A brief scale for assessing patients' satisfaction with care in outpatient psychiatric services

OBJECTIVE: The authors evaluated the reliability and preliminary validity of the Charleston Psychiatric Outpatient Satisfaction Scale, a 15-item measure of patients' satisfaction designed for use in outpatient settings. The instrument uses a 5-point Likert-type response format that minimizes positive response bias and optimizes variability and predictive validity. METHODS: The Charleston Psychiatric Outpatient Satisfaction Scale was administered to 282 patients seen in psychiatric outpatient clinics affiliated with a public-academic psychiatric institution over a one-week period in 1995. RESULTS: The internal reliability of the instrument was high (alpha=.87), and its convergent validity was supported by the significant correlation of all items with anchor items that measured overall satisfaction with care and likelihood of recommending the clinic to others. The best predictors of overall ratings of care were the items measuring patients' satisfaction with helpfulness of the services and with the respect shown for patients' opinions about treatment. The best predictors of recommendation of the program to others were the items measuring satisfaction with matching of the treatment plan to patients' individual needs and with the respect shown for patients' opinions about treatment. Mean scores for all items ranged from 3.6 (satisfaction with parking) to 4.5 (satisfaction with helpfulness of the secretary and with the overall quality of care), indicating that overall satisfaction in this sample was high. CONCLUSIONS: The results provide preliminary support for the reliability and validity of the Charleston Psychiatric Outpatient Satisfaction Scale:     

Attitudes of Israeli primary care physicians towards mental health care

Rates of depression and anxiety are increasing all over the world in developed and developing countries as well and Israel is no exception to this trend. People suffering from depression and anxiety disorders tend not to turn for professional help to mental health clinics but to primary care. This cross-sectional study examines the attitudes and barriers of primary care physicians in the southern region of Israel toward providing care for depression and anxiety in their practices. In 2002 we sent a questionnaire concerning attitudes and barriers toward depression and anxiety to 99 primary care physicians from 14 primary care clinics with a response rate of 67.7% (67 physicians); 80.6% of the participants agreed with the statement that depression and anxiety are frequent problems in primary care and they should be treated in primary care clinics, but 37.3% reported to have little interest in treating mental disorders, 47.7% thought depression and anxiety should be treated in mental health clinics; 43.3% of the participants declared that they experienced a personal difficulty in taking care of patients with depression and anxiety, and 85% identified time constraint as a major barrier to care of depression and anxiety in primary care. This study suggests that in order to improve treatment of depression and anxiety in primary care, there is a need for a change of attitudes of the primary care providers.     

Beliefs about psychotropic medication and psychotherapy among primary care patients with anxiety disorders

Primary health care clinics are increasingly providing psychiatric/psychological treatment of anxiety disorders, particularly for patients who do not have adequate access to specialty mental health services. Adequate treatment requires knowledge of and attention to patients' beliefs about available treatment options. The current investigation examined beliefs about psychotropic medications and psychotherapy among a sample of primary care patients with anxiety disorders. The influence of key demographic variables on strength of these beliefs was also explored. The presence of specific anxiety disorders was not found to impact strength of beliefs about either type of treatment. In contrast, there was a trend for the presence of depression to relate to more favorable attitudes toward psychotropic medication. Consistent with previous studies, ethnic minority patients reported less favorable attitudes toward both psychotropic medications and psychotherapy. These findings underscore the importance of assessing patient beliefs prior to the initiation of either psychotropic medications or psychotherapy across diagnostic and demographic groups. Practitioners should be particularly alert to the possibility that patients with anxiety disorders and members of ethnic minority groups may have less favorable attitudes toward treatment options. Treatment adherence may therefore be increased by addressing these beliefs directly.     

