Impact of illness scale: reliability, validity, and cross-cultural utility.

We report on the development of a brief (nine-item) Impact of Illness Scale (IIS), which measures the degree that an illness is perceived to restrict psychosocial functioning. The measure is shown to have high internal consistency in a variety of samples. Its construct validity is indicated by correlations with other scales measuring general functioning in samples affected by illness. There is little variation in correlations between the IIS and other measures across a number of groups from different language and cultural backgrounds. This, together with the finding that items retain their psychometric properties when used to make general ratings of mental disorders, suggests that the content of the IIS is valid. The results suggest the IIS is a reliable and valid measure of psychosocial impact of illness that may be applicable in a wide range of sociocultural settings.

Determinants of anti-psychotic medication compliance in a multicultural population.

The efficacy of medication in controlling or ameliorating symptoms of psychotic conditions is well established in clinical trials, but medication effectiveness in mental health services is considerably affected by the extent to which clients actually comply to their prescribed medication. This study aimed to assess the relative influence of demographic, medication, social support and relationship variables on perceived compliance with medication in a sample of clients with serious mental illness from diverse ethnic backgrounds. It also aimed to explore whether compliance differed by matching clients with a case manager from the same ethno-linguistic background. Data on medication compliance, administration route, medication dose, sex, age, impairment of thought processes, mood abnormality, ability to manage money, acceptance of illness (insight), social network size, alcohol and drug use, impulse control, and cooperation with staff were provided by case managers for 168 clients from diverse ethnic backgrounds. Multiple regression analysis was used to examine the predictors of medication compliance. The main predictors of greater compliance were greater general cooperation with staff, better insight, and matching clients with a case manager from the same ethnic background.

Acculturation and dental health among Vietnamese living in Melbourne, Australia.

OBJECTIVES: To describe the relationship between acculturation and oral health status, oral health knowledge and frequency of dental visits in subjects of Vietnamese background, 18 years or older, living in Melbourne, Australia. METHODS: Oral health status was measured using the DMFS index. Oral health knowledge was estimated by responses to six specific oral preventive measures: brushing, flossing, use of fluorides, diet, and dental visits. Dental visits was measured by the number of visits in the 12 months prior to the survey. Acculturation was measured along two dimensions, psychological and behavioural, using the Psychological-Behavioural Acculturation Scale. Data were analysed using multivariate analysis to identify the combined effect of eight predictors (age, gender, occupational status, education, reason for migration, proportion of life in the host country, behavioural acculturation and psychological acculturation) against the dependent variables. RESULTS: The analysis was conducted on a sample of 147 subjects and showed significant interactions between the acculturation variables and three outcome measures: dental caries, knowledge of preventive measures and dental visits. Results indicated that acculturation was an important intervening variable. Psychological acculturation was strongly related to the three oral health outcomes, although the effect of behavioural acculturation was also apparent regarding dental status. CONCLUSIONS: This study offers several insights for understanding the mechanisms by which acculturation impacts oral health status. Interventions that simplify the cultural influence of immigrant groups by focusing on socio-demographic differences and even immigration variables to define risk groups might not produce predicted changes in oral health status.

Continuity of contact with psychiatric services: immigrant and Australian-born patients.

BACKGROUND: Under-representation of ethnic minority groups in psychiatric services has been widely reported in Western nations. The present study examined whether there were differences between immigrant and Australian-born patients in their maintenance of contact with a statewide psychiatric service system. METHODS: Groups were selected on the empirical grounds that they are differently represented in this service system. Employing a form of case-control design, four groups of patients were compared: those born in Australia, the United Kingdom, Southern Europe, and South East/East Asia respectively (n = 79 for each). Groups were identically matched on sex, age, diagnosis (either schizophrenia or bipolar illness) and locality of service. The groups did not differ as to the timing of their first appearance in the 3-year period in which their psychiatric contact was examined. RESULTS: Despite their different representation in the psychiatric service system, the four groups did not differ on measures of continuity of contact. Measures included number of contacts with mental health community services, number of admissions to inpatient wards, length of stay in hospital and the longest interval between any two successive service contacts. CONCLUSIONS: The commonly reported underrepresentation of immigrant groups in the psychiatric service system does not appear to be due to greater discontinuation of contact with services. If the assumption of equal community prevalence of disorder is made, then the observed under-representation may be due to differential rates of access to (that is, initial contact with) psychiatric services.

