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The concurrent validity of items in the quality-of-life index in a cohort of HIV-positive and HIV-negative gay men
The Concurrent Validity of Items in the Quality-of-Life Index in a Cohort of HIV-Positive and HIV-Negative Gay Men Janet B.W. Williams, DSW, and Judith G. Rabkin, PhD Department of Psychiatry, Columbia University, N e w York, N e w York
ABSTRACT: The concurrent validity of the Quality-of-Life Index (QLI) is examined by comparing it with other standard measures of psychopathology and psychosocial and physical functioning in a sample of HIV-positive (HIV + ) and HIV-negative (HIV-) men. Fifty gay men (29 HIV+ and 21 H I V - ) were assessed on the QLI and a number of other instruments covering medical, psychological, and social factors in order to examine the validity of the five domains (activity, health, support, outlook, and daily living) of the QLI as a measure of health-related quality of life. A highly significant correlation was found between the support domain of the QLI and the Social Supports Scale. A significant correlation was found between the QLI outloook domain and most measures of psychopathology including depression, anxiety, distress, and hopelessness. A modest but significant correlation was found between the activity domain of the QLI and a medical staging scale, and the Global Assessment of Functioning Scale. It can be concluded that the QLI successfully measures different areas of functioning related to quality of life. KEY WORDS: Health status, quality-of-life measures, AIDS
INTRODUCTION A primary objective of this conference is to define criteria for choosing a m o n g quality-of-life measures for use in clinical trials. The criteria will be based on evidence about the performance characteristics of the various measures to be considered. An informed choice of m e a s u r e s m u s t be, at least in part, based on evidence of reliability and validity. In this paper, the c o n c u r r e n t validity of the Quality of Life Index [1] is e x a m i n e d by c o m p a r i n g it with other standard measures of p s y c h o p a t h o l o g y a n d psychosocial functioning in a v o l u n t e e r sample of HW-positive (HIV + ) a n d HIV-negative ( H I V - ) gay men. The AIDS epidemic has b e e n a catastrophic experience for m e m b e r s of the gay c o m m u n i t y . An u n d e r s t a n d i n g of the personal a n d e n v i r o n m e n t a l factors that influence the risks of transmission a n d rates of disease progression is crucial to the p r e v e n t i o n a n d m a n a g e m e n t of the illness. It is in this context
Address reprint requests to: Dr. J. Williams, Box 74, 722 West 168 Street, New York, NY 10032. ReceivedJuly 11, 1990; revised March 25, 1991.
ControlledClinicalTrials12:129S-141S(1991) © ElsevierSciencePublishingCo., Inc. 1991 655 Avenueof the Americas,New York, New York10010
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J.B.W. Williams and J.G. Rabkin that the present study was conceived. In the fall of 1987, NIMH funds established the HIV Center for Clinical and Behavioral Studies at Columbia University and collaborating institutions. One of its major research projects is the Follow-up Project, a prospective study of HIV + and H I V - gay men. The study is designed to examine the natural history of HIV infection and to identify factors that may influence disease progression. Medical, neurologic, neuropsychologic, psychiatric, psychosocial, and psychosexual factors will be evaluated every six months for five years. The authors of this paper are involved in the Psychiatric/Psychosocial Assessment Core of the HIV Center, and their role in the Follow-up Project is to design assessments to explore psychiatric and psychosocial factors that are most likely related to progression of HIV infection. Measures that cover a wide range of relevant domains have been included in the assessments. A quality-of-life measure was added to the battery of instruments because an individual's quality of life may mediate disease progression, and because the project provided an opportunity to study the psychometric properties of such an instrument with this population. The variety and scope of measures provide a valuable opportunity to examine the validity of the components of our quality-of-life measure by comparing them to other, more detailed measures of the same domains.
METHOD Sample Recruitment Participants were gay men who volunteered for this study. They were required to have prior knowledge of their HIV antibody status and not to have a diagnosis of AIDS at study entry. (They responded to announcements about the study in newletters of two local gay organizations and a notice in a commercial newspaper with a predominantly gay readership.)
Procedure Each participant was seen for a full day of assessments that included neurologic and medical examinations and blood work (with a confirmatory HIV test), psychiatric, psychosocial, and psychosexual interviews, and neuropsychological tests. All participants gave written informed consent and were paid $10/hour for their time. One week prior to interview, each participant was sent a packet of selfreport measures to complete and bring to his appointment. Clinicians were masked to the results of these self-report questionnaires. A list of questionnaires administered to the participants appears in Table 1; the various instruments are described below. Interviewers were trained to conduct the psychiatric, psychosocial (including the quality-of-life measure), and psychosexual interviews. All were master's level clinicians or above, and all had had prior extensive clinical experience, although not necessarily with this population. Because of our commitment to the highest possible quality of evaluations, nearly all interviews were supervised either in person or on audiotape by a senior clinician.
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Table 1 Psychiatric and Psychosocial Assessment Questionnaires Administered by Questionnaire Clinician Structured Clinical Interview for DSM-III-R (SCID) Hamilton Depression Rating Scale (HDRS) Hamilton Anxiety Rating Scale (HARS) Global Assessment of Functioning Scale (GAF) Quality of Life Index (QLI) Self Brief Symptom Inventory (BSI) Social Support Scale Hopelessness Scale Texas Revised Inventory of Grief Scale Pleasure Scale Most of the interviews were discussed by the senior clinician the interviewer so that final diagnostic decisions and ratings on all instruments reflect consensus judgments between two clinicians.
Medical Staging Scale The purpose of this scale is to assess the severity of physical symptoms potentially related to HW infection. (Neurologic, neuropsychologic, and psychiatric symptoms are not considered, and may be present at any stage in the scale.) The medical staging scale is one key outcome variable in this study of risk and protective factors influencing disease progression. Scale scores are based on two sets of data: medical history taken by a nurse, and physical examination conducted by a physician masked to the participant's HIV status until the conclusion of the exam. Scores are assigned by the examining physician, based on the physical exam and the medical history. A second physician later reviews all data and generates an independent scale score. In cases of discrepancy, a consensus is reached through joint review of the data by both physicians involved.
Diagnostic Evaluations The Structured Clinical Interview for DSM-III-R (SCID) was chosen as the major diagnostic instrument [2]. The SCID is a general clinical interview guide that enables clinicians to gather appropriate information to make a diagnosis according to the third edition-revised of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) [3].