Development of an antidepressant compliance questionnaire

OBJECTIVE: The development of the Antidepressant Compliance Questionnaire (ADCQ), assessing patients' attitudes and beliefs on depression and antidepressants. METHOD: A 51-item questionnaire was applied to 85 psychiatric out-patients with a DSM-IV diagnosis of major depressive disorder (MDD). This data set was used to assess psychometric properties of the ADCQ. The questionnaire was also applied to 272 primary care out-patients with MDD. RESULTS: A principal component analysis revealed four dimensions with good internal consistency and acceptable test-retest reliability: 'perceived doctor-patient relationship', 'preserved autonomy', 'positive beliefs on antidepressants' and 'partner agreement', resulting in a final questionnaire comprising 33-items. Responses were independent from depression severity and patient age. The response patterns of both psychiatric and primary care patients are provided and illustrate the many erroneous beliefs on antidepressants. CONCLUSION: The ADCQ has good psychometric properties; further investigation should investigate whether this questionnaire is predictive of patient compliance.     

Using five questions to screen for five common mental disorders in primary care: diagnostic accuracy of the Anxiety and Depression Detector

OBJECTIVE: Primary care providers are increasingly taking on the role of ad hoc mental health provider. However, before patients in primary care can be treated, they must be identified. This study set out to validate a very brief screening instrument for identifying primary care patients with anxiety and depression. METHOD: Eight hundred one primary care patients completed a questionnaire screening for (1) panic disorder, posttraumatic stress disorder (PTSD) and social phobia, or (2) panic disorder, generalized anxiety disorder (GAD) and major depression. Screening was followed by a diagnostic interview. The properties of the questionnaires were examined to identify a small set of items that effectively and efficiently screened for panic disorder, PTSD, social phobia, GAD and depression. RESULTS: Five items were selected across the two versions of the questionnaire, comprising the Anxiety and Depression Detector (the ADD). The sensitivities for the items ranged from 0.62 to 1.00, and the specificity values ranged from 0.56 to 0.83. When a "yes" answer to any of the screening questions was used to predict the presence of any diagnosis, sensitivity values were 0.92 to 0.96 and specificity values were 0.57 to 0.82. Sensitivity and specificity values varied little by gender, age or ethnicity. CONCLUSIONS: The five items of the ADD appear to comprise a useful screening device for anxiety and depressive disorders in primary care settings.     

A Delusion Assessment Scale for Psychotic Major Depression: Reliability, Validity, and Utility

BACKGROUND: Although delusions are the hallmark of major depression with psychotic features, a scale to measure the intensity of beliefs across multiple delusional domains in this condition has been unavailable. The development and assessment of the Delusional Assessment Scale (DAS) are described. METHODS: Scale items were selected initially based on previous studies of delusional ideation in schizophrenia. A three-point item to assess mood congruence was added. A 15-item scale was assessed in 92 subjects participating in the four-site collaborative study of the pharmacotherapy of major depression with psychotic features. Maximum likelihood method was used to determine scale factors. The internal consistency of these factors was determined. Comparisons between scale scores and ratings from the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham 1962) were used to assess convergent and discriminant validity. RESULTS: The data were fit by a five-factors model (impact, conviction, disorganization, bizarreness, and extension). Inter-rater reliability of the five factors ranged from .77 for conviction and .74 for impact to .37 for disorganization. Internal consistency for each of the five factors was > or =.72. Scores on specific domains were significantly correlated with the BPRS unusual thought content item and positive symptom subscale scores. CONCLUSIONS: The DAS is a reliable measure of 5 delusional domains.     

Using the GAF as a national mental health outcome measure in the Department of Veterans Affairs

OBJECTIVE: Data from the Veterans Health Administration (VHA) were used to evaluate the strengths and weaknesses of the Global Assessment of Functioning (GAF), a single-item mental health status measure, as an outcome measure for large mental health care systems. METHODS: The sample consisted of VHA mental health patients who had at least two GAF scores 45 days apart in 2002 (N=283,754). First, to evaluate the discriminant validity of the GAF change measures, the authors examined the association of these measures with sociodemographic and clinical characteristics. Facility-level risk-adjusted measures of GAF change were then created in three different clinical samples at more than 130 VHA medical centers, adjusting for patients' sociodemographic characteristics and diagnoses. The internal consistency of the scale created by using these items and their consistency across medical centers over time was evaluated. RESULTS: The analysis supported the discriminant validity of the GAF-derived measures. As expected, veterans who had a diagnosis of schizophrenia or Alzheimer's disease or who had service-connected disability ratings above 50 percent had lower baseline GAF scores and showed less improvement. The overall GAF performance measure had a high level of internal consistency (a standardized alpha of .85) and was highly consistent across facilities over time. CONCLUSIONS: The results of this study provide preliminary empirical support for cautious use of a GAF-derived scale in monitoring changes in average facility-level outcomes over time. However, because of the potential for gaming of the measures and uncontrolled variation in the scale's administration across facilities, the scale should not be used to compare outcomes across facilities.     

