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Objectives: To compare explicit and implicit stigmatizing attitudes towards mental illness among undergraduate students, medical school students, and psychiatrists, and to assess whether attitudes are associated with education level, exposure to, and personal experience with mental illness., Methods: Participants from McMaster University were recruited through email. Participants completed a web-based survey consisting of demographics; the Opening Minds Scale for Healthcare Providers (OMS-HC) 12-item survey, which measures explicit stigma; and an Implicit Association Test (IAT), measuring implicit bias toward physical illness (diabetes mellitus) or mental illness (schizophrenia)., Results: A total of 538 people participated: undergraduate students ( n = 382), medical school students ( n = 118), and psychiatrists ( n = 38). Psychiatrists had significantly lower explicit and implicit stigma than undergraduate students and medical school students. Having been diagnosed with mental illness or having had a relationship with someone experiencing one was significantly associated with lower explicit stigma. Mean scores on the OMS-HC "disclosure/help-seeking" subscale were higher compared with the "attitudes towards people with mental illness" subscale. There was no correlation between the OMS-HC and IAT., Conclusions: These findings support the theory that increased education and experience with mental illness are associated with reduced stigma. Attitudes regarding disclosure/help-seeking were more stigmatizing than attitudes towards people with mental illness. The groups identified in this study can potentially benefit from anti-stigma campaigns that focus on reducing specific components of explicit, implicit, public and self-stigma.

Purpose: Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF., Methods: Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model., Results: In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not., Conclusion: While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: PG was on contract to the Mental Health Commission of Canada as the overall research lead. CA was on contract to the Mental Health Commission of Canada as the quantitative research lead. Their roles were otherwise the same as all other academic investigators. RB, BK, and SV were on contract to the Mental Health Commission of Canada for their contribution as analysts (RB, SV) or study research associate (BK).

Objective: An empirically derived prediction model was developed in a private practice setting to monitor on-track and off-track weekly treatment progress in an intensive outpatient program (IOP)., Method: The predictive equation was derived as a function of the baseline measure and time. The formulae for the predictive equations were derived from two groups of psychiatric patients (N = 400 each) in an IOP diagnosed with major depression. Each equation was cross-validated between these two psychiatric IOP samples and a dual diagnosis sample (N = 198) using κ, the reliable change index (RCI), receiver operating characteristic curves, and Youden's J., Results: Using varying RCI classifications, approximately 66-75% of both samples reliably improved, 23-24% were indeterminant, and only 1-3% deteriorated. Of patients identified as off-track, which included patients classified as indeterminant and deteriorated, 83% were correctly identified. Of those identified as on-track, 85% were correctly classified. Those identified as on-track (85%) are highly likely to respond to treatment as expected., Conclusions: The overall efficiency index (hit rate) for the correct classification of all patients was 85%. Implications for using this predictive model as a clinical support decision tool with relatively homogeneous populations in other practice settings are discussed.

Objective: Housing First with assertive community treatment (ACT) is a promising approach to assist people with serious mental illness to exit homelessness. The article presents two-year findings from a multisite trial on the effectiveness of Housing First with ACT., Methods: The study design was a randomized controlled trial conducted in five Canadian cities. A sample of 950 participants with serious mental illness who were absolutely homeless or precariously housed were randomly assigned to receive either Housing First with ACT (N=469) or treatment as usual (N=481)., Results: Housing First participants spent more time in stable housing than participants in treatment as usual (71% versus 29%, adjusted absolute difference [AAD]=42%, p<.01). Compared with treatment-as-usual participants, Housing First participants who entered housing did so more quickly (73 versus 220 days, AAD=146.4, p<.001), had longer housing tenures at the study end-point (281 versus 115 days, AAD=161.8, p<.01), and rated the quality of their housing more positively (adjusted standardized mean difference [ASMD]=.17, p<.01). Housing First participants reported higher quality of life (ASMD=.15, p<.01) and were assessed as having better community functioning (ASMD=.18, p<.01) over the two-year period. Housing First participants showed significantly greater gains in community functioning and quality of life in the first year; however, differences between the two groups were attenuated by the end of the second year., Conclusions: Housing First with ACT is an effective approach in various contexts for assisting individuals with serious mental illness to rapidly exit homelessness.

