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2007 - Are Important Patient-rated Outomes in Community Mental Health Care Explained by Only One Factor - APS 116, 113-118

2007 - Are Important Patient-rated Outomes in Community Mental Health Care Explained by Only One Factor - APS 116, 113-118

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A ('/cIP .m -hitll' Sccm d :!O !l7:"":
1 0 -1 1 1 i
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D O l:
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A lltllO '..
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2 0 0 7
B I,,('k ...e ll
Ml l l l k s i!(1 o ,d
A C T A
P S rC H IA T R IC A
S C A N D I/I.'A F lC A
A re im p o rta n t
p a tie n t-ra te d
o u tc o m e s
i n
c o m m u n ity
m e n ta l h e a lth
c a re e x p la in e d
b y
o n ly o n e fa c to r?
H ansson
L . B j6 rk m a n
T . P rie b e S , A re im p o rta n t
p a tie n t-ra te d
o u tc o m e s
in c o m m u n ity
m e n ta l h e a lth
c a re e x p la in e d
b y o n ly
o n e
fa c to r?
In tro d u c tio n :
T he
s tu d y
te s te d
w h e th e r
fo u r c o m m o n ly
u s e d p a tie n t-
ra te d
o u tc o m e s
a re e x p la in e d
b y o n ly
o n e
fa c to r.
re fle c tin g
a general
a p p ra is a l
te n d e n c y
o f p a tie n ts .
M e th o d :
Q u a lity
o f life . n e e d s a n d s y m p to m s
w ere rated
b y 9 2 p a tie n ts
in c o m m u n ity
m e n ta l h e a lth
care at baseline
a n d
a fte r
1 8 m o n th s
a n d
6 y e a rs fo llo w -u p
p e rio d s .
A t fo llo w
u p s tre a tm e n t
s a tis fa c tio n
w as
a ls o
assessed. Scores and
c h a n g e
scores w ere subjected
t o
fa c to r
a n a ly s e s , W e th e n te s te d
w h ic h in d iv id u a l
ite m s p re d ic te d
factor scores.
R e s u lts :
O n e fa c to r
e x p la in e d
b e tw e e n
5 5 (~ o a n d
6 6 %
o f th e v a ria n c e
of the tested
p a tie n t-ra te d
o u tc o m e s
c ro s s -s e c tio n a lly
a n d
lo n g itu d in a lly .
O n ly c h a n g e
scores of treatm ent
s a tis fa c tio n
lo a d e d
o n
a separate
fa c to r. S e v e n ite m s c o n s is te n tly
e x p la in e d
m o re th a n
8 0 %
o f
th e v a ria n c e
of the general
fa c to r.
C o n c lu s io n :
F o u r im p o rta n t
p a tie n t-ra te d
o u tc o m e s
a re u n ifo rm ly
a n d
s u b s ta n tia lly
in flu e n c e d
by a general tendency
fo r p o s itiv e
o r n e g a tiv e
a p p ra is a ls .
T h is
te n d e n c y
c a n
be assessed
m o re sim p ly
th a n
u s in g
current Iy esta blishcd
m ethods.
L.Hansson1, T.Bjorkman1,
S . P rie b e 2
' D e p a r t m e n to f H e a l t h S c i e n c e s ,
lu n d U n iv e r s ity ,
lu n d ,