Severity of Depressive Symptoms An important strategy in evaluation is the inclusion of measures of the severity of psychopathology. Such measures are useful both for data analysis purposes in comparing different samples of participants, and for following participants over time. Because the SCID is by and large limited to diagnostic judgments, it does not contain severity scales. Depression and anxiety are generally acknowledged to be the most prevalent areas of psychopathology
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J.B.W. Williams and J.G. Rabkin in this population, so the severity of symptomatology present in these two areas was given special attention. The Hamilton Depression Rating Scale (HDRS) [4] is the preeminent clinician-rated scale measuring severity of depressive symptoms. In numerous studies, the total HDRS score has proven reliable and to have a high degree of validity [5, 6]. We chose to use the Structured Interview Guide for the Hamilton Depression Rating Scale (SIGHD) developed by Williams [7], since it has been demonstrated to increase the reliability of the scale items and to facilitate training. The 17-item version is used, with a time frame of the past week. Based on broad experience, mild depression is defined by scores in the 10-14 range, while scores below seven are often used as the definition of recovery or not depressed.
Anxiety No single scale adequately measures the severity of anxiety symptoms, given our current recognition of the many different types of anxiety, such as generalized anxiety, panic attacks, and phobic dread or fear [8]. There are, however, several scales available for measuring the severity of each of these different types of anxiety. The Hamilton Anxiety Scale [9] was chosen for this study because it covers several different types of anxiety, and because it is fairly widely used, enabling us to compare our results with those of other studies. For this study, we developed an interview guide for this rating scale similar to that developed for the HDRS [7].
Self-Report Measures of Severity of Psychopathology In order to correct for possible examiner bias, a self-report measure of symptom severity was also used. The 53-item version of the SCL-90, the Brief Symptom Inventory [10], is a widely-used self-rating scale that provides subscale scores in nine symptom areas, focusing on the past week. Higher scores signify greater symptomatology.
Social Supports Numerous studies have shown that social factors and life events are associated with the onset or exacerbation of mental and physical disorders [11, 12], and even survival. More recently, the impact of environmental, social, psychologic, and physiologic stresses on immunologic status and susceptibility to infectious diseases has received attention in a new field called psychoneuroimmunology. We chose the Social Support Scale [13] developed by Wortman for the Coping and Change Project, a longitudinal, psychosocial study of a Chicago cohort of gay and bisexual men that is part of the Multicenter AIDS Cohort Study (MACS). This scale assesses six different components of social support: perceived availability of emotional and material support, objective and subjective social integration, affirmation (e.g., others think "it's all right to feel what you're feeling"), and social conflict. A total Social Support Scale score is derived by summing scores on the first five subscales. The scale was de-
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veloped specifically for use in a sample such as ours, and as such, contained items that seemed particularly relevant for our cohort.
Hopelessness The struggle to maintain hope has been described as one of the most striking and recurrent themes faced by clinicians working with HIV-spectrum people. Hope (or hopelessness) is believed to be related to psychiatric status, endocrine function, and immunologic function. In the present study we chose Beck and colleagues' 20-item Hopelessness Scale to measure this variable [14]. This self-rated scale with a True/False format was designed to "reflect different facets of the spectrum of negative attitudes about the future." Three factors have been identified in the scale: feelings about the future, giving up, and future expectations (a cognitive dimension). Nine items are keyed "False" and 11 items are keyed "True"; the total hopelessness score is the sum of items keyed in the "hopeless" direction. Therefore, low scores signify hope, defined as faith that good times lie ahead and that the respondent continues to have a fighting spirit.
Grief Because so many of our subjects had recently lost close friends and lovers through death because of AIDS, grief was a salient stressor to be measured. Therefore, each subject who reported losing a lover, close friend, or relative from AIDS completed a modified version of the Texas Revised Inventory of Grief [15].
Pleasure/Anhedonia Our assessment battery obviously focuses mainly on factors that are sources of distress. After the first few interviews were completed, we found that subjects were leaving the interview reflecting mainly on negative aspects of their lives. Therefore, in order to end the interview on a more upbeat note, and to add more balance to the tone of our instrument battery, we added the Pleasure Scale of Fawcett et al. [16]. This scale asks respondents to note how much pleasure each situation described would have given them during the past week. The situations are things such as: "You sit watching a beautiful sunset in an isolated, untouched part of the world," and "You come to the end of a difficult and complicated task without having made a single mistake." Feedback from subjects was very positive about the addition of this scale.
Measurement of Overall Assessment of Functioning The SCID includes a Global Assessment of Functioning Scale (GAF Scale) [3]. The GAF Scale provides a global assessment of current psychologic, social, and occupational functioning on a 90-point continuum ranging from positive mental health (scores of 70 and above) to severe impairment. Scores below 40 are usually found among hospitalized psychiatric patients [17]. GAF scores
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J.B.W. Williams and J.G. Rabkin indicate the lowest level of functioning during the week of poorest functioning in the month prior to the interview.
Quality-of-Life Measure The Spitzer et al. Quality of Life Index (QLI) (Appendix A) was chosen for inclusion in this study because it is brief, does not require a significant amount of training of the raters, covers a range of domains, and has adequate psychometric characteristics [1]. The QLI was developed in an effort to supplement "hard" data (e.g., recurrence and survival rates) in treatment studies of cancer and other chronic diseases. It was hoped that the instrument would be useful for assessing the risks and benefits of different treatments and treatment programs, such as hospice programs. The QLI was developed in consultation with panels of healthy people, relatives of patients with cancer and (other) chronic diseases, health-care workers, and patients themselves. The instrument went through several major drafts that were each pretested on large samples. The final items were chosen from groupings that emerged from the previous analyses, and that preserved simplicity and feasibility. The QLI covers five domains: involvement in own occupation (activity), activities of daily living (daily living), perception of own health (health), support of family and friends (support), and outlook on life (outlook). These domains cover physical, social, and emotional aspects of life. Each is represented by a single item scored 2 (for highest level of functioning), 1, or 0. A total score, ranging from 0 to 10, is the sum of item scores. The content validity of the QLI domains was assessed by two groups w h o were asked to assess the appropriateness, sufficiency, importance, and the likely discriminative ability of each. Construct validation was achieved by comparing the QLI to a very simple unidimensional scale and a comprehensive multidimensional questionnaire, all administered simultaneously to a group of participants. Discriminative construct validity was confirmed by the QLI ratings of physicians on groups of progressively more ill patients, with a finding of diminishing QLI mean scores as the health status of the patients decreased. The intemal consistency of the items in the QLI was assessed by calculating Cronbach's alpha on the intercorrelations of the item scores that were obtained. Cronbach's alpha was 0.78, indicating a clear relationship among the items, while still preserving distinctiveness. Interrater agreement was measured by comparing the ratings of paired physicians w h o applied the QLI independently to a series of patients, with a test-retest interval of within seven days. With a sample of 64 patients, this study yielded a correlation coefficient of 0.81. In an additional study, physician QLI ratings were compared with patients' ratings based on a self-administered format of the Index. With a sample of 161 patients in Australia, Spearman's rho -- 0.61; a study with a sample of 51 Canadian patients yielded a rho = 0.69. Clearly, all of these indices of agreement indicate substantial reliability for the QLI. The authors of the QLI conclude, based on their tests, that the QLI is "valid for patients with definite disease," that it "discriminates between healthy
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subjects and diseased patients," and that it "may well achieve the objective of helping physicians to assess relative benefits and risks of various treatments in diseased subjects." For these reasons, the QLI seemed a suitable instrument for use in the Follow-up Study, and an instrument worth studying for its potential value in controlled clinical trials as a generic discriminative and evaluative measure of health-related quality of life.
