Quality of Life Measurement Among Persons with Chronic Mental Illness: A Critique of Measures and Methods

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5. Evaluative Review of Quality of Life Instruments

5.1 Quality of Life Instruments

Note: All instruments in bold font have been used to some degree with a mental health population. Other instruments are included due to their potential use with mental health clients or because of a unique methodology which may be of interest to those developing new tools for use in the mental health field. A distinction is made between instruments used for clinical and assessment purposes and those which are primarily used as screening surveys for population health monitoring activities. For each instrument, the holder of its copyright is reported for sourcing. When a fee is required, this is also noted.

i. Comprehensive Quality of Life Scale (Cummins)

The COMQoL is a clinical tool which was developed for use with a mentally handicapped population. There are problems with internal consistency of scales (.65 - .73) and lower than desirable test-retest coefficients (.6).

Cummins, R.A. (1991).

-Source: Robert A. Cummins, Department of Psychology, Victoria College, 336 Glenferrie Road, Malvern, Vic. 3144, Australia.

ii. General Health Questionnaire (Goldberg)

The GHQ is a very widely used (in population health surveys as well as clinical settings) and quickly administered screening instrument with fair to good reliability (alpha = .81). Criterion related validity has been established among persons with neurotic symptoms in that it can distinguish persons at risk for acute psychological distress from "normals". Convergent correlations have been reported with the Beck Depression Inventory (.49) which suggests some problems with its discriminant power if the intent is to describe the construct of anxiety as different from cognitive depression.

Kind, P. & Gudex, C.M. (1994).

-Source: Goldberg, D. (1978). Manual of the General Health Questionnaire. Windsor: NFER.

iii. Goteborg Quality of Life Instrument (Tibblin)

This clinical tool addresses a wide range of physical, psychological and social experiences. The psychological component evaluates the dimensions of fatigue, concentration, depression, memory, sleep and agitation. The internal consistency of scales is fair to good (.72 - .85), particularly since symptom items often lack conceptual coherence in that they address very different aspects of physiological and mental experience. Construct validity is only partially supported by confirmatory factor analysis. The health scale has been shown to have predictive validity with respect to the survival rate of cardiac patients. A notable weakness when working with chronic psychiatric populations is that depression and anxiety symptoms are not adequately separated by the instrument.

Sullivan, M., Karlsson, J., Bengtsson, C., Furunes, B., Lapidus, L. & Lissner, L. (1993).

Tibblin, G., Svardsudd, K., Welin, L., Erikson, H. & Larsson, B. (1993).

-Source: Dr. M. Sullivan, Health Care Research Unit, Sahlgrenska Hospital, S-413 45 Goteborg, Sweden.

iv. Health Measurement Questionnaire (Gater)

The HMQ was developed to generate Rosser Index Scores of disability and distress (i.e., QALY) and tested for use as a QoL screening survey during psychiatric consultation. No reliability coefficients were reported in recent literature. Fair to good convergence with psychiatric ratings of disability and distress was obtained (kappa = .29), agreeing 74% of the time and being within one level of clinician-rated severity in 88% of cases. The HMQ score correlations with the Psychiatric Assessment Schedule (PAS) subscales are fair to good (.35 - .59).

Gater, R.A., Kind, P. & Gudex, C. (1995).

Kind, P. & Gudex, C.M. (1994).

-Source: Dr. Gater, Mental Illness Research Unit, University of Manchester, Withington Hospital, West Didsbury, Manchester, M20 8LR.

v. Lancashire Quality of Life Profile (Oliver)

This clinical assessment interview is based on a shorter form of Lehman's QoL Interview. Interview results provide an overall well-being score as well as QoL scores on seven point Likert scales in a wide range of life domains (see Table 1, Chapter 2). The interview is geared towards assessment of persons with chronic mental illness.

Bridges, K., Gage, A., Oliver, J., Ewert, C., Kershaw, A. & Wood, L. (1993).