S w e d e n a n d ' U n i t f o r S o c i a la n d C o m m u n i t yP s y c h i a t r y ,
Q u e e nM a ry .U n iv e rs ityo f lo n d o n , L o n d o n ,U K
K e y w o rd s :p a tie n t-ra te do u tc o m e s ;
c o m m u n i t ym e n t a l
h e a lth c a re ; e v a lu a tio n ;lo n g -te rm o u tc o m e
P ro f la rs H a n s s o n .
D e p a rtm e n l
o f H e a lth S c ie n c e s ,
lu n d U n iv e r s ity ,
P O B o x 1 5 7 . S E . 2 2 1 0 0l u n d , S w e d e n .
E .m a il:la r s .h a n s s o n @ m e d .lu .s e
A c c e p te dfo r p u b lic a tio nJ a n u a ry 1 5 , 2 0 0 7
S ig n ific a n t
o u tc o m e s
.
M o re th a n 5 0 % , o f th e v a ria tio n in p a tie n t ra tin g s o f q u a lity o f life . n e e d s . s y m p to m s a n d tre a tm e n t
s a tis fa c tio n a re e x p la in e d b y a g e n e ra l te n d e n c y o f p a tie n ts fo r p o s itiv e o r n e g a tiv ea p p ra is a ls .
.T h is a p p lie s c ro s s -s e c tio n a lly a n d -
w ith th e e x c e p tio n o f tre a tm e n t s a tis fa c tio n- a ls o fo r c h a n g e
s c o re s
o v e r
p e rio d s
of several
y e a rs .
.
T he
g e n e ra l
a p p ra is a l
te n d e n c y
c a n
be assessed
u s in g
o n ly
s e v e n
in d iv id u a l
item s
in s te a d
o f lo n g e r
e s ta b lis h e d
s c a le s .
lim ita tio n s
\u00b7A lth o u g h
th e
fin d in g s
a re
i n
lin e
w ith
o th e r
lite ra tu re .
all the
e v id e n c e
fo r th e
s ig n ific a n c e
o f th e
g e n e ra l
a p p ra is a l
te n d e n c y
h a s s o fa r o rig in a te d
fro m
o n ly tw o
c o u n trie s ,
i.e . G e rm a n y
a n d
Sw eden.
.
T he results are
fro m
a s in g le s a m p le o f p a tie n ts w ith
s e v e re m e n ta l illn e s s in c o m m u n ity m e n ta l
h e a l t h c a r e a n d m i g h t n o t b e g e n e r a l i z a b l et o o t h e r s e t t i n g s a n d s a m p l e s .
.
It h a s n o t b e e n te s te d w h e th e r th e g e n e ra l a p p ra is a l te n d e n c y a ls o in flu e n c e s o th e r p a tie n t-ra te d
o u tc o m e s th a n th e o n e s a s s e s s e d in th is s tu d y .
In tro d u c tio n
P a tie n t-ra te d
o u tc o m e s
h a v e
becom e
in c re a s in g ly
im p o rta n t
i n
th e
e v a lu a tio n
o f
p h a rm a c o lo g ic a l
a n d
p s y c h o s o c ia l
tre a tm e n ts
a s
w e ll
a s
c o m p le x
in te rv e n tio n s
in m e n ta l
h e a lth
care. Such
o u tc o m e s
a re in te n d e d
to c a p tu re
p a tie n ts '
v ie w s . fe e lin g s a n d
ju d g e m e n ts .
T erm s
u s e d
t o
d e s c rib e
th e m
in c lu d e
1 1 3
H ansson
et a!.
's u b je c tiv e e v a lu a tio n c rite ria '. 'p a tie n t-d riv e n o u t-
com es'
a n d
's e lf - r a te d
o u tc o m e s '.
T he
