Spanish Versions of the Outcome Rating Scale and the Session Rating Scale: Normative Data, Reliability, and Validity

Routine outcome monitoring (ROM) uses standardized measures to both track and inform mental health service delivery. Use of ROM has been shown to improve the outcome of psychotherapy when applied to different types of patients. The present research was designed to determine the reliability and validity of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) in a sample of Spanish patients. After a controlled process of translation into the Spanish that is spoken and written in Spain (i.e., in Europe, as distinct from, e.g., Latin American Spanish), both measures were completed by patients of an outpatient mental health unit during eight sessions of psychotherapy. Sixty mental health patients filled out the ORS and 59 the SRS. In addition, the ORS was completed by 33 people who constituted the non-clinical sample. The cut-off of the ORS was 24.52 points, and the Reliable Change Index (RCI) was 9.15 points. ORS and SRS scores exhibited excellent internal consistency. The temporal stability of the SRS was adequate. The convergent and discriminant validity of the two measures were adequate. Regarding the factorial validity of the ORS and the SRS, in the third psychotherapy session, confirmatory factor analyses evidenced the existence of a unifactorial model. The predictive validity of SRS was acceptable. The ORS was sensitive to changes in patients’ symptoms. In conclusion, compared to the original English versions of the ORS and SRS measures, the Spanish versions of the measures are also reliable and valid.

Social Cognition and General Functioning in Bipolar Disorder

Introduction:

Bipolar patients show a significant degree of psychosocial disfunction even in euthymia. Recent studies have reported deficits in Theory of Mind and emotion recognition in BD. Our hypothesis is that social cognition deficit could be associated with a poor general functioning and psychosocial disadvantage in BD.

Methods:

A sample of 27 euthymic bipolar patients were recluted. Based on Global Assessment of Functioning, they were divided into two groups: good or low general functioning. Euthymia was defined as YMRS < 6 and HDRS < 8, during a 3-month period. Patients with high (n 18) and low (n 9) functioning were compared on several clinical variables and on social / general cognitive measures. Both verbal and non verbal Theory of Mind capacities were assesed (faux pas test and face emotion recognition test). Finally, sustained attention and executive functions were evaluated (Asarnow Test and WSCT).

Results:

High- and low-functioning groups did not differ with respect to demographic and clinical variables (age, sex, age at onset, years of evolution of illness, history of prior psychotic symptoms; p = n.s.). However, low-functioning group showed poorer performance than high-functioning group both in faux pas test (U Mann Whitney; p=0.035) and face emotion recognition (U; p = 0.021). In addition, low-functioning group also showed a significant impairment in general cognitive funtions such as sustained attention (U, p = 0.007) and executive funtions (U, p = 0.046).

Conclusion:

Social cognition deficit is associated with a poorer general functioning and psychosocial disadvantage.

Patient-Therapist Perspective of the Working Alliance in Psychotherapy

This study aimed to examine perceptions of the working alliance in a sample of Spanish patients and therapists. The alliance was measured after the third and tenth psychotherapy sessions using patient and therapist versions of the Spanish adaptation of the Working Alliance Inventory (WAI). After both sessions, correlations between the patients' and therapists' ratings, both of total alliance and of the various dimensions of the alliance, were moderate at best. Moreover, after the third psychotherapy session, patients' scores for the total alliance and the Goal and Task subscales were significantly higher than the scores from their therapists in these dimensions. Following the tenth session, patient ratings exceeded those of their therapists only on the Task subscale. Finally, in contrast to the ratings of patients, therapists' alliance ratings increased significantly between the third and tenth sessions of psychotherapy. Certain recommendations are presented to improve the study of patient and therapist perceptions of the working alliance and to increase the convergence between them with regard to this central treatment variable.

Spanish adaptation of the Revised Helping Alliance Questionnaire (HAq-II)

BACKGROUND

The working or helping alliance is one of the most widely studied constructs in psychotherapy process research.

AIM

The aim of this study was to adapt the patient and therapist forms of the Revised Helping Alliance Questionnaire II (HAq-II-P and HAq-II-T, respectively) into Spanish.

METHOD

The two measurement instruments were adapted through a systematic translation process, a pilot study and a clinical study. The psychometric properties were examined following the third psychotherapy session.

