Statewide replication of predictive validation for the Multnomah Community Ability Scale

Longitudinal relationships between mismatch negativity, cognitive performance, and real-world functioning in early psychosis

BACKGROUND

Reduced mismatch negativity (MMN) is observed in early psychosis (EP) and correlated with cognition and functioning, but few studies have examined their longitudinal relationships and diagnostic specificity. We examined MMN, neuro- and social-cognition, and functional measures in EP patients with schizophrenia-spectrum (SZ) or bipolar disorder (BD) over a 1-year follow-up.

METHODS

54 EP patients (SZ: n = 24; BD: n = 30) and 42 healthy controls completed baseline measures: MMN, neuro- and social-cognition, and functional assessments. 30 EP patients completed 12-month follow-up assessments. Patients and controls were compared on MMN at baseline and follow-up, and diagnostic subgroup analyses were performed. Associations amongst MMN, neuro- and social cognition, and clinical measures were examined and predictive models of follow-up outcomes were conducted.

RESULTS

EP patients showed significantly reduced MMN compared to controls at baseline (p = 0.023). MMN was impaired in SZ patients at baseline (p = 0.017) and follow-up (p = 0.003); BD patients did not differ from controls at either timepoint. MMN was associated with symptom severity and functioning at baseline, and with social cognition and functioning at follow up, but was not predictive of functional outcomes at follow-up.

CONCLUSIONS

MMN abnormalities were evident in EP SZ-spectrum disorders at both timepoints, but not in BD at either timepoint. MMN was associated with functioning cross-sectionally, but did not predict future functional outcomes. However, deficits in MMN were associated with social cognition, which may have downstream effects on community functioning. Implications for targeted interventions to improve social processing and community outcomes are discussed.

A systematic review of clinician-rated instruments to assess adults' levels of functioning in specialised public sector mental health services

BACKGROUND

Functioning is one of the key domains emphasised in the routine assessment of outcomes that has been occurring in specialised public sector mental health services across Australia since 2002, via the National Outcomes and Casemix Collection. For adult consumers (aged 18-64), the 16-item Life Skills Profile (LSP-16) has been the instrument of choice to measure functioning. However, review of the National Outcomes and Casemix Collection protocol has highlighted some limitations to the current approach to measuring functioning. A systematic review was conducted to identify, against a set of pre-determined criteria, the most suitable existing clinician-rated instruments for the routine measurement of functioning for adult consumers.

METHOD

We used two existing reviews of functioning measures as our starting point and conducted a search of MEDLINE and PsycINFO to identify articles relating to additional clinician-rated instruments. We evaluated identified instruments using a hierarchical, criterion-based approach. The criteria were as follows: (1) is brief (<50 items) and simple to score, (2) is not made redundant by more recent instruments, (3) relevant version has been scientifically scrutinised, (4) considers functioning in a contemporary way and (5) demonstrates sound psychometric properties.

RESULTS

We identified 20 relevant instruments, 5 of which met our criteria: the LSP-16, the Health of the Nation Outcome Scales, the Illness Management and Recovery Scale-Clinician Version, the Multnomah Community Ability Scale and the Personal and Social Performance Scale.

CONCLUSION

Further work is required to determine which, if any, of these instruments satisfy further criteria relating to their appropriateness for assessing functioning within relevant service contexts, acceptability to clinicians and consumers, and feasibility in routine practice. This should involve seeking stakeholders' opinions (e.g. about the specific domains of functioning covered by each instrument and the language used in individual items) and testing completion rates in busy service settings.

Psychometric Properties of the Milestones of Recovery Scale-Older Adult Version

The Milestones of Recovery Scale (MORS) is a tool that mental health professionals can use to track clients' recovery. It has been shown to have good reliability and validity in an adult population. It is important to demonstrate its psychometric properties among the elderly. This study assessed the reliability and validity of the MORS among a multi-ethnic (52 % White) sample of adults 54 and older (M = 67) at several mental health agencies in California. The clients, N = 432, were assessed by two raters each at two time points 2 weeks apart. Ratings were obtained on the MORS, the modified Global Assessment of Functioning scale (mGAF), and the Multnomah Community Ability Scale (MCAS). The MORS demonstrated acceptable reliability: inter-rater r = .65 and test-retest r = .71; the mGAF was .56 and .79; the MCAS was .66 and .85. The validity of the MORS was also supported: mGAF-MORS r = .68 and MCAS-MORS r = .74. This study lends support for the use of the MORS in older adult populations. In addition, this is the first report of the psychometric properties of the MCAS with an entirely older adult sample.

Continuity of care: validation of a self-report measure to assess client perceptions of mental health service delivery

The psychometric characteristics of an instrument to assess perceived continuity of care among mental health patients were examined. 441 adults with severe and persistent mental illness were recruited from 70 inpatient, outpatient, emergency and community treatment programs (n = 259 females; M age = 42.5, SD = 10.3 years) in Alberta, Canada. Respondents completed a 43-item self-report questionnaire to rate perceived continuity. Item quality was assessed by examining missing data and frequency distributions. In a randomly selected subsample (n = 171), exploratory factor analysis identified 3 dimensions: (1) perceived attentiveness to individual needs or changes in illness or life circumstances (Individualized Care; alpha = .64); (2) perceptions of a coherent system characterized by good communication between providers (Responsive System; alpha = .71); and (3) perceived responsiveness on the part of a primary provider (Responsive Caregiver; alpha = .52). In a second random subsample (n = 181), confirmatory factor analysis provided support for this 3-factor structure and the inclusion of a second-order "continuity" factor (alpha = .72), and informed further item reduction. Split-half reliability for the second-order factor was calculated. Associations between the factors and "objective" measures of continuity, as well as relevant clinical, quality of life, and service satisfaction variables, are reported. Use of the measure for clinical and research purposes and its limitations are considered.

