Quality of life

Though there have been definitional and methodological problems with the quality-of-life construct, especially as it has been applied in somatic disease areas, our review of the literature(68) suggests that it may be a clinically useful tool capable of reflecting treatment-related change. The most promising of the quality-of-life measures for mental health outcome research are those based on a broad definition of quality of life—covering role functioning and social-material conditions as well as life satisfaction or well being—and which can be applied across disorders and across treatments. More widespread use and testing of quality-of-life instruments is suggested to establish their utility and to help resolve a number of important measurement issues, including the value of more 'objective' indices of quality of life and the relationship between symptoms and quality-of-life judgements.

Utilization of treatment services

The impact of a treatment on usage of other health-related services is a factor to be considered in determining the cost-effectiveness of that treatment. To date, many of the findings on the relationship between psychopathology and service utilization come from national and epidemiological surveys that included questions about the number of hospital days, bed days, and visits to medical providers. However, there are two instruments that were designed to assess changes in service usage over the course of treatment. The Treatment Services Review(69) is a 5-minute interview that documents the number and types of treatment services received during rehabilitation from substance abuse. Linehan (Z9 developed the Treatment History Inventory to assess the amount of professional and non-professional mental health and medical services received by patients with borderline personality disorder. These instruments were designed for a specific diagnostic group, but they could be adapted for use with other clinical populations or serve as exemplars for the development of new scales.

Theory-based measures

Evaluation of the hypothesized important psychological constructs of a particular psychotherapy can serve as outcome measures in their own right or as mediators of change in symptoms and functioning. For example, the cognitive model of depression holds that distorted cognitions about the self and world are responsible for generating and maintaining negative emotions. Measures of depressogenic cognitions are therefore included as outcomes and mediators of symptom change in studies of cognitive therapy for depression. The Hopelessness Scale is a 20-item self-report scale that assesses the hopelessness and pessimism associated with suicidal ideation and intent. The Dysfunctional Attitudes Scale (72) is a 40-item index of general attitudes and beliefs hypothesized by Beck and colleagues to underlie a propensity for depressive thinking, whereas the Automatic Thoughts Questionnaire (73) covers 30 negative thoughts proposed to occur during a symptomatic depressed state. There is evidence for the validity and reliability of these scales, and their sensitivity to change has been demonstrated in efficacy studies of cognitive therapy.

In regard to psychodynamic psychotherapy, theory-specific mediators include measures of core conflicts (74) and self-understanding. (75> Measures of these constructs, however, are rather early in development and cannot as yet be widely recommended for psychotherapy evaluation studies.

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