Testing the Validity of the QLI Items In the Follow-up Study, the QLI was completed at the end of each interview by the clinical interviewer, who based his or her ratings on all of the information collected in the entire two-hour psychiatric/psychosocial interview. Because the QLI was rated simultaneously with the information collected by the other instruments, we can examine the "concurrent" construct validity of the QLI items. RESULTS
Sample Fifty gay men were rated on the QLI; 29 of them were HIV +, and 21 were HIV - . Ninety percent of the total sample of 208 (of which the 50 in this study are a subset) were white; 62% graduated from college and 26% had graduate or professional degrees. The average annual household income was $47,000. The average age of the total sample was 39, with a range from 22 to 59. In terms of sexual orientation, in the total sample 92% described themselves as exclusively homosexual, and 8% as bisexual.
Intercorrelations of QLI Items Although in this sample, the QLI items "activity," was uncorrelated with "health," "support" and "outlook," "outlook" was significantly correlated with both "health" and "support," and all items were substantially correlated with the QLI total score (Table 2).
Table 2 Intercorrelations of Quality of Life Index Items (n = 50) Activity Health Support Outlook
Health
Support
Outlook
QL Total
0.17
0.07 0.07
0.24 0.64a 0.40~
0.49~ 0.69~ 0.62a 0.86a
ap < 0.01 (two-tailed).
Did the QLI Discriminate Between HIV + and H I V - Groups? The frequencies of scores on each QLI item for both HIV + and H W groups are presented in Table 3. Although for each QLI item there is a trend in which a higher proportion of the H I V - group received a higher score,
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J.B.W. Williams and J.G. Rabkin there are no statistically significant differences (using chi-square) b e t w e e n the groups. The m e a n QLI total score for the HIV + subjects was 8.69; for the H I V - sample 9.38, not a meaningful or statistically significant difference. Therefore, in this study sample, the QLI did not discriminate b e t w e e n relatively asymptomatic HIV + subjects a n d those not infected by HIV.
Table 3 QLI item
Frequencies of Scores on QLI Items ( H I V - subjects, N = 21 / HIV + subjects, N = 29)a Activity
Health
Support
Outlook
score b
HIV +
HIV -
HW +
HW -
HIV +
HIV -
HIV +
HW -
2 1 0
79 (23) 17 (5) 3 (1)
100 (21) 0 0
62 (18) 38 (11) 0
71 (15) 29 (6) 0
86 (25) 3 (1) 10 (3)
95 (20) 0 5 (1)
59 (17) 38 (11) 3 (1)
76 (16) 24 (5) 0
aPercentages given; n u m b e r of participants in parentheses. bA score of 2 indicates highest functioning; 0 indicates lowest.
Hypotheses About QLI Activity Item Table 4 presents correlations between the QLI item about daily activity (working, studying, or managing a household) and the variables we hypothesized w o u l d be related to it. As can be seen, in the total sample, there were modest but statistically significant correlations b e t w e e n this QLI item a n d both our medical staging scale and the Global Assessment of Functioning Scale, a measure of overall functioning that includes psychologic, social, a n d occupational functioning.
Table 4
Correlations of QLI Activity a n d Health Items With Other Variables (n = 50)
QLI, Item/Other Variable Activity/medical stage Activity/GAF Health/medicabstage
T
-0.41 (p = 0.003) 0.36 (p = 0.01) -0.14 (NS)
Hypothesis About QLI Health Item Surprisingly, a n d despite the obvious similarity in content, there appeared to be no relationship between the QLI item rating physical health a n d the medical staging scale used in the Follow-up Study (Table 4).
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Cohort of HW-Positive and HIV-Negative Men Table 5
Correlations of QLI Support Item with Social Support Scale (N= 50) QLI Support Item Total samples a
Total Social Support Scale score Social support subscales Perceived emotional support Perceived material support Affirmation Subjective social integration Objective social integration Social conflict
0.72 0.69 0.69 0.47 0.47 0.34 - 0.45
aAll correlations p < 0.05 (two-tailed).
Hypotheses About QLI Support Item Not surprisingly, as seen in Table 5, the QLI support item was highly and significantly correlated with the total Social Support Scale score. Correlations with all of the subscales were also statistically significant, and all correlations but one (with the objective social integration subscale) were substantial. Correlation with the social conflict subscale, as expected, was in the negative direction, indicating that the greater the support rated on the QLI item, the less the social conflict in the individual's personal relationships. For comparison, Table 6 presents the intercorrelations in this sample of all the instrument's subscales. Table 6
Intercorrelations of Social Support Subscales
Subscale Perceived emotional support Perceived material support Affirmation Subjective social integration Objective social integration Social conflict
Perc. mat. supp. 0.81
Aff.
Subj. soc. integ,
Obj. soc. integ,
Soc. conflict
Total soc. supp. score
0.64
0.52
0.30
- 0.45
0.87
0.49
0.41
0.20
-0.44
0.79
0.54
0.36 0.44
- 0.50 -0.50
0.81 0.83
-0.30
0.56 - 0.69
Hypotheses About QLI Outlook Item As indicated in Table 7, the QLI outlook item was significantly correlated with most of the measures of psychopathology (depression, anxiety, distress, and hopelessness). There was little or no relationship between the item a n d our measures of grief, and anhedonia or pleasure.