m ost
com m on
p a tie n t-ra te d
outcom e criteria are treat-
m ent
s a tis fa c tio n
a n d
self-ratings of
sym ptom s.
q u a lity o f life a n d n e e d s . E a c h o f th e s e c o n s tru c ts
h a s
b e e n
in v e s tig a te d
i n
extensive research. and
num erous
scales have
b e e n e s ta b lis h e d
t o
a s s e s s
th e m
(1 -5 ).
S tu d ie s
u s in g
m ore
th a n
o n e
o f
p a tie n t-ra te d
o u tc o m e s h a v e m o s tly fo u n d ' m o d e ra te
t o
stro n g
c o rre la tio n s
am ong
them . It
h a s
been suggested
th a t
o n e
single general appraisal
fa c to r e x p la in s
m o re th a n
5 0 %
o f th e v a ria n c e o f a ll fo u r m a jo r
p a tie n t-ra te d
o u tc o m e
c r i t e r i a
(6 ).
T he
fa c to r
re R e c ts th e g e n e ra l te n d e n c y o f p a tie n ts fo r p o s itiv e
ra tin g s . i.e . h ig h
degrees of
q u a lity
o f
life and
tre a tm e n t s a tis fa c tio n a n d lo w le v e ls o f n e e d s a n d
sym ptom s.
o r
n e g a tiv e
ra tin g s
re s p e c tiv e ly . In
s a m p le s w ith s e v e re m e n ta l illn e s s F a k h o u ry
e t a l.
(7) show ed that
th e g e n e ra l fa c to r e x p la in e d 5 0 -
6 9 %
o f th e v a ria n c e o f th re e c rite ria
b o th
c r o s s -
s e c tio n a lly a n d
lo n g itu d in a lly . T h e g e n e ra l fa c to r
w a s s tro n g ly a s s o c ia te d w ith m o o d . a n d
b e tw e e n
4 6 'Y oa n d
71% of
i t s
v a ria n c e
w e re p re d ic te d
b y
o n ly
tw o s in g le ite m s o f th e u n d e rly in g s c a le s . If
re p lic a te d .
th e s e
p relim in ary
fin d in g s h a v e
w id e
im p lic a tio n s
fo r
th e
assessm ent and
use of self-
ra te d
o u tc o m e s . H o w e v e r. th e lo n g itu d in a l re s u lts
were based on
o n ly
tw o s a m p le s o f le s s th a n
6 0
p a tie n ts e a c h ; b o th
sam ples w ere from
G erm any;
th e re w e re o n ly
tw o p o in ts o f m e a s u re m e n t; a n d
th e in te rv a l b e tw e e n th e tw o a s s e s s m e n ts w a s n o t
lo n g e r th a n
1 8 m o n th s w h ic h is a re la tiv e ly s h o rt
p e rio d
o f
tim e
t o
assess long-term
o u tc o m e
i n
c o m m u n ity m e n ta l h e a lth c a re .
A im s o f th e s tu d y
T h e a im o f th is s tu d y w a s to c o n s o lid a te th e a b o v e
p relim in ary
fin d in g s in c o m m u n ity
m e n ta l h e a lth
c a re
in S w e d e n u s in g-
w hen
com pared
w ith
th e
p re v io u s s tu d y in th e lite ra tu re -
a larger sam ple.
m ore points of m easurem ent and
lo n g e r in te rv a ls
betw een assessm ents w ith a
to ta l s tu d y
p e rio d o f
6 years.
I n
p a rtic u la r.
w e addressed
th re e
q u e s -
tio n s :
i )

