinical Global Impression – Severity (CGI-S) scale [Reference Correll, Dombi, Barabássy, Németh, Brevig and McIntyre10]. The TGI-P is designed to be concise, intuitive, and clinically useful; facilitating rapid assessment and visual feedback through a symptom map that enables the global understanding of psychopathology and of its evolution over time [Reference Correll, Dombi, Barabássy, Németh, Brevig and McIntyre10].
The importance of including multiple perspectives in psychiatric evaluation is increasingly recognized [Reference Smith11, Reference Peters, Taylor, Lyketsos and Chisolm12]. The “Triangle of Care” (ToC) model highlights the value of integrating views from clinicians, patients, and caregivers to gain a more complete picture of mental health conditions [13]. This process is fundamental for triadic shared decision making [Reference Schuster, Holzhüter, Heres and Hamann14], as patient and caregiver insights not only help contextualize symptoms but also contribute to treatment planning and the building of a therapeutic alliance [Reference Bradley and Green15].
Consequently, patient-reported outcome measures (PROMs) have gained attention and are increasingly utilized [Reference Zini and Banfi16], providing valuable insights and reflecting a shift toward more patient-centred approaches [Reference Awad17, Reference Mendlovic, Roe, Markusfeld, Mainz, Kristensen and Goldzweig18]. While offering unique insights, PROMS can also be adversely influenced by non-response, fatigue, timing, language, and recall biases [Reference Zini and Banfi16]; as well as may introduce potential biases associated with subjective self-assessment, especially in symptom domains where insight may be compromised, such as mania or psychosis [Reference McIntyre, Ismail, Watling, Weiss, Meehan and Musingarimi19]. Nonetheless, research shows moderate-to-strong correlations between patient/caregiver reports and clinician ratings, supporting the value of integrating these different, yet complementary perspectives [Reference Mendlovic, Roe, Markusfeld, Mainz, Kristensen and Goldzweig18, Reference Hershenberg, McDonald, Crowell, Riva-Posse, Craighead and Mayberg20]. Importantly, PROMs reflect internal experiences, such as mood changes and subjective distress better than external observations, and such internal states are not necessarily explored in clinical interviews [Reference Scanferla, de Bienassis, Pachoud and Gorwood21]. However, there are several barriers to implementing PROMs, including overly complex formats and content, as well as the time involved in completing the self-reports [Reference Wolpert, Curtis-Tyler and Edbrooke-Childs22]. Indeed, measures that are “quick,” “simple,” and “well-explained” are much preferred [Reference Wolpert, Curtis-Tyler and Edbrooke-Childs22].
Against this background, patient- and informant-rated versions of the TGI-P scale were developed which had been introduced as a clinician-rated instrument first [Reference Correll, Dombi, Barabássy, Németh, Brevig and McIntyre10]. This paper outlines the development process and presents findings from an initial feasibility study of the TGI-P patient and informant versions.
Methods
The development of the TGI-P clinician version
The 10 symptom domains included in the TGI-P were originally defined based on a synthesis of expert consensus and empirical research, as outlined in our previously published clinician-scale paper [Reference Correll, Dombi, Barabássy, Németh, Brevig and McIntyre10]. Each symptom domain of the TGI-P is rated on a seven-point severity scale (1 – normal/not at all; 2 – minimal; 3 – mild; 4 – moderate; 5 – marked; 6 – severe; 7 – extreme), which is aligned with the widely accepted and used CGI-S scale [Reference Correll, Dombi, Barabássy, Németh, Brevig and McIntyre10]. The ratings are then plotted onto a symptom map, creating a visual clinical footprint that aids in understanding the patient’s current mental health status [Reference Correll, Dombi, Barabássy, Németh, Brevig and McIntyre10]. The development process followed key principles of scale design as summarized by Boateng et al., including domain conceptualization, item generation, and cognitive testing [Reference Boateng, Neilands, Frongillo, Melgar-Quiñonez and Young23].