Generalized anxiety disorder severity scale (GADSS): a preliminary validation study

To assist researchers and clinicians in primary care with assessment and treatment of generalized anxiety disorder (GAD), we developed a simple standardized instrument, similar to the Panic Disorder Severity Scale. Independent evaluators used the six-item Generalized Anxiety Disorder Severity Scale (GADSS) to conduct telephone assessments of 330 patients from four primary care facilities with DSM-IV diagnoses of GAD and/or panic disorder who were participating in a study of the effectiveness of collaborative care treatment. Participants were also evaluated at a 12-month follow-up. Internal consistency, convergent and discriminant validity, and sensitivity to change were determined. The GADSS had high internal consistency, and showed good validity and sensitivity to change. Change in GADSS scores discriminated between two different treatment strategies. GADSS is a simple, efficient way to rate severity over the telephone in patients with established diagnoses of GAD.     

Assessing the biopsychosociospiritual model in primary care: development of the biopsychosociospiritual inventory (BioPSSI)

OBJECTIVE: There is growing evidence in support of the Biopsychosociospiritual Model. However, a cohesive instrument to measure each dimension in terms of its dimension-specific symptoms and functional status does not exist, serving as an obstacle to future research in this area. The purpose of this study was to develop and validate an instrument to measure each dimension in terms of its dimension-specific symptoms, appraisals, and functional status in an unselected group of primary care patients. METHOD: An instrument that assessed biopsychosociospiritual symptoms and function and health outcomes was administered to 289 patients attending two primary care clinics. Responses were analyzed using principal component factor analysis with Equimax rotation. This led to the development of five Biopsychosociospiritual Inventory scales (impaired functional status, physical symptoms, psychological symptoms, social symptoms, and spiritual symptoms). Demographic differences in mean scale scores were sought. In addition to internal consistency, construct validity was assessed based upon dimension-specific health care utilization, life satisfaction, and perceived health status. RESULTS: All five scales had excellent internal consistency (alpha > 0.8) and construct validity. Differences were strongly related to income, marital status, and employment in a manner consistent with previous research. CONCLUSIONS: This study developed and validated the Biopsychosociospiritual Inventory which could potentially provide a holistic estimate of the impact of disease and its treatment, support research in this area, and lead to the expansion of classification systems that include spirituality. Further validation of this instrument in other primary care sites using diverse patient populations as well as its function over time is needed.     

Enhancing adherence to prevent depression relapse in primary care

We performed a randomized trial to prevent depression relapse in primary care by evaluating intervention effects on medication attitudes and self-management of depression. Three hundred and eighty six primary care patients at high risk for recurrent depression were randomized to receive a 12-month intervention. Interviews at baseline, 3, 6, 9, and 12-months assessed attitudes about medication, confidence in managing side effects, and depression self-management. This depression relapse prevention program significantly increased: 1) favorable attitudes toward antidepressant medication [Beta =.26, 95% C.I. = (.18,.33)]; 2) self-confidence in managing medication side effects [Beta =.53, 95% C.I. = (.15,.91)]; 3) depressive symptom monitoring [O.R. = 4.08, 95% C.I. = (2.80, 5.94)]; 4) checking for early warning signs [O.R. = 3.27, 95% C.I. = (2.32, 4.61)]; and, 5) planful coping [O.R. = 2.01, 95% C.I. = (1.49, 2.72)]. Significant predictors of adherence to long-term pharmacotherapy were: favorable attitudes toward antidepressant treatment [OR = 2.20, 95% CI = (1.50, 3.22)], and increased confidence in managing medication side effects [OR = 1.10, 95% CI = (1.04, 1.68)]. Among primary care patients at high risk for depression relapse, enhanced attitudes towards antidepressant medicines and higher confidence in managing side effects were key factors associated with greater adherence to maintenance pharmacotherapy.     