RESULTS

Mean scores on the Spanish-language HAq-II-P and HAq-II-T were high. The corrected item-total correlations for >94% of the items were >0.30. Cronbach's α values for internal consistency were 0.88 and 0.93, respectively. Correlations for convergent validity with the respective versions of the Spanish-language Working Alliance Inventory were 0.80 and 0.87, respectively. In terms of predictive validity, there was a significant correlation between HAq-II-T and the patients' residual gain scores on the Spanish-language Beck Depression Inventory after the tenth psychotherapy session.

CONCLUSIONS

These results are consistent with studies using the original English versions of the HAq-II.

Familiarity and face emotion recognition in patients with schizophrenia

OBJECTIVE

To assess the emotion recognition in familiar and unknown faces in a sample of schizophrenic patients and healthy controls.

METHODS

Face emotion recognition of 18 outpatients diagnosed with schizophrenia (DSM-IVTR) and 18 healthy volunteers was assessed with two Emotion Recognition Tasks using familiar faces and unknown faces. Each subject was accompanied by 4 familiar people (parents, siblings or friends), which were photographed by expressing the 6 Ekman's basic emotions. Face emotion recognition in familiar faces was assessed with this ad hoc instrument. In each case, the patient scored (from 1 to 10) the subjective familiarity and affective valence corresponding to each person.

RESULTS

Patients with schizophrenia not only showed a deficit in the recognition of emotions on unknown faces (p=.01), but they also showed an even more pronounced deficit on familiar faces (p=.001). Controls had a similar success rate in the unknown faces task (mean: 18 +/- 2.2) and the familiar face task (mean: 17.4 +/- 3). However, patients had a significantly lower score in the familiar faces task (mean: 13.2 +/- 3.8) than in the unknown faces task (mean: 16 +/- 2.4; p<.05). In both tests, the highest number of errors was with emotions of anger and fear. Subjectively, the patient group showed a lower level of familiarity and emotional valence to their respective relatives (p<.01).

CONCLUSIONS

The sense of familiarity may be a factor involved in the face emotion recognition and it may be disturbed in schizophrenia.

Social cognition and interaction training (SCIT) for outpatients with bipolar disorder

INTRODUCTION

Patients with bipolar disorder show social cognition deficits during both symptomatic and euthymic phases of the illness, partially independent of other cognitive dysfunctions and current mood. Previous studies in schizophrenia have revealed that social cognition is a modifiable domain. Social cognition and interaction training (SCIT) is an 18-week, manual-based, group treatment designed to improve social functioning by way of social cognition.

METHOD

37 outpatients with DSM-IV-TR bipolar and schizoaffective disorders were randomly assigned to treatment as usual (TAU)+SCIT (n=21) or TAU (n=16). Independent, blind evaluators assessed subjects before and after the intervention on Face Emotion Identification Task (FEIT), Face Emotion Discrimination (FEDT), Emotion Recognition (ER40), Theory of Mind (Hinting Task) and Hostility Bias (AIHQ).

RESULTS

Analysis of covariance revealed significant group effects for emotion perception, theory of mind, and depressive symptoms. The SCIT group showed a small within-group decrease on the AIHQ Blame subscale, a moderate decrease in AIHQ Hostility Bias, a small increase in scores on the Hinting Task, a moderate increase on the ER40, and large increases on the FEDT and FEIT. There was no evidence of effects on aggressive attributional biases or on global functioning.

LIMITATION

No follow up assessment was conducted, so it is unknown whether the effects of SCIT persist over time.

CONCLUSION

This trial provides preliminary evidence that SCIT is feasible and may improve social cognition for bipolar and schizoaffective outpatients.

Absence of protective ethnic density effect on Ecuadorian migrants' mental health in a recent migration setting: a multilevel analysis

PURPOSE

We aimed to study the association between the Ecuadorians' ethnic density (EED) of the areas of residence (AR) with the mental health of Ecuadorians in Spain.

METHODS

Multilevel study of 568 Ecuadorian adults in 33 AR randomly selected from civil registries and interviewed at home. Possible psychiatric case (PPC) was measured by scoring ≥5 in General Health Questionnaire-28. Ecuadorians' ethnic density was dichotomized in high and low EED (<6 %). Multilevel logistic regression was used to estimate odds ratios (OR) and 95 % confidence intervals (CI).