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Table
Correlations of QLI Outlook Item with Psychosocial Measures (n = 50) Psychosocial Measure
Depression HDRS score BSI subscale score Anxiety HARS score BSI generalized anxiety subscale BSI phobic anxiety subscale BSI global severity index BSI distress scale Hopelessness scale Grief scale Pleasure scale
Total Sample -0.68 a 0.61a
-
- 0.63a -0.63 a -0.57 a ,0.67 a - 0.52° -0.51 ~ -0.20 NS 0.02 NS
ap <0.05 (two-tailed). DISCUSSION The table of intercorrelations of the QLI items in this sample (Table 2) indicates that, although all of the items were significantly related to the total scale score, they each contribute specific information. The QLI was not intended for the measurement of quality of life in ostensibly healthy people. Although the HIV + subjects in the Follow-up Study are certainly not totally healthy, they were selected for this study only if they were currently asymptomatic or had only mild current symptoms of the infection. Therefore, it is not surprising that the QLI scores did not differentiate the HIV + subjects from those who are H I V - at this baseline evaluation (Table 3). As the disease progresses in some of our participants, we would expect the Index scores of the two groups to diverge. Most of our a priori hypotheses were confirmed. The relevant QLI items were related, in the expected directions, to the corresponding Follow-up Study instruments. This suggests that, at least in the areas we were able to test (i.e., all except the QLI daily living item), the Quality of Life Index does successfully measure different areas of functioning. For example, the concurrent validity of the QLI support item is supported by the high correlations between this item and the subscales and total scale score of Wortman's Social Support Scale (Table 5). Based on these findings, we conclude that the Quality of Life Index provides a reasonable measure of several areas of functioning that have traditionally been summed and equated to. quality of life. This study was supported in part by NIMH/NIDAGrant #1PS0 MH 43520, HIV Center for Clinical and Behavioral Studies, Anke A. Ehrhardt, PhD, Center Principal Investigator, lack Gorman, MD, Project Principal Investigator.
APPENDIX
A
(Spitzer WO, Dobson AJ, Hall J, Chesterman E, Levi J, Shepherd R, Battista RN, Catchlove BR: Measuring the quality of life of cancer patients: A concise QL-index for use by physicians. J Chronic Dis 34:585-597, 1981.)
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Score each heading 2, 1 or 0 according to y o u r m o s t recent assessment of the subject.
Activity
During the last week the subject - - has b e e n working or studying full-time, or nearly so, in usual occupation; or managing o w n household; or participating in u n p a i d or v o l u n t a r y activities, w h e t h e r retired or not . . . . . . . . . . . . . . . . . . . . . . - - has b e e n working or studying in usual occupation or m a n a g i n g o w n h o u s e h o l d or participating in u n p a i d or v o l u n t a r y activities; but requiring major assistance or a significant reduction in h o u r s w o r k e d or a sheltered situation or was on sick leave . . . . . . . . . . . . . . . . . . . . - - has not been working or studying in a n y capacity a n d not m a n a g i n g own household ..............................................
2
Daily Living
During the last week, the subject - - has b e e n self-reliant in eating, washing, toiletting a n d dressing; using u
public transportation or driving o w n car . . . . . . . . . . . . . . . . . . . . . . . . has been requiring assistance (another p e r s o n or special e q u i p m e n t ) for daily activities and transport but p e r f o r m i n g light tasks . . . . . . . has not b e e n managing personal care nor light tasks and/or not leaving o w n h o m e or institution at all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health
During the last week, the subject - - has been appearing to feel well or reporting feeling "great" m o s t of the time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - has been lacking e n e r g y or not feeling entirely " u p to par" m o r e than just occasionally . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - has b e e n feeling very ill or "lousy," seeming w e a k and w a s h e d out most of the time or was unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . .
Support
During the last week the subject has b e e n having good relationships with others and receiving strong s u p p o r t from at least one family m e m b e r and/or friend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s u p p o r t received or perceived has b e e n limited from family a n d / o r friends b y the subject's condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s u p p o r t from family and friends occurred infrequently or only w h e n absolutely necessary or subject was unconscious . . . . . . . . . . . . . . . .
2 1 0
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Outlook
During the past week the subject - - has usually been appearing calm and positive in outlook, accepting and in control of personal circumstances, including surroundings - - has sometimes been troubled because not fully in control of personal circumstances or has been having periods of obvious anxiety or depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - has been seriously confused or very frightened or consistently anxious and depressed or unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
1 0
Quality of Life Index Total H o w confident are y o u that y o u r scoring of the preceding dimensions is accurate? Please circle the appropriate category. Absolutely Confident 1
Very Confident 2
Quite Confident 3
Not Very Confident 4
Very Doubtful 5
Not at all Confident 6
REFERENCES 1. Spitzer WO, Dobson AJ, Hall J, Chesterman E, Levi J, Shepherd R, Battista RN, Catchlove BR: Measuring the quality of life of cancer patients: A concise QL-index for use by physicians. J Chronic Dis 34:585-597, 1981 2. Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-III-R (SCID)---Non-patient HIV Version, Biometrics Research Department, New York State Psychiatric Institute, 1987 3. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed-rev (DSM-III-R). Washington, DC, American Psychiatric Press, 1987 4. Hamilton M: A rating scale for depression. J Neurol, Neurosurg, Psychiatry 23:5662, 1960 5. Carroll BJ, Fielding JM, Blashki TG: Depression rating scales: A critical review. Arch Gen Psychiatry 28:361-366, 1973 6. Hedlund JL, Vieweg BW: The Hamilton rating scale for depression: A comprehensive review. J Oper Psychiatry 10:149-165, 1979 7. Williams JBW: A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry 45:742-747, 1988 8. Fyer AJ, Mannuzza S, Endicott J: Differential diagnosis and assessment of anxiety: Recent developments. In: Psychopharmacology--The Third Generation of Progress, Meltzer HY, Ed. New York, Raven, 1987, pp 1177-1191 9. Hamilton M: The assessment of anxiety states by rating. Br J Med Psychol 32:5055, 1959 10. Derogatis LR, Melisaratos N: The Brief Symptom Inventory: An introductory report. Psychol Med 13:595-605, 1983 11. Rabkin JG: Stressful life events in schizophrenia: A review of the research literature. Psychol Bull 87:408-425, 1980 12. Rabkin J: Stress and psychiatric disorders. In: Handbook of Stress, Goldberger L, Breznitz S, Eds. New York, Free Press, 1982, pp 566-584