Objective: This study examined whether Housing First fidelity ratings correspond to program operation descriptions from administrative data and predict client outcomes., Methods: A multisite, randomized controlled trial (At Home/Chez Soi) in five Canadian cities included two assessments of 12 programs over two years. Outcomes for 1,158 clients were measured every six months. Associations between fidelity ratings and administrative data (Spearman correlations) and participant outcomes (mixed-effects modeling) were examined., Results: Fidelity ratings were generally good (mean ± SD=136.6 ± 10.3 out of a possible range of 38-152; 87% of maximum value). Fidelity was significantly associated with three of four measures of program operation, with correlations between .55 and .60. Greater program fidelity was associated with improvement in housing stability, community functioning, and quality of life., Conclusions: Variation in program fidelity was associated with operations and outcomes, supporting scale validity and intervention effectiveness. These findings reinforced the value of using fidelity monitoring to conduct quality assurance and technical assistance activities.

Importance: Scattered-site housing with Intensive Case Management (ICM) may be an appropriate and less-costly option for homeless adults with mental illness who do not require the treatment intensity of Assertive Community Treatment., Objective: To examine the effect of scattered-site housing with ICM services on housing stability and generic quality of life among homeless adults with mental illness and moderate support needs for mental health services., Design, Setting, and Participants: The At Home/Chez Soi project was an unblinded, randomized trial. From October 2009 to July 2011, participants (N = 1198) were recruited in 4 Canadian cities (Vancouver, Winnipeg, Toronto, and Montreal), randomized to the intervention group (n = 689) or usual care group (n = 509), and followed up for 24 months., Interventions: The intervention consisted of scattered-site housing (using rent supplements) and off-site ICM services. The usual care group had access to existing housing and support services in their communities., Main Outcomes and Measures: The primary outcome was the percentage of days stably housed during the 24-month period following randomization. The secondary outcome was generic quality of life, assessed by a EuroQoL 5 Dimensions (EQ-5D) health questionnaire., Results: During the 24 months after randomization, the adjusted percentage of days stably housed was higher among the intervention group than the usual care group, although adjusted mean differences varied across sites. [table: see text] The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group (60.5 [95%CI, 58.6 to 62.5] at baseline and 67.2 [95%CI, 65.2 to 69.1] at 24 months for the intervention group vs 62.1 [95% CI, 59.9 to 64.4] at baseline and 68.6 [95%CI, 66.3 to 71.0] at 24 months for the usual care group, difference in mean changes, 0.10 [95%CI, −2.92 to 3.13], P=.95)., Conclusions and Relevance: Among homeless adults with mental illness in 4 Canadian cities, scattered site housing with ICM services compared with usual access to existing housing and community services resulted in increased housing stability over 24 months, but did not improve generic quality of life., Trial Registration: isrctn.org Identifier: ISRCTN42520374.

Purpose: Participant retention is an important challenge in longitudinal research on homeless people. High attrition can threaten validity, and may represent lost opportunities to deliver interventions. In this article, we report on attrition in the At Home/Chez Soi study, a multi-site randomized controlled trial of a housing intervention for homeless people with mental illness., Methods: We first calculate life tables, and then use clustered logistic regression to implement a discrete-time survival model. We use splines and indicator variables to capture non-linear and group-specific variation over time in the hazard function. As potential predictors, we consider study group, site, date of recruitment, age, sex, baseline substance dependence, baseline psychotic disorder, time homeless in life, community functioning, and education., Results: The study recruited 2,148 homeless people with mental illness. Of these, 1,158 were randomized to the housing first intervention (HF), and 990 to treatment as usual (TAU). Excluding 79 people known to have died, attrition was 14%. This proportion was higher in TAU than in HF (21 vs. 8%, p < 0.01). Attrition was significantly lower in one site than elsewhere, and was also lower among those with substance dependence (13 vs. 18%, p < 0.01) and among those enrolled earlier in the study. The hazard varied over time in complex ways., Conclusions: Results imply that study factors are more important than participant characteristics as determinants of retention, and that the immediate period after randomization is a crucial one. The high overall retention demonstrates the effectiveness of existing techniques for retaining participants.