The three-syndrome model of schizophrenia: meta-analysis of an artefact.

In two recent studies, Smith et al. (Smith, D.A., Mar, C.M., Turoff, B.K., 1998. The structure of schizophrenic symptoms: a meta-analytic confirmatory factor analysis. Schizophr. Res. 31, 57-70) and Grube et al. (Grube, B.S., Bilder, R.M., Goldman, R.S., 1998. Meta-analysis of symptom factors in schizophrenia. Schizophr. Res. 31, 113-120) used meta-analysis to examine the syndromal structure of schizophrenia. A limitation of both these studies is that the nine subscale scores from Andreasen's Scales for Assessment of Positive and Negative symptoms formed the basis of the analyses. These nine ratings, only four of which represent positive symptoms, do not adequately respresent the diversity of positive symptoms. A review of studies that examined the correlation between the individual items of these scales failed to support the classification of symptoms into these nine subgroups. Studies that indicated low numbers of syndromes suffered from one or more of the following limitations: (1) samples that were restricted to chronic schizophrenia, (2) exclusion of many items from analysis, and (3) a poor fit of the symptom model to the data. Studies not limited in these ways indicated the presence of at least 11 major dimensions of schizophrenic symptomatology, not including affective symptoms. It is concluded that the three-syndrome model of schizophrenia is largely an artefact of inadequate measurement at the symptom level.

The treated prevalence of mental disorder amongst immigrants and the Australian-born: community and primary-care rates.

The objective of the study was to explore the relationship between birthplace and the treated prevalence of mental disorder in Australia. Treated prevalence rates were derived from two surveys. These were the 1989-1990 National Health Survey, carried out by the Australian Bureau of Statistics, and the general practice component of a one-day mental health census carried out in the state of Victoria by the authors in 1993. Differences due to the age and sex composition of birthplace groups were controlled statistically. Treated rates of mental disorder, and the use of psychotropic medication, were consistently high amongst those born in Greece, and low amongst those born in the U.K./Ireland or in South East Asia, compared to the Australian-born. Country of birth has a significant effect on the treated prevalence of mental disorder, as reported by patients or their doctor. Further research is needed to reveal the underlying causes of these differences.

Cultural diversity in Australian medical education.

The present study sought to explore the relevance of cultural dimensions and cultural diversity among overseas and local medical students. The main comparison among the fourth year medical students studied was between Asian origin and Anglophone background students. The measures used included cultural variation, reasons for studying medicine, learning approaches and strategies, patient interaction confidence, and medical practices anxieties. Results indicated cultural differences between the two groups, and relationships between cultural variables and, in particular, reasons for studying medicine, learning approaches and strategies, and patient interaction confidence. Results were interpreted according to Hofstede's (1980, 1986) theory of cultural dimensions as they may apply in the educational setting.

English language ability and mental health service utilisation: a census.

OBJECTIVE: To explore the relationship between English language proficiency and mental health service utilisation. METHODS: In September 1993, a sample census was conducted of all mental health services in the State of Victoria, including public and private hospital wards, outpatient consultations provided by psychiatrists and clinical psychologists, and primary mental health care provided by general practitioners. Response rates ranged from 37% for monolingual general practitioners (GPs) to 96% for inpatient units. Particular emphasis was placed on patients' English language proficiency and the role played by bilingual clinicians. RESULTS: Over 80% of inpatients received a diagnosis of either dementia or psychosis. This proportion was even greater in the case of patients with English language difficulties. The latter group of patients underutilised specialist outpatient services, and those using these services were less likely to receive psychotherapy than fluent English speakers. They utilised GPs for mental disorder at at least the same rate as other patients. There was a marked preference for bilingual GPs, with 80% of patients with poor English language skills consulting GPs who spoke their native language. CONCLUSION: There appears to be considerable underutilisation of specialist mental health services by patients who are not fluent in English. The liaison-consultation model of psychiatric care may be an effective way of addressing this problem, given the important role already played by billingual GPs in the psychiatric care of those whose native language is not English.

