Are the available apathy measures reliable and valid? A review of the psychometric evidence

Objective

Apathy is highly prevalent among neuropsychiatric populations and is associated with greater morbidity and worse functional outcomes. Despite this, it remains understudied and poorly understood, primarily due to lack of consensus definition and clear diagnostic criteria for apathy. Without a gold standard for defining and measuring apathy, the availability of empirically sound measures is imperative. This paper provides a psychometric review of the most commonly used apathy measures and provides recommendations for use and further research.

Methods

Pertinent literature databases were searched to identify all available assessment tools for apathy in adults aged 18 and older. Evidence of the reliability and validity of the scales were examined. Alternate variations of scales (e.g., non-English versions) were also evaluated if the validating articles were written in English.

Results

Fifteen apathy scales or subscales were examined. The most psychometrically robust measures for assessing apathy across any disease population appear to be the Apathy Evaluation Scale and the apathy subscale of the Neuropsychiatric Inventory based on the criteria set in this review. For assessment in specific populations, the Dementia Apathy Interview and Rating for patients with Alzheimer's dementia, the Positive and Negative Symptom Scale for schizophrenia populations, and the Frontal System Behavior Scale for patients with frontotemporal deficits are reliable and valid measures.

Conclusion

Clinicians and researchers have numerous apathy scales for use in broad and disease-specific neuropsychiatric populations. Our understanding of apathy would be advanced by research that helps build a consensus as to the definition and diagnosis of apathy and further refine the psychometric properties of all apathy assessment tools.     

Determinants of geriatric patients’ quality of life after stroke rehabilitation

Objectives: Geriatric patients’ physical disabilities, dependency on care, and possible psychological ill-being may negatively affect both the patient's quality of life and the informal caregiver burden. Focusing on this interrelationship which can be particularly prominent in geriatric patients with stroke, the objective of this study was to identify determinants of patients’ quality of life and informal caregiver burden.

Method: This is a prospective, multicentre, cohort study. Data were collected in 84 geriatric home-dwelling patients with stroke three months after their rehabilitation period in skilled nursing facilities (SNFs). We assessed patients’ quality of life, depressive complaints, neuropsychiatric symptoms, balance, (instrumental) activities of daily living, and informal caregiver burden. Linear regression models were constructed to study the association between the variables.

Results: For several domains, high quality of life of these geriatric patients was associated with high functional independence, less neuropsychiatric symptoms, and less depressive complaints. Informal caregiver burden was not associated with patients’ quality of life, but patients’ neuropsychiatric symptoms were a significant determinant of high informal caregiver burden.

Conclusion: The presence of neuropsychiatric symptoms (more specifically depressive complaints) negatively affects the quality of life of geriatric patients. Their neuropsychiatric symptoms also affect caregiver burden. Health care professionals in SNFs can play an important role in providing the necessary psychosocial support and aftercare.     

How useful is the calculation of total scores for questionnaires concerning health related quality of life?

Questionnaires for health related quality of life generally comprise several subscales. These subscales can be summarized into a total score. The aim of this article is to test the justification of such an integration from a statistical point of view. By means of a representative sample of the German population (n = 1981) the correlative relationships among six questionnaires are assessed: NHP, EORTC QLQ-C30, HADS, MFI-20, GBB-24 and Whiteley index. The corrrelations between the total scores are markedly higher than the mean correlations among the subscales between the tests. Even in those cases where the subscales share the same subdimension the correlations are not higher than the correlations between these subscales and the (unspecific) total scores. The advantage of sharing a common area is as great as the disadvantage of the lower number of items. By means of the Spearman-Brown formula the relationship between the number of items and the reliability of the scale is discussed in detail. It can be concluded that the calculation of total scores is useful and justified from a statistical perspective.     

Does carotid endarterectomy lead to a decline in cognitive function or health related quality of life?

