Tom Trauer

The validity of the 21‐item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure

Objective: This study aimed to test the validity of the 21-item Depression Anxiety Stress Scales (DASS-21) as a routine clinical outcome measure in the private in-patient setting. We hypothesized that it would be a suitable routine outcome instrument in this setting. Method: All in-patients treated at a private psychiatric hospital over a period of 24 months were included in the study. Data were collected on demographics, service utilization, diagnosis and a set of four routine measures both at admission and discharge. These measures consisted of the Clinical Global Impressions (CGI) scales, Health of the Nation Outcome Scales (HoNOS), the Mental Health Questionnaire (MHQ-14) and DASS-21. The results of these measures were compared. Results: Of 786 admissions in total, the number of fully completed (ie paired admission and discharge) data sets for the DASS-21 depression, anxiety and stress subscales were 337, 328 and 347, respectively. All subscales showed statistically significant reductions in mean scores from admission to discharge (P < 0.001) and were significantly correlated with all MHQ-14 subscales and significantly related to CGI scale categories. The total DASS-21 and total HoNOS scores were also significantly correlated. Conclusions: The findings from the present study support the validity of DASS-21 as a routine clinical outcome measure in the private in-patient setting.

Why are we weighting? The role of importance ratings in quality of life measurement

Many Quality of Life (QoL) instruments ask respondents to rate a number of life domains in terms of satisfaction and personal importance, and derive weighted satisfaction scores by multiplying the two ratings. This paper demonstrates that this practice is both undesirable and unnecessary. QoL domains are selected on the basis of their inherent importance, rendering separate importance rating partially redundant. Weighted scores present difficulties in interpretation. Further, we show that multiplicative composites have undesirable psychometric properties. There is evidence that multiplicative composites have little or no advantage over unweighted ratings in correlational or predictive studies. Apart from the face validity and the intuitive appeal of multiplying satisfaction ratings by importance ratings, there appear to be no sound reasons for doing so, and several good reasons not to do so.

Prevalence of psychiatric disorder in a methadone maintenance population

Objective: The objective of this study was to examine the prevalence of psychiatric disorders in a group of patients who had recently entered a methadone maintenance programme. Method: A total of 62 patients were interviewed using the Composite International Diagnostic Interview (CIDI) within 6 months of commencing methadone maintenance. The CIDI was used to establish symptoms of psychiatric illness at interview and in the 12 months prior. Results: In the 12 months prior to interview, 76% of the sample fulfilled ICD-10 criteria for a psychiatric disorder other than substance-use disorder. Over half of the group interviewed fulfilled ICD-10 criteria for an affective disorder, two-thirds fulfilled criteria for an anxiety disorder and just under half fulfilled diagnostic criteria for both an affective disorder and an anxiety disorder in the 12 months prior to interview. At the time of interview, 19% fulfilled ICD-10 diagnostic criteria for a moderate or severe affective disorder. Seventy per cent of males and 89% of females interviewed had a comorbid psychiatric illness. In 71% of the group who had a comorbid psychiatric illness, the onset of psychiatric symptomatology was reported to predate the use of heroin. Conclusion: The prevalence of psychiatric disorder is up to 10 times higher in the population on methadone maintenance than in the general population and is two to three times higher than that found in community surveys of those with a substance-use disorder. These results are consistent with earlier findings and have implications for service planning.

The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use.

OBJECTIVE The Clinical Global Impression Scale (CGI) is established as a core metric in psychiatric research. This study aims to test the validity of CGI as a clinical outcome measure suitable for routine use in a private inpatient setting. METHODS The CGI was added to a standard battery of routine outcome measures in a private psychiatric hospital. Data were collected on consecutive admissions over a period of 24 months, which included clinical diagnosis, demographics, service utilization and four routine measures (CGI, HoNOS, MHQ-14 and DASS-21) at both admission and discharge. Descriptive and comparative data analyses were performed. RESULTS Of 786 admissions in total, there were 624 and 614 CGI-S ratings completed at the point of admission and discharge, respectively, and 610 completed CGI-I ratings. The admission and discharge CGI-S scores were correlated (r = 0.40), and the indirect improvement measures obtained from their differences were highly correlated with the direct CGI-I scores (r = 0.71). The CGI results reflected similar trends seen in the other three outcome measures. CONCLUSIONS The CGI is a valid clinical outcome measure suitable for routine use in an inpatient setting. It offers a number of advantages, including its established utility in psychiatric research, sensitivity to change, quick and simple administration, utility across diagnostic groupings, and reliability in the hands of skilled clinicians.

A systematic review of instruments related to family caregivers of palliative care patients

Support for family caregivers is a core function of palliative care. However, there is a lack of consistency in the way needs are assessed, few longitudinal studies to examine the impact of caregiving, and a dearth of evidence-based interventions. In order to help redress this situation, identification of suitable instruments to examine the caregiving experience and the effectiveness of interventions is required. A systematic literature review was undertaken incorporating representatives of the European Association for Palliative Care’s International Palliative Care Family Caregiver Research Collaboration and Family Carer Taskforce. The aim of the review was to identify articles that described the use of instruments administered to family caregivers of palliative care patients (pre and post-bereavement). Fourteen of the 62 instruments targeted satisfaction with service delivery and less than half were developed specifically for the palliative care context. In approximately 25% of articles psychometric data were not reported. Where psychometric results were reported, validity data were reported in less than half (42%) of these cases. While a considerable variety of instruments have been administered to family caregivers, the validity of some of these requires further consideration. We recommend that others be judicious before developing new instruments for this population.