The development of the TGI-P patient and informant version
The primary aim in developing the patient and informant versions of the scale was to produce two formats that mirrored the original clinician-rated version while remaining easily understandable to non-clinician users. To achieve this goal, each symptom domain was reformulated as a question, using non-clinical language to enhance accessibility (e.g., hallucinations from the positive symptom domain were described as “seeing or hearing things that others could not”). At the same time, it was essential to retain the same response format as the original scale to ensure consistency across versions.
In the finalized versions of the TGI-P patient and informant scales, all patient items begin with the prompt: “In the past week, to what extent have you…,” while the informant version uses: “In the past week, how much have you noticed that the person you provide care for….” The initial item formulations were drafted by Zs.B.D. and subsequently reviewed and refined collaboratively with the co-authors to ensure clarity, clinical relevance, and accessibility across user groups. Each version is accompanied by a brief introductory text designed to orient respondents to the purpose and format of the scale. For patients, the instruction reads: “The Transdiagnostic Global Impression – Psychopathology (TGI-P) scale aims to gain a deeper understanding of the symptoms you have experienced and their intensity over the past 7 days. The scale uses a 7-point rating from 1 (not at all) to 7 (extreme severity). Please read each question and circle the number that best corresponds to your experience. If you did not experience a certain symptom at all, please circle 1 (not at all).” For informants, the adapted instruction states: “The Transdiagnostic Global Impression – Psychopathology (TGI-P) scale aims to gain a deeper understanding of the symptoms experienced by the person you care for over the past 7 days. Please read each question carefully and circle the number that best reflects your impression of the intensity of their symptoms. If they did not experience a certain symptom at all, please circle 1 (not at all).” These introductions were designed to improve user comprehension and support more consistent, informed responses.
Survey design
In line with established scale development procedures, the next step after item formulation was to administer the scale to a sample representative of the target population to assess feasibility and user satisfaction [Reference Boateng, Neilands, Frongillo, Melgar-Quiñonez and Young23]. To this end, a targeted survey was conducted in collaboration with a research agency (Inspira Research). A total of 50 participants (25 patients and 25 informants) were recruited from the UK and US and their identities remained anonymous to the authors. Inclusion criteria for patients were a self-reported diagnosis of bipolar disorder, major depressive disorder, or schizophrenia. Informants were eligible if they provided care for someone with one of these diagnoses. Notably, informants were not matched with the patients.
Participants completed the draft TGI-P scales along with a structured feedback questionnaire. The assessment focused on four key areas: (1) clarity and comprehensibility of the wording and instructions; (2) usability and emotional impact; (3) appropriateness of the response options; and (4) perceived comparability to other commonly used rating tools. Additionally, open-ended questions invited suggestions for improving the format and design of the scale. Importantly, responses to the TGI-P scale items themselves were not recorded; only feedback about the questionnaire was collected and analysed.
Results
Participant characteristics
A total of 50 participants took part in the study, comprising 25 patients and 25 caregivers. Of the patients, 12 were from the UK and 13 from the US. Among caregivers, 13 were based in the UK and 12 in the US (Table 1). The majority of participants were female (72%), with identical gender distributions among patients and caregivers. Participants ranged in age from 18 to over 60, with a mean age of 44.5 years (SD = 9.9). Nearly half of the sample (46%) were between 18 and 39 years old, and smaller proportions were aged 40–49 years (26%), 50–59 years (20%), and 60 years or older (8%). Caregivers were more likely to fall into the youngest age group (52%), while patients were more evenly split between 18–39 and 40–49 years (40% each).
Participant characteristics of the patient-caregiver survey
Educational attainment was generally high, with 68% of participants reporting a university degree, including 72% of patients and 64% of caregivers. Smaller proportions reported completing high school only (24%) or vocational training (8%). Household sizes varied: 30% of participants lived in households of four or more, 26% lived with one other person, 22% with two others, and 22% lived alone. Notably, a higher proportion of patients (36%) lived alone compared to caregivers (8%), while caregivers were more likely to live in three-person households (36% vs. 8% of patients).
Regarding clinical characteristics, among the patient group, major depressive disorder was the most frequently reported diagnosis (40%), followed by bipolar disorder (36%) and schizophrenia (24%). Caregivers reported providing support most often to individuals with schizophrenia (44%), followed by bipolar disorder (32%) and major depression (24%).