Positive and negative symptoms in neuroleptic-free psychotic inpatients.

Andreasen's scales for the assessment of positive (SAPS) and negative (SANS) symptoms and the Brief Psychiatric Rating Scale (BPRS) were administered to a group of 70 neuroleptic-free psychotic inpatients. Individual ratings from the SAPS and SANS, together with the 18-item BPRS, were examined to identify clusters of symptoms. The findings, consistent with our previous studies using medicated patients, did not support a simple positive-negative dichotomy. Independent syndromes representing negative symptoms and thought disorder were apparent, although within the negative syndrome there were three related sub-syndromes of flat affect, alogia and social dysfunctions. Hallucinations and delusions did not form a homogeneous group of symptoms. Paranoia emerged as a distinct syndrome, and the remaining symptoms could be subdivided into hallucinations, grandiose delusions, and 'loss of boundary' delusions (e.g., thought broadcasting, mind reading). These syndromes, with the exception of loss of boundary delusions, which consisted of SAPS delusions alone, correspond to syndromes of psychosis identified by Lorr and his colleagues thirty years ago. It is concluded that the currently popular 'three syndrome' model does not adequately represent the diversity of psychotic symptoms.

Immigrant status and gender effects on psychopathology and self-concept in adolescents: a test of the migration-morbidity hypothesis.

Evidence for a relationship between immigrant status and psychological morbidity (which we shall refer to as the "migration-morbidity" hypothesis) in adolescents is variable and inconclusive. The present study tests this hypothesis and also explores gender differences in self-reported psychopathology and self-concept measures. Native-born Australians, Australian-born adolescent children of immigrants, and immigrant and refugee adolescents are compared on a number of relevant measures. The results do not support the migration-morbidity hypothesis. However, Vietnamese refugee adolescents had poorer self-concept than the other groups.

Validity of a single-item index of acculturation in Vietnamese immigrant youth.

A single-item index of acculturation towards a host culture is described. The index appears to have good construct validity as assessed in a sample of 177 young Vietnamese immigrants in Australia.

Language, culture and psychiatric services: a survey of Victorian clinical staff.

In planning psychiatric services for non-English speaking immigrant communities it is essential to know what resources are available for the implementation of service plans. A survey of 991 professionals from a variety of disciplines working in Victorian state operated inpatient and community psychiatric services demonstrates that, although there is a substantial number of bilingual clinicians working in the system, there is a poor match between languages spoken by patient groups and clinicians, infrequent contact between bilingual clinicians and patients speaking the same language, and inadequate availability of interpreting services. Clinicians' knowledge of cultural issues relevant to assessment and treatment is inadequate, and there is some enthusiasm among clinical staff for remedying this deficiency. Clinicians express the opinions that services to non-English speaking patients are inferior, and clinical outcome is worse than for the Australian-born. There appears to be general support for changes which would seek to more adequately meet the psychiatric service needs of immigrants.

Positive and negative symptoms in the psychoses: principal components analysis of items from the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms.

The present study investigated the factor structure of the items contained in Andreasen's scales for the assessment of positive and negative symptoms (SAPS and SANS) by use of a series of principal components analyses (PCAs) with oblique rotations of the axes. It was found that the structure could be summarized by three major components labeled negative symptoms, thought disorder, and delusions/hallucinations. Dimensionality could meaningfully be increased to five components. Negative symptoms was found to separate into two components that we labeled negative signs and social dysfunctions. The delusions/hallucinations factor could be separated into two components, delusions and hallucinations, with "loss of boundary" delusions being related to both factors. Delusions of persecution were independent of other symptoms. The thought disorder factor did not decompose meaningfully within the investigated dimensionality. A two-factor solution did not explain the correlation between symptoms adequately. The results do not support the simple dichotomy between positive and negative symptoms in psychosis, but suggest that a wider dimensional concept may be more useful in future studies.

Positive and negative symptoms in the psychoses. Re-analysis of published SAPS and SANS global ratings.