The role of cardiovascular disease in the identification and management of depression by primary care physicians.

OBJECTIVE: The objective of this study was to describe the influence of cardiovascular disease (CVD) on identification and management of depression by primary care physicians. METHOD: Three hundred fifty-five adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate completed a baseline in-home assessment. CVD was assessed by self-report and psychologic status was assessed with commonly used, validated standard questionnaires. At the index visit, doctors' ratings of depression and reports of active management were obtained on 340 of the 355 patients who completed in-home interviews. RESULTS: Older adults who reported heart failure were more likely to be identified as depressed than were older adults who did not report heart failure (unadjusted odds ratio [OR]: 2.34; 95% confidence interval [CI]: 1.13-4.85; Wald chi(2) = 5.20, df = 1, p = 0.023). In multivariate models that controlled for potentially influential characteristics such as age, marital status, education, ethnicity, functional status, level of depression, cognitive impairment, attitudes about depression, use of medical care, and number of medications, the findings remained statistically significant. Among older adults identified as depressed, older adults with heart failure were significantly less likely to be actively managed for depression than were older adults without heart failure (unadjusted OR: 0.33; 95% CI: 0.14-0.76; Wald chi(2) = 6.73, df = 1, p = 0.009). After controlling for potentially influential covariates, these findings remained substantially unchanged. CONCLUSIONS: CVD, in particular heart failure, may influence the identification and management of depression among older patients by primary care physicians. The findings underlie the importance of developing interventions that integrate the management of depression and CVD in primary care settings.     

Improving the validity of measures of patient satisfaction with psychiatric care and treatment

Surveys of consumer satisfaction with psychiatric services are frequently included in program evaluations, ostensibly providing the patient's perspective. However, the consistently high levels of satisfaction reported, despite a wide variety of measures, suggest that these surveys may be of questionable validity. Recognizing that most surveys ask patients to rate aspects of care that professionals feel are important, the authors used a focus-group method to generate attributes of ideal care from the patient's viewpoint. A pool of 50 patient-generated items were rated for importance by a second group of inpatients on locked units of a provincial psychiatric hospital. A factor analysis and mean importance ratings identified interpersonal relations with staff as a key factor of patient satisfaction. The authors designed a seven-item measure of satisfaction based on this key factor.     

How do Chinese patients with dementia rate their own quality of life?

OBJECTIVE: This study examines the psychometric properties and clinical experience in using the Mandarin translation of the Quality of Life-Alzheimer's Disease (QoL-AD) instrument in Chinese patients with dementia in Singapore. METHODS: A Mandarin version of QoL-AD was established following standard guidelines for transcultural adaptation of QoL measures. The instrument was administered to 70 patient-carer dyads; patients with severe dementia (MMSE < 10) were excluded. Reliability by internal consistency and test-retest, and construct validity by correlating the known domains of QoL-AD with validity measures for the respective domains, was performed. Guidelines for Rating Awareness Deficits (GRAD) measured patients' insight into their deficits. RESULTS: Three patients were not able to complete the QoL-AD. Internal consistency (Cronbach's alpha) was high for both patient (0.9) and carer (0.8) QoL-AD ratings, as was test-retest reliability, intraclass correlation coefficient (ICC) 0.7 and 0.8 respectively. Correlation of QoL-AD with domain measures was moderate for carer ratings (0.21 < r < 0.51) and poor for patient (-0.17 < r < 0.13). Patient self-rated QoL correlated poorly with, and was significantly higher than, carer-rated QoL. Correlation between patient and carer QoL-AD was stronger in patients with better insight (GRAD 3-4). CONCLUSIONS: The results suggest that while the Mandarin version of QoL-AD can be used reliably in our population, patients' self perceived QoL can be different from carer ratings and from objective QoL measures. The disparity can be attributed to patients' poor insight, denial, fear of "losing face," normalization and accommodation of standards with aging. The patients' lack of education and seclusion from Western cultural exposure are also contributory.     