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13. Wortman CB: Coping and change: A survey of Chicago men. Collaborative Howard Brown Memorial Clinic, University of Michigan, Ann Arbor, MI, 1987 14. Beck AT, Weissman A, Lester D, Trexler: The measurement of pessimism: The Hopelessness Scale. J Consult and Clin Psychol 42:861-865, 1974 15. Faschingbauer TR, DeVaul RA, Zisook S: Development of the Texas Revised Inventory of Grief. Am J Psychiatry 134:696-698, 1977 16. Fawcett J, Clark D, Scheftner W, Gibbons R: Assessing anhedonia in psychiatric patients: The Pleasure Scale. Arch Gen Psychiatry 40:79-84, 1983 17. Endicott J, Spitzer RL, Fleiss J, Cohen J: The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 33:766-771, 1976
ABSTRACT: The concurrent validity of the Quality-of-Life Index (QLI) is examined by comparing it with other standard measures of psychopathology and psychosocial and physical functioning in a sample of HIV-positive (HIV + ) and HIV-negative (HIV-) men. Fifty gay men (29 HIV+ and 21 H I V - ) were assessed on the QLI and a number of other instruments covering medical, psychological, and social factors in order to examine the validity of the five domains (activity, health, support, outlook, and daily living) of the QLI as a measure of health-related quality of life. A highly significant correlation was found between the support domain of the QLI and the Social Supports Scale. A significant correlation was found between the QLI outloook domain and most measures of psychopathology including depression, anxiety, distress, and hopelessness. A modest but significant correlation was found between the activity domain of the QLI and a medical staging scale, and the Global Assessment of Functioning Scale. It can be concluded that the QLI successfully measures different areas of functioning related to quality of life. KEY WORDS: Health status, quality-of-life measures, AIDS
INTRODUCTION A primary objective of this conference is to define criteria for choosing a m o n g quality-of-life measures for use in clinical trials. The criteria will be based on evidence about the performance characteristics of the various measures to be considered. An informed choice of m e a s u r e s m u s t be, at least in part, based on evidence of reliability and validity. In this paper, the c o n c u r r e n t validity of the Quality of Life Index [1] is e x a m i n e d by c o m p a r i n g it with other standard measures of p s y c h o p a t h o l o g y a n d psychosocial functioning in a v o l u n t e e r sample of HW-positive (HIV + ) a n d HIV-negative ( H I V - ) gay men. The AIDS epidemic has b e e n a catastrophic experience for m e m b e r s of the gay c o m m u n i t y . An u n d e r s t a n d i n g of the personal a n d e n v i r o n m e n t a l factors that influence the risks of transmission a n d rates of disease progression is crucial to the p r e v e n t i o n a n d m a n a g e m e n t of the illness. It is in this context
Address reprint requests to: Dr. J. Williams, Box 74, 722 West 168 Street, New York, NY 10032. ReceivedJuly 11, 1990; revised March 25, 1991.
ControlledClinicalTrials12:129S-141S(1991) © ElsevierSciencePublishingCo., Inc. 1991 655 Avenueof the Americas,New York, New York10010
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J.B.W. Williams and J.G. Rabkin that the present study was conceived. In the fall of 1987, NIMH funds established the HIV Center for Clinical and Behavioral Studies at Columbia University and collaborating institutions. One of its major research projects is the Follow-up Project, a prospective study of HIV + and H I V - gay men. The study is designed to examine the natural history of HIV infection and to identify factors that may influence disease progression. Medical, neurologic, neuropsychologic, psychiatric, psychosocial, and psychosexual factors will be evaluated every six months for five years. The authors of this paper are involved in the Psychiatric/Psychosocial Assessment Core of the HIV Center, and their role in the Follow-up Project is to design assessments to explore psychiatric and psychosocial factors that are most likely related to progression of HIV infection. Measures that cover a wide range of relevant domains have been included in the assessments. A quality-of-life measure was added to the battery of instruments because an individual's quality of life may mediate disease progression, and because the project provided an opportunity to study the psychometric properties of such an instrument with this population. The variety and scope of measures provide a valuable opportunity to examine the validity of the components of our quality-of-life measure by comparing them to other, more detailed measures of the same domains.
METHOD Sample Recruitment Participants were gay men who volunteered for this study. They were required to have prior knowledge of their HIV antibody status and not to have a diagnosis of AIDS at study entry. (They responded to announcements about the study in newletters of two local gay organizations and a notice in a commercial newspaper with a predominantly gay readership.)
Procedure Each participant was seen for a full day of assessments that included neurologic and medical examinations and blood work (with a confirmatory HIV test), psychiatric, psychosocial, and psychosexual interviews, and neuropsychological tests. All participants gave written informed consent and were paid $10/hour for their time. One week prior to interview, each participant was sent a packet of selfreport measures to complete and bring to his appointment. Clinicians were masked to the results of these self-report questionnaires. A list of questionnaires administered to the participants appears in Table 1; the various instruments are described below. Interviewers were trained to conduct the psychiatric, psychosocial (including the quality-of-life measure), and psychosexual interviews. All were master's level clinicians or above, and all had had prior extensive clinical experience, although not necessarily with this population. Because of our commitment to the highest possible quality of evaluations, nearly all interviews were supervised either in person or on audiotape by a senior clinician.
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Table 1 Psychiatric and Psychosocial Assessment Questionnaires Administered by Questionnaire Clinician Structured Clinical Interview for DSM-III-R (SCID) Hamilton Depression Rating Scale (HDRS) Hamilton Anxiety Rating Scale (HARS) Global Assessment of Functioning Scale (GAF) Quality of Life Index (QLI) Self Brief Symptom Inventory (BSI) Social Support Scale Hopelessness Scale Texas Revised Inventory of Grief Scale Pleasure Scale Most of the interviews were discussed by the senior clinician the interviewer so that final diagnostic decisions and ratings on all instruments reflect consensus judgments between two clinicians.
Medical Staging Scale The purpose of this scale is to assess the severity of physical symptoms potentially related to HW infection. (Neurologic, neuropsychologic, and psychiatric symptoms are not considered, and may be present at any stage in the scale.) The medical staging scale is one key outcome variable in this study of risk and protective factors influencing disease progression. Scale scores are based on two sets of data: medical history taken by a nurse, and physical examination conducted by a physician masked to the participant's HIV status until the conclusion of the exam. Scores are assigned by the examining physician, based on the physical exam and the medical history. A second physician later reviews all data and generates an independent scale score. In cases of discrepancy, a consensus is reached through joint review of the data by both physicians involved.
Diagnostic Evaluations The Structured Clinical Interview for DSM-III-R (SCID) was chosen as the major diagnostic instrument [2]. The SCID is a general clinical interview guide that enables clinicians to gather appropriate information to make a diagnosis according to the third edition-revised of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) [3].
