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Residual symptoms and social functioning over six-months in recovered outpatients with chronic depression
Journal of Affective Disorders 52 (1999) 251–255
Brief report
Residual symptoms and social functioning over six-months in recovered outpatients with chronic depression Vito Agosti* Psychiatric Institute, 722 West 168 th Street, Unit 35, New York, N.Y. 10032, USA Received 6 February 1998; accepted 9 March 1998
Abstract Background: Scant data exists regarding the global mental health of recovered chronically depressed outpatients. The purpose of this study was to compare the symptoms and functioning of these patients to those found in a normal control group (NCG). Methods: Social functioning was assessed by the Social Adjustment Scale interview. Symptoms were measured with the Symptom Check List-90. Results: The overall social functioning of recovered females was more impaired than a NCG. Recovered males and females had more psychiatric symptoms than a NCG. Limitations: The two samples were not demographically similar. Conclusions: Though the differences in social functioning and symptoms between the recovered patients and NCG’s were statistically significant, they were not clinically meaningful. In general, recovered females had a relatively robust level of mental health. 1999 Elsevier Science B.V. All rights reserved. Keywords: Social functioning; Chronic depression; Recovery
There have been few published follow-up studies of chronically depressed outpatients (Kocsis et al., 1991; Klein et al., 1988a,b; Agosti and Stewart, 1996). Six month follow-up studies have reported recovery rates to vary from 25% (Klein et al., 1988a,b) to 75% (Agosti and Stewart, 1996). Follow-up studies have typically used a categorical definition of recovery, namely, a minimum period
*Tel.: 1 1-212-5435605; fax: 1 1-212-5432326.
of eight consecutive weeks without sufficient symptoms to qualify for a diagnosis of depression (Frank et al., 1991). Since this definition of recovery has not be empirically established, it is unclear if patients who meet criteria for recovery have clinically significant residual symptoms and social impairment. The purpose of this study was to assess the symptoms and social functioning of recovered chronically depressed outpatients by comparing their psychosocial outcomes to the those found in psychiatrically normal community samples.
0165-0327 / 99 / $ – see front matter 1999 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 98 )00041-X
252
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255
1. Patients and methods
1.1. Sample These data were derived from the public access tape of the NIMH Treatment of Depression Collaborative Research Program (TDCRP) (Elkins et al., 1989). Briefly, the TDCPR sample included 239 patients who completed, dropped out, or were withdrawn from a randomized trial which compared interpersonal psychotherapy, cognitive-behavioral psychotherapy, imipramine clinical management, or pill placebo plus clinical management treatment. Subjects with a bipolar disorders, schizophrenia, panic disorder, substance abuse, antisocial personality disorder, Briquet’s syndrome, psychosis, or had significant schizotypal features, were excluded from the study. A naturalistic follow-up of patients who entered the clinical trial was part of the TDCPR’s research design. This report assessed the psychosocial outcomes of patients six months after leaving research treatment.
1.2. Assessments The Schedule of Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978) was used to make categorical distinctions. Patients were defined as having chronic depression if they had a current episode of Major Depression of two years or more, or met criteria for Intermittent Depression. The Hamilton Depression Rating Scale (Ham-d) (Hamilton, 1969) was based upon the first 17 items. The Ham-d was rated by a clinical evaluator who was blind to the experimental treatment condition. The Ham-d was administered at several periods during the experimental phase of the study and during the follow-up interviews. The Longitudinal Interval Follow-up Evaluation (LIFE-II) (Keller et al., 1987) was used to assess the course of illness during the follow-up period. This is a semi-structured interview that assesses psychopathology, retrospectively, over a period of six months. Weekly psychiatric status ratings (PSR’s) are made on a six-point scale for episodic affective
disorders, ranging from meeting Research Diagnostic Criteria (RDC) for the index episode (rating of 5 or 6) to no residual symptoms (rating of 1). The Symptoms Check List (SCL-90-R) (Derogatis, 1977) is a self-rated instrument containing 90 symptom related questions. The subject assesses the degree of severity of each symptom: The scale ranges from: 0 (‘Not at all’) 1 (‘A little bit’) 2 (‘Moderately’) 3 (‘Quite a bit’) to 4 (‘Extremely’). The Social Adjustment Scale (SAS)-II (Schooler et al., 1979) is a modified version of the interviewbased Social Adjustment Scale (Weissman et al., 1971). The instrument is administered in a semistructured manner. Ratings of role functioning are made on the basis of all available information, rather than relying only on the subject’s report. The interviewer makes global judgment assessments for each area of the subject’s functioning, and of their overall level of adaptation. The ratings are made in relationship to the ‘‘community norm’’ of social adjustment on a scale of 1 (‘Excellent’) to 7 (‘Severe Impairment’).