Oliver, J. P. J. (1992).

-Source: Oliver, J.P.J. (1992). The social care directive: Development of a quality of life profile for use in community services for the mentally ill. Social Work & Social Sciences Review, 3, 5-45.

vi. Lehman's Quality of Life Interview (Lehman)

This semi-structured interview is designed to assess the life circumstances of persons with severe mental illness on both objective and evaluative dimensions. The instrument has been used to investigate QoL of chronic mentally ill populations in a wide variety of settings. The internal consistency of evaluative scales is fair to good (.79 - .88) but some inconsistency is present in the objective scales (.44 - .82). One week test-retest reliabilities between .41 and .95 are reported for evaluative scales and between .29 and .98 for objective measures. Convergent validation with the Quality of Life Scale resulted in low to moderate coefficients (.26 - .52). The instrument demonstrates more strength during the assessment of psychotic and depressive symptomatology: .49 - .51 with the Brief Psychiatric Rating Scale - BPRS (Overall & Gorham, 1962).

Draine, J. & Solomon, P. (1993).

Lehman, A.F. (1983).

Lehman, A.F. (1988).

Lehman, A.F., Postrado, L.T., & Rachuba, L.T. (1993).

Lehman, A.F., Slaughter, J.G. & Myers, C.P. (1991).

Mechanic, D., McAlpine, D., Rosenfield, S. & Davis, D. (1994).

Oliver, J.P.J. & Mohamed, H. (1992).

Overall, J.E. & Gorham, D.R. (1962).

-Source: Center for Mental Health Services Research, Department of Psychiatry, University of Maryland, 645 West Redwood Street, Baltimore, MD 21201; Phone 410-706-2490

vii. Life-as-a-Whole Index (Andrews & Withey)

This global uniscale is suited for use as a quick screening tool for the measurement of cognitive life satisfaction. Respondents are ask to provide a rating (from delighted to terrible) on the item "How do you feel about your life as a whole?". This measure possesses fair to good correlations with other scales measuring patient satisfaction in specific domains of marriage, work, standard of living, leisure, friendship and health. Responses to this scale are strongly influenced by mood and affect.

Headey, B., Kelley, J. & Wearing, A. (1993).

Headey, B., Veenhoven, R. & Wearing, A. (1991).

-Source: Andrews, F. M. & Withey, S. B. (1976). Social indicators of well-being. Plenum, New York.

viii. Life Experiences Checklist (Ager)

LEC is a clinical tool designed to assess QoL through endorsement of a wide range of experiences, events and activities. A small sample (n=20) test-retest reliability coefficient of .93 is reported. No internal consistency estimates are available. Validity coefficients are modest at best (.3 - .4). Authors of the Twelfth Mental Measurements Yearbook (1995) suggest it is still in its development phase. There was little other recent information on its psychometric properties.

Conger, J. (1995).

-Source: NFER-Nelson Publishing Co., Ltd. England (fee).

ix. Life Satisfaction Index (Neugarten)

LSI is a widely-used clinical tool which measures well-being (past, present and future). It has been translated into many languages. The instrument possesses adequate internal consistency (.84). The LSI shows some criterion related validity with psychologist ratings of life adjustment (.55). Correlations between the LSI and both the UCLA Social Loneliness scores (-.41) (Anderson & Malikois-Loizos, 1992; Russell, Peplau & Cutrona, 1980) and Emotional Loneliness scores (-.55) provide convergent validation. A confirmatory factor analysis (using LISREL) suggests some construct instability in that the structure may change across gender and race groupings. Other studies suggest that use of the LSI with cognitively impaired or depressed subjects may further compromise the internal consistency and longitudinal stability of the instrument.

Abraham, I.L. (1992).

Malikois-Loizos, M., & Anderson, L.R. (1994).

McCulloch, B.J. (1992).

