Quality of life is a process not an outcome

Quality improvement mechanisms increasingly use outcome measures to evaluate health care providers. This move toward outcome measures is a radical departure from the traditional focus on process measures. More radical still is the proposal to shift from relatively simple and proximal measures of outcome, such as mortality, to complex outcomes, such as quality of life. While the practical, scientific, and ethical issues associated with the use of outcomes such as mortality and morbidity to compare health care providers have been well rehearsed, the specific concerns associated with the use of quality of life measures in quality of care research have received little attention. As with much research on quality of life there is a tendency to assume that the disadvantages are outweighed by the general virtue of ??listening?? to patients. In this paper we disagree with this assumption and argue that quality of life is a process, not an outcome.     

The stigma of having a parent with mental illness: Genetic attributions and associative stigma

Children often report associative stigma because they are ‘contaminated’ by association with a parent who has a mental illness. An exploratory study was conducted to investigate the role of genetic attributions in the aetiology of associative stigma. The first hypothesis was that genetic attributions would predict associative stigma over and above the contribution of biochemical and stressful‐event attributions, while the second hypothesis was that the relationship between genetic attributions and associative stigma would be mediated by the perceived likelihood that children would develop the same disorder as their parents. Two‐hundred‐and‐two individuals were asked to read a hypothetical scenario describing a teenage girl whose mother had been diagnosed with either schizophrenia or depression. Both hypotheses were supported. The findings of the study have implications for a number of professions working in the community such as teachers and psychologists. Additional avenues for future research are also explored.     

Leadership as a predictor of stigma and practical barriers toward receiving mental health treatment: a multilevel approach

The present research examined positive and negative leadership behaviors as predictors of stigma and practical barriers to mental health treatment. Soldiers completed measures of noncommissioned officer (NCO) and officer leadership, stigma, and practical barriers to getting mental health treatment at 2, 3, and 4 months following a 15-month deployment to Afghanistan. The results revealed that positive and negative NCO and officer leader behaviors were predictive of overall stigma and barriers to care (collapsed across the three time periods), with only NCO positive and negative behaviors being uniquely predictive of stigma when included in the same model with officer behaviors. In addition, negative and positive NCO leader behaviors were predictive of stigma within participants over the course of the three month time period, and positive NCO leader behaviors were inversely related to practical barriers to mental health treatment within participants across the same time period. The results are discussed in terms of how different leader behaviors may be linked to different factors influencing a soldier's decision to seek mental health treatment.     

Adolescent over-general memory,life events and mental health outcomes: Findings from a UK cohort study

Previous research suggesting that over-general memory (OGM) may moderate the effect of life events on depressive symptoms and suicidality has sampled older adolescents or adults, or younger adolescents in high-risk populations, and has been conducted over relatively short follow-up periods. The authors examined the relationship between OGM at age 13 and life events and mental health outcomes (depression, self-harm, suicidal ideation and planning) at age 16 years within a sample of 5792 adolescents participating in the Avon Longitudinal Study of Parents and Children (ALSPAC), approximately 3800 of whom had also provided data on depression and self-harm. There was no clear evidence of either direct or interactive effects of OGM at age 13 on levels of depression at age 16. Similarly there was no clear evidence of either direct or interactive effects of OGM on suicidal ideation and self-harm. Although there was some evidence that over-general autobiographical memory was associated with reduced risk of suicidal planning and increased risk of self-harm, these associations were absent when confounding variables were taken into account. The findings imply that although OGM is a marker of vulnerability to depression and related psychopathology in high-risk groups, this cannot be assumed to generalise to whole populations.     

Life transitions and mental health in a national cohort of young Australian women

Young adulthood, a time of major life transitions and risk of poor mental health, may affect emotional well-being throughout adult life. This article uses longitudinal survey data to examine young Australian women's transitions across 4 domains: residential independence, relationships, work and study, and motherhood. Changes over 3 years in health-related quality of life, optimism, depressive symptoms, stress, and life satisfaction, were examined in relation to these transitions among 7,619 young adult participants in the nationally representative Australian Longitudinal Study on Women's Health. Positive changes in mental health occurred for women moving into cohabitation and marriage, whereas reductions were observed among those experiencing marital separation or divorce and those taking on or remaining in traditionally "feminine" roles (out of the workforce, motherhood). The data suggest that women cope well with major life changes at this life stage, but reductions in psychological well-being are associated with some transitions. The findings suggest that preventive interventions to improve women's resilience and coping might target women undergoing these transitions and that social structures may not be providing sufficient support for women making traditional life choices.     