1.3. Community normal control groups The normal sample for the interview-based SAS was composed of females who ‘were screened to be without overt psychiatric disturbance, previous psychiatric treatment of any nature, or current medical illness’ (Weissman et al., 1971). The SCL-90-R used a stratified random sample of community residents who were not receiving psychiatric treatment (Derogatis, 1977).
1.4. Recovery criteria The TDCP’s criteria for recovery was used for this study, namely, a stable symptomatic remission from Major Depression and / or Intermittent Depression: requiring LIFE-II PSR’s of 1 or 2 (minimal or no symptoms) for 8 consecutive weeks after leaving the controlled treatment. For this report, patients must have been recovered during the last 2 months of the six month follow-up.
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255
2. Results
253
extended-family functioning and marital functioning than the control group. Work functioning did not differ between these two groups.
2.1. Sample Forty-two percent (101 / 239) in the TDCRP met criteria for chronic depression, 47 of whom met criteria for recovery. The study group consisted mostly of relatively well-educated, moderately depressed, mostly white females, aged 22 to 59 (Table 1).
2.2. Social adjustment scale The validity of the interview-based SAS (Weissman et al., 1971) was established by comparing the scores of normal and depressed females. Therefore, in order to validly compare the control group with the recovered patient sample, recovered males were not included in the statistical analysis. Table 2 reveals that recovered females had less impairment in social-leisure functioning, but had more impairment in overall functioning than the NCG. Recovered females had less impairment in Table 1 Pretreatment clinical and demographic characteristics
Female Married Caucasian Attended college Age Hamilton depression scale Age of onset, major depression Intermittent depression (current)
N
(%)
34 13 41 37 47
(72) (28) (87) (78)
25.3 34
Mean
(SD)
35.9 18.6
(9.2) 4.3 12
(72)
2.3. Symptom check list The recovered group, composed of males and females, had significantly higher Obsessive-Compulsive, Interpersonal-Sensitivity, Depression, Anxiety, Psychotic, and Total SCL-90-R scores than the NCG. However, the mean subscale scores for both groups were well below a clinically significant threshold of severity. The recovered and normal control groups manifested nonsignificant differences Anxiety, Somatization, Hostility, Paranoia, and Phobia subscale scores (Table 3).
3. Conclusions These results suggests that chronically depressed females, who met categorically defined criteria for recovery, had a generally robust level of social functioning when compared to a normal community sample. Recovered male and female patients had manifested more Obsessive-Compulsive, InterpersonalSensitivity, Depression, Paranoia, Psychotic, and total SCL-90-R symptom scores than found in the general population. However, the large sample size of the control group may have caused a bias in favor of finding significant between group differences (Type I error). Nevertheless, the differences do not appear to be clinically meaningful. The mean symptom scores for both groups were near 1 (‘‘A little
Table 2 Comparison of the SAS global scores of NCG and recovered females Recovered group
Work Extended family Marital Social Overall
Normal control group
P
N
Mean
SD
N
Mean
SD
34 33 12 34 34
1.5 1.64 1.69 2.05 2.91
0.48 0.51 0.59 0.77 1.06
40 39 33 40 40
1.47 2.23 2.52 2.41 2.46
0.60 0.78 0.83 0.60 0.72
NS 0.000 0.002 0.02 0.04
254
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255
Table 3 A comparison of SCL90 scores recovered patients and commmunity controls Recovered group N 5 39
Depression Obsessive-compulsive Interpersonal-sensitivity Hostility Paranoia Somatization Anxiety Phobia Psychotic Total
Control group N 5 974
P
Mean
S.D.
Mean
S.D.