Severity of Depressive Symptoms An important strategy in evaluation is the inclusion of measures of the severity of psychopathology. Such measures are useful both for data analysis purposes in comparing different samples of participants, and for following participants over time. Because the SCID is by and large limited to diagnostic judgments, it does not contain severity scales. Depression and anxiety are generally acknowledged to be the most prevalent areas of psychopathology
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J.B.W. Williams and J.G. Rabkin in this population, so the severity of symptomatology present in these two areas was given special attention. The Hamilton Depression Rating Scale (HDRS) [4] is the preeminent clinician-rated scale measuring severity of depressive symptoms. In numerous studies, the total HDRS score has proven reliable and to have a high degree of validity [5, 6]. We chose to use the Structured Interview Guide for the Hamilton Depression Rating Scale (SIGHD) developed by Williams [7], since it has been demonstrated to increase the reliability of the scale items and to facilitate training. The 17-item version is used, with a time frame of the past week. Based on broad experience, mild depression is defined by scores in the 10-14 range, while scores below seven are often used as the definition of recovery or not depressed.
Anxiety No single scale adequately measures the severity of anxiety symptoms, given our current recognition of the many different types of anxiety, such as generalized anxiety, panic attacks, and phobic dread or fear [8]. There are, however, several scales available for measuring the severity of each of these different types of anxiety. The Hamilton Anxiety Scale [9] was chosen for this study because it covers several different types of anxiety, and because it is fairly widely used, enabling us to compare our results with those of other studies. For this study, we developed an interview guide for this rating scale similar to that developed for the HDRS [7].
Self-Report Measures of Severity of Psychopathology In order to correct for possible examiner bias, a self-report measure of symptom severity was also used. The 53-item version of the SCL-90, the Brief Symptom Inventory [10], is a widely-used self-rating scale that provides subscale scores in nine symptom areas, focusing on the past week. Higher scores signify greater symptomatology.
Social Supports Numerous studies have shown that social factors and life events are associated with the onset or exacerbation of mental and physical disorders [11, 12], and even survival. More recently, the impact of environmental, social, psychologic, and physiologic stresses on immunologic status and susceptibility to infectious diseases has received attention in a new field called psychoneuroimmunology. We chose the Social Support Scale [13] developed by Wortman for the Coping and Change Project, a longitudinal, psychosocial study of a Chicago cohort of gay and bisexual men that is part of the Multicenter AIDS Cohort Study (MACS). This scale assesses six different components of social support: perceived availability of emotional and material support, objective and subjective social integration, affirmation (e.g., others think "it's all right to feel what you're feeling"), and social conflict. A total Social Support Scale score is derived by summing scores on the first five subscales. The scale was de-
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veloped specifically for use in a sample such as ours, and as such, contained items that seemed particularly relevant for our cohort.
Hopelessness The struggle to maintain hope has been described as one of the most striking and recurrent themes faced by clinicians working with HIV-spectrum people. Hope (or hopelessness) is believed to be related to psychiatric status, endocrine function, and immunologic function. In the present study we chose Beck and colleagues' 20-item Hopelessness Scale to measure this variable [14]. This self-rated scale with a True/False format was designed to "reflect different facets of the spectrum of negative attitudes about the future." Three factors have been identified in the scale: feelings about the future, giving up, and future expectations (a cognitive dimension). Nine items are keyed "False" and 11 items are keyed "True"; the total hopelessness score is the sum of items keyed in the "hopeless" direction. Therefore, low scores signify hope, defined as faith that good times lie ahead and that the respondent continues to have a fighting spirit.
Grief Because so many of our subjects had recently lost close friends and lovers through death because of AIDS, grief was a salient stressor to be measured. Therefore, each subject who reported losing a lover, close friend, or relative from AIDS completed a modified version of the Texas Revised Inventory of Grief [15].
Pleasure/Anhedonia Our assessment battery obviously focuses mainly on factors that are sources of distress. After the first few interviews were completed, we found that subjects were leaving the interview reflecting mainly on negative aspects of their lives. Therefore, in order to end the interview on a more upbeat note, and to add more balance to the tone of our instrument battery, we added the Pleasure Scale of Fawcett et al. [16]. This scale asks respondents to note how much pleasure each situation described would have given them during the past week. The situations are things such as: "You sit watching a beautiful sunset in an isolated, untouched part of the world," and "You come to the end of a difficult and complicated task without having made a single mistake." Feedback from subjects was very positive about the addition of this scale.
Measurement of Overall Assessment of Functioning The SCID includes a Global Assessment of Functioning Scale (GAF Scale) [3]. The GAF Scale provides a global assessment of current psychologic, social, and occupational functioning on a 90-point continuum ranging from positive mental health (scores of 70 and above) to severe impairment. Scores below 40 are usually found among hospitalized psychiatric patients [17]. GAF scores
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J.B.W. Williams and J.G. Rabkin indicate the lowest level of functioning during the week of poorest functioning in the month prior to the interview.
Quality-of-Life Measure The Spitzer et al. Quality of Life Index (QLI) (Appendix A) was chosen for inclusion in this study because it is brief, does not require a significant amount of training of the raters, covers a range of domains, and has adequate psychometric characteristics [1]. The QLI was developed in an effort to supplement "hard" data (e.g., recurrence and survival rates) in treatment studies of cancer and other chronic diseases. It was hoped that the instrument would be useful for assessing the risks and benefits of different treatments and treatment programs, such as hospice programs. The QLI was developed in consultation with panels of healthy people, relatives of patients with cancer and (other) chronic diseases, health-care workers, and patients themselves. The instrument went through several major drafts that were each pretested on large samples. The final items were chosen from groupings that emerged from the previous analyses, and that preserved simplicity and feasibility. The QLI covers five domains: involvement in own occupation (activity), activities of daily living (daily living), perception of own health (health), support of family and friends (support), and outlook on life (outlook). These domains cover physical, social, and emotional aspects of life. Each is represented by a single item scored 2 (for highest level of functioning), 1, or 0. A total score, ranging from 0 to 10, is the sum of item scores. The content validity of the QLI domains was assessed by two groups w h o were asked to assess the appropriateness, sufficiency, importance, and the likely discriminative ability of each. Construct validation was achieved by comparing the QLI to a very simple unidimensional scale and a comprehensive multidimensional questionnaire, all administered simultaneously to a group of participants. Discriminative construct validity was confirmed by the QLI ratings of physicians on groups of progressively more ill patients, with a finding of diminishing QLI mean scores as the health status of the patients decreased. The intemal consistency of the items in the QLI was assessed by calculating Cronbach's alpha on the intercorrelations of the item scores that were obtained. Cronbach's alpha was 0.78, indicating a clear relationship among the items, while still preserving distinctiveness. Interrater agreement was measured by comparing the ratings of paired physicians w h o applied the QLI independently to a series of patients, with a test-retest interval of within seven days. With a sample of 64 patients, this study yielded a correlation coefficient of 0.81. In an additional study, physician QLI ratings were compared with patients' ratings based on a self-administered format of the Index. With a sample of 161 patients in Australia, Spearman's rho -- 0.61; a study with a sample of 51 Canadian patients yielded a rho = 0.69. Clearly, all of these indices of agreement indicate substantial reliability for the QLI. The authors of the QLI conclude, based on their tests, that the QLI is "valid for patients with definite disease," that it "discriminates between healthy
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subjects and diseased patients," and that it "may well achieve the objective of helping physicians to assess relative benefits and risks of various treatments in diseased subjects." For these reasons, the QLI seemed a suitable instrument for use in the Follow-up Study, and an instrument worth studying for its potential value in controlled clinical trials as a generic discriminative and evaluative measure of health-related quality of life.