Opinion on rating scales in general
Participants varied in their experience and attitudes toward using rating scales (Table 2). While only a small proportion (8%) reported completing rating scales frequently or on a weekly basis, 44% did so occasionally (monthly), and 36% reported rarely completing them (less than monthly). A minority (12%) stated they had never used rating scales. Interestingly, caregivers were more likely than patients to report occasional use (56% vs. 32%), whereas patients more frequently reported rare use (48% vs. 24%).
General attitudes towards rating scales
Perceived helpfulness of rating scales was generally positive. Overall, 26% of participants found them very helpful and 34% somewhat helpful, with patients more likely to report “somewhat helpful” (40%) compared to caregivers (28%). About 28% of the total sample felt neutral, and a small minority found rating scales somewhat (8%) or very exhausting (4%).
A clear preference for visual outputs from rating tools was evident, with 58% of participants indicating they “much more preferred” visual formats and an additional 28% reporting a “little more” preference. Only 14% reported no preference for visual output. Format preferences were also explored: 58% preferred digital formats, 12% preferred paper, and 30% liked both. Caregivers were slightly more likely to favour digital formats (64%) compared to patients (52%).
Opinion on the TGI-P scale
Participant feedback on the TGI-P scale is provided in Table 3. The majority (68%) reported that the aim of the scale was very clear, with the remaining 32% finding it somewhat clear; no participant reported confusion about the purpose. Instructions were generally easy to follow; 80% found them very easy, and another 16% rated them as easy. Confidence when completing the scale was high: 76% felt completely confident, and the remaining 24% felt somewhat confident. No participant reported needing assistance. Most participants (72%) completed the scale in under 5 min, with nearly all others completing it within 5–10 min. The process of completing the scale was described as very easy or easy by 94% of participants, with no reports of difficulty.
Results of the patient-caregiver survey
a only ‘No’ answers displayed.
Only minor wording aspects were noted, primarily relating to items on self-harm (10%), manic symptoms (8%), and positive or addiction symptoms (6% each), mostly among UK caregivers. Despite these few points, the response options were deemed very appropriate by 86% of participants, with no one finding them inappropriate. Most participants (96%) experienced no difficulties during completion. Regarding the scale’s visual output, a graphical symptom profile, 58% found it very helpful, and 40% somewhat helpful.
Most participants (74%) reported not feeling overwhelmed by the TGI-P scale, with the highest comfort observed among UK caregivers (85%) and UK patients (77%). A quarter of respondents felt slightly overwhelmed, but no participants across any group reported feeling very overwhelmed. The tool was generally not perceived as burdensome, with 86% rating it as not at all burdensome and no one reporting it as very burdensome. Emotional triggering was minimal overall; 68% were not triggered, 30% slightly triggered, and only one patient (8%) in the UK group reported being very triggered.
When compared to other clinical rating tools, 76% of participants rated the TGI-P as better or much better, with only one person describing it as worse. Suggestions for future improvements included further shortening the format (50%), simplifying wording (36%), and improving clarity of instructions (18%). The foregoing suggestions were more frequent among UK caregivers and US patients.
In response to the final open-ended question, 68% of participants voluntarily provided additional comments. Of these, 26% noted that the scale was clear and easy to understand, 30% found it helpful and elaborated on its usefulness, and 12% identified challenges or proposed suggestions for further refinement. While the visual output and overall wording were generally well received, several participants recommended simplifying certain terms and including explanatory notes alongside the visual feedback to explain its nature and purpose better. A small number of respondents also reflected on the concept itself, noting that completing the scale could be emotionally triggering.
Finalisation of the TGI-P scale patient and informant versions
Following analysis of participant feedback from the survey, the patient and informant versions of the TGI-P scale were finalized through targeted refinements. While the total number of items remained unchanged, several questions were reworded to improve clarity, address commonly reported challenges, and reduce perceived complexity. Notably, the phrasing of each item was adjusted to begin unanimously for patients with: “In the past week, how severe were your symptoms/experiences of…,” and for informants with: “In the past week, how severe were the symptoms/experiences of the person you provide care for in terms of….” These revisions aimed to anchor responses more clearly within a defined time frame and to improve interpretability across both TGI-P user groups. The refinement was a collaborative work involving all members of the development team. Details of wording changes are in the Supplementary Material.