Development and initial validation of a brief mental health outcome measure

Using a combination of classical test theory and Rasch item analysis, we developed a short scale designed to measure the effectiveness of mental health treatment across a wide range of mental health services and populations. Item development for the scale was guided by literature review and interviews with senior clinicians and with patients. Using 3 different samples consisting of inpatients, outpatients, and nonpatients, we reduced our initial item pool from 81 to 10 items. The 10-item scale had an alpha of .96 and showed strong correlations with commonly used measures of psychological well-being and distress. Our results suggest that the scale appears to measure a broad domain of psychological health. The scale appeared to lack ceiling and floor effects, and it discriminated between inpatients, outpatients, and nonpatients, suggesting the scale has excellent potential to be broadly responsive to a variety of treatment effects. In addition, the new scale proved to be sensitive to treatment changes in a sample of 20 psychiatric inpatients. Overall, the initial data suggest that we have developed a brief, sensitive outcome measure designed to have wide application across psychiatric and psychological treatments and populations.     

Comparison of two outcome groups in a school-based mental health project

Two samples of school-maladjusted children responding most and least favorably to a helping program with nonprofessional child-aides were compared on demographic, referral, and program experience variables. Outcome measures other than teacher ratings used to select the samples validated the inferred improvement differences. Subjects with poor outcomes were significantly more likely to reside in the city, older, from lower socioeconomic backgrounds, and initially more maladjusted than those with good outcomes, but there were no group differences in age, repeat in grade, or program experience variables. Implications of these data for future program directions and modifications of aide-training procedures are discussed.     

When simplifying life is not so bad: the link between rigidity, stressful life events, and mental health in an undergraduate population

Decades of research have generally shown that being more rigid is associated with poorer mental health. We investigated whether all aspects of what has been termed “rigidity” are harmful. In particular, we hypothesized that the desire for simple structure (DSS) will not be associated with poor mental health, and in some cases might be associated with better mental health. In contrast, the intolerance of uncertainty (IU) was hypothesized to be associated with a wide range of indices of poor mental health. We also hypothesized that people high in IU would be less resilient in the face of stressful life events. Results across two cross-sectional surveys (N=240; N=331) supported our hypotheses. DSS was associated with less hopelessness, whereas IU was associated with more depression, anxiety, stress, suicidal ideation, and hopelessness. In addition, moderational analysis supported the hypothesis that IU magnifies the adversive effect of stressful life events on depression, anxiety and hopelessness. IU was more strongly related to the negative indices of well-being than to the positive index of life satisfaction. The implications of these findings for cognitive behavioural therapy practice are discussed.     

Migrant mental health: a model for indicators of mental health and health care consumption.

OBJECTIVE: This study explores the relationship between mental health and health care consumption among migrants in the Netherlands. DESIGN: Samples of the Turkish (n = 648), Moroccan (n = 102), and Surinamese (n = 311) populations in Amsterdam were examined. The study tested a hypothesized model of risk factors for psychiatric morbidity, indicators of well-being, and indicators of health care consumption. The model was specified on the basis of information from earlier research on the sample and literature on the topic. The model was tested and refined using structural equation modeling. MAIN OUTCOME MEASURES: Psychiatric morbidity and well-being measures were assessed with the CIDI 1.1 and MOS-sf-36 subscales, respectively. Health care consumption was assessed by the question "Have you ever consulted one or more of these professionals or health care facilities with respect to mental health problems or problems related to alcohol or drugs usage?" RESULTS: The primary result of this study was the confirmation that health care consumption among migrants is predicted by need and predisposition factors, such as health condition and sociodemographic characteristics. In addition, mental health care consumption of migrants is predicted by acculturation characteristics. This result suggests an effect of cultural and migrant-specific factors in help-seeking behavior and barriers to mental health care facilities. CONCLUSIONS: Findings confirm the existence of migrant-specific mechanisms in health care consumption. Mental health care professionals should be aware of these. However, ignoring common ground for interventions unnecessarily creates distance between migrant groups and between migrant and indigenous Dutch groups.     