1.03 0.80 0.80 0.37 0.58 0.41 0.55 0.18 0.41 0.63
0.93 0.85 0.81 0.45 0.79 0.45 0.70 0.33 0.48 0.60
0.36 0.39 0.29 0.30 0.34 0.36 0.30 0.13 0.14 0.31
0.44 0.45 0.39 0.40 0.44 0.42 0.37 0.31 0.25 0.31
bit’’), across symptom clusters. The low mean Hamd score, 7.4 (s.d 5 7.5) of the recovered group suggests that the level of depressive symptomatology was not clearly pathological. The overall social functioning of recovered females was more impaired than found in Weissman’s psychiatrically normal sample of women. Though the difference was statistically significant, the mean scores for both groups were within the ‘‘Good’’ to ‘‘Mildly Maladjusted’’ of impairment. Among recovered females, work functioning appeared to have normalized. Surprisingly, the marital and extended-family functioning of the recovered group was superior to the normal control group. This may be a chance finding, which requires replication for it to be considered valid. Since Weissman’s NCG contained a small number of single females (N 5 12), it was not possible to validly compare their social functioning with the single, recovered female sample. Of note is that only 28% of the recovered females, whose average age was 35, were married. In comparison, United States Census data revealed that 69% of females between the ages of 35 to 44 were living with their spouses. The relatively high proportion of unmarried females patients suggests that their long history of depression may have been accompanied by a considerable degree of persistent social withdrawal, interpersonal inhibition, or rejection sensitivity.
0.000 0.005 0.000 NS 0.07 NS 0.03 NS 0.00 0.002
4. Unlinked references Statistical Abstract of the United States (1992); Weissman and Bothwell (1976) References Agosti, V., Stewart, J.W., 1996. Six month follow-up of early-onset chronic depression. Depression 4, 63–67. Derogatis, L.R., 1977. SCL-90-R: Administration Scoring and Procedures Manual. Clinical Psychometrics Research, Baltimore, MD. Elkins, I., Shea, T., Watkins, J.T., et al., 1989. National institute of mental health treatment of depression collaborative research program. Arch. Gen. Psychiatry 46, 971–982. Endicott, J., Spitzer, R.L., 1978. A diagnostic interiew: the schedule for affective disorders and schizophrenia. Arch. Gen. Psychiatry 35, 837–844. Frank, E., Prien, R.F., Jarrett, R., et al., 1991. Conceptualization and rationale for consensus definitions of terms in major depressive disorders: remission, recovery, relapse, and recurrence. Arch. Gen. Psychiatry 48, 851–855. Hamilton, M.A., 1969. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 44, 540–548. Keller, M.B., Lavori, P.W., Friedman, B., et al., 1987. The longitudinal interval follow-up evaluation: a comprehensive method of assessing outcome in propsective studies. Arch. Gen. Psychiatry 44, 540–548. Klein, D.N., Taylor, E.B., Harding, K., et al., 1988. Double depression and episodic major depression: demographic, clinical, familial, personality, and socioenvironmental characteristics and short-term outcome. Am. J. Psychiatry 145 (10), 1226–1231.
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255 Klein, D.N., Taylor, E.B., Dickstein, S., et al., 1988. Primary early-onset dysthymia: comparison with primary nonbipolar nonchronic major depression on demographic, clinical, familial, personality, and socioenvironmental characteristics and short-term outcome. J. Abnorm. Psychol. 97 (4), 387–397. Kocsis, J.H., Sutton, B.M., Frances, A.J., 1991. Long-term followup of chronic depression treated with imipramine. J. Clin. Psychiatry 52, 256–259. Schooler, N., Hogarty, G., Weissman, M.M., 1979. Social Adjustment Scale II. In: Hargreaves, W.A., Attkinson, C.C., Sorenson, J.E. (Eds.), Resource Materials for Community Mental Health
255
Program Evaluators. US Dept. of Health, Education, and Welfare. Bethesda MD. Statistical Abstract of the United States, 1992. Department of Commerce; Bureau of the Census, 112th Edition. Weissman, M.M., Paykel, E.S., Siegel, R., et al., 1971. The social role performance of depressed women: comparisons with a normal group. Am. J. Orthopsychiatry 41 (3), 391–405. Weissman, M.M., Bothwell, S., 1976. Assessment of social adjustment by patient self-report. Arch. Gen Psychiatry 33, 1111–1115.