Testing the Validity of the QLI Items In the Follow-up Study, the QLI was completed at the end of each interview by the clinical interviewer, who based his or her ratings on all of the information collected in the entire two-hour psychiatric/psychosocial interview. Because the QLI was rated simultaneously with the information collected by the other instruments, we can examine the "concurrent" construct validity of the QLI items. RESULTS
Sample Fifty gay men were rated on the QLI; 29 of them were HIV +, and 21 were HIV - . Ninety percent of the total sample of 208 (of which the 50 in this study are a subset) were white; 62% graduated from college and 26% had graduate or professional degrees. The average annual household income was $47,000. The average age of the total sample was 39, with a range from 22 to 59. In terms of sexual orientation, in the total sample 92% described themselves as exclusively homosexual, and 8% as bisexual.
Intercorrelations of QLI Items Although in this sample, the QLI items "activity," was uncorrelated with "health," "support" and "outlook," "outlook" was significantly correlated with both "health" and "support," and all items were substantially correlated with the QLI total score (Table 2).
Table 2 Intercorrelations of Quality of Life Index Items (n = 50) Activity Health Support Outlook
Health
Support
Outlook
QL Total
0.17
0.07 0.07
0.24 0.64a 0.40~
0.49~ 0.69~ 0.62a 0.86a
ap < 0.01 (two-tailed).
Did the QLI Discriminate Between HIV + and H I V - Groups? The frequencies of scores on each QLI item for both HIV + and H W groups are presented in Table 3. Although for each QLI item there is a trend in which a higher proportion of the H I V - group received a higher score,
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J.B.W. Williams and J.G. Rabkin there are no statistically significant differences (using chi-square) b e t w e e n the groups. The m e a n QLI total score for the HIV + subjects was 8.69; for the H I V - sample 9.38, not a meaningful or statistically significant difference. Therefore, in this study sample, the QLI did not discriminate b e t w e e n relatively asymptomatic HIV + subjects a n d those not infected by HIV.
Table 3 QLI item
Frequencies of Scores on QLI Items ( H I V - subjects, N = 21 / HIV + subjects, N = 29)a Activity
Health
Support
Outlook
score b
HIV +
HIV -
HW +
HW -
HIV +
HIV -
HIV +
HW -
2 1 0
79 (23) 17 (5) 3 (1)
100 (21) 0 0
62 (18) 38 (11) 0
71 (15) 29 (6) 0
86 (25) 3 (1) 10 (3)
95 (20) 0 5 (1)
59 (17) 38 (11) 3 (1)
76 (16) 24 (5) 0
aPercentages given; n u m b e r of participants in parentheses. bA score of 2 indicates highest functioning; 0 indicates lowest.
Hypotheses About QLI Activity Item Table 4 presents correlations between the QLI item about daily activity (working, studying, or managing a household) and the variables we hypothesized w o u l d be related to it. As can be seen, in the total sample, there were modest but statistically significant correlations b e t w e e n this QLI item a n d both our medical staging scale and the Global Assessment of Functioning Scale, a measure of overall functioning that includes psychologic, social, a n d occupational functioning.
Table 4
Correlations of QLI Activity a n d Health Items With Other Variables (n = 50)
QLI, Item/Other Variable Activity/medical stage Activity/GAF Health/medicabstage
T
-0.41 (p = 0.003) 0.36 (p = 0.01) -0.14 (NS)
Hypothesis About QLI Health Item Surprisingly, a n d despite the obvious similarity in content, there appeared to be no relationship between the QLI item rating physical health a n d the medical staging scale used in the Follow-up Study (Table 4).
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Correlations of QLI Support Item with Social Support Scale (N= 50) QLI Support Item Total samples a
Total Social Support Scale score Social support subscales Perceived emotional support Perceived material support Affirmation Subjective social integration Objective social integration Social conflict
0.72 0.69 0.69 0.47 0.47 0.34 - 0.45
aAll correlations p < 0.05 (two-tailed).
Hypotheses About QLI Support Item Not surprisingly, as seen in Table 5, the QLI support item was highly and significantly correlated with the total Social Support Scale score. Correlations with all of the subscales were also statistically significant, and all correlations but one (with the objective social integration subscale) were substantial. Correlation with the social conflict subscale, as expected, was in the negative direction, indicating that the greater the support rated on the QLI item, the less the social conflict in the individual's personal relationships. For comparison, Table 6 presents the intercorrelations in this sample of all the instrument's subscales. Table 6
Intercorrelations of Social Support Subscales
Subscale Perceived emotional support Perceived material support Affirmation Subjective social integration Objective social integration Social conflict
Perc. mat. supp. 0.81
Aff.
Subj. soc. integ,
Obj. soc. integ,
Soc. conflict
Total soc. supp. score
0.64
0.52
0.30
- 0.45
0.87
0.49
0.41
0.20
-0.44
0.79
0.54
0.36 0.44
- 0.50 -0.50
0.81 0.83
-0.30
0.56 - 0.69
Hypotheses About QLI Outlook Item As indicated in Table 7, the QLI outlook item was significantly correlated with most of the measures of psychopathology (depression, anxiety, distress, and hopelessness). There was little or no relationship between the item a n d our measures of grief, and anhedonia or pleasure.
