Validity of the self-rated 36-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 as a measure of functioning in Swedish psychiatric outpatients.

PURPOSE: The aim of this study was to investigate concurrent validity of the Swedish self-rated 36-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 by comparison with professional Global Assessment of Functioning (GAF) ratings in psychiatric outpatients. MATERIAL AND METHODS: A cross-sectional convenience sample of 444 patients was recruited from their regular psychiatric outpatient settings. The patients filled out the WHODAS 2.0; their clinicians provided clinical information and performed GAF ratings blinded to the patients' assessments. Analyses of correlations, variance components, and ROC curves were performed to investigate the validity of the WHODAS 2.0 through comparison with the GAF. The variance component analyses included working status, psychosocial problems, number of diagnostic groups, and remission status. GAF ratings were separated as total (GAF-T), symptoms (GAF-S), and functioning (GAF-F). RESULTS: There was significant correlation (p < 0.001) between WHODAS 2.0 total and domain scores and GAF-S, GAF-F, and GAF-T ratings. The correlations varied from r = 0.29 to r = 0.48, with the highest being between GAF-F rating and WHODAS 2.0 total score. Repeating the analyses for separate diagnostic groups replicated the findings, though not for psychotic, substance-related, and eating disorders. The WHODAS 2.0 showed good ability to distinguish impaired functioning below a fixed GAF-T cut-off of 70 (area under the curve: 0.74-0.78). The explained variance was lower for the WHODAS 2.0 than for the GAF (38.9% vs. 59.2%). CONCLUSIONS: Concurrent validity was found when comparing the Swedish self-administered 36-item version of WHODAS 2.0 with the expert-rated GAF in psychiatric outpatients.

Evidence for validity of the Swedish self-rated 36-item version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in patients with mental disorders: a multi-centre cross-sectional study using Rasch analysis.

BACKGROUND: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a generic instrument for the assessment of functioning in six domains, resulting in a total health-related disability score. The aim of this study was to investigate the psychometric properties of the Swedish-language version of the self-rated 36-item version in psychiatric outpatients with various common psychiatric diagnoses using Rasch analysis. A secondary aim was to explore the correlation between two methods of calculating overall scores to guide clinical practice: the WHODAS simple (summative) model and the WHODAS complex (weighted) model. METHODS: Cross-sectional data from 780 Swedish patients with various mental disorders were evaluated by Rasch analysis according to the partial credit model. Bivariate Pearson correlations between the two methods of calculating overall scores were explored. RESULTS: Of the 36 items, 97% (35 items) were within the recommended range of infit mean square; only item D4.5 (Sexual activities) indicated misfit (infit mean square 1.54 logits). Rating scale analysis showed a short distance between severity levels and disordered thresholds. The two methods of calculating overall scores were highly correlated (0.89-0.99). CONCLUSIONS: The self-administered WHODAS 2.0 fulfilled several aspects of validity according to Rasch analysis and has the potential to be a useful tool for the assessment of functioning in psychiatric outpatients. The internal structure of the instrument was satisfactorily valid and reliable at the level of the total score but demonstrated problems at the domain level. We suggest rephrasing the item Sexual activities and revising the rating scale categories. The WHODAS simple model is easier to use in clinical practice and our results indicate that it can differentiate function among patients with moderate psychiatric disability, whereas Rasch scaled scores are psychometrically more precise even at low disability levels. Further investigations of different scoring models are warranted.

Psychometric evaluation of the Swedish self-rated 36-item version of WHODAS 2.0 for use in psychiatric populations - using classical test theory.

AIM: The aim of this study was to evaluate the reliability and validity of the Swedish version of the self-rated 36-item WHODAS 2.0 in patients from Swedish psychiatric outpatient settings, using classical test theory. METHODS: The 36-item WHODAS 2.0, together with the Sheehan Disability Scale (SDS), was filled in by a sample of 780 participating psychiatric patients: 512 (65.6%) women, 263 (33.7%) men, and 5 (0.6%) who did not report any sex. RESULTS: The internal consistency, measured by Cronbach's alpha, for the different domains of functioning were between 0.70 and 0.94, and interpreted as good. The confirmatory factor analysis (CFA) revealed two levels: the first level consisted of a general disability factor, while the second level consisted of the six domains of the scale, respectively. The model had borderline fit. There was a significant correlation between WHODAS 2.0 36-item and SDS (n = 395). The WHODAS 2.0 differed significantly between diagnostic groups. CONCLUSION: The present study demonstrates that the Swedish self-rated 36-item version of WHODAS 2.0, within a psychiatric outpatient population, showed good reliability and convergent validity. We conclude that the self-rated 36-item Swedish version of WHODAS 2.0 can be used for valid interpretations of disability in patients with psychiatric health conditions.

Exploring the relationship between activities and emotional experience using a diary in a mental health inpatient setting.

