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A brief follow-up rating
A Brief Follow-up
Rating
By DAVID A. SOSKIS
T
HE AIM OF THE PRESENT STUDY was to develop a follow-up rating for psychiatric inpatients which would be quantitative, relatively inexpensive, and usable by personnel at various levels of training. The rating was developed and tested in the course of a more extensive follow-up study on first admission schizophrenic patients who had been hospitalized three to seven years previously on the psychiatric ward of The Yale-New Haven Hospital.lJ Although subjects were interviewed personally by the author in this study, the rating was designed so that necessary information might also be obtained from a relative, friend, or both. In the course of analyzing the data obtained from the interviews, four areas were chosen as sources for the rating. These were: hospitalizations, work, family, and social life. The study group consisted of 32 subjects, 41 per cent males, with an average age of 25 years and an average hospital stay of 2.5 months. At follow-up, 16 per cent of the subjects were employed in professional positions, 19 per cent in “white-collar” and 13 per cent in “blue-collar” jobs. Of the remainder, 31 per cent were housewives, I2 per cent students, and 9 per cent were hospitalized. Forty-seven per cent of the group had some college level education on admission. In addition to the data necessary for computation of the Brief Follow-Up Rating (henceforth “BFR”), each subject also completed the five “9 forms of the Katz Adjustment Scales. These forms consist of a total of 133 simple multiple choice questions. The forms are: S-l: Level of Symptom Discomfort, S-2: Level of Performance of Socially Expected Activities, S-3: Level of Expectations for Performance of Social Activities, S-4: Level of Free-Time Activities, and S-5: Level of Satisfaction With Free-Time Activities. The “R” forms of Katz’s scales, which cover the same areas but are completed by a relative, were not used in the present study. The Katz Adjustment Scales have been well-validated in previous work by Katz and Lyerly.3 These additional ratings were utilized in the process of arriving at the final formula and later in validating the results obtained. The formula was arrived at by a trial-and-error process during the course of the study and represented a balance between ease of calculation and consistency with the other function scales. For each subject in the study group the BFR, the Katz Adjustment Scales, and the number of re-hospitalizations at follow-up (treated as a separate “rating”) were recorded on IBM cards, and Pearsonian Correlation CO&cients were calculated for all combinations of variables. DAVID A. SOSKIS,M.D.: Assistant and USPHS Fellow in Psychiatry, University of Assistant Resident in Psychiatry, Strong Rochester School of Medicine and Dentistry; Memorial Hospital, Rochester, N.Y. COMPREHENSIVE
PSYCHIATRY,VOL. 11, No. 5 (SEPTEMBER),
1970
445
446
DAVID A.
SOSKIS
DESCRIPTIONAND SCORINGOF BFR The BFR is a numerical rating based on the answers to nine questions. These answers may be obtained from the subject, a relative, a friend or any combination and may be solicited in a personal interview, on the phone, or in a written questionnaire. The nine questions are:
1. What percentage of the time since discharge has the subject been functioning in the community (i.e., working, at school, as a housewife)? Unemployment, non-attendance at school, or inability to perform household duties are not considered “functioning in the community,” even if they have been characteristic of the subject’s premorbid adjustment. Since exact tabulations are not practical in a question of this type, the information is recorded as a number from 1 to 4 representing a quartile: 1 = O-25 per cent, 2 = 25-50 per cent, 3 = 50-75 per cent, and 4 = 75-100 per cent. 2. What was the subject’s occupation two years prior to admission? 3. What is the subject’s occupation at follow-up? 4. What were the subject’s living arrangements two years prior to admission? 5. What are the subject’s living arrangements at follow-up? 6. How many close friends does the subject claim at follow-up? 7. Of how many organizations is the subject an active member at follow-up? 8. How many times during an average month does the subject now visit with or receive visits at home from people outside his family? 9. How many times has the subject been psychiatrically hospitalized since discharge? The BFR is computed from the formula: B,FR = A( B+C+D-E). A-E are computed from the answers to the nine questions above. A is the number obtained in answer to question 1. B is obtained by comparing the answers to questions 2 and 3 and deciding whether the subject has risen, fallen, or maintained the same level occupationally. B is expressed as 2 = fallen, 3 = same, and 4 = risen. C is obtained by comparing the answers to questions 4 and 5. Living arrangements are classified as either dependent, independent or supportive, and C is scored as 2 if the subject has moved towards dependence or abandoned a supportive role, 3 if the subject has maintained the same “level” in this area, and 4 if the subject has moved from dependence toward independence or from independence to a supportive role. D is derived from the numbers which are required in answer to questions 6, 7’ and 8. Answers to questions 6 and 7 which are greater than zero and to question 8 which are equal to or greater than 2 each give one point, giving D a possible range of O-3. E is the number given in answer to question 9. RESULTS
Results for the BFR in the study group are shown in Fig. 1. The mean score was 24.9 with a standard deviation of k10.5. As the figure shows, the scores were distributed in a roughly normal fashion with a skew towards the higher scores.