-Source: Neugarten, B. L., Havighurst, R. J. & Tobin, S. S. (1961). The measurement of life satisfaction. Journal of Gerontology, 31, 134-143.

x. MOS Short Form 36 (Ware & Sherbourne)

This is a comprehensive and very widely used survey tool designed to assess perceived health status. Two scoring protocols are available (RAND 36 and the SF-36). Ware and Sherbourne (1992) published the MOS 36 Item Short-Form Health Survey (SF-36), consisting of 36 items for the Medical Outcomes Study. The SF-36 items and scoring rules are distributed by MOS Trust Inc. Strict adherence to item wording and scoring recommendations is required in order to use the SF-36 trademark. The RAND 36 item Health Survey 1.0, distributed by Rand, includes the same items as those in the SF-36 but the recommended scoring algorithm is somewhat different from that of the SF-36.

The instrument possesses some internal consistency weakness (alpha's ranging from .77 to .88). There are some reports of very low internal consistency estimates for the Health Perception Scale (global ratings of health perception in general). The Mental Health scale focuses mostly on affect (e.g., depression, happiness, and anxiety) and can discriminate between a clinically depressed and non-depressed sample. Vitality scale items may overlap with Mental Health items which might be expected given its affective focus. See Solomon, Skobieranda & Gragg (1993) for a copy of the instrument.

Aaronson, N.K. et al. (1992).

Hays, R.D., Sherbourne, C.D. & Mazel, R.M. (1993).

McHorney, C.A., Ware, J.E., & Raczek, A.E. (1993).

Solomon, G.D., Skobieranda, F.G. & Gragg, L.A. (1993).

Stewart, A. L., Hays, R. D., Wells, K. B., Rogers, W. H., Spritzer, K. L.

& Greenfield, S. (1994).

Stewart, A.L., Hays, R.D. & Ware, J.E. (1988).

Ware, J. E., & Gandek, B. (1994).

-need permission to use, although copy found in articles. Note that two scoring protocols exist and apparently two holders of copyrights to scoring protocols.

-Source 1: Rand Corporation, 1700 Main Street, Santa Monica, CA 90406 (fee).

-Source 2: Medical Outcomes Trust, P.O. Box 1917, Boston, MA 02205.

xi. (Multifaceted) Lifestyle Satisfaction Scale (Harner & Heal)

The (M)LSS is a clinical tool intended to assess individuals' satisfaction with their lifestyle. The internal consistency of the total instrument is reported as .88. Some subscale instability is noted with four of the seven scales below .75. Test-retest reliability coefficients of .70 and .86 are reported for the total scale. Low to moderate convergence is reported between the LSS and the Quality of Life Questionnaire subscales (.20 - .52). The instrument appears to be suitable for use with persons with limited intelligence. Its suitability for use with chronic mentally ill populations is unclear.

Harner, C.J. & Heal, L.W. (1993).

-Source: International Diagnostic Systems, Inc., 868 Cherryfield Avenue, Columbus, OH 43235 (fee).

xii. Nottingham Health Profile (Gater)

The Nottingham is a widely used general survey and screening instrument in the UK but less so in America. Recently, the Nottingham is reported (by authors of the Health Measurement Questionnaire-HMQ) to compare less favourably than the HMQ in terms of its face validity as perceived by psychiatric inpatients. Items may also have difficulty discriminating with patients experiencing higher levels of disability. Little psychometric information was found in the recent literature.

Gater et al. (1995).

-Source: Dr.Gater, Mental Illness Research Unit, University of Manchester, Withington Hospital, West Didsbury, Manchester M2O 8LR.

xiii. Quality of Life in Depression Scale (Hunt & McKenna)

The QLDS is a clinical assessment tool whose face and content validity has been demonstrated through qualitative interviews. Further tests of reliability and construct validity show promise. The internal consistency of the QLDS was rated at over .94 on two occasions and the authors report a two week test-retest reliability of .81. The construct validity coefficient between the QLDS and the General Well-Being Index was reported to be .79 among a psychiatrically depressed population of inpatients as well as outpatients.