RESULTS

Prevalence of PPC, 24 % (95 %CI 20-28 %), varied by area of residence. Ecuadorians' ethnic density varied by area of residence ranging from 0.9 to 19.5 %. PPC prevalence in High Ecuadorians' ethnic density AR was 29.5 and 20.4 % in low EED AR (p 0.013). Ecuadorians from High EED AR had higher odds of PPC than those from Low EED AR (OR 1.65 95 %CI 1.01-2.72). Adjusting for individual confounders (largely self-perceived discrimination), OR decreased to 1.48 (95 %CI 0.87-2.55). The final model, adjusted by area of residence and educational level, yielded an OR 1.37 (95 %CI 0.78-2.40).

CONCLUSIONS

No protective association between the Ecuadorians' ethnic density of the Area of residence and Ecuadorian migrants' mental health was found. Mechanisms underlying beneficial ethnic density effects may be absent in recent migration settings.

Social-cognitive bias and depressive symptoms in outpatients with bipolar disorder

A deficit of social cognition in bipolar disorder has been shown, even when patients are stable. This study compares the attribution of intentions (social-cognitive bias) in a group of 37 outpatients with bipolar disorder with 32 matched control subjects. Bipolar patients scored significantly higher in the Ambiguous Intentions Hostility Questionnaire, showing an angry and intentionality bias (P = .001, P = .02). Differences in blame scale and hostility bias did not reach statistical significance, but a trend was found (P = .06). Bipolar patients with depressive symptoms presented a higher score in the angry bias scale (P = .03) and aggressivity bias scale (P = .004). The global functioning (GAF) correlates significantly with intentionality (P = .005), angry (P = .027), and aggressivity (P = .020) biases. Bipolar patients show a social-cognitive bias that may play a role in their functional outcome.

Mental health in Ecuadorian migrants from a population-based survey: the importance of social determinants and gender roles

PURPOSE

To describe the prevalence of and the risk factors for poor mental health in female and male Ecuadorian migrants in Spain compared to Spaniards.

METHOD

Population-based survey. Probabilistic sample was obtained from the council registries. Subjects were interviewed through home visits from September 2006 to January 2007. Possible psychiatric case (PPC) was measured as score of ≥5 on the General Health Questionnaire-28 and analyzed with logistic regression.

RESULTS

Of 1,122 subjects (50% Ecuadorians, and 50% women), PPC prevalence was higher in Ecuadorian (34%, 95% CI 29-40%) and Spanish women (24%, 95% CI 19-29%) compared to Ecuadorian (14%, 95% CI 10-18%) and Spanish men (12%, 95% CI 8-16%). Shared risk factors for PPC between Spanish and Ecuadorian women were: having children (OR 3.1, 95% CI 1.4-6.9), work dissatisfaction (OR 4.1, 95% CI 1.6-10.5), low salaries (OR 2.5, 95% CI 1.1-5.9), no economic support (OR 1.8, 95% CI 0.9-3.4), and no friends (OR 2.2, 95% CI 1.1-4.2). There was an effect modification between the nationality and educational level, having a confidant, and atmosphere at work. Higher education was inversely associated with PPC in Spanish women, but having university studies doubled the odds of being a PPC in Ecuadorians. Shared risk factors for PPC in Ecuadorian and Spanish men were: bad atmosphere at work (OR 2.4, 95% CI 1.3-4.4), no economic support (OR 3.5, 95% CI 1.3-9.5), no friends (OR 2.5, 95% CI 0.9-6.6), and low social support (OR 1.6, 95% CI 0.9-2.9), with effect modification between nationality and partner's emotional support.

CONCLUSIONS

Mental health in Spanish and Ecuadorian women living in Spain is poorer than men. Ecuadorian women are the most disadvantaged group in terms of prevalence of and risk factors for PPC.