BRIEF FOLLOW-UP
447
RATl?JG
8 4
8
Fig.
12
16
20
L-Distribution
24
_L
of BFR
Correlations among methods of evaluation shown in Table 1.
scores.
of post-hospital
adjustment
are
It will be seen that the BFR correlated at the 1 per cent level with the number of hospitalizations; this would be expected since this figure determines E and plays a part in A. The BFR also correlated with two of the Katz Scales: with the S-Z scales (Level of Performance of Socially Expected Activities) at the 1 per cent level, and with the S-4 scale (Level of Free-Time Activities ) at the 5 per cent level. Correlations are all in the expected direction. Differences in sign of correlation coefficients are due to ditferences in scoring methods. None of the Katz Adjustment Scales correlated significantly with the number of subsequent hospitalizations. DISCUSSION The significant correlations with two of Katz’s scales provide initial validation of the BFR when compared with an accepted instrument for the measure-
Table L-Correlations
Among Measurements
of Post-hospital
BFR
Number of Hospitalizations
BFR
+ 1.000
- 0.650
-0.16
+0.63’
Number of Hospitalizations
- 0.65’
+ 1.00”
+ 0.09
-0.29
*p
S-l
s-2
Adjustment s-4
s-5
+0.30
-0.43t
-0.01
-0.10
+0.15
-0.06
s-3
448
DAVID A.
SOSKIS
ment of post-hospital adjustment. The S-2 scale (Level of Performance of Socially Expected Activities) had the highest correlation with the BFR, and this was also the scale which Katz and Lyerly found to correlate best (among the S forms) with clinicians’ ratings of post-hospital adjustment in their own study group.” Since the BFR does not include information on symptom discomfort, it is not surprising that it did not correlate with the S-l scale. In contrast, none of Katz’s scales correlated with number of re-hospitalizations, a factor weighted heavily in construction of the BFR. The BFR, then, may be seen as a broad evaluation of total post-hospitaI adjustment with less of an emphasis than Katz’s scales on the detailed examination of the subject’s feelings and function at a particular point in time. The time perspective of the BFR has two distinctive features: it utilizes a percentage figure in A to make at least partial correction for the use of different follow-up periods within the same study, and a “reference” point within the subject’s own life is used for evaluating work and family adjustment (B and C). This allows for the fact that many psychiatric inpatients have a lifelong history of marginal adjustment and puts the emphasis on intra- rather than inter-personal comparison as the basis for scoring, Ideally the scoring of a numerical follow-up rating should approach the scientific “ideal” for true quantitative data. Interesting efforts have been made in this direction.4 Many follow-up ratings in present use, however, rely on the evaluation of key areas of post-hospital adjustment by a skilled interviewer and assign “numbers” to the evaluations in each area, totaling these to obtain a “score” (e.g., Mandel Social Adjustment Scale).” The B’FR shares many features with this approach, but modifies it in several areas. The data on which it is based (answers to questions l-9) are either “facts” or actual numbers, and may be collected from one or severa sources by personnel at various levels of training. Value judgments are required in the BFR (in arriving at B and C) but the data on which they are based is easily accessible, thus simplifying the training of raters and validation of inter-rater reliability. Freeman and Simmons have estimated the cost of a completed interview in their detailed follow-up study as $100 per subject.6 The BFR, in an effort to produce an economical rating, naturally sacrifices some elements of accuracy and detail. Since it was developed in a study of a group of former schizophrenic patients with relatively high levels of premorbid function, its use in very different diagnostic and social groups remains to be evaluated. SUMMARY
The BFR is presented as an economical method for evaluating post-hospital adjustment in former psychiatric patients. It incorporates areas of post-hospital function which are generally accepted as having social significance and does not emphasize the subject’s current level of symptom discomfort, An attempt is made to incorporate information concerning the totality of the subject’s adjustment since discharge rather than utilizing information about a single point in time, and to employ reference points relating to premorbid adjustment. The information required for the rating may be collected and scored by personnel at various levels of training. The BFR score correlates significantly
BRIEF FOLLOW-UP
449
RATING
with two of Katz’s Adjustment Scales: well validated but considerably complex measures of post-hospital adjustment.
