Substance use problems

Because of the frequent comorbidity of substance use problems with other Axis I disorders, it is important to evaluate the level of drug and alcohol use when screening patients for study enrolment or when characterizing a sample. The substance use modules of the DSM-IV Structured Clinical Interview are frequently used for this purpose. The Addiction Severity Index (42> has the advantage of providing more comprehensive and detailed information on problem areas associated with abuse, and yields scores that can be compared across patients, and from the beginning to the end of treatment. Because it is a rather time-consuming interview, it is recommended only in instances when the rates of substance use and related problems are expected to be high and their measurement is a research priority.

Measure of global psychological functioning/psychopathology

The rationale for using measures that cover a broad range of psychopathology is that they characterize the sample in terms of associated symptoms (i.e. symptoms other than those of primary interest) and provide a global measure of subjective distress. They have also proved to be quite useful in detecting treatment-related changes in evaluations of diverse psychotherapies.

Two popular self-report measures of general psychopathology are the SCL-90-R (and its abbreviated version, the Brief Symptom Inventory) (43) and the Minnesota Multiphasic Personality Inventory (MMPI).(44)

The SCL-90-R is a 90-item scale; the Brief Symptom Inventory is composed of 53 items. Both yield nine symptom dimensions and three global indices of distress. Because correlations between the two instruments are very high, it is recommended that the latter be used when time is an issue or when this measure is included as part of a larger core battery of assessment. Clinician-rated versions of these scales are also available. Evidence indicating that the nine subscales lack discriminant validity has led some to conclude that the instruments are best used as measures of overall distress. (45>

An alternative to the SCL-90 is the MMPI, which remains one of the most popular of all psychological tests and provides information on ten symptom clusters. However, the MMPI's usefulness in efficacy studies is limited by its length, its use of diagnostic constructs that could be considered obsolete, and questionable psychometrics/45>

Measures of self

Participants in a recent assessment conference^6 recommended that measures of self be included in outcome batteries, citing research evidence linking attitudes about self to the maintenance of behavioural change in areas of anxiety, depressive, and personality disorders. Furthermore, many psychotherapies explicitly attempt to improve self-esteem, self-concept, and self-confidence, and therefore it is relevant to examine the extent to which treatment successfully impacts on these domains.

One of the oldest and most widely used measures of self-esteem is the Rosenberg Self-Esteem Scale,(47) an easily administered 10-item Likert-type scale yielding a unidimensional indicator of global self-esteem. More recent work in this area aims to distinguish other self-related constructs (such as self-concept) from self-esteem, develop more theoretically based multifactorial models, and improve upon the psychometrics of earlier measures. (48) Some resulting scales, such as the Beck Self-Concept Test(49,> or the Selves Questionnaire, (,59 are appropriate for patients with a fairly wide range of psychiatric diagnoses.

Personality assessment

Personality variables typically appear in evaluations of psychological treatment as either primary outcomes (as in the study of psychotherapy for personality pathology), or as prognostic indicators in studies of other Axis I disorders. They might also be included as part of a larger effort to thoroughly describe the patient sample. There are two ways to approach the evaluation of personality within these contexts: determination of the presence or absence of a DSM personality disorder, and dimensional ratings of personality features. Much of the research in this area is relatively recent. In their 1995 review of the literature, Lambert et al.(51,) list 20 personality disorder instruments, all of which 'require further investigation'. A number of authors have discussed the theoretical, methodological, and practical challenges to the assessment of both initial or 'baseline' personality and change in personality features. (5 53 and 54) Interested readers are directed to these more comprehensive reviews, which examine, among other issues, the debate surrounding the optimal method of classifying traits (categorical versus dimensional), the adequacy of DSM-IV Axis II in defining diagnoses, the theoretical and measurement implications of comorbidity (of personality disorders with Axis I disorders, and within personality disorders), and the value of collateral informants.

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