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Outcome measures for mental health services need to adopt a service-user recovery focus.
To develop and validate a 10- and 20-item self-report recovery-focused quality of life outcome measure named Recovering Quality of Life (ReQoL).
Qualitative methods for item development and initial testing, and quantitative methods for item reduction and scale construction were used. Data from >6500 service users were factor analysed and item response theory models employed to inform item selection. The measures were tested for reliability, validity and responsiveness.
ReQoL-10 and ReQoL-20 contain positively and negatively worded items covering seven themes: activity, hope, belonging and relationships, self-perception, well-being, autonomy, and physical health. Both versions achieved acceptable internal consistency, test–retest reliability (>0.85), known-group differences, convergence with related measures, and were responsive over time (standardised response mean (SRM) > 0.4). They performed marginally better than the Short Warwick-Edinburgh Mental Well-being Scale and markedly better than the EQ-5D.
Both versions are appropriate for measuring service-user recovery-focused quality of life outcomes.
Declaration of interest
M.B. and J.Co. were members of the research group that developed the Clinical Outcomes in Routine Evaluation (CORE) outcome measures.
Effective psychological therapies have been recommended for common mental health problems, such as depression and anxiety, but provision has been poor. Improving Access to Psychological Therapies (IAPT) may provide a cost-effective solution to this problem.
To determine the cost-effectiveness of IAPT at the Doncaster demonstration site (2007–2009).
An economic evaluation comparing costs and health outcomes for patients at the IAPT demonstration site with those for comparator sites, including a separate assessment of lost productivity. Sensitivity analyses were undertaken.
The IAPT site had higher service costs and was associated with small additional gains in quality-adjusted life-years (QALYs) compared with its comparator sites, resulting in a cost per QALY gained of £29 500 using the Short Form (SF-6D). Sensitivity analysis using predicted EQ-5D scores lowered this to £16 857. Costs per reliable and clinically significant (RCS) improvement were £9440 per participant.
Improving Access to Psychological Therapies provided a service that was probably cost-effective within the usual National Institute for Health and Clinical Excellence (NICE) threshold range of £20 000-30 000, but there was considerable uncertainty surrounding the costs and outcome differences.
Psychotherapy's equivalence paradox is that treatments tend to have equivalently positive outcomes despite non-equivalent theories and techniques. We replicated an earlier comparison of treatment approaches in a sample four times larger and restricted to primary-care mental health.
Patients (n=5613) who received cognitive–behavioural therapy (CBT), person-centred therapy (PCT) or psychodynamic therapy (PDT) at one of 32 NHS primary-care services during a 3-year period (2002–2005) completed the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) at the beginning and end of treatment. Therapists indicated which approaches were used on an End of Therapy form. We compared outcomes of groups treated with CBT (n=1045), PCT (n=1709), or PDT (n=261) only or with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1 (n=1035), PCT+1 (n=1033), or PDT+1 (n=530), respectively.
All six groups began treatment with equivalent CORE-OM scores, and all averaged marked improvement (overall pre/post effect size=1.39). Neither treatment approach nor degree of purity (‘only’ v. ‘+1’) had a statistically significant effect. Distributions of change scores were all similar.
Replicating the earlier results, the theoretically different approaches tended to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, incomplete data, and other issues. Insofar as these routine treatments appear effective for patients who complete them, those who fail to complete (or to begin) treatment deserve attention by researchers and policymakers.
Although measures of psychopathology are designed for use in clinical
populations, their meaning derives from comparison with normal
To compare the distribution of scores on the Clinical Outcomes in Routine
Evaluation — Outcome Measure (CORE-OM) from a general population sample
with the distribution in an aggregated clinical sample to derive
recommended cut-off points for determining clinical significance.