more
REFERENCES 1. Soskis, D.A., Harrow, M., and Detre, T.P. : Long-term follow-up of schizophrenics admitted to a general hospital psychiatric ward. Psychiat. Quart. 43~525-534, 1969. 2.-, and Bowers, M.B.: The schizophrenic experience: A follow-up study of attitude and post-hospital adjustment. J. Nerv. Ment. Dis. 149:443-449, 1969. 3. Katz, M.M., and Lyerly, S.B.: Methods for measuring adjustment and social behavior in the community. I. Rationale, description, discriminative validity and scale development. Psychol. Rep. 13:503-535,
1963. 4. Glueck, B.C., Jr. (Ed.) : Report of Conference on Social Adjustment Rating Scales. Minneapolis, University of Minnesota Press, 1958. 5. Mandel, N.G.: Mandel Social Adjustment Scale. Minneapolis, University of Minnesota Department of Psychiatry Research, 1959. 6. Freeman, H.E., and Simmons, O.G.: The use of the survey in mental illness research. Ment. Hyg. 44:400410, 1960.
Rating
By DAVID A. SOSKIS
T
HE AIM OF THE PRESENT STUDY was to develop a follow-up rating for psychiatric inpatients which would be quantitative, relatively inexpensive, and usable by personnel at various levels of training. The rating was developed and tested in the course of a more extensive follow-up study on first admission schizophrenic patients who had been hospitalized three to seven years previously on the psychiatric ward of The Yale-New Haven Hospital.lJ Although subjects were interviewed personally by the author in this study, the rating was designed so that necessary information might also be obtained from a relative, friend, or both. In the course of analyzing the data obtained from the interviews, four areas were chosen as sources for the rating. These were: hospitalizations, work, family, and social life. The study group consisted of 32 subjects, 41 per cent males, with an average age of 25 years and an average hospital stay of 2.5 months. At follow-up, 16 per cent of the subjects were employed in professional positions, 19 per cent in “white-collar” and 13 per cent in “blue-collar” jobs. Of the remainder, 31 per cent were housewives, I2 per cent students, and 9 per cent were hospitalized. Forty-seven per cent of the group had some college level education on admission. In addition to the data necessary for computation of the Brief Follow-Up Rating (henceforth “BFR”), each subject also completed the five “9 forms of the Katz Adjustment Scales. These forms consist of a total of 133 simple multiple choice questions. The forms are: S-l: Level of Symptom Discomfort, S-2: Level of Performance of Socially Expected Activities, S-3: Level of Expectations for Performance of Social Activities, S-4: Level of Free-Time Activities, and S-5: Level of Satisfaction With Free-Time Activities. The “R” forms of Katz’s scales, which cover the same areas but are completed by a relative, were not used in the present study. The Katz Adjustment Scales have been well-validated in previous work by Katz and Lyerly.3 These additional ratings were utilized in the process of arriving at the final formula and later in validating the results obtained. The formula was arrived at by a trial-and-error process during the course of the study and represented a balance between ease of calculation and consistency with the other function scales. For each subject in the study group the BFR, the Katz Adjustment Scales, and the number of re-hospitalizations at follow-up (treated as a separate “rating”) were recorded on IBM cards, and Pearsonian Correlation CO&cients were calculated for all combinations of variables. DAVID A. SOSKIS,M.D.: Assistant and USPHS Fellow in Psychiatry, University of Assistant Resident in Psychiatry, Strong Rochester School of Medicine and Dentistry; Memorial Hospital, Rochester, N.Y. COMPREHENSIVE
PSYCHIATRY,VOL. 11, No. 5 (SEPTEMBER),
1970
445
446
DAVID A.