Carotid endarterectomy has been shown to reduce the long-term risk of stroke in selected patients. The present study was designed to examine cognitive function and health related quality of life in a series of carotid endarterectomy patients. One hundred and nine patients undergoing carotid endarterectomy were assessed before surgery and at 6 months post op (n = 100) on standard cognitive function tests and quality of life surveys. Microembolisation was detected using transcranial Doppler ultrasonography. Multivariate repeated measures analysis if variance identified evidences of significant impairments on some tests. Further analysis revealed that particulate Microembolisation detected during the procedure was a significant risk factor associated with declining cognitive function. Patients' self-reported health related quality of life had not deteriorated at 6 month following surgery.     

Are needs and satisfaction of care associated with quality of life?

Is the quality of life of severe mentally ill patients influenced by the intensity of the care provided, their satisfaction with services and/or the amount of unmet needs? The interrelatedness of these three outcome measures was investigated in a sample of 101 patients dependent on long-term psychiatric care in the Northeast of the Netherlands. Instruments used were the Camberwell Assessment of Needs, the Verona Service Satisfaction Schedule and a health related quality of life instrument, the EuroQoL. Quality of life was unrelated to satisfaction with services but was strongly associated with unmet needs in the area of mental and physical health, and of rehabilitation. Quality of life decreased as needs increased. Needs were also strongly related to diagnosis and cognitive functioning. Furthermore, more intensive care settings were provided as needs increased. Demographic, diagnostic and treatment variables did not explain much extra variance in quality of life. Despite the availability of various services in the region there was a lack of tailor made care which took into account specific unmet needs with regard to information, social contacts, and daily activities.     

Worth a thousand words? Visual concept mapping of the quality of life of people with severe mental health problems

Objectives

Conventional approaches to quality of life (QoL) measurement rely heavily on verbal, language‐based communication. They require respondents to have significant cognitive and verbal ability, making them potentially unsuitable for people with severe mental health problems. To facilitate an alternative approach to QoL assessment, the current study aims to develop an alternative, visual representation of QoL for people with severe mental health problems.

Methods

An alternative, visual adaptation of the concept mapping method was used to construct this visual representation of QoL. Eighty‐two participants (i.e., patients, care professionals, and family members) contributed to this study. Results were processed statistically to construct the concept map.

Results

The concept map contains 160 unique visual statements, grouped into 8 clusters labelled (1) Support and Attention, (2) Social Contacts, (3) Happiness and Love, (4) Relaxation and Harmony, (5) Leisure, (6) Lifestyle, (7) Finances, and (8) Health and Living. Examples of visual statements are pictures of family silhouettes, romantic couples, natural scenes, houses, sports activities, wallets and coins, smiley faces, and heart shapes. The clusters were interpreted and labelled by participants.

Conclusions

Almost all of the statements correspond to clusters found in previous (non‐visual) QoL research. Hence, QoL domains can also be presented visually.     

Is torture reliably assessed and a valid indicator of poor mental health?

Torture is thought to confer worse mental health than other war-related traumatic events. However, reliability of torture assessment and validity of torture constructs as indicators of poor mental health have not been systematically evaluated. Study aims were to assess the psychometric properties of 2 common torture constructs. Refugees were assessed for having experienced torture by 1 subjective and 1 objective criterion. A subset was interviewed about definitions and effects of torture. Reliability and validity of torture constructs were assessed with general linear models. Interview data were analyzed for consistency of themes. Reliability of torture constructs was moderate, which paralleled inconsistencies in interview themes. Both torture criteria had similar dose-dependent relationships to mental health. Multivariate analyses showed that torture was not an independent predictor of poor mental health when controlling for the number of war-related events. Further work is needed to define torture from distinct medical and legal perspectives to improve reliability and validity.     

Quality of life measurement: a fashion or a valid assessment?