C a n a m a jo r p a rt o f th e v a ria n c e o f s e lf-ra tin g s o f q u a lity o f life . s y m p to m s . n e e d s a n d tre a t- m e n t s a tis fa c tio n b e e x p la in e d b y o n e g e n e ra l fa c to r -

reflecting a

te n d e n c y fo r p o s itiv e o r n e g a tiv e a p p ra is a ls - a n d . if s o . d o e s th is a p p ly b o th c ro s s -s e c tio n a lly a n d lo n g itu d in a lly ?

ii) W h a t e x te rn a l fa c to rs a re a s s o c ia te d w ith th e
g e n e ra l te r:td e n c yo f th e p a tie n ts fo r p o s itiv e o r
n e g a tiv e a p p ra is a ls ?
1 1 4
iii) C an

th e g e n e ra l a p p ra is a l fa c to r b e p re d ic te d b y in d iv id u a l ite m s o f th e s c a le s u s e d to a s s e s s p a tie n t-ra te d o u tc o m e s . i.e . tre a tm e n t s a tis fa c -

tio n . s y m p to m s . q u a lity o f life a n d n e e d s '?
M aterial
a n d
m e th o d s
D e s ig n
The present study is based on a 6-year follow -up of
p a tie n ts
a d m itte d
t o
te n
p ilo t s e rv ic e s w ith
c a s e
m anagem ent
i n
S w e d e n (8 ). P a tie n ts
w ere inter-
v ie w e d a t b a s e lin e . a n d
a t
1 8 -m o n th a n d
6 -y e a r
fo llo w -u p s .
A t
a ll
th re e
p o in ts
o f
assessm ent
p a tie n ts
ra te d
th e ir q u a lity
o f life . n e e d s fo r c a re
a n d
sym ptom s. T he
1 8 -m o n th a n d 6 -y e a r fo llo w -
u p
in te rv ie w s a ls o
in c lu d e d
ra tin g s

o f tre a tm e n t s a tis fa c tio n . w h ils t a t b a s e lin e tre a tm e n t s a tis fa c - tio n c o u ld n o t b e a s s e s s e d a s tre a tm e n t in th e n e w

program m e
h a d
n o t
y e t
b e e n
s ta rte d .
F u rth e r
assessm ents of
th e
s o c ia l n e tw o rk .
p s y c h o s o c ia l
fu n c tio n in g
a n d
social and
d e m o g ra p h ic
c h a ra c -
te ris tic s w e re a ls o o b ta in e d .
P a rtic ip a n ts
T h e b a s e lin e s a m p le c o n s is te d o f 1 7 6 s u b je c ts . A t
th e
6 -y e a r
fo llo w -u p .
1 4
p e rs o n s
h a d
d ie d .
1 6
c o u ld
n o t
b e
tra c e d .
a n d
2 1
w e re ju d g e d
t o
b e
to o ill to c o m p it:lc a n in te rv ie w . O f th e re m a in in g
125. 33
re je c te d
fu rth e r
p a rtic ip a tio n
a n d

th e fin a l 6 -y e a r fo llo w -u p s a m p le th u s c o n s is te d o f 9 2 persons. Com parisons

b e tw e e n th e
9 2
re m a in in g
p a tie n ts
a n d
th e
to ta l
num ber
o f
d ro p o u ts ,

8 4 p a tie n ts . s h o w e d n o s ig n ific a n t d iffe re n c e s re g a rd - in g in itia l b a c k g ro u n d

characteristics such as sex.
a g e . c iv il s ta tu s .
le v e l o f e d u c a tio n .
liv in g s itu -
a tio n . a n d
w ork
s itu a tio n . d u ra tio n
o f illn e s s o r
d ia g n o s tic
s u b g ro u p .
F u rth e r.
n o
s ig n ific a n t d if-
ferences w ere found
re g a rd in g

b a s e lin e le v e ls o f psychosocial functioning. needs for care. psychi- a t r i c

sym ptom s.
s o c ia l
n e tw o rk
o r
s u b je c tiv e
q u a lity
o f life . T h e
present sam ple
m ay
th u s
b e
re g a rd e d
a s
f a i r l y
re p re s e n ta tiv e
o f
th e
b a s e lin e
sam ple.
M e a s u re s
S u b je c tiv e q u a lity
o f life w a s a t b a s e lin e a n d
th e
1 8 -m o n th
fo llo w -u p
a s s e s s e d
b y
th e
L a n c a s h ire
Q u a lity
o f
L ife
P ro file
(L Q O L P )
(9 ).
T he
LQ O LP
i s
a
s tru c tu re d
s e lf - r e p o r t
in te rv ie w
w hich assesses objective and

s u b je c tiv e in d ic a to rs o f q u a lity o f life . A t th e 6 -y e a r fo llo w -u p a s h o rt version of the LQOLP was used. the M anchester S h o rt