SOSKIS
DESCRIPTIONAND SCORINGOF BFR The BFR is a numerical rating based on the answers to nine questions. These answers may be obtained from the subject, a relative, a friend or any combination and may be solicited in a personal interview, on the phone, or in a written questionnaire. The nine questions are:
1. What percentage of the time since discharge has the subject been functioning in the community (i.e., working, at school, as a housewife)? Unemployment, non-attendance at school, or inability to perform household duties are not considered “functioning in the community,” even if they have been characteristic of the subject’s premorbid adjustment. Since exact tabulations are not practical in a question of this type, the information is recorded as a number from 1 to 4 representing a quartile: 1 = O-25 per cent, 2 = 25-50 per cent, 3 = 50-75 per cent, and 4 = 75-100 per cent. 2. What was the subject’s occupation two years prior to admission? 3. What is the subject’s occupation at follow-up? 4. What were the subject’s living arrangements two years prior to admission? 5. What are the subject’s living arrangements at follow-up? 6. How many close friends does the subject claim at follow-up? 7. Of how many organizations is the subject an active member at follow-up? 8. How many times during an average month does the subject now visit with or receive visits at home from people outside his family? 9. How many times has the subject been psychiatrically hospitalized since discharge? The BFR is computed from the formula: B,FR = A( B+C+D-E). A-E are computed from the answers to the nine questions above. A is the number obtained in answer to question 1. B is obtained by comparing the answers to questions 2 and 3 and deciding whether the subject has risen, fallen, or maintained the same level occupationally. B is expressed as 2 = fallen, 3 = same, and 4 = risen. C is obtained by comparing the answers to questions 4 and 5. Living arrangements are classified as either dependent, independent or supportive, and C is scored as 2 if the subject has moved towards dependence or abandoned a supportive role, 3 if the subject has maintained the same “level” in this area, and 4 if the subject has moved from dependence toward independence or from independence to a supportive role. D is derived from the numbers which are required in answer to questions 6, 7’ and 8. Answers to questions 6 and 7 which are greater than zero and to question 8 which are equal to or greater than 2 each give one point, giving D a possible range of O-3. E is the number given in answer to question 9. RESULTS
Results for the BFR in the study group are shown in Fig. 1. The mean score was 24.9 with a standard deviation of k10.5. As the figure shows, the scores were distributed in a roughly normal fashion with a skew towards the higher scores.
BRIEF FOLLOW-UP
447
RATl?JG
8 4
8
Fig.
12
16
20
L-Distribution
24
_L
of BFR
Correlations among methods of evaluation shown in Table 1.
scores.
of post-hospital
adjustment
are
It will be seen that the BFR correlated at the 1 per cent level with the number of hospitalizations; this would be expected since this figure determines E and plays a part in A. The BFR also correlated with two of the Katz Scales: with the S-Z scales (Level of Performance of Socially Expected Activities) at the 1 per cent level, and with the S-4 scale (Level of Free-Time Activities ) at the 5 per cent level. Correlations are all in the expected direction. Differences in sign of correlation coefficients are due to ditferences in scoring methods. None of the Katz Adjustment Scales correlated significantly with the number of subsequent hospitalizations. DISCUSSION The significant correlations with two of Katz’s scales provide initial validation of the BFR when compared with an accepted instrument for the measure-
Table L-Correlations
Among Measurements
of Post-hospital
BFR
Number of Hospitalizations
BFR
+ 1.000
- 0.650
-0.16
+0.63’
Number of Hospitalizations
- 0.65’
+ 1.00”
+ 0.09
-0.29
*p
S-l
s-2
Adjustment s-4
s-5
+0.30
-0.43t
-0.01
-0.10
+0.15
-0.06
s-3
448
DAVID A.