[How does collective violence shape the health status of its victims? Conceptual model and design of the ISAVIC study]

OBJECTIVES

Epidemiologic research on collective violence (violence exerted by and within groups in pursuit of political, social or economic goals) is very scarce despite its growing recognition as a major public health issue. This paper describes the conceptual model and design of one of the first research studies conducted in Spain aiming to assess the impact of collective violence in the health status of its victims (study known as ISAVIC, based on its Spanish title Impacto en la SAlud de la VIolencia Colectiva).

METHODS

Starting with a comprehensive but non-systematic review of the literature, the authors describe the sequelae likely produced by collective violence and propose a conceptual model to explain the nature of the relationships between collective violence and health status. The conceptual model informed the ISAVIC study design and its measurement instruments.

RESULTS

The possible sequelae of collective violence, in the physical, emotional and social dimensions of health, are described. Also, the review distinguishes the likely impact in primary and secondary victims, as well as the interplay with the social environment. The mixed methodological design of the ISAVIC study supports the coherence of the conceptual model described.

CONCLUSIONS

The ISAVIC study suggests that collective violence may affect the main dimensions of the health status of its victims, in intimate relation to the societal factors where it operates. It is necessary to validate these results with new studies.

Sense of familiarity and face emotion recognition in schizophrenia

Introduction

Patients with schizophrenia show a deficit in emotion recognition through facial expression. Familiarity means the implicit memory of past affective experiences and it involves fast cognitive processes and it is triggered by certain signals.

Objectives

To assess the emotion recognition in familiar and unfamiliar faces in a sample of schizophrenic patients and healthy controls.

Methods

18 outpatients diagnosed with schizophrenia (DSM-IVTR) and 18 healthy volunteers were assessed with the Ekman Test of emotion recognition in unfamiliar faces. In addition each subject was accompanied by 4 familiar people (parents, siblings or friends), which was photographed by expressing the 6 Ekman’s basic emotions.

Results

Schizophrenic patients recognize worse emotions in their relatives than in neutral faces, a greater extent than controls (Mann-Whitney U = 81, p = .01). The patient group showed a mean score on the Ekman test (neutral faces) lower than control group (16 (SD 2.38) versus 17.82 (2.13; U p = 0.03). Regarding familiar faces, the group patients showed a worse performance than the control group (13.22 (3.8) versus 17.18 (2.82); U p = 0.00). In both tests, the highest number of errors was with emotions of anger and fear. The patients group showed a lower level of familiarity and emotional valence to their families (U = 33, p < 0.01).

Conclusions

The sense of familiarity may be a factor involved in face emotion recognition and it may be disturbed in schizophrenia.

Transitory Ischemia as a form of white torture: a case description in Spain

Transitory Ischemia is a form of torture that has been insufficiently described and studied in forensic and psychiatric studies of torture. It is usually left out of medical evaluation reports and not explored in detail under the Istanbul Protocol. Although ischemia, when experienced during brief periods of time, does not produce any detectable sequelae, prolonged periods of ischemia can be detected by either clinical examination or electromyography. The authors describe the use of brief periods of ischemia as a torture technique against a non-violent activist in Seville (Spain).

Discrimination and mental health in Ecuadorian immigrants in Spain

BACKGROUND

The aim of this study was to examine the effects of ethnic discrimination on the mental health of Ecuadorian immigrants in Spain and to assess the roles of material and social resources.

METHODS

Data were taken from the "Neighbourhood characteristics, immigration and mental health" survey conducted in 2006 in Spain. Psychological distress measured as "Possible Psychiatric Case" (PPC) was measured by the GHQ-28. A logistic regression was fitted to assess the association between PPC and discrimination. Interactions of discrimination with social and material resources were tested using product terms.

RESULTS

Some 28% of the participants met our definition of PPC. About 20% of those who reported no discrimination were PPCs, rising to 30% of those who sometimes felt discriminated against and 41% of those who continually perceived discrimination. The OR for continuous discrimination was 12 (95% CI 3.5 to 40.3) among those with high financial strain, and 10 (2.4 to 41.7) when there was lack of economic support. Emotional support had an independent effect on PPC (OR 1.8, 95% CI 1.0 to 3.6, for those who reported having no friends). Social integration through a community group or association was positively related to the probability of being a PPC (OR 1.7, 95% CI 1.0 to 2.9).