Background: Fewer than half of individuals with a mental disorder seek formal care in a given year. Much research has been conducted on the factors that influence service use in this population, but the methods generally used cannot easily identify the complex interactions that are thought to exist. In this paper, we examine predictors of subsequent service use among respondents to a population health survey who met criteria for a past-year mood, anxiety or substance-related disorder., Methods: To determine service use, we use an administrative database including all physician consultations in the period of interest. To identify predictors, we use classification tree (CART) analysis, a data mining technique with the ability to identify unsuspected interactions. We compare results to those from logistic regression models., Results: We identify 1213 individuals with past-year disorder. In the year after the survey, 24% (n=312) of these had a mental health-related physician consultation. Logistic regression revealed that age, sex and marital status predicted service use. CART analysis yielded a set of rules based on age, sex, marital status and income adequacy, with marital status playing a role among men and by income adequacy important among women. CART analysis proved moderately effective overall, with agreement of 60%, sensitivity of 82% and specificity of 53%., Conclusion: Results highlight the potential of data-mining techniques to uncover complex interactions, and offer support to the view that the intersection of multiple statuses influence health and behaviour in ways that are difficult to identify with conventional statistics. The disadvantages of these methods are also discussed.

Purpose: to assess the prevalence of suicide ideation among community-dwelling older adults and the relationship between suicide ideation, major psychiatric disorder, and mental health service use., Design and Methods: we use data from the Canadian Community Health Survey 1.2: Mental Health and Well-being (CCHS 1.2). We estimate the prevalence of suicide ideation and the prevalence of major psychiatric disorder and service use among ideators versus nonideators. In multivariate models, we consider the sociodemographic, social, and mental health correlates of suicide ideation and mental health care use., Results: in our sample, more than 2% of older adults reported suicide ideation in the past year and more than two thirds of these respondents did not meet the criteria for any of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition disorders assessed in the CCHS 1.2. In multivariate models, being male, younger, or widowed, reporting lower social support and higher psychological distress increased the likelihood of suicide ideation. More than 50% of the respondents who reported suicidal thoughts did not access any type of mental health care use., Implications: although suicide ideation is associated with depression and anxiety disorders, many older adults with suicidal thoughts do not meet the criteria for these clinical disorders. The low prevalence of service use among older adults with suicide ideation suggests the need for further inquiry into the factors associated with discussing mental health concerns with health care providers, particularly among older adults who do not meet the criteria for clinical disorder.

Objective: To examine the incidence of psychiatric disorders in the Quebec older adult population., Method: Data from the Enquête sur la Santé des Aînés (ESA) study conducted in 2005 to 2008 using a representative sample (n = 2784) of community-dwelling adults aged 65 years and older were used., Results: The ESA study's results indicate that 12.0% of the respondents met the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, criteria for depression, mania, anxiety disorders, or benzodiazepine drug dependency at the baseline interview. Our results also indicate that the 12-month rate of incident cases of DSM-IV disorders was 6.2%. The proportion of incident cases was higher for the depression group (3.4%) than for the anxiety disorders group (2.3%). The results showed that the probability to develop an incident psychiatric condition after 1 year of follow-up, compared with the noncases group, varied according to sex (OR 2.18; 95% CI 1.39 to 3.44). Our results also showed that the number of chronic health problems (OR 1.20; 95% CI 1.09 to 1.33) and the change in the number of chronic health problems reported between the baseline and the second interview (OR 1.14; 95% CI 1.01 to 1.30) increased the probability to be an incident case at Time 2. The results indicated that social support did not influence the probability to develop a psychiatric disorder., Conclusion: These results indicate that sex and physical health status have an impact on the incidence of DSM-IV disorders in the elderly. This finding underscores the need for improved recognition and treatment of psychiatric disorders associated with physical illness in the older population.

Objective: To estimate the proportion of older adults who have used mental health services in the past 12 months among those who meet the criteria for one or more Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, 12-month psychiatric disorders. We also examine the factors associated with mental health care use in this population., Method: We used secondary data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). We first estimated the proportion of adults aged 55 years and older who used a range of mental health services. Next, using logistic regression, we examined the relative contribution of predisposing, enabling, and need characteristics in predicting any service use in this population., Results: Among the 12 792 adults aged 55 years and older in the CCHS 1.2, 513 (4.23%, 95% CI 3.89% to 4.95%) met the criteria for at least one 12-month DSM-IV disorder. Among these respondents, 37% (95% CI 31% to 43%) saw at least one type of mental health care provider in the past 12 months. Visits to a general health care provider for mental health reasons were most common, followed by specialist care. Only psychological distress was significantly and positively associated with using mental health care services., Conclusions: Over 60% of the older adults who met the criteria for a DSM-IV disorder were not using mental health care services. Social and demographic factors did not predict service use in this population.