Cognitive and psychiatric predictors of medical treatment adherence among older adults in primary care clinics

OBJECTIVES: Medical treatment non-adherence among older adults is common and represents a significant public health care concern. Treatment non-adherence has been associated with a number of factors in older adults; however few studies have delineated the role of cognition and psychiatric status. PARTICIPANTS: Data were collected from 212 ethnically diverse older primary care patients as part of a larger study. MEASUREMENTS: Cognitive status was evaluated with the Mattis Dementia Rating scale (DRS). Psychiatric status was evaluated using the Geriatric Depression Scale (GDS) and the Beck Anxiety Inventory (BAI). Treatment adherence was assessed by the total number of missed healthcare appointments and by physician and patient ratings. Physician ratings of patients' understanding of medical instructions were also obtained. DESIGN: A series of multiple regression analyses were conducted to determine cognitive and psychiatric predictors for each measure of treatment adherence. RESULTS: GDS and DRS memory scores were both independent predictors of the total number of missed medical appointments, F(7,55) = 2.34, p = 0.038. GDS score was also shown to be a significant predictor of physician ratings of patients' understanding of medical instructions, F(7,33) = 0.89, p = 0.031. Neither cognitive performance nor psychiatric status was associated with patient or physician ratings of treatment adherence. CONCLUSIONS: Measures of cognitive functioning and depression severity were supported as predictors of objective measures of treatment adherence but they were not associated with physician or patient ratings of adherence. Patient depression may influence physician ratings of patients' comprehension of medical instructions.     

Depression in primary care. 2: general practitioners' recognition of major depression in elderly patients.

BACKGROUND: It is important that serious depressive illness be recognized and treated appropriately by primary care practitioners. This and the preceding article in this issue examine (a) factors responsible for older patients' decision to report depressive symptoms to their doctor and (b) general practitioners' (GPs') recognition of depression when it was present. METHODS: A survey was conducted of a stratified sample of 1,021 patients aged 70+ years of 30 GPs in Melbourne, Australia, using the Canberra Interview for the Elderly, which generates rigorous ICD-10 research diagnoses. RESULTS: GPs' ratings of depression were best predicted in descending order of importance by patients' past contact with a psychiatrist, the doctor's view that a patient did not have dementia, the number of current depressive symptoms, patients' disclosure of these symptoms, and current physical pain. Physicians' assessments of patients' mood concurred with research diagnoses in 23 of 35 (66%) cases of ICD-10 mild depressive episode and 23 of 26 (88%) cases of moderate or severe depressive episode. GPs were unaware, however, of many depressive symptoms and often rated patients as being depressed when they were not. CONCLUSION: The use of a simple checklist of depressive symptoms would lead to a dramatic improvement in doctors' knowledge of patients' current psychiatric status.     

Abbreviated brief symptom inventory for use as an anxiety and depression screening instrument in primary care

Background: Screening for anxiety and depression in primary‐care clinics has the potential to increase identification and treatment of affected patients. The feasibility of such screening, however, depends on the availability of quick, easily interpretable screening tools. Methods: In this pair of studies, a 4‐item screening instrument was developed from the depression and anxiety scales of the Brief Symptom Inventory. One sample of undergraduate volunteers was used to identify pairs of items to be included in the screener. A second sample of primary‐care patients was used to evaluate the performance of these items as compared to other measures of the same construct and a standardized clinical interview. Results: The studies suggest that 4 items from the Brief Symptom Inventory can be used to identify patients with depression and/or anxiety in primary care. Conclusions: Circumstances under which this measure, compared to other measures such as the Patient Health Questionnaire, would be appropriate are discussed. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