A ssessm ent of Q uality
o f
L ife (M A N S A )
- - - -
~ '
I
t
1I
1.
J
1 .
" J
,.I
j
(10). In
b o th
v e rs io n s p a tie n t
r a t e
th e ir s a tis fa c -
tio n
w ith
l i f e
a s
a
w h o le
a n d
d iffe re n t
l i f e
dom ains.
T he
m ean
s c o r e
o f
th e s e
s a tis fa c tio n
ra tin g s is ta k e n
a s a m e a s u re o f s u b je c tiv e q u a l-
i t y
o f life . N e e d s fo r
c a re
were at baseline and
1 8 -m o n th
fo llo w -u p
a s s e s s e d
b y
C a m b e rw e ll
A ssessm ent of
N eeds
in te rv ie w
(1 1 ). T h e
C A N
assesses needs for
c a re
i n
2 2
d iffe re n t d o m a in s .
A t th e 6 -y e a r-fo llo w -u p a
short version of CA N ,
th e
C a m b e rw e ll
A ssessm ent
o f
N eeds
S h o rt
A ssessm ent interview
(C A N S A S ) (1 1 ) w a s
u s e d .
S u m
scores of unm et
needs, m et
needs and
a ll
n e e d s m a y b e o b ta in e d . A B n t:tJ s
are the sum
o f
m et and
unm et needs. Sym ptom s w ere rated
b y
th e
H o p k in s
S y m p to m
C heck
L ist-9 0
(S C L -9 0 )
(12) and
tre a tm e n t
s a tis fa c tio n
w as m easured
o n
a
n in e
ite m
scale derived
fro m
a

q u e s tio n n a ire d e v e lo p e d in S w e d e n b y th e S w e d is h In s titu te fo r H e a lth

S e rv ic e s D e v e lo p m e n t
(13). Psychosocial
fu n c tio n in g
w as
ra te d
a c c o rd in g
t o
th e
S tr a u s s
C a rp e n te r
s c a le
w h ic h
a s s e s s e s
th e
s itu a tio n
d u rin g
th e
m o n th
b e fo re
in d e x
c o n ta c t
w ith
re g a rd
t o
s o c ia l c o n ta c ts
a n d
p s y c h ia tric
sym p-
tom s,
a n d
w ith
re g a rd
t o
th e
p re v io u s
y e a r
c o n c e rn in g
e m p lo y m e n t
a n d
u se
o f
p s y c h ia tric
in p a tie n t
s e rv ic e s (1 4 ). P a tie n t
sociodem ographic
a n d c H n ic u lc h u r a c te r :t';t:c $
\V ~ !"~a ls o Q b ta in e d a t
th e
in te rv ie w .
A
m ore
d e ta ile d
d e s c rip tio n
o f th e
in s tru m e n ts
m ay
b e
fo u n d
i n
B jo rk m a n
a n d
H ansson
(8 ).
S ta tis tic a la n a ly s is
Spearm an
ra n k
c o rre la tio n s
w ere used to
in v e s ti-
g a te
b iv a ria te
a s s o c ia tio n s
b e tw e e n
v a ria b le s .
P rin c ip a l
c o m p o n e n ts
fa c to r
a n a ly s e s
w ith
n o
ro ta tio n s w e re p e rfo rm e d
to in v e s tig a te th e fa c to r
s tru c tu re
o f
fo u r
s u b je c tiv e
e v a lu a tio n
c rite ria :
s y m p to m a to lo g y
(S C L -9 0 ), s u b je c tiv e q u a lity

o f life (L Q O L P : M A N S A ), n e e d s (C A N , C A N S A S ) a n d p a tie n t s a tis fa c tio n w ith tre a tm e n t. T h e la tte r

assessm ent
w as
how ever
n o t
u s e d
a t
b a s e lin e .
K aiser-M eyer O lkin's test for sam pling adequacy
w as
perform ed
i n
o rd e r
t o
in v e s tig a te
i f
a n y
s u p e r
o rd in a te
fa c to rs
c o u ld
b e
id e n tifie d .
I n
a d d itio n
B a rtle tt's
te s t
o f
s p h e ric ity
w as
e m p lo y e d
t o
v e rify
th a t
th e
c o rre la tio n
m atrix
d id
n o t
in d ic a te
a n
in a p p ro p ria te
fa c to r
m o d e l.
F a c to rs
w ith
a n
e ig e n v a lu e o f
1 and
above were
in c lu d e d ,
a n d
fa c to r
lo a d in g s
b e lo w
0 .4 5

w ere d is re g a rd e d . M u ltip le s te p w is e re g re s s io n a n a ly s e s w ere