In response to concerns about the clarity of the visual output, the introductory texts were also revised to better explain the scale’s purpose and how results are used. For patients, the updated instruction now reads: “The TGI-P scale is designed to provide a global overview of your symptoms and mental health experiences over the past 7 days. Please read each question carefully and rate how severe these symptoms and/or experiences have been for you on average during the past week, using a scale from 1 (not at all/normal) to 7 (extreme). If you did not experience a particular symptom, please select 1. Your responses will be plotted onto a symptom map, creating a clinical footprint of your current state – helping your care team better understand your overall symptom profile and areas that may need attention.”
For informants, the corresponding version states: “The TGI-P scale is designed to provide a global overview of the symptoms and mental health experiences of the one you provide care for over the past 7 days. Please read each question carefully and rate how severe these symptoms and/or experiences have been for the one you provide care for on average during the past week, using a scale from 1 (not at all/normal) to 7 (extreme). If they did not experience a particular symptom, please select 1. Your responses will be plotted onto a symptom map, creating a clinical footprint of their current state – helping the care team better understand their overall symptom profile and areas that may need attention.”
The final pen-and-paper versions of the TGI-P patient and informant scales are in the Supplement.
Discussion
Summary of key findings
The findings based on the user satisfaction/feasibility study support the usability, acceptability, and clarity of the TGI-P patient and informant scales. Most participants found the tool quick and easy to complete, with clear instructions and appropriate response options. The visual symptom map was well received, and the scale was generally preferred over traditional tools. Presenting the symptom composition, as opposed to using a composite score (which is a common method for summarizing scale measurements), may allow clinicians to describe individual symptoms more clearly to patients and caregivers. This approach is especially relevant when the TG-P is filled out regularly and, therefore, symptom evolution is tracked via the change of the symptom map; the closer the shape moves to the middle, the less severe the symptoms are. Results of the survey also support this by showing that patients and caregivers have a clear preference for visual output.
The findings suggest that the TGI-P scale is broadly acceptable in terms of emotional and cognitive load, though slight emotional responses and perceived burden among some participants warrant attention in future implementations. Indeed, one third of the patients felt slightly triggered when completing the scale, which might require attention, particularly in case of vulnerable individuals. All in all, the results suggest preliminary feasibility of using the scale in everyday practice.
The role of TGI-P in advancing measurement-based care through triangle of care
The present findings align with growing interest in incorporating patient and informant perspectives into psychiatric care [Reference Buila and Swanke24]. Previous research highlights the value of multi-informant ratings, particularly in chronic mental illness, where insight and symptom variability may impact clinician-only assessments [Reference Awad17, Reference Mendlovic, Roe, Markusfeld, Mainz, Kristensen and Goldzweig18]. Patient- and informant-reported tools can capture subjective distress, identify unmet needs, and improve engagement in care [Reference Scanferla, de Bienassis, Pachoud and Gorwood21]. However, common concerns with these tools include complexity, emotional burden, and questionable alignment with clinician assessments [Reference Wolpert, Curtis-Tyler and Edbrooke-Childs22]. The TGI-P patient and informant versions address many of these limitations by being brief and intuitive. Additionally, the visual output of the TGI-P, a symptom map, provides a novel way to describe clinical states and also an opportunity to discuss areas that need further support with patients and informants openly. By comparing the three versions of the TGI-P, with just one look, clinicians have the ability to get a comprehensive picture of the symptom complex the patient experiences from multiple perspectives, which can also be tracked over time and put into the context of treatment changes.