Sources of avoidance motivation: Valence effects from physical effort and mental rotation

When reaching goals, organisms must simultaneously meet the overarching goal of conserving energy. According to the law of least effort, organisms will select the means associated with the least effort. The mechanisms underlying this bias remain unknown. One hypothesis is that organisms come to avoid situations associated with unnecessary effort by generating a negative valence toward the stimuli associated with such situations. Accordingly, merely using a dysfunctional, ‘slow’ computer mouse causes participants to dislike ambient neutral images (Study 1). In Study 2, nonsense shapes were liked less when associated with effortful processing (135° of mental rotation) versus easier processing (45° of rotation). Complementing ‘fluency’ effects found in perceptuo-semantic research, valence emerged from action-related processing in a principled fashion. The findings imply that negative valence associations may underlie avoidance motivations, and have practical implications for educational/workplace contexts in which effort and positive affect are conducive to success.     

Moving forward is not only a metaphor: Approach and avoidance lead to self-evaluative assimilation and contrast

Could it be that walking toward (vs. away) someone else changes your self-evaluation in the direction of what this person is? We answer positively and argue that approach movements lead to self-evaluative assimilation (a higher self-evaluation with a high vs. a low standard), while avoidance movements lead to self-evaluative contrast (a lower self-evaluation with a high vs. a low standard). Hence, we predict that approach/avoidance moderates the impact of comparison information on self-evaluation. To test this idea, participants were either primed with approach or avoidance before processing comparison information (Study 1) or physically had to walk toward or away from this information (Studies 2 and 3). Results on self-evaluated adjustment (Studies 1 and 2) and self-evaluated attractiveness measures (Study 3) confirmed our predictions. These studies suggest ways to behave to self-evaluate positively when hearing about others.     

Alexithymia, emotional disclosure, and health: a program of research

This article reviews a program of research on alexithymia, emotional disclosure, and health. The article first describes two lines of research and then outlines current work attempting to integrate these lines. The first research line involves basic correlational studies on alexithymia's link to health problems; these studies suggest that alexithymia is a potential risk factor for symptoms and illness behavior, although not necessarily organic disease. The second research line involves experimental studies of the health effects of emotional disclosure via expressive writing or talking; these studies suggest that disclosure improves health on average, but that the effects are not that robust and that various moderators likely are involved. The next section of the article describes recent attempts to integrate the two research lines by examining how baseline levels of alexithymia influence the effects of emotional disclosure; these analyses suggest that alexithymia interferes with or attenuates the health benefits of disclosure. Finally, the article describes initial forays into research on interventions with the alexithymic patients. This evolving program of research demonstrates the value of integrating emotion, personality, and health, and highlights the bidirectional relationship between clinical problems and basic research.     

Mood-congruent free recall bias in anxious individuals is not a consequence of response bias

The status of mood-congruent free recall bias in anxious individuals was evaluated following incidental encoding of target words. Individuals with high and low levels of trait anxiety completed a modified Stroop task, which revealed an attentional bias for threat-related stimuli in anxious individuals. This group was significantly slower in naming the colour in which threat-related words were displayed compared to neutral words. In a subsequent free recall test for the words used in the modified Stroop task, anxious individuals recalled more threat-related words compared to low-anxious people. This difference was significant even when controlling for the false recall of items that had not been presented during study. These results support the view put forward by Russo, Fox, Bellinger, and Nguyen-Van-Tam (2001) that mood-congruent free recall bias in anxious individuals can be observed if the target material is encoded at a relatively shallow level. Moreover, contrary to Dowens and Calvo (2003), the current results show that the memory advantage for threat-related information in anxious individuals is not a consequence of response bias.     