Brief report
Residual symptoms and social functioning over six-months in recovered outpatients with chronic depression Vito Agosti* Psychiatric Institute, 722 West 168 th Street, Unit 35, New York, N.Y. 10032, USA Received 6 February 1998; accepted 9 March 1998
Abstract Background: Scant data exists regarding the global mental health of recovered chronically depressed outpatients. The purpose of this study was to compare the symptoms and functioning of these patients to those found in a normal control group (NCG). Methods: Social functioning was assessed by the Social Adjustment Scale interview. Symptoms were measured with the Symptom Check List-90. Results: The overall social functioning of recovered females was more impaired than a NCG. Recovered males and females had more psychiatric symptoms than a NCG. Limitations: The two samples were not demographically similar. Conclusions: Though the differences in social functioning and symptoms between the recovered patients and NCG’s were statistically significant, they were not clinically meaningful. In general, recovered females had a relatively robust level of mental health. 1999 Elsevier Science B.V. All rights reserved. Keywords: Social functioning; Chronic depression; Recovery
There have been few published follow-up studies of chronically depressed outpatients (Kocsis et al., 1991; Klein et al., 1988a,b; Agosti and Stewart, 1996). Six month follow-up studies have reported recovery rates to vary from 25% (Klein et al., 1988a,b) to 75% (Agosti and Stewart, 1996). Follow-up studies have typically used a categorical definition of recovery, namely, a minimum period
*Tel.: 1 1-212-5435605; fax: 1 1-212-5432326.
of eight consecutive weeks without sufficient symptoms to qualify for a diagnosis of depression (Frank et al., 1991). Since this definition of recovery has not be empirically established, it is unclear if patients who meet criteria for recovery have clinically significant residual symptoms and social impairment. The purpose of this study was to assess the symptoms and social functioning of recovered chronically depressed outpatients by comparing their psychosocial outcomes to the those found in psychiatrically normal community samples.
0165-0327 / 99 / $ – see front matter 1999 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 98 )00041-X
252
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255
1. Patients and methods
1.1. Sample These data were derived from the public access tape of the NIMH Treatment of Depression Collaborative Research Program (TDCRP) (Elkins et al., 1989). Briefly, the TDCPR sample included 239 patients who completed, dropped out, or were withdrawn from a randomized trial which compared interpersonal psychotherapy, cognitive-behavioral psychotherapy, imipramine clinical management, or pill placebo plus clinical management treatment. Subjects with a bipolar disorders, schizophrenia, panic disorder, substance abuse, antisocial personality disorder, Briquet’s syndrome, psychosis, or had significant schizotypal features, were excluded from the study. A naturalistic follow-up of patients who entered the clinical trial was part of the TDCPR’s research design. This report assessed the psychosocial outcomes of patients six months after leaving research treatment.
1.2. Assessments The Schedule of Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978) was used to make categorical distinctions. Patients were defined as having chronic depression if they had a current episode of Major Depression of two years or more, or met criteria for Intermittent Depression. The Hamilton Depression Rating Scale (Ham-d) (Hamilton, 1969) was based upon the first 17 items. The Ham-d was rated by a clinical evaluator who was blind to the experimental treatment condition. The Ham-d was administered at several periods during the experimental phase of the study and during the follow-up interviews. The Longitudinal Interval Follow-up Evaluation (LIFE-II) (Keller et al., 1987) was used to assess the course of illness during the follow-up period. This is a semi-structured interview that assesses psychopathology, retrospectively, over a period of six months. Weekly psychiatric status ratings (PSR’s) are made on a six-point scale for episodic affective
disorders, ranging from meeting Research Diagnostic Criteria (RDC) for the index episode (rating of 5 or 6) to no residual symptoms (rating of 1). The Symptoms Check List (SCL-90-R) (Derogatis, 1977) is a self-rated instrument containing 90 symptom related questions. The subject assesses the degree of severity of each symptom: The scale ranges from: 0 (‘Not at all’) 1 (‘A little bit’) 2 (‘Moderately’) 3 (‘Quite a bit’) to 4 (‘Extremely’). The Social Adjustment Scale (SAS)-II (Schooler et al., 1979) is a modified version of the interviewbased Social Adjustment Scale (Weissman et al., 1971). The instrument is administered in a semistructured manner. Ratings of role functioning are made on the basis of all available information, rather than relying only on the subject’s report. The interviewer makes global judgment assessments for each area of the subject’s functioning, and of their overall level of adaptation. The ratings are made in relationship to the ‘‘community norm’’ of social adjustment on a scale of 1 (‘Excellent’) to 7 (‘Severe Impairment’).