Many cross-sectional surveys in psychiatric epidemiology report estimates of lifetime prevalence, and the results consistently show a declining trend with age for such disorders as depression and anxiety. In a closed cohort with no mortality, lifetime prevalence should increase or remain constant with age. For mortality to account for declining lifetime prevalence, mortality rates in those with a disorder must exceed those without a disorder by a sufficient extent that more cases would be removed from the prevalence pool than are added by new cases, and this is unlikely to occur across most of the age range. We argue that the decline in lifetime prevalence with age cannot be explained by period or cohort effects or be due to a survivor effect, and are likely due to a variety of other factors, such as study design, forgetting, or reframing. Further, because lifetime prevalence is insensitive to changes in treatment effectiveness or demand for services, it is a parameter that should be dropped from the lexicon of psychiatric epidemiology.

Community mental health services benefit from measuring clinical outcomes relevant to a community-based context in contrast to medically modeled outcomes. The Multnomah Community Ability Scale (MCAS) addresses broad dimensions of community functioning and was developed for clinical and evaluation purposes. We assessed the structural consistency and fit of the scale as a measure of community functioning through confirmatory factor analysis using a longitudinal sample of individuals (n=408) with severe and persistent mental illness receiving services from community mental health programs. None of the previously hypothesised factor solutions achieved a good fit and a high degree of invariance over time was observed. Through exploratory factor analysis, the possibility of alternative solutions was explored. After exclusion of two of the 17 items, four models--including four-, three-, two- and one-factor solutions--were tested for fit and invariance with no improvement. We discuss our findings of poor fit under the assumption that the MCAS should psychometrically behave as a scale. Alternative interpretations for the tool and suggestions for the use of its items as an index that measures aspects of disability are proposed.

Objective: To document the prevalence of psychiatric disorders in Quebec's older adult population., Method: Data came from the Enquête sur la santé des aînés study conducted in 2005--2006 using a representative sample (n = 2798) of community-dwelling older adults., Results: Our results indicate that 12.7% of the respondents met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for depression, mania, anxiety disorders, or benzodiazepine dependency. The 12-month prevalence rate of major depression was 1.1% and the prevalence of minor depression 5.7%. A total of 5.6% of the respondents reported an anxiety disorder. The most prevalent anxiety disorders were specific phobia (2.0%), obsessive-compulsive disorder (OCD) (1.5%), and generalized anxiety disorder (GAD) (1.2%). Agoraphobia without panic disorder and panic disorder were reported by 0.3% and 0.6% of the respondents, respectively. The prevalence rate of benzodiazepine dependency was 2.3%. The 12-month comorbidity prevalence rate between any psychiatric disorders was 2.2%. Among those with depressive disorder, the most frequent comorbidity was observed between minor depression and specific phobia (4.3%), GAD (4.3%), OCD (3.7%), and mania (1.3%). Further, only 39% of those having at least one active DSM-IV diagnosis reported having used health services for their psychological distress symptoms during the previous 12 months. Among those who consulted health services, 85% visited a general practitioner., Conclusions: Our results indicate that a large proportion of the elderly population in Quebec presents mental health needs. Longitudinal research focusing on the individual and social consequences of mental health problems reported by older adults is needed to avoid misinterpretation of this finding.

Objective: Short screening instruments, which exclude respondents unlikely to have psychiatric disorders, can make epidemiologic surveys shorter and more cost-effective. The Kessler 6-Item Psychological Distress Scale (K6), a measure of generalized distress, has been proposed for this role and has shown good agreement with the Composite International Diagnostic Interview (CIDI). However, performance of the K6 may vary for individual disorders or combinations of disorders. In this report, we examine the ability of the K6 to detect disorders among respondents in different diagnostic categories., Method: We used data from Cycle 1.2 of the Canadian Community Health Survey to assemble 5 groups of respondents with different 12-month psychiatric disorders (n = 4481). A sixth group comprised those with 2 or more disorders. We examined the sensitivity of the K6 among respondents with an individual disorder as well as those with multiple disorders., Results: The sensitivity of the K6 varies significantly by disorder; it is highest among respondents with multiple disorders and lowest among those with agoraphobia only., Conclusions: Use of the K6 as a screen for the CIDI is likely to result in biased prevalence estimates. However, both instruments should be compared with a third standard to fully assess the benefits and drawbacks of their combination.