The relationship between social networks and occupational and self-care functioning in people with psychosis.

Abstract.Background: Relatively few studies have examined relationships between the social networks of people with psychotic disorder and other aspects of their functioning. The aim of this paper is to describe the social networks of people with psychosis and to investigate relationships between social networks and personal and occupational functioning, taking account of illness course. Methods: A two-phase epidemiological survey of persons with psychosis was conducted in four predominantly urban areas of Australia. A census and screen for psychosis was followed by a semi-structured interview of a stratified random sample of participants to assess their functioning. Data relating to functioning and social networks from 908 individuals (most with a diagnosis of schizophrenia) were analysed using structural equation modelling (SEM). Results: The majority of people with psychosis (67 %) had a network comprising of family and friends, 15 % were defined as having a family-dominated network, 11 % a friends-dominated network and 7 % of participants were defined as socially isolated (no family or friends). Participants who had friends and family in their network (12 %) or who had a family-dominated network (7 %) were more likely to be in full-time employment compared with those with a friends-dominated network (4 %) or those who were socially isolated (5 %). Dysfunction in self-care was more frequently reported among socially isolated people (50 %) and those with family-dominated networks (47 %) than among those with friends-dominated networks (35 %) and those who had friends and family in their social network (23 %). SEM revealed a strong association between social integration and functioning (r = 0.71), even after controlling for illness course. Social integration was defined as having contact with family and/or friends and functioning was defined as having employment and no difficulties in self-care. Male gender was associated with poorer self-care, and female gender was slightly, but significantly, associated with a greater likelihood of having friends. Conclusion: There is a strong relationship between social networks and functioning after taking account of course of illness. That is, the presence of family and friends is generally associated with better self-care and employment. Interventions that are targeted at improving social relationships are likely to have a positive impact on self-care and occupational functioning (and vice versa).

On the non-significance of internal versus external auditory hallucinations.

Traditionally, auditory hallucinations (AHs) heard outside the head have been regarded as more pathological than those heard inside, partly on the basis that internal AHs are conceptually closer to normal thinking than external AHs. Our data show that many patients hear AHs both internally and externally, and there were very few associations between location and demographic and clinical characteristics of the patients or with other characteristics of the AHs themselves. There was evidence that AHs heard internally were associated with better insight than those heard externally. Of those patients whose AHs included commands, greater proportions of those who heard them externally said they could resist than those who heard them internally or in both locations. There appears to be no consistent differential impact and effect of internal and external AHs, and there was no support for the historical view that internal AHs are more benign.

Approach to treatment of mental illness and substance dependence in remote Indigenous communities: Results of a mixed methods study

OBJECTIVE To develop and evaluate a culturally adapted brief intervention for Indigenous people with chronic mental illness. DESIGN A mixed methods design in which an exploratory phase of qualitative research was followed by a nested randomised controlled trial. SETTING Psycho-education resources and a brief intervention, motivational care planning (MCP), were developed and tested in collaboration with aboriginal mental health workers in three remote communities in northern Australia. PARTICIPANTS A total of 49 patients with mental illness and 37 carers were recruited to a randomised controlled trial that compared MCP (n = 24) with a clinical control condition (treatment as usual, n = 25). INTERVENTION The early treatment group received MCP at baseline and the late treatment group received delayed treatment at six months. MAIN OUTCOME MEASURES The primary outcome was mental health problem severity as measured by the health of the nation outcome scales. Secondary measures of well-being (Kessler 10), life skills, self-management and substance dependence were chosen. Outcome assessments were performed at baseline, six-month, 12-month and 18-month follow up. RESULTS Random effects regression analyses showed significant advantage for the treatment condition in terms of well-being with changes in health of the nation outcome scales (P < 0.001) and Kessler 10 (P = 0.001), which were sustained over time. There was also significant advantage for treatment for alcohol dependence (P = 0.05), with response also evident in cannabis dependence (P = 0.064) and with changes in substance dependence sustained over time. CONCLUSIONS These results suggest that MCP is an effective treatment for Indigenous people with mental illness and provide insight into the experience of mental illness in remote communities.

Reducing the psychological distress of family caregivers of home based palliative care patients: longer term effects from a randomised controlled trial

Background: Palliative care incorporates comprehensive support of family caregivers because many of them experience burden and distress. However, evidence‐based support initiatives are few.

Schizophrenia, mental state, and mother– infant interaction: examining the relationship

Objective: The aim of this study is to examine the role that disturbance of mental state of hospitalised mothers with a postpartum schizophrenic illness plays in determining the quality of mother-infant interactions. Method: We examined the relationship between the nature and severity of symptomatology in mothers with schizophrenia and the quality of her interactions with her infant in a sample of 15 mother-infant dyads admitted to a psychiatric Mother-Baby Unit. Data were obtained at admission and discharge. Results: Mothers with florid positive symptoms and prominent negative symptoms of schizophrenia and their infants were identified as being at particular risk of displaying disturbed interactions. The adverse contribution of negative symptoms was often not evident until after the positive symptoms had resolved. Conclusions: Given that negative symptoms are often treatment resistant, optimal care of mothers with schizophrenia and their infants needs to involve ongoing therapeutic intervention which specifically addresses disturbances of mother-infant interaction. Further research is required to identify which interventions are likely to be of greatest benefit.