National suicide prevention lifeline: enhancing mental health care for suicidal individuals and other people in crisis

Linking at-risk callers to ongoing mental health care is a key goal of crisis hotline interventions that has not often been addressed in evaluations of hotlines' effectiveness. We conducted telephone interviews with 376 suicidal and 278 nonsuicidal crisis callers to the National Suicide Prevention Lifeline (Lifeline) to assess rates of mental health care utilization following Lifeline calls and to assess attitudinal and structural barriers to service utilization. Postcall utilization rates were approximately 50% for suicidal and crisis callers who received mental health care referrals. Lack of health insurance and callers' perceptions about mental health problems emerged as significant barriers to accessing continued help.     

An empirical examination of stigma toward mental health problems and psychotherapy use in Veterans and active duty service members

Although many Veterans and active duty service members experience mental health problems, most do not seek out any sort of mental health help. Stigma (a significant predictor of treatment-seeking) has been documented among Veterans and active duty service members; however, previous research on stigma in these groups has primarily utilized correlational and qualitative designs. The purpose of this study was to gain a better understanding of stigma toward mental health problems in Veterans and active duty service members using an experimental design. One hundred sixty-five Veterans and active duty service members were randomized to read a vignette that described a Veteran who either did or did not experience a mental health problem and did or did not seek psychotherapy. Results indicated that the participants held more stigmatizing attitudes toward the Veteran who was described as having a mental health problem, but not toward the Veteran who was described as seeking psychotherapy. Additionally, participants held more positive attitudes toward the Veteran, compared to the attitudes that they believed other military members would hold. Last, with this sample of Veterans and active duty service members, self-stigma toward seeking psychotherapy was found to partially mediate the relationship between perceived public stigma and attitudes. Implications for addressing stigma in military service members and Veterans are discussed.     

When planning is needed: Implementation intentions and attainment of approach versus avoidance health goals

OBJECTIVE: This study tested whether forming implementation intentions is an effective strategy for attaining health goals focused on trying to avoid a negative state. DESIGN: Participants chose to either eat more healthy snacks (i.e., an approach goal) or eat fewer unhealthy snacks (i.e., an avoidance goal) over two weeks and were randomly assigned to create an implementation intention to do this or not. MAIN OUTCOME MEASURES: The authors measured fat and calorie intake after one week and after two weeks. RESULTS: After two weeks, the participants who ate most unhealthily were those who pursued an avoidance goal and did not form an implementation intention. CONCLUSION: These results suggest that forming implementation intentions for avoidance goal pursuit can help people attain important health goals.     

Development of a spanish version of the Schwartz Outcome Scale-10: a brief mental health outcome measure.

The lack of culturally appropriate psychometric instruments for the assessment of cognitive and emotional functioning in minority populations has been a concern often discussed in the assessment literature. With the increased focus on the measurement of outcome in mental health treatment, the lack of appropriate instruments for minorities has become readily apparent in this venue as well. We report on the Spanish translation of a brief and reliable measure of psychological health and well-being that has been shown to be sensitive to treatment outcomes. The original and Spanish translated versions of this measure are highly correlated, providing clinicians and organizations with a instrument that can be used for assessment of psychological well-being and treatment outcomes with Hispanic patients.     

Longer term outcome of cognitive-behavioural and psychodynamic psychotherapy in routine mental health care: randomised controlled trial

We investigated the comparative effectiveness of cognitive-behavioural (CBT) and psychodynamic therapy (PDT) under clinically representative conditions as a subtrial of a prior study (Watzke et al., 2010, BJP). A consecutive sample of 147 patients with common mental disorders was randomised to either CBT or PDT in routine mental health care. In a primary per-protocol analysis patients randomised to CBT had a significantly better longer term outcome in the primary outcome symptom severity (General Severity Index of the SCL-14; p=.001; partial η(2)=0.073) as well as in health related quality of life (Mental Component Summary of the SF-8; p=.013; partial η(2)=.041) and concerning interpersonal issues (Inventory of Interpersonal Problems, IIP-C; p=.001; partial η(2)=.070) 6 months after treatment than patients randomised to PDT. These results could be confirmed in intention-to-treat analyses (n=180) suggesting that there was no substantial attrition bias due to drop outs at the follow-up assessment. Thus, the so called equivalence outcome paradox was not replicated in this study.