The CORE-OM general population sample was based on a weighted subsample
of participants in the psychiatric morbidity follow-up survey who
completed valid CORE-OM forms following their interview (effective
Comparison of the CORE-OM general population sample with a clinical
sample aggregated from previous studies (n=10761)
yielded a cut-off score of 9.9 on the 0–40 scale of the CORE-OM. The
CORE-OM was highly correlated (r=0.77) with the Clinical
Interview Schedule — Revised, supporting convergent validity.
We recommend rounding the CORE-OM cut-off score to 10. However, cut-off
scores must be used thoughtfully and adjusted to fit context and
There is a need for reliable assessment tools that are suitable for the counselling and the psychological therapy services in primary and secondary care settings.
To test the suitability and utility of the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE–OM) and CORE–Assessment (CORE–A) assessment tools.
Service intake data were analysed from counselling and psychological therapy services in 32 primary care settings and 17 secondary care settings.
Completion rates exceeded 98% in both of the settings sampled. Intake severity levels were similar but secondary care patients were more likely to score above the risk cut-off and the severe threshold and to have experienced their problems for a greater duration.
The CORE–OM and CORE–A are suitable assessment tools that show small but logical differences between psychological therapy services in primary- and secondary-based care.
To describe food sources of nutrient intake for white and African American adults in the Lower Mississippi Delta (LMD), and their use in the development of a regional food-frequency questionnaire (FFQ) based on an earlier version of the National Cancer Institute's Health Habits and History Questionnaire.
We ranked food sources of energy, macronutrients, vitamins and minerals, and examined portion size distributions for 842 white and 857 African American residents aged 19 years and older, using 24-hour dietary intake recall data from a telephone survey of 36 LMD counties. These values were used to develop a regional FFQ, which was then field-tested with 100 subjects and revised to improve interpretability.
The LMD region of the USA.
White and African American adult residents of the LMD.
LMD African Americans obtained more of their energy and nutrient intakes from poultry, processed meat, salty snacks, fruit drinks, pork and cornbread; and less from milk, alcohol, legumes, salad dressing, butter/margarine and sweetened tea than did white residents. Regional foods not on nationally used FFQs included grits, turnip greens, okra, ham hocks, chitterlings, crawfish, catfish, cracklings, jambalaya, potato logs, chicken and dumplings, and sweet potato pie. Based on responses during field-testing, the questionnaire was also designed to add four portion sizes for each food item, presented as questions, rather than in grid format.
Regional food use patterns differ from national patterns and furthermore differ between African American and white adults in the LMD. The resulting Delta NIRI FFQ for Adults should contribute to improved assessment of usual intake for use in studies of diet and health in this region.
An acceptable, standardised outcome measure to assess efficacy and effectiveness is needed across multiple disciplines offering psychological therapies.
To present psychometric data on reliability, validity and sensitivity to change for the CORE–OM (Clinical Outcomes in Routine Evaluation – Outcome Measure).
A 34-item self-report instrument was developed, with domains of subjective well-being, symptoms, function and risk. Analysis includes internal reliability, test–retest reliability, socio-demographic differences, exploratory principal-component analysis, correlations with other instruments, differences between clinical and non-clinical samples and assessment of change within a clinical group.
Internal and test–retest reliability were good (0.75–0.95), as was convergent validity with seven other instruments, with large differences between clinical and non-clinical samples and good sensitivity to change.
The CORE–OM is a reliable and valid instrument with good sensitivity to change. It is acceptable in a wide range of practice settings.
Measurement is the foundation of evidence-based practice. Advances in measurement procedures should extend to psychotherapy practice.
To review the developments in measurement relevant to psychotherapy.
Domains reviewed are: (a) interventions; (b) case formulation; (c) treatment integrity; (d) performance (including adherence, competence and skilfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine outcome measurement.
Modern methods of measurement can support ‘evidence-based practice’ for psychological treatments. They also support ‘practice-based evidence’, a complementary paradigm to improve clinical effectiveness in routine practice via the infrastructure of Practice Research Networks (PRNs).
Advances in measurement derived from psychotherapy research support a model of professional self-management (practice-based evidence) which is widely applicable in psychiatry and medicine.
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