Factor structure of the Multnomah Community Ability Scale--longitudinal analysis

Community mental health services benefit from measuring clinical outcomes relevant to a community-based context in contrast to medically modeled outcomes. The Multnomah Community Ability Scale (MCAS) addresses broad dimensions of community functioning and was developed for clinical and evaluation purposes. We assessed the structural consistency and fit of the scale as a measure of community functioning through confirmatory factor analysis using a longitudinal sample of individuals (n=408) with severe and persistent mental illness receiving services from community mental health programs. None of the previously hypothesised factor solutions achieved a good fit and a high degree of invariance over time was observed. Through exploratory factor analysis, the possibility of alternative solutions was explored. After exclusion of two of the 17 items, four models--including four-, three-, two- and one-factor solutions--were tested for fit and invariance with no improvement. We discuss our findings of poor fit under the assumption that the MCAS should psychometrically behave as a scale. Alternative interpretations for the tool and suggestions for the use of its items as an index that measures aspects of disability are proposed.

Measuring illness management outcomes: a psychometric study of clinician and consumer rating scales for illness self management and recovery

Psychometric properties of the Illness Management and Recovery (IMR) Scales (consumer and clinician versions), new 15-item instruments measuring illness self-management and pursuit of recovery goals, were evaluated in consumers with severe mental illness. Both versions had moderate internal consistency and high 2-week test-retest reliability. In addition, the consumer version was correlated with self-ratings of recovery and symptoms, and the clinician version was correlated with clinician ratings of community functioning, indicating convergent validity. The results suggest the IMR Scales have adequate psychometric properties and may be useful in treatment planning and assessing recovery in individuals with severe mental illness.

The University of California Performance Skills Assessment (UPSA) in schizophrenia

This study evaluated the University of California Performance-based Skills Assessment (UPSA) in a Canadian outpatient schizophrenia setting. The UPSA was administered to 64 patients with schizophrenia and schizoaffective disorder and to 42 nonpsychiatric controls. Patient and control samples did not differ in age, gender composition, first language or country of birth. Patients demonstrated significantly lower performance than healthy participants on 3 of 5 UPSA subscales as well as on a summary index. Moreover, performance varied significantly with patients' support requirements in the community. In contrast, the Household Management and Transportation subscales yielded non-significant group differences and failed to correlate with community support requirements. Examination of score distributions raised the possibility of a ceiling effect that limited the discriminating power of UPSA subscales, thus imposing qualifications on clinical interpretations of this instrument. Performance-based assessment of life skills provides an important new perspective on functional outcome in schizophrenia and serious mental illness. However, psychometric properties, task difficulty and the nature of different mental health settings, populations and communities must be considered in the design and application of these instruments.

An expanded version of the Multnomah Community Ability Scale: anchors and interview probes for the assessment of adults with serious mental illness

Objective clinical assessments are important in psychiatric settings to assess patients' functioning and the outcome of rehabilitation interventions. We developed anchors of the Multnomah Community Ability Scale (MCAS) and tested the inter-rater reliability of the expanded instrument. Twenty patients receiving psychiatric rehabilitation services participated in a structured interview and were rated by two raters. Intraclass correlation coefficients were .96 for the total and .87-.99 for the subscale scores. The expanded MCAS can serve as a reliable assessment tool.

Mental health program monitoring: towards simplifying a complex task

Finding measures that can assess areas of expected program impact, provide valid results, and be easily integrated into routine program practices is a significant challenge. This paper is intended to assist program staff by providing an accessible inventory of measures appropriate for routine monitoring of the status and outcome of individuals using mental health outpatient and community programs. The inventory is not exhaustive, but rather includes examples of solid measures for assessing outcomes in four key domains--symptoms, functioning, quality of life, and satisfaction. These can provide a core of information, to which measurement of more in-depth issues can be added to address specific concerns.

Factor structure of the Multnomah Community Ability Scale

More and more, Intensive Community Treatment programs in Canada use questionnaires to evaluate the health and social functioning of individuals suffering from a severe mental illness. However, seldom are these tools subject to psychometric analyses to establish their validity on independent samples. This article presents the results of the validation of the French version of the Multnomah Community Ability Scale. Confirmatory factor analyses were carried out to assess the factorial structure. The factor structure, four dimensions with three items, emerging from a first sample was replicated with data from a different sample of clients. Moreover, these four dimensions respect the initial factor solution of the Multnomah Community Ability Scale, which are a) interference with functioning, b) adjustment to living, c) social competence, and d) behavior problems. The study shows the structural validity of this brief questionnaire, which could be useful both for clinical and research settings to evaluate the effectiveness of interventions.

A test of the reliability and validity of the Multnomah Community Ability Scale

Previous research shows that the Multnomah Community Ability Scale (MCAS) total score is reliable and has predictive validity. This study evaluates the MCAS total and sub-scale scores on a sample of 1,250 outpatient mental health clients in Washington State. The MCAS sub-scales are reliable, and there is evidence for their concurrent validity. However, the factor structure of the MCAS only partially replicated the hypothesized sub-scales, and the authors recommend that sub-scales as currently constructed not be used as performance indicators. If only the total MCAS is of interest to users, the authors recommend using the single-item SOFAS rather than the 17-item MCAS.