Limitations
Several limitations must be acknowledged. First of all, the present study was a user satisfaction/feasibility study, which cannot provide information on validity and reliability. Therefore, proper psychometric testing is underway, focusing on reliability, construct validity, and inter-rater agreement with clinician-rated versions. Second, the survey sample was relatively small and limited to the UK and US. Third, the high average educational attainment may have positively biased results regarding scale clarity and usability. Education is an important factor when analysing feasibility and user satisfaction as higher educational attainment may increase the likelihood of favourable results. Fourth, patients and caregivers were not matched, so that results could not be compared. Fifth, psychiatric diagnoses were self-reported, and no external verification was obtained. Finally, the TGI-P scales are symptom-focused. However, to provide a broader, transdiagnostic assessment platform of meaningful clinical outcomes that can inform care, several additional TGI scales are being developed concurrently. These include the TGI – Adverse Events, TGI – Functioning, TGI – Caregiver burden, TGI – Satisfaction with Life, and TGI – Satisfaction with Care scales. Except for the TGI Satisfaction with Life and TGI Satisfaction with Care scales that are patient-rated only, all other TGI scales are developed as a clinician, patient and informant version.
Future research
Future research is needed to establish the validity and reliability of the TGI-P scales. Such studies will need to include large and diverse populations, and test the implementation of the TGI-P Patient and/or TGI-P Informant versions across different treatment settings. To this end, psychometric validation of the TGI-P patient and informant versions together with the TGI-P Clinician version is currently ongoing, including assessment of reliability, construct validity, and inter-rater agreement with clinician-rated versions. Longitudinal data collection will further help evaluate the scale’s sensitivity to change and its utility in routine monitoring as part of clinical care. In addition, the impact on overall satisfaction with care and cost effectiveness of treatment when routinely implementing TGI-P is a future research consideration [Reference McIntyre, Konarski and Editorial25].
Conclusion
The TGI-P patient and informant scales were developed to offer a brief, transdiagnostic tool suitable for routine clinical use. Designed to complement the clinician-rated version, these two companion scales empower patients and informants to contribute to the understanding of symptom severity across 10 domains. The visual output of the TGI-P may support shared understanding and decision-making between clinicians, patients, and families. With proper validation, the TGI-P scales (alone or together with the additional TGI scales that are being developed) are hoped to help bridge the gap between time-consuming measurement-based research data collection in selected patient samples and scalable and informative MBC implemented as part of real-world psychiatric practice.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1192/j.eurpsy.2025.10069.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Acknowledgements
We acknowledge the contributions of Gabriella Korom and Zsolt Abonyi from Inspira Research.
Financial support
The patient-caregiver survey was funded by Gedeon Richter Plc.
Competing interests
R.M. has received research grant support from CIHR/GACD/National Natural Science Foundation of China (NSFC) and the Milken Institute; speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Neurawell, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, Abbvie and Atai Life Sciences. Z.B.D., Á.B., G.N., and T.B. are employees of Gedeon Richter Plc. C.U.C. has been a consultant and/or advisor to or has received honoraria from: AbbVie, Alkermes, Allergan, Angelini, Aristo, Autobahn, Boehringer-Ingelheim, Bristol-Meyers Squibb, Cardio Diagnostics, Cerevel, CNX Therapeutics, Compass Pathways, Darnitsa, Delpor, Denovo, Draig, Eli Lilly, Eumentis Therapeutics, Gedeon Richter, GH, Hikma, Holmusk, IntraCellular Therapies, Jamjoom Pharma, Janssen/J&J, Karuna, LB Pharma, Lundbeck, MedInCell, MedLink, Merck, Mindpax, Mitsubishi Tanabe Pharma, Maplight, Mylan, Neumora Therapeutics, Neuraxpharm, Neurocrine, Neurelis, NeuShen, Newron, Noven, Novo Nordisk, Orion Pharma, Otsuka, PPD Biotech, Recordati, Relmada, Response Pharmaeutical, Reviva, Rovi, Saladax, Sanofi, Seqirus, Servier, Sumitomo Pharma America, Sunovion, Sun Pharma, Supernus, Tabuk, Takeda, Teva, Terran, Tolmar, Vertex, Viatris and Xenon Pharmaceuticals. He provided expert testimony for Janssen, Lundbeck, Neurocrine, and Otsuka. He served on a Data Safety Monitoring Board for Compass Pathways, IntraCellular Therapies, Relmada, Reviva, Rovi. He has received grant support from Boehringer-Ingelheim, Janssen and Takeda. He received royalties from UpToDate and is also a stock option holder of Cardio Diagnostics, Kuleon Biosciences, LB Pharma, MedLink Global, Mindpax, Quantic, Terran.
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