Hunt, S.M. & McKenna, S.P. (1992).

McKenna, S.P. & Hunt, S.M. (1992).

-Source: Medical Affairs department, Chapel Hill, Basingstoke, Hampshire, RG212SY, UK.

xiv. Quality of Life Enjoyment and Satisfaction Questionnaire (Endicott)

The Q-LES-Q is a clinical tool which was developed to provide clinicians with an easily obtainable and sensitive self-report measure of the degree of enjoyment and satisfaction in various areas of daily living. It was intended for use with a wide variety of mental and medical disorders. This instrument possesses good internal consistency and test-retest reliability on all but two of the eight scales. Studies of convergent validation have been completed using the Hamilton Rating Scale for Depression, Clinical Global Impressions, Severity of Illness and Global Improvement scales, Beck Depression Inventory and the Symptom Checklist - 90. Fair to good (negative) correlations (-.30 to -.54) were obtained between Hamilton (D) and Global Improvement Scores and Q-LES-Q scales. Studies are currently under way with schizophrenic, substance abuse, and anxiety disordered populations.

Endicott, J., Nee, J., Harrison, W. & Blumenthal, R. (1993).

-Source: Dr. Jean Endicott, Department of Research Assessment and Training, New York State Psychiatric Institute, Suite 123, Room 341, 722 West 168th Street, New York, NY.

xv. Quality of Life Index (Spitzer)

This quickly administered screening tool, used with cancer patients, consists of five items which tap activity, daily living, health, support and outlook. It possesses fair to good internal reliability (.78); however, it should be kept in mind that the authors employed a standardized item alpha which is adjusted upward to account for the small number of items (5). Professional ratings of the same patient groups within seven days resulted in inter-rater reliability coefficients (Spearman Rank Order or rho) of .81. The instrument appears to be able to distinguish between healthy, chronic and seriously ill groups of cancer patients. Patients' self-report rating on the global uniscale may be heavily influenced by their emotional state (Note: A uniscale is a one-item scale intended to measure a single construct).

Lamping, D.L. (1994).

-Source: Spitzer, W.O., Dobson, A.J., Hall, J., Chesterman, E., Levi, J., Shepherd, R., Battista, R.N., & Catchlove, B.R. (1981). Measuring the quality of life of cancer patients. Journal of Chronic Disease, 34, 585-597.

xvi. Quality of Life Index for Mental Health (Becker & Diamond)

The QLI-MH is a new and innovative clinical instrument being developed specifically for use with mental health populations. The test-retest coefficients of this instrument were greater than .82 on all nine scales. The instrument is reported to provide clinically useful information and contains a set of goal attainment scales. Convergence was assessed between the QLI-MH and the BPRS, QL-Index, and Uniscale - among others. High criterion related validity coefficients were observed between the QLI-MH and the Quality of Life Index (.91), patient uniscale ratings (.68), and provider uniscale ratings (.80).

Becker, M., Diamond, R. & Sainfort, F. (1993).

Sainfort, F., Becker, M. & Diamond, R. (1996).

-Source: Dr. M. Becker, Center for Health Systems Research and Analysis, University of Wisconsin-Madison, WARF Building, 610 Walnut St., Madison, WI 53705.

xvii. Quality of Life Interview Schedule (Holcomb)

This promising semi-structured clinical interview was designed and tested on mentally ill patients living in either a state hospital or community residential facility. Initial factor analysis suggests four coherent factors (Autonomy, Self-esteem, Social Support & Physical Health) with internal consistency coefficients in excess of .85. However, four additional scales (Anger/Hostility, Somatization/Anxiety, Activity/Mobility and Accessibility to Medical Services) had alpha coefficients ranging from .72 to .77. The overall percent of the variance explained by the factor solution was under 50%, indicating weak scale construction. The authors note that more work is needed on some of the scales within this instrument. The QOLIS can correctly classify 88.6% of people living in the community vs. those in hospital.