SOSKIS
ment of post-hospital adjustment. The S-2 scale (Level of Performance of Socially Expected Activities) had the highest correlation with the BFR, and this was also the scale which Katz and Lyerly found to correlate best (among the S forms) with clinicians’ ratings of post-hospital adjustment in their own study group.” Since the BFR does not include information on symptom discomfort, it is not surprising that it did not correlate with the S-l scale. In contrast, none of Katz’s scales correlated with number of re-hospitalizations, a factor weighted heavily in construction of the BFR. The BFR, then, may be seen as a broad evaluation of total post-hospitaI adjustment with less of an emphasis than Katz’s scales on the detailed examination of the subject’s feelings and function at a particular point in time. The time perspective of the BFR has two distinctive features: it utilizes a percentage figure in A to make at least partial correction for the use of different follow-up periods within the same study, and a “reference” point within the subject’s own life is used for evaluating work and family adjustment (B and C). This allows for the fact that many psychiatric inpatients have a lifelong history of marginal adjustment and puts the emphasis on intra- rather than inter-personal comparison as the basis for scoring, Ideally the scoring of a numerical follow-up rating should approach the scientific “ideal” for true quantitative data. Interesting efforts have been made in this direction.4 Many follow-up ratings in present use, however, rely on the evaluation of key areas of post-hospital adjustment by a skilled interviewer and assign “numbers” to the evaluations in each area, totaling these to obtain a “score” (e.g., Mandel Social Adjustment Scale).” The B’FR shares many features with this approach, but modifies it in several areas. The data on which it is based (answers to questions l-9) are either “facts” or actual numbers, and may be collected from one or severa sources by personnel at various levels of training. Value judgments are required in the BFR (in arriving at B and C) but the data on which they are based is easily accessible, thus simplifying the training of raters and validation of inter-rater reliability. Freeman and Simmons have estimated the cost of a completed interview in their detailed follow-up study as $100 per subject.6 The BFR, in an effort to produce an economical rating, naturally sacrifices some elements of accuracy and detail. Since it was developed in a study of a group of former schizophrenic patients with relatively high levels of premorbid function, its use in very different diagnostic and social groups remains to be evaluated. SUMMARY
The BFR is presented as an economical method for evaluating post-hospital adjustment in former psychiatric patients. It incorporates areas of post-hospital function which are generally accepted as having social significance and does not emphasize the subject’s current level of symptom discomfort, An attempt is made to incorporate information concerning the totality of the subject’s adjustment since discharge rather than utilizing information about a single point in time, and to employ reference points relating to premorbid adjustment. The information required for the rating may be collected and scored by personnel at various levels of training. The BFR score correlates significantly
BRIEF FOLLOW-UP
449
RATING
with two of Katz’s Adjustment Scales: well validated but considerably complex measures of post-hospital adjustment.
more
REFERENCES 1. Soskis, D.A., Harrow, M., and Detre, T.P. : Long-term follow-up of schizophrenics admitted to a general hospital psychiatric ward. Psychiat. Quart. 43~525-534, 1969. 2.-, and Bowers, M.B.: The schizophrenic experience: A follow-up study of attitude and post-hospital adjustment. J. Nerv. Ment. Dis. 149:443-449, 1969. 3. Katz, M.M., and Lyerly, S.B.: Methods for measuring adjustment and social behavior in the community. I. Rationale, description, discriminative validity and scale development. Psychol. Rep. 13:503-535,
1963. 4. Glueck, B.C., Jr. (Ed.) : Report of Conference on Social Adjustment Rating Scales. Minneapolis, University of Minnesota Press, 1958. 5. Mandel, N.G.: Mandel Social Adjustment Scale. Minneapolis, University of Minnesota Department of Psychiatry Research, 1959. 6. Freeman, H.E., and Simmons, O.G.: The use of the survey in mental illness research. Ment. Hyg. 44:400410, 1960.