During 20 last years, there has been an exponential growth in the literature related to quality of life (QoL). The usual indicators of results are not always responsive to new strategies or new systems of care organization. While assessment of QoL by patients and by the medical community is an old concern, the issue of standardized instruments is more recent. Despite the need, the use of QoL questionnaires remains rare because of the lack of sufficiently dedicated tools. In the specific field of motoneuron diseases, a search of the literature should be helpful to clarify the definition of quality of life. It should also be helpful in determining the limits of the debate on quantification of an impression considered to be subjective. The goal is to clarify methods for standardizing QoL evaluation, to specify nosographic notions affecting the choice of measuring instruments, to recall the prerequisite of validation before use, and finally to specify the fields of application of such tools. Thus in the field of motoneuron diseases, recognizing the limitations of QoL instruments should enable a more enlightened approach to overall assessment of the burden of these diseases.     

Are mood disorders and obesity related? A review for the mental health professional

OBJECTIVE: We reviewed evidence regarding a possible relationship between mood disorders and obesity to better inform mental health professionals about their overlap. METHOD: We performed a MEDLINE search of the English-language literature for the years 1966-2003 using the following terms: obesity, overweight, abdominal, central, metabolic syndrome, depression, mania, bipolar disorder, binge eating, morbidity, mortality, cardiovascular, diabetes, cortisol, hypertriglyceridemia, sympathetic, family history, stimulant, sibutramine, antiobesity, antidepressant, topiramate, and zonisamide. We evaluated studies of obesity (and related conditions) in persons with mood disorders and of mood disorders in persons with obesity. We also compared studies of obesity and mood disorders regarding phenomenology, comorbidity, family history, biology, and pharmacologic treatment response. RESULTS: The most rigorous clinical studies suggest that (1). children and adolescents with major depressive disorder may be at increased risk for developing overweight; (2). patients with bipolar disorder may have elevated rates of overweight, obesity, and abdominal obesity; and (3). obese persons seeking weight-loss treatment may have elevated rates of depressive and bipolar disorders. The most rigorous community studies suggest that (1). depression with atypical symptoms in females is significantly more likely to be associated with overweight than depression with typical symptoms; (2). obesity is associated with major depressive disorder in females; and (3). abdominal obesity may be associated with depressive symptoms in females and males; but (4). most overweight and obese persons in the community do not have mood disorders. Studies of phenomenology, comorbidity, family history, biology, and pharmacologic treatment response of mood disorders and obesity show that both conditions share many similarities along all of these indices. CONCLUSION: Although the overlap between mood disorders and obesity may be coincidental, it suggests the two conditions may be related. Clinical and theoretical implications of this overlap are discussed, and further research is called for.     

Is region-of-interest overlap comparison a reliable measure of category specificity?

Analysis of the degree of overlap between functional magnetic resonance imaging-derived regions of interest (ROIs) has been used to assess the functional convergence and/or segregation of category-selective brain areas. An examination of the extant literature reveals no consistent usage for how such overlap is calculated, nor any systematic comparison between different methods. We argue that how ROI overlap is computed, especially the choice of the denominator in the formula, can profoundly affect the results and interpretation of such an analysis. To do this, we compared the overlap of the FFA-FFA (fusiform face area) and FFA-FGA (fusiform Greeble-selective area) in a localizer study testing both Greeble novices and experts. When using a single ROI as the denominator, we found a significant difference in FFA-FFA versus FFA-FGA overlap, consistent with the result of a previous study arguing for face specificity of the FFA [Rhodes, G., Byatt, G., Michie, P. T., & Puce, A. Is the fusiform face area specialized for faces, individuation, or expert individuation? J Cogn Neurosci, 16, 189-203, 2004]. However, these ROI overlap differences disappeared when the denominator combined both of the involved ROIs, and the patterns of such overlap comparisons were dependent on given statistical thresholds. We also found proportionally decreasing FFA-FFA overlap with increasing center-of-FFA distance, resolving an apparent contradiction between the consistency of the location of the FFA and the seemingly low FFA-FFA overlap. Finally, Monte Carlo simulations revealed the most stable formula-the most resistant to ROI size variations-to be the average of the two single-ROI-denominator-based overlap indices. In sum, ROI overlap analysis is not a reliable tool for assessing category specificity, and caution should be exercised with regard to ROI overlap definition, underlying assumptions, and interpretation.