1.3. Community normal control groups The normal sample for the interview-based SAS was composed of females who ‘were screened to be without overt psychiatric disturbance, previous psychiatric treatment of any nature, or current medical illness’ (Weissman et al., 1971). The SCL-90-R used a stratified random sample of community residents who were not receiving psychiatric treatment (Derogatis, 1977).
1.4. Recovery criteria The TDCP’s criteria for recovery was used for this study, namely, a stable symptomatic remission from Major Depression and / or Intermittent Depression: requiring LIFE-II PSR’s of 1 or 2 (minimal or no symptoms) for 8 consecutive weeks after leaving the controlled treatment. For this report, patients must have been recovered during the last 2 months of the six month follow-up.
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255
2. Results
253
extended-family functioning and marital functioning than the control group. Work functioning did not differ between these two groups.
2.1. Sample Forty-two percent (101 / 239) in the TDCRP met criteria for chronic depression, 47 of whom met criteria for recovery. The study group consisted mostly of relatively well-educated, moderately depressed, mostly white females, aged 22 to 59 (Table 1).
2.2. Social adjustment scale The validity of the interview-based SAS (Weissman et al., 1971) was established by comparing the scores of normal and depressed females. Therefore, in order to validly compare the control group with the recovered patient sample, recovered males were not included in the statistical analysis. Table 2 reveals that recovered females had less impairment in social-leisure functioning, but had more impairment in overall functioning than the NCG. Recovered females had less impairment in Table 1 Pretreatment clinical and demographic characteristics
Female Married Caucasian Attended college Age Hamilton depression scale Age of onset, major depression Intermittent depression (current)
N
(%)
34 13 41 37 47
(72) (28) (87) (78)
25.3 34
Mean
(SD)
35.9 18.6
(9.2) 4.3 12
(72)
2.3. Symptom check list The recovered group, composed of males and females, had significantly higher Obsessive-Compulsive, Interpersonal-Sensitivity, Depression, Anxiety, Psychotic, and Total SCL-90-R scores than the NCG. However, the mean subscale scores for both groups were well below a clinically significant threshold of severity. The recovered and normal control groups manifested nonsignificant differences Anxiety, Somatization, Hostility, Paranoia, and Phobia subscale scores (Table 3).
3. Conclusions These results suggests that chronically depressed females, who met categorically defined criteria for recovery, had a generally robust level of social functioning when compared to a normal community sample. Recovered male and female patients had manifested more Obsessive-Compulsive, InterpersonalSensitivity, Depression, Paranoia, Psychotic, and total SCL-90-R symptom scores than found in the general population. However, the large sample size of the control group may have caused a bias in favor of finding significant between group differences (Type I error). Nevertheless, the differences do not appear to be clinically meaningful. The mean symptom scores for both groups were near 1 (‘‘A little
Table 2 Comparison of the SAS global scores of NCG and recovered females Recovered group
Work Extended family Marital Social Overall
Normal control group
P
N
Mean
SD
N
Mean
SD
34 33 12 34 34
1.5 1.64 1.69 2.05 2.91
0.48 0.51 0.59 0.77 1.06
40 39 33 40 40
1.47 2.23 2.52 2.41 2.46
0.60 0.78 0.83 0.60 0.72
NS 0.000 0.002 0.02 0.04
254
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255
Table 3 A comparison of SCL90 scores recovered patients and commmunity controls Recovered group N 5 39
Depression Obsessive-compulsive Interpersonal-sensitivity Hostility Paranoia Somatization Anxiety Phobia Psychotic Total
Control group N 5 974
P
Mean
S.D.
Mean
S.D.