The validity of the simple dichotomy between positive and negative symptoms was examined by reanalysing the results of published studies using global ratings from Andreasen's SAPS and SANS. Global ratings from our own sample of 114 diagnostically heterogenous psychotic patients were also analysed. In none of the studies was a simple positive-negative dichotomy an adequate representation of symptom structure. The most commonly occurring structure consisted of three independent groups: Hallucinations/Delusions, Positive Thought Disorder and Negative Symptoms. These findings applied to both manic and schizophrenic groups of patients. An important implication of these results for future studies is that combining positive symptoms into a single scale is inappropriate because possibly differential relationships between Hallucinations/Delusions and Thought Disorder and a variety of external measures may be obscured by such a means of data reduction.

The factor structure of the Turkish version of the General Health Questionnaire.

The 60-item General Health Questionnaire (GHQ) was translated into Turkish and administered to a community sample of 437 Turkish-speaking immigrants resident in Melbourne, Australia. The factor structures of the 60-item and 28-item versions of the GHQ were examined to determine the cross-cultural validity of the four subscales of the 28-item GHQ "anxiety/insomnia", "social dysfunction", "severe depression" and "somatic complaints". Four-factor principal components analyses yielded factors which corresponded to similar underlying traits, but the pattern of symptom loadings differed in several ways. Insomnia was less closely associated with anxiety, and general illness ratings such as "not feeling perfectly well" were not uniquely associated with somatic symptoms. The "anxiety/insomnia" and "severe depression" factors overlapped, with many symptoms partially correlated with both factors. These factors appeared to be due to variations in the frequency of occurrence of these symptoms rather than a qualitative distinction between anxiety and depression.

Positive and negative symptoms in the psychoses: multidimensional scaling of SAPS and SANS items.

Recently, the validity of the simple dichotomy between positive and negative symptoms in psychosis has been questioned. A newly admitted group of 114 DSM-III patients with psychotic disorder were assessed using Andreason's positive and negative symptoms scales. Multidimensional scaling, augmented by cluster analysis, was applied to the full item set of these scales and showed clearly that there are three major, independent groups of symptoms: Hallucinations/Delusions, Positive Thought Disorder and Negative Symptoms. Within the Hallucinations/Delusions and Negative Symptoms groups there was some additional structure which does not conform to the SAPS and SANS sub-scales. In particular there was considerable heterogeneity within the Hallucinations/Delusions group, and delusions of persecution may represent a fourth independent dimension of psychopathology which is under-represented in these scales.

The PBI-BC: a brief current form of the Parental Bonding Instrument for adolescent research.

The present report describes the development of a brief form of the Parental Bonding Instrument (PBI-BC) intended to measure perceptions of current parental characteristics. The PBI-BC, consisting of eight items and inquiring into parental characteristics as perceived by the adolescent respondent over the previous 3 months, is shown to closely replicate the factor structure reported for the PBI. The scales are shown to have reasonable internal reliability. Arithmetic difference scores representing the two bipolar factors seem to be adequate for studies requiring easily calculated measures of parental care versus rejection, and parental control versus autonomy. The PBI-BC may be particularly useful in multivariate studies of adolescent samples, where the two dimensions of parental care versus rejection and parental control versus autonomy are thought to be potentially relevant.

Construct validation in adolescents of the brief current form of the Parental Bonding Instrument.

We have reported elsewhere the development of a brief version of the Parental Bonding Instrument (PBI), which we have called the Parental Bonding Instrument-Brief Current form (PBI-BC), for use in survey research in adolescent samples. It was shown in that report that PBI-BC retained the factor structure of the original instrument. The structure remained stable in adolescents' ratings of their mothers and their fathers. Given the evidence of a relationship between the dimensions from the original scale and psychopathology, it was expected that the PBI-BC would be similarly related to measures of psychopathology, namely, that there would be a set of positive correlations between the perceived parental bonding styles of high control and low autonomy-giving and measures of pathology, with a negative relationship between pathology and perceived parental styles of high care and low rejection. In addition, the present study explored the relationships between perceived parental styles and bipolar positive and negative self-concept measures, with the expectations that high control and low autonomy would be associated with more negative self-concept and that high care and low rejection would be associated with more positive self-concept. The results generally confirmed these expectations, suggesting that the brief instrument has adequate construct validity and would be particularly useful as a brief index in studies of adolescents.