CONCLUSION

Ethnic discrimination is associated with psychological distress in these Ecuadorian immigrants in Spain. Discrimination effects may be exacerbated among those facing economic stress and those without economic support. These particularly vulnerable immigrants should be the subject of social and health interventions.

Association Between Olfactory Identification and Face Emotion Recognition in Euthymic Bipolar Patients

Introduction:

The close anatomical and functional connection between the orbitofrontal cortex and olfactory processing suggests that emotion regulation and olfactory identification could be associated. Smell identification deficit (SID) is common in adult schizophrenia, but it has been less studied in bipolar patients, who also show a significant degree of social disadvantage.

Methods:

A sample of 27 euthymic bipolar patients were recluted. Euthymia was defined as YMRS < 6 and HDRS < 8, during a 3-month period. Patients were assessed with the University of Pennsylvania Smell Identification Test (UPSIT), Face Recognition Test and a verbal Theory of Mind test (Faux Pas Test), in order to examine the association between olfactory identification ability and social cognition domains.

Results:

According to the hypothesis, olfactory identification was positively correlated with Face Emotion Recognition (Pearson, p = 0.007) and verbal Theory of Mind (Pearson, p=0.030). Smell identification was similar in smoker (15/27) and non-smoker subgroup of the sample (U Mann Whitney; p = n.s). No differences were neither found between male (14/27) and female subgroup (U; p = n.s).

Conclusion:

Olfactory identification and social cognition (specially, face emotion recognition) appear to represent two correlated traits in bipolar disorder, suggesting a possible common neural substrate.

[Validation of the Spanish version of PRIME-MD: a procedure for diagnosing mental disorders in primary care]

INTRODUCTION

Psychiatric disorders occurs in at least 20% of patients attending Primary Care settings, however, only 50% of them are detected by primary care physicians. Therefore a tool is required which can help primary care physicians to detect and diagnose psychiatric disorders. PRIME-MD (Primary Care Evaluation of Mental Disorders) is a questionnaire designed with this aim. In this article the results of the validation study of the Spanish version of this questionnaire are presented.

MATERIALS AND METHODS

312 patients were interviewed by primary care physicians using PRIME-MD and by psychiatrists using SCAN (Schedules for Clinical Assessment in Neuropsychiatry).

RESULTS

The time most frequently spent in questionnaire application by the physician was 10 minutes. PRIME-MD detected the presence of at least one psychiatric disorder in 44.3% of patients. PRIME-MD diagnoses agree well with SCAN diagnoses for mood disorders (coefficient of agreement: 0.50) and for anxiety disorders (coefficient of agreement: 0.35), but not for somatoform disorders or alcohol-related disorders.

CONCLUSIONS

The Spanish version of PRIME-MD questionnaire in a useful tool to identify and diagnose mood and anxiety disorders in Primary Care settings.

[Prevalence of psychiatric disorders in primary care using the PRIME-MD questionnaire]

OBJECTIVE

To quantify the frequency of psychiatric disorders detected by primary care doctors, using the PRIME-MD questionnaire, and by psychiatrists using a structured clinical interview.

DESIGN

An observational, descriptive, crossover study, using a questionnaire. One of each two patients was selected until reaching the total number of patients.

SETTING

The study was conducted in five primary care centres in Madrid.

PATIENTS

To be included in the study, patients had to consent verbally, be able to understand the questions asked and have been previously diagnosed as psychotic or demented. 395 patients were recruited, of which 312 completed the study.

INTERVENTIONS

The primary care doctor administered the PRIME-MD questionnaire to each patient, and then a psychiatrist conducted the SCAN interview.

RESULTS

The time spent by the doctor on the PRIME-MD questionnaire was usually 10 minutes. The doctor had previously detected psychiatric pathology in 18.5% of his/her patients; with the PRIME-MD questionnaire he/she detected it in 53.5%. The psychiatrist with the SCAN detected psychiatric pathology in 41.3% of patients.

CONCLUSIONS

The high frequency of psychiatric disorders in primary care patients and primary care doctors' lack of ability in detecting these disorders was confirmed by this study. The PRIME-MD questionnaire, an instrument for rapid detection of the most commonly found psychiatric disorders within primary care, may considerably improve this situation.