Holcomb, W.R., Morgan, P., Adams, N.A., Ponder, H. & Farrel, M. (1993).

-Source: Drs. W. R. Holcomb & P. Morgan, Fulton State Hospital, Fulton, Missouri.

xviii. Quality of Life Inventory (Frisch)

The QOLI is a clinical tool which possesses fair to good internal consistency (.79) and two week test-retest (.73) reliability. Good convergent validity has been demonstrated between QOLI total score and both the Satisfaction With Life Scale (.56) and the Quality of Life Index scores (.75). The scale is adequately sensitive to clinical improvement and authors provide evidence for its clinical utility as a treatment planning tool within inpatient and outpatient mental health settings.

Frisch, M.B., Cornell, J., Villanueva, M. & Retzlaff, B.J. (1992).

-Source: National Computer Systems Inc., P.O. Box 1416, Minneapolis, MN, 55440 (fee).

xix. Quality of Life Questionnaire (Schalock)

The QOL-Q is a clinical tool designed as an outcome measure for persons with developmental disabilities and mental retardation. Scales include: Satisfaction (alpha = .78), Competence/Productivity (alpha = .90), Empowerment/Independence (alpha = .82) and Community Integration (alpha = .67). The internal consistency of the total score is estimated at .90. Inter-rater reliabilities are reported between .73 - .83 with a test-retest coefficient of .87. This instrument has a strong history of criterion and construct validation with other populations. Its use with a mentally ill population is unclear.

Schalock, R.L., Bartnik, E., Wu, F., Konig, A., Lee, C. & Reiter, S. (1990).

Sinnott-Oswald, M., Gliner, J. A. & Spencer, K.C. (1991).

-Source: Schalock, R.L., Keith, K.D., Hoffman, K., & Karan, O.C. (1989). Quality of Life: Its measurement and use. Mental Retardation, 27, 25-31. -or - IDS Publishing, P.O. Box 389, Worthington, Ohio 43085.

xx. Quality of Life Questionnaire / Interview (Bigelow)

The QoL Questionnaire/Interview is a clinical tool which is sometimes administered as a questionnaire and sometimes as an interview. It has been widely tested, has good face validity and is clinically informative for use with mentally ill persons. It is reported to have fair to good internal consistency (higher than .82) on most scales but falls short with respect to the social and productivity scales. Inter-rater reliability is good for most scales (.70 - .80) but again the author recognizes its weakness on scales which are either internally inconsistent or not routinely observed by the interviewers (.32 - .68). The instrument has been shortened to improve its psychometric qualities. The instrument is sensitive enough to discriminate between mental health and non-mental health community residents and has been used in several treatment evaluation studies.

Bigelow, D.A., Gareau, M.J. & Young, D.J. (1990).

Bigelow, D.A., McFarland, B.H. & Olson, M.M. (1991).

Bigelow, D.A. & Young, D.J. (1991).

-Source: Dr. D.A. Bigelow, Ministry of Health, Blanchard Building, 5th floor, 1515 Blanchard Street, Victoria, British Columbia V8W 3C8.

xxi. Quality of Life Scale (Heinrichs)

This clinical instrument, designed for interview administration (good inter-rater reliabilities are reported, ranging from .85 to .97), provides information on symptoms and functioning over the last month. The QLS was specifically intended to measure the schizophrenia deficit symptoms in non-institutionalized patients. The construct validity of scales (i.e., Intrapsychic Foundations, Interpersonal Relations, Instrumental Role and Common Objects/Activities) is fairly well supported by factor analysis and convergent validation with the Lehman QoL Interview.

Heinrichs, D.W., Hanlon, T.E. & Carpenter, W.T. (1984).

Lehman, A.F. et al. (1993).