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Table
Correlations of QLI Outlook Item with Psychosocial Measures (n = 50) Psychosocial Measure
Depression HDRS score BSI subscale score Anxiety HARS score BSI generalized anxiety subscale BSI phobic anxiety subscale BSI global severity index BSI distress scale Hopelessness scale Grief scale Pleasure scale
Total Sample -0.68 a 0.61a
-
- 0.63a -0.63 a -0.57 a ,0.67 a - 0.52° -0.51 ~ -0.20 NS 0.02 NS
ap <0.05 (two-tailed). DISCUSSION The table of intercorrelations of the QLI items in this sample (Table 2) indicates that, although all of the items were significantly related to the total scale score, they each contribute specific information. The QLI was not intended for the measurement of quality of life in ostensibly healthy people. Although the HIV + subjects in the Follow-up Study are certainly not totally healthy, they were selected for this study only if they were currently asymptomatic or had only mild current symptoms of the infection. Therefore, it is not surprising that the QLI scores did not differentiate the HIV + subjects from those who are H I V - at this baseline evaluation (Table 3). As the disease progresses in some of our participants, we would expect the Index scores of the two groups to diverge. Most of our a priori hypotheses were confirmed. The relevant QLI items were related, in the expected directions, to the corresponding Follow-up Study instruments. This suggests that, at least in the areas we were able to test (i.e., all except the QLI daily living item), the Quality of Life Index does successfully measure different areas of functioning. For example, the concurrent validity of the QLI support item is supported by the high correlations between this item and the subscales and total scale score of Wortman's Social Support Scale (Table 5). Based on these findings, we conclude that the Quality of Life Index provides a reasonable measure of several areas of functioning that have traditionally been summed and equated to. quality of life. This study was supported in part by NIMH/NIDAGrant #1PS0 MH 43520, HIV Center for Clinical and Behavioral Studies, Anke A. Ehrhardt, PhD, Center Principal Investigator, lack Gorman, MD, Project Principal Investigator.
APPENDIX
A
(Spitzer WO, Dobson AJ, Hall J, Chesterman E, Levi J, Shepherd R, Battista RN, Catchlove BR: Measuring the quality of life of cancer patients: A concise QL-index for use by physicians. J Chronic Dis 34:585-597, 1981.)
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Score each heading 2, 1 or 0 according to y o u r m o s t recent assessment of the subject.
Activity
During the last week the subject - - has b e e n working or studying full-time, or nearly so, in usual occupation; or managing o w n household; or participating in u n p a i d or v o l u n t a r y activities, w h e t h e r retired or not . . . . . . . . . . . . . . . . . . . . . . - - has b e e n working or studying in usual occupation or m a n a g i n g o w n h o u s e h o l d or participating in u n p a i d or v o l u n t a r y activities; but requiring major assistance or a significant reduction in h o u r s w o r k e d or a sheltered situation or was on sick leave . . . . . . . . . . . . . . . . . . . . - - has not been working or studying in a n y capacity a n d not m a n a g i n g own household ..............................................
2
Daily Living
During the last week, the subject - - has b e e n self-reliant in eating, washing, toiletting a n d dressing; using u
public transportation or driving o w n car . . . . . . . . . . . . . . . . . . . . . . . . has been requiring assistance (another p e r s o n or special e q u i p m e n t ) for daily activities and transport but p e r f o r m i n g light tasks . . . . . . . has not b e e n managing personal care nor light tasks and/or not leaving o w n h o m e or institution at all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health
During the last week, the subject - - has been appearing to feel well or reporting feeling "great" m o s t of the time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - has been lacking e n e r g y or not feeling entirely " u p to par" m o r e than just occasionally . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - has b e e n feeling very ill or "lousy," seeming w e a k and w a s h e d out most of the time or was unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . .
Support
During the last week the subject has b e e n having good relationships with others and receiving strong s u p p o r t from at least one family m e m b e r and/or friend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s u p p o r t received or perceived has b e e n limited from family a n d / o r friends b y the subject's condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s u p p o r t from family and friends occurred infrequently or only w h e n absolutely necessary or subject was unconscious . . . . . . . . . . . . . . . .
2 1 0
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Outlook
During the past week the subject - - has usually been appearing calm and positive in outlook, accepting and in control of personal circumstances, including surroundings - - has sometimes been troubled because not fully in control of personal circumstances or has been having periods of obvious anxiety or depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - has been seriously confused or very frightened or consistently anxious and depressed or unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
1 0
Quality of Life Index Total H o w confident are y o u that y o u r scoring of the preceding dimensions is accurate? Please circle the appropriate category. Absolutely Confident 1
Very Confident 2
Quite Confident 3
Not Very Confident 4
Very Doubtful 5
Not at all Confident 6
REFERENCES 1. Spitzer WO, Dobson AJ, Hall J, Chesterman E, Levi J, Shepherd R, Battista RN, Catchlove BR: Measuring the quality of life of cancer patients: A concise QL-index for use by physicians. J Chronic Dis 34:585-597, 1981 2. Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-III-R (SCID)---Non-patient HIV Version, Biometrics Research Department, New York State Psychiatric Institute, 1987 3. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed-rev (DSM-III-R). Washington, DC, American Psychiatric Press, 1987 4. Hamilton M: A rating scale for depression. J Neurol, Neurosurg, Psychiatry 23:5662, 1960 5. Carroll BJ, Fielding JM, Blashki TG: Depression rating scales: A critical review. Arch Gen Psychiatry 28:361-366, 1973 6. Hedlund JL, Vieweg BW: The Hamilton rating scale for depression: A comprehensive review. J Oper Psychiatry 10:149-165, 1979 7. Williams JBW: A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry 45:742-747, 1988 8. Fyer AJ, Mannuzza S, Endicott J: Differential diagnosis and assessment of anxiety: Recent developments. In: Psychopharmacology--The Third Generation of Progress, Meltzer HY, Ed. New York, Raven, 1987, pp 1177-1191 9. Hamilton M: The assessment of anxiety states by rating. Br J Med Psychol 32:5055, 1959 10. Derogatis LR, Melisaratos N: The Brief Symptom Inventory: An introductory report. Psychol Med 13:595-605, 1983 11. Rabkin JG: Stressful life events in schizophrenia: A review of the research literature. Psychol Bull 87:408-425, 1980 12. Rabkin J: Stress and psychiatric disorders. In: Handbook of Stress, Goldberger L, Breznitz S, Eds. New York, Free Press, 1982, pp 566-584
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13. Wortman CB: Coping and change: A survey of Chicago men. Collaborative Howard Brown Memorial Clinic, University of Michigan, Ann Arbor, MI, 1987 14. Beck AT, Weissman A, Lester D, Trexler: The measurement of pessimism: The Hopelessness Scale. J Consult and Clin Psychol 42:861-865, 1974 15. Faschingbauer TR, DeVaul RA, Zisook S: Development of the Texas Revised Inventory of Grief. Am J Psychiatry 134:696-698, 1977 16. Fawcett J, Clark D, Scheftner W, Gibbons R: Assessing anhedonia in psychiatric patients: The Pleasure Scale. Arch Gen Psychiatry 40:79-84, 1983 17. Endicott J, Spitzer RL, Fleiss J, Cohen J: The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 33:766-771, 1976