Mental health inpatient milieus have repeatedly been found to be associated with passivity, social disengagement, and low levels of interaction with staff. However, little is known about patients' experiences related to different ward activities. In the present study, we aimed to study the reports of activities and associated experiences of patients admitted to acute psychiatric inpatient wards. Disengaged, inactive, and solitary activities were hypothesized to be associated with less reward and more distress than their counterparts. We also aimed to investigate if such activities predicted distress, and if they were associated with clinical severity. Participants (n = 102) recorded their activities along with concurrent ratings of reward and distress in a structured 1-day diary, and nurses provided clinical severity ratings. On average, 3.74 of the 11 hours assessed (34%) were spent doing nothing, only 0.88 hours (8%) were spent with staff, and most of the time was spent in solitude. Doing nothing, being alone, and passivity were associated with the greatest levels of distress and lowest levels of reward, whereas informal socializing demonstrated the opposite pattern. Distress was not predicted by activity or reward when adjusting for baseline distress. Clinical severity was not associated with the amount of time spent alone or the experience of reward during activity. In conclusion, the risk for passivity and social disengagement during admission prevails. This activity pattern could have detrimental emotional consequences and warrants action, but more studies are needed to determine if activity actually precedes emotional experience.

Behavioral activation in acute inpatient psychiatry: a multiple baseline evaluation.

BACKGROUND AND OBJECTIVES: The present study employed a multiple baseline study design with repeated measures to explore clinical outcomes, therapy mechanisms, and feasibility of Behavioral Activation for persons admitted to inpatient psychiatry. METHODS: Six adult inpatients with depressive symptoms and different psychiatric disorders were randomized to different lengths of baseline standard inpatient treatment. Subsequently a 5-day, 10-session Behavioral Activation protocol was added. Daily self-report outcome and process measures were administered and supplemented with hourly self-reports and clinician assessments before and after each study phase. RESULTS: After a relatively stable baseline, at least four participants showed marked gradual improvements both in terms of outcome as well as activation and avoidance as Behavioral Activation was initiated. The temporal relation between process and outcome differed somewhat across metrics. In most instances however, change in activation and avoidance either coincided or preceded decreased depression. LIMITATIONS: We did not include some relatively common disorders, did not control for the effects of increased attention, did not investigate treatment integrity, and did not conduct follow-up after discharge. Raters were not blind and measures were mainly focused on depressive symptoms. All received concurrent medical treatment. CONCLUSIONS: This preliminary study further supports the promise of Behavioral Activation as an inpatient treatment for persons with a variety of psychiatric disorders. Results also lends preliminary support for the purported mechanisms of Behavioral Activation.

Reliability of global assessment of functioning ratings made by clinical psychiatric staff.

OBJECTIVE: In the Swedish psychiatric care system, systematic follow-up of clinical work with patients is becoming a part of regular service, and a number of care providers are using the Global Assessment of Functioning (GAF) to measure outcomes. This study investigated the reliability of the GAF and analyzed certain factors that affect measurement errors when the scale is used by regular psychiatric staff. METHODS: Eighty-one raters from various psychiatric outpatient clinics rated eight case vignettes. Interrater reliability was assessed by using intraclass correlation coefficients (ICCs), and factors associated with reliability were analyzed by using raters' unique residual values. RESULTS: The results showed that staff who are responsible for assessing first-time patients at outpatient psychiatric clinics and making diagnoses are using the GAF with satisfactory reliability (ICC(1,1)=.81). The factors associated with reliability were raters' subjective attitude toward the GAF and motivation to use the scale and other measurement instruments in psychiatry. CONCLUSIONS: GAF ratings made by an individual rater can be used to measure changes and outcomes at the group level. However, the measurement error is too large for assessment of change for an individual patient, in which case it might be necessary to use several raters. If raters are positively inclined to use rating instruments, measurement errors are minimized and reliability is maximized.

Relationship between the Global Assessment of Functioning and other DSM axes in routine clinical work.

OBJECTIVES: The aim of this study was to investigate the validity of the Global Assessment of Functioning (GAF) when routinely used in clinical work by focusing on the relations between the GAF, other axes in the DSM system, and some demographic variables conceptually derived on theoretical and clinical grounds. METHODS: A clinical database containing data for 5,538 patients assessed by 181 raters as a part of routine practice in psychiatric outpatient settings in Sweden was used. A hierarchical linear regression model and a variance component model were used to analyze the data. Regression models were also used to determine how the relation between the GAF and axis I depends on the selection of diagnostic groups in the sample. RESULTS: Seventeen percent of the systematic variance in GAF scores was explained by diagnostic differences as defined on DSM-IV axis I, and 5.1 percent was explained by psychosocial and environmental problems as measured on DSM-IV axis IV. Unexpectedly, the site of the investigation explained another 3.6 percent of the variance. CONCLUSIONS: The GAF can be used as a comprehensive measure of global mental health in routine clinical work for assessment and for outcome management.