-Source: Dr. D.W. Heinrichs, Maryland Psychiatric Research Center, P.O. Box 3235, Baltimore, MD, 21228.

xxii. Quality of Life Self-Assessment Inventory (Skantze)

This clinical instrument possesses good face and content validity when used with persons with schizophrenia or other severe mental disorders. It has clinical utility, tapping patients' ambitions/goals, perceptions of the present and needs for change in 14 domains of life. A seven day test-retest reliability of .88 is reported.

Skantze, K. & Malm, U. (1994).

Skantze, K., Malm, U., Dencker, S.J., May, P.R.A. & Corrigan, P. (1992).

-Source: Kerstin Skantze, Psychiatric Department II Centrum, Lillhagen Hospital, Box 3005, S-42203 Hisings Backa, Gothenburg, Sweden.

xxiii. Quality of Life Systemic Inventory (Dupuis)

This new clinically based assessment methodology is used to evaluate QoL in cardiac patients based on subjects' capacity to reach personal goals in different life domains. Instead of using pencil and paper or verbally presented items, visual representations of pressure gauges and slide bar indicator scales are used by patients within an interview setting to rate their current state, personal goals and ideal goals. The importance of life domains is also rated using visual analogues. Discrepancy ratings have good test-retest reliability and authors say that pictorial methods are not as easily influenced by social desirability bias during the interview process. As yet, no studies have been performed on a population with mental illness.

Duquette, R.L., Dupuis, G., & Perrault, J. (1994).

-Source: Dr. Dupuis, Research Centre, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec H1T 1C8; Phone : 514-376-3330, fax : 514-376-1355.

xxiv. Quality of Well-Being Scale (Kaplan)

Early studies developed the QWB scale for use within general health surveys using QALY methods. Low to moderate correlations have been reported between QWB scale and the Profile of Mood States (POMS) (McNair, Lorr & Drappleman, 1980) anger/hostility (-.16), confusion/bewilderment (-.35), depression/dejection (-.35), fatigue/inertia (-.34), tension/anxiety (-.31) and vigour/activity (.32) scales as well as the Beck Depression Inventory (-.49).

Kaplan, R. M. & Anderson, J. P. (1990).

Kaplan, R. M., Bush, J. W. & Berry, C. C. (1976).

Kaplan, R.M., McCutchan, J.A., Atkinson, J.H. & Grant, I. (1995).

-Source: Dr. R. Kaplan, Division of Health Care Sciences 0622, Dept. of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA 92093-0622.

xxv. Satisfaction With Life Scale (Diener)

This clinical scale was developed to measure the judgmental component of subjective well-being. Earlier work by Diener suggests that the scale is a unidimensional, multi-item scale with good internal consistency and reliability (Diener, Emmons, Larsen & Griffin, 1985). Internal consistencies of .85 and test-retest coefficients of .84 are reported. The measure has been validated through peer reports and clinical ratings using the Philadelphia Geriatric Morale Scale and other independent life satisfaction measures. Lending criterion related support, the SWLS scale is negatively correlated with clinical measures of distress, Beck Depression Inventory (-.72), Symptom Checklist (SCL-90) - Anxiety (-.54) and Psychological Distress (-.55) scales.

Headey, B. et al. (1993).

Pavot, W. & Deiner, E. (1993b). Review of the satisfaction with life scale.

Psychological Assessment, 5, 164-172.

Pavot, W., Diener, E., Colvin, C.R. & Sandvik, E. (1991).

-Source: Reproduced within articles listed.

xxvi. Schedule for the Evaluation of Individual Quality of Life (O'Boyle)

The SEIQoL is considered by many QoL researchers in oncology to be the gold standard of clinical QoL measurement tools. Authors report an internal reliability of .60 to 75. While these reliability estimates appear low, they are not based on group aggregates but are the means of consistency estimates across individuals (i.e., in their endorsement of self-defined dimensions). The R-squared coefficients from individuals' regression equations (i.e., an estimate of the stability of individuals' QoL judgements) are given as a validity coefficient. This is also a somewhat atypical coefficient and should be interpreted carefully. A test-retest coefficient of .88 has been reported for the global scale of the SEIQoL. Assessment of its application for persons with dementia suggests that cognitive impairment may hinder completion of the interview. Use of proxy responses has been suggested as an alternative; this approach, however, would compromise the very characteristics (quantification of individuals' QoL judgements) for which the SEIQoL is known.