Late-life depression and mental health services in primary care

Mental health services in the treatment of late-life depression are critical in the primary care arena. A significant proportion of elderly patients experience depression, a problem causing a far-reaching impact on morbidity, mortality, and quality of life. A number of barriers may prevent effective depression treatment including negative physician and patient attitudes toward the stigma of depression, somatically focused clinical presentations, health care plan constraints, and competing medical demands, as well as gender and geographic isolation. Screening for depression in primary care settings is not always standard fare as physicians may feel confident in their diagnostic abilities. Research addressing effective depression treatment in the primary care setting has been limited to few clinical trials and physician-focused academic detailing. Future research should address real-world scenarios encountered by the primary care physician in their treatment of the "old-old" patient with complex medical comorbidities and functional decline.     

Satisfaction with mental health services in older primary care patients.

OBJECTIVE: This study examines whether older adult primary care patients are satisfied with two intervention models designed to ameliorate their behavioral health problems. METHODS: A total of 1,052 primary care patients aged 65 and older with depression, anxiety, or at-risk drinking were randomly assigned to and participated in either integrated care (IC) or enhanced specialty referral (ESR) model and completed the Client Satisfaction Questionnaire (CSQ) administered at three-month follow-up assessment. RESULTS: Older adult patients' satisfaction with IC (mean: 3.4, standard deviation [SD]: 0.60) was significantly higher than that with ESR (mean: 3.2, SD: 0.78), but the absolute difference was modest. Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction. Stigma toward mental illness was negatively associated with satisfaction with mental health services. CONCLUSIONS: Older adults are more likely to have greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics.     

Independent validation of the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS)

IntroductionObsessive-compulsive disorder (OCD) is a clinically heterogeneous condition characterized by a few consistent, temporally stable symptom dimensions. The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) is a recently developed instrument that allows patient and clinician ratings of dimension-specific symptom severity, as well as estimates of global symptom severity in patients with OCD.MethodsWe examined the psychometric properties of the DY-BOCS in a sample of 128 European adult patients with OCD.ResultsThe results of the psychometric analyses were overall excellent. The internal consistency across the domains of time, distress and interference for each dimension was high. The subscales of the DY-BOCS were largely independent from one another. The convergent and discriminant validity of the DY-BOCS subscales were adequate. The Global Severity and Interference scales were largely intercorrelated, suggesting that they may be redundant. The level of agreement between self-report and expert ratings was adequate although somewhat lower than in the original validation study.ConclusionThe results of the present study confirm the excellent psychometric properties of the DY-BOCS reported in the original validation study.     

Attitudes about impairment and depression in elders suffering from chronic heart failure

OBJECTIVES: This study examines the relationship between functional impairment and depression in patients with heart failure using a new measure of Attitudes about Impairment. METHODS: Sixty-nine patients with chronic heart failure completed diagnostic interviews and questionnaires about mood, comorbid illness, functional impairment, and social support. Study design was case-control with cases selected because they met criteria for DSM-IV major or minor depression (n = 23). Controls reported no or very few depressive symptoms (n = 46). A preliminary study of the psychometric properties of a new 15-item measure of Attitudes about Impairment was conducted. RESULTS: The Attitudes about Impairment measure had a Cronbach's alpha = 0.81. A factor analysis revealed content domains of negative attitudes about dependency, lack of recreational activities, and concerns about being a burden both currently and in the future. This measure correlated highly with the Geriatric Depression Scale (r = 0.61) and remained high even after controlling for medical burden and social support. Patients were diagnosed with either major, minor or no depression using a DSM-IV based structured interview. Depressed patients had significantly more negative attitudes about impairment and the association between depression and physical impairment was no longer significant after controlling for scores on the Attitudes about Impairment measure. DISCUSSION: Negative attitudes about loss of autonomy, concerns about being a burden and having few recreational activities are strongly associated with depression in patients with heart failure. These attitudes account, in part, for the association between impairment and depression in these patients. The Attitudes about Impairment measure has adequate internal consistency and both convergent and discriminant validity with related measures of social support, functional disability and depression.