1.03 0.80 0.80 0.37 0.58 0.41 0.55 0.18 0.41 0.63
0.93 0.85 0.81 0.45 0.79 0.45 0.70 0.33 0.48 0.60
0.36 0.39 0.29 0.30 0.34 0.36 0.30 0.13 0.14 0.31
0.44 0.45 0.39 0.40 0.44 0.42 0.37 0.31 0.25 0.31
bit’’), across symptom clusters. The low mean Hamd score, 7.4 (s.d 5 7.5) of the recovered group suggests that the level of depressive symptomatology was not clearly pathological. The overall social functioning of recovered females was more impaired than found in Weissman’s psychiatrically normal sample of women. Though the difference was statistically significant, the mean scores for both groups were within the ‘‘Good’’ to ‘‘Mildly Maladjusted’’ of impairment. Among recovered females, work functioning appeared to have normalized. Surprisingly, the marital and extended-family functioning of the recovered group was superior to the normal control group. This may be a chance finding, which requires replication for it to be considered valid. Since Weissman’s NCG contained a small number of single females (N 5 12), it was not possible to validly compare their social functioning with the single, recovered female sample. Of note is that only 28% of the recovered females, whose average age was 35, were married. In comparison, United States Census data revealed that 69% of females between the ages of 35 to 44 were living with their spouses. The relatively high proportion of unmarried females patients suggests that their long history of depression may have been accompanied by a considerable degree of persistent social withdrawal, interpersonal inhibition, or rejection sensitivity.
0.000 0.005 0.000 NS 0.07 NS 0.03 NS 0.00 0.002
4. Unlinked references Statistical Abstract of the United States (1992); Weissman and Bothwell (1976) References Agosti, V., Stewart, J.W., 1996. Six month follow-up of early-onset chronic depression. Depression 4, 63–67. Derogatis, L.R., 1977. SCL-90-R: Administration Scoring and Procedures Manual. Clinical Psychometrics Research, Baltimore, MD. Elkins, I., Shea, T., Watkins, J.T., et al., 1989. National institute of mental health treatment of depression collaborative research program. Arch. Gen. Psychiatry 46, 971–982. Endicott, J., Spitzer, R.L., 1978. A diagnostic interiew: the schedule for affective disorders and schizophrenia. Arch. Gen. Psychiatry 35, 837–844. Frank, E., Prien, R.F., Jarrett, R., et al., 1991. Conceptualization and rationale for consensus definitions of terms in major depressive disorders: remission, recovery, relapse, and recurrence. Arch. Gen. Psychiatry 48, 851–855. Hamilton, M.A., 1969. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 44, 540–548. Keller, M.B., Lavori, P.W., Friedman, B., et al., 1987. The longitudinal interval follow-up evaluation: a comprehensive method of assessing outcome in propsective studies. Arch. Gen. Psychiatry 44, 540–548. Klein, D.N., Taylor, E.B., Harding, K., et al., 1988. Double depression and episodic major depression: demographic, clinical, familial, personality, and socioenvironmental characteristics and short-term outcome. Am. J. Psychiatry 145 (10), 1226–1231.
V. Agosti / Journal of Affective Disorders 52 (1999) 251 – 255 Klein, D.N., Taylor, E.B., Dickstein, S., et al., 1988. Primary early-onset dysthymia: comparison with primary nonbipolar nonchronic major depression on demographic, clinical, familial, personality, and socioenvironmental characteristics and short-term outcome. J. Abnorm. Psychol. 97 (4), 387–397. Kocsis, J.H., Sutton, B.M., Frances, A.J., 1991. Long-term followup of chronic depression treated with imipramine. J. Clin. Psychiatry 52, 256–259. Schooler, N., Hogarty, G., Weissman, M.M., 1979. Social Adjustment Scale II. In: Hargreaves, W.A., Attkinson, C.C., Sorenson, J.E. (Eds.), Resource Materials for Community Mental Health
255
Program Evaluators. US Dept. of Health, Education, and Welfare. Bethesda MD. Statistical Abstract of the United States, 1992. Department of Commerce; Bureau of the Census, 112th Edition. Weissman, M.M., Paykel, E.S., Siegel, R., et al., 1971. The social role performance of depressed women: comparisons with a normal group. Am. J. Orthopsychiatry 41 (3), 391–405. Weissman, M.M., Bothwell, S., 1976. Assessment of social adjustment by patient self-report. Arch. Gen Psychiatry 33, 1111–1115.