Browne, J.P. et al. (1994).

Coen, R et al. (1993).

McGee, H.M., O'Boyle, C.A., Hickey, A., O'Malley, & Joyce, C.R.B. (1991).

O' Boyle, C.A., McGee, H.M. & Joyce, C.R.B. (1994).

Source: Professor Ciaran O'Boyle, Dept. of Psychology, Royal College of Surgeons, Ireland Medical School, 123 St. Steven's Green Dublin 2, Ireland, Fax 353-1-478-0934.

xxvii. Sickness Impact Profile (Bergner)

The SIP is a very widely used population health survey in North America, less so in the UK, tapping domains associated with perceived health status (focusing on physical health). Good internal consistency estimates range from .94 to .97 with test-retest stability coefficients of .88 to .92. Construct validity has been examined using the Katz Activities of Daily Living-ADL (.64) (Bergner, Bobbitt, Carter & Gilson, 1981). Some wording may be confusing and sensitive to educational level. There is some skew towards healthy reporting.

Brooks, W. B., Jordan, J. S., Divine, G. W., Smith, K. S. & Neelon, F. A. (1990).

Fisher, D.C., Lake, K.D., Reutzel, T.J. & Emery, R.W. (1995).

Moore, A.D., Stambrook, M., Gill, D.D. & Lubusko, A.A. (1992).

Smith, H.E. (1992).

-Source: Department of Health Services, University of Washington (fee).

xxviii. SmithKline Beecham Quality of Life Scale (Stoker)

The SBQL is a clinical tool whose scales possess high internal consistency (.89 - .95), with moderate to high test-retest reliabilities (.66 - .83). The instrument exhibited good convergence between the Self-Now/Ideal Self discrepancy and both the General Health Questionnaire (.69) and the Sickness Impact Profile (.66). Self-Now and Sick-Self discrepancies exhibited moderate to high negative correlations with the GHQ (.44) and the SIP (.54 - .61). There may be some need to familiarize subjects with the discrepancy procedure. The SBQL has been validated for use with a depressed and anxious population using the Hamilton Depression and Anxiety Scales.

Stoker, M.J., Dunbar, G.C. & Beaumont, G. (1992).

-Source: CNS Therapeutic Unit, Clinical Research and Development, Smithkline Beecham Pharmaceuticals, 47-49 London Road, Reigate, Surrey RH2 9YF.

5.2 Future Trends and Potential Directions

There is a need for a comprehensive and standardized comparison of QoL instruments using several different Canadian populations of patients with mental illness. This body of research should address the following issues: (a) the development and psychometric evaluation of QoL instruments within the Canadian milieu; (b) empirical demonstration of the strengths of particular instruments for particular purposes and tasks, for example cost indicators, health indicators and clinical/relapse indicators; (c) convergent validity between a selection of promising QoL measures; (d) determination of the sensitivity of measures to criterion clinical and health monitoring indicators among specific populations; and (e) the impact of different types of psychiatric and psychological impairment on self-report measurement tools.

There is also a need to determine the adequacy of instruments for specific evaluation related tasks, particularly with respect to global versus disease-specific indicators, cost-effectiveness determinations, maintenance of treatment effects and predictive utility of QoL scales in the above areas.

Finally, there is a need for a strategic plan to direct future mental health service evaluation and planning in Canada with respect to: the training of persons with sufficient skills and knowledge to oversee and conduct program evaluation initiatives; the implementation of QoL measurement in health monitoring systems; and the formulation and implementation of system wide treatment standards.

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