u s e d
t o
e x p lo re
a s s o c ia tio n s
b e tw e e n
th e
g e n e ra l
s u b je c tiv e
e x te rn a l
in d e p e n d e n t
fa c to rs ,
a n d
item s
o f
th e
s u b je c tiv e
e v a lu a tio n
c rite ria .
T he
s ta tis tic a l
so ftw are
p a c k a g e
u s e d
w as
s p s s ,
(S P S S In c ., C h ic a g o , IL . U S A ) 1 1 .5 .
P a tie n t-ra te d
o u tc o m e s
R e su lts
Som e
b a c k g ro u n d
c h a ra c te ris tic s
a t
th e
tim e
o f

fo llo w u p a re p re s e n te d in T a b le 1 . M o s t s u b je c ts w e re liv in g a lo n e in o w n fla ts , w e re n o t w o rk in g a n d m a in ly o n a d is a b ility p e n s io n . A p p ro x im a te ly 6 0 %

o f th e s u b je c ts h a d a s c h iz o p h re n ia d ia g n o s is
a n d
a
fu rth e r
2 0 %
o th e r d ia g n o s e s o f p s y c h o tic
d iso rd e rs.
B iv a ria te
a s s o c ia tio n s
b e tw e e n
th e
s u b je c tiv e
e v a lu a tio n
c r i t e r i a
a re
show n
i n
T a b le 2 .
T he

m o s t c o n s is te n t s ig n ific a n t c o rre la tio n s w e re a t a ll th re e a s s e s s m e n ts s h o w n b e tw e e n s u b je c tiv e q u a lity o f life a n d s e lf-ra te d s y m p to m s a n d

betw een self-
ra te d

symptoms and needs. Factor analyses,PCA w ith n o ro ta tio n s , re v e a le d c o n s is te n tly a t b a s e lin e , 1 8 -m o n th a n d

6 -y e a r fo llo w -u p th a t
th e

p a tie n t- ra te d c rite ria lo a d e d in to o n e s in g le fa c to r. w ith a n e x p la in e d v a ria n c e o f 6 6 % , 5 7 %

and 58%
re s p e c t-
iv e ly , a s s h o w n in T a b le 3 .
F a c to r
a n a ly s e s in c lu d in g c h a n g e s c o re s in
th e
s u b je c tiv e
c r i t e r i a
b e tw e e n
assessm ents
show ed
that change scores betw een baseline and
the tw o
T a b le 1 . B a c k g ro u n dc h a ra c te ris tic so f th e s a m p lea t tim e o f th e 6 -y e a rfo llo w -u p
(n =
9 2 1
1 1 5
n
%
S ex
M a le
4 3
4 7
F e m a le
4 9
5 3
A g e fm , ra n g e l
4 7 1 2 9 -6 B I
E d u c a tio n( n =
9 0 1
P rim a rys c h o o l
3 0
3 3
C o lle g e
3 7
4 1
U n iv e r s ity
2 3
2 6
C iv il s ta tu s( n =
B B )
M a rrie d
2
2
D iv o r c e d
1 5
1 7
N e v e rm a rrie d
7 1
B I
liv in g s itu a tio n
A lo n e
7 5
8 2
P a n n e r
5 .
5
P a re n ts
7
B
O th e r
5
5
A c c o m m o d a tio n
( n=
9 1 )
O w n apanm ent
7 3
8 0
lo d g e r
3
3
S u p p o n e dh o u s in g
9
1 0
O th e r
6
7
W o rk s itu a tio n( n =
9 1 )
C o m p e t i l i v ew o r k
B
9
S u p p o n e dw o r k
B
9
U n e m p lo y e d
5
5
S tu d e n t
6
7
D is a b ility p e n s io n
6 4
7 0
D ia g n o s is( n =
7 7 )
S c h iz o p h r e n ia
4 6
6 0
O th e r p s y c h o s is
1 4
1 8
N o n - p s y c h o s is
1 7
2 2
D u ra tio n o f illn e s s (m , ra n g e )
2 2 (7 -4 4 )
M . m ean.

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