This article examines the psychometric properties of the clinician version of the Apathy Evaluation Scale (AES-C) to determine its ability to characterize, quantify and differentiate apathy. Critical appraisals of the item-reduction processes, effectiveness of the administration, coding and scoring procedures, and the reliability and validity of the scale were carried out. For training, administration and rating of the AES-C, clearer guidelines, including a more standardized list of verbal and non-verbal apathetic cues, are needed. There is evidence of high internal consistency for the scale across studies. In addition, the original study reported good test-retest and inter-rater reliability coefficients. However, there is a lack of replication on these more stable and informative measures of reliability and as such they warrant further investigation. The research evidence confirms that the AES-C shows good discriminant, convergent and criterion validity. However, evidence of its predictive validity is limited. As this aspect of validity refers to the scale's ability to predict future outcomes, which is important for treatment and rehabilitation planning, further assessment of the predictive validity of the AES-C is needed. In conclusion, the AES-C is a reliable and valid measure for the characterization and quantification of apathy., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

Objective: To determine the prevalence of mood, anxiety, and other disorders in the population of Canadians aged 55 years and over., Method: We undertook an analysis of the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2)., Results: There was a linear decrease for all disorders after age 55 years. This was true for men and women; for anglophones, francophones, and allophones; and for both people born in Canada and people who immigrated to Canada after age 18 years. Consistent with previous research, the prevalences were higher for women than men. Immigrants reported fewer problems than nonimmigrants, with the differences decreasing with age. Francophones of both sexes reported more mood disorder than anglophones, but francophone men had less anxiety disorder than anglophone men., Conclusions: Unlike other studies that have found an upturn in the prevalence of depression and anxiety in the elderly, our results indicate a steady decrease in these disorders. Our findings are discussed in terms of explanations for age-related differences in psychiatric disorders.

Establishing an argument of causation is an important research activity with major clinical and scientific implications. Sir Austin Bradford Hill proposed criteria to establish such an argument. These criteria include the strength of the association, consistency, specificity, temporal sequence, biological gradient, biologic rationale, coherence, experimental evidence, and analogous evidence. These criteria are reviewed with the goal of facilitating an increase in rigor for establishing arguments of causation in neuropsychiatry. The challenges and opportunities related to these criteria in neuropsychiatry are reviewed, as are two important arguments for causation: one for poststroke depression and one for brain injury as a cause of psychiatric disorders.

When one variable is studied to try to explain another, the relationship between them may be biased by a third variable. The bias, known as "confounding," is common and must be minimized in research. This description is deceptively simple, though. Identifying confounding is complex but can be reduced to a stepped procedure. By way of examples, this article describes confounding and how to recognize it.

This article describes various indices of risk, which is the probability that a person will develop a specific outcome. The risk difference is the absolute difference in risks between 2 groups and can be used either to compare the outcome of 2 groups, one of which was exposed to some genetic or environmental factor, or to see how much of an effect a treatment may have. The reciprocal of the risk difference, the number needed to treat, expresses how many patients must receive the intervention in order for 1 person to derive some benefit. Attributable risk reflects the proportion of cases due to some putative cause and indicates the number of cases that can be averted if the cause were removed. Finally, the relative risk and odds ratio reflect the relative differences between groups in achieving some outcome, either good (a cure) or bad (development of a disorder).

Previous research has shown that the SCL-90 predicts response to treatment by substance abusers. However, the construct validity of the subscales has been questioned. The present study assessed the factor structure of the SCL-90 in 740 outpatients with coexisting substance use and nonsubstance use psychiatric disorders. The congruency coefficient and salient similarity index tested factorial invariance across gender. Exploratory factor analyses assessed the scale's empirical factor structure. The pattern of loadings for the first three factors was congruent in each gender. The factor analysis yielded three inter-correlated factors that together accounted for 38% of the variance in ratings from the entire sample. A single higher-order factor was identified that explained 60% of the variance in factor scores. These findings are consistent with previous studies that obtained a single predominant factor, and suggest that the SCL-90 primarily taps general psychiatric distress in comorbid substance abusers.

The traditional purpose of psychiatric epidemiologic surveys has been the assessment of mental illness and, by implication, the need for care. Previous research has focused on unmet need, defined as those who meet "caseness" but do not receive care, but has rarely examined the converse. Since survey respondents receiving care but not meeting caseness have been found to represent up to one-half of mental health service users, this is a significant service delivery issue. The data are drawn from the Mental Health Supplement to the Ontario Health Survey (the Supplement), a household survey of 9,953 respondents, which used the University of Michigan's version of the Composite International Diagnostic Interview (UM-CIDI) as its diagnostic instrument. Community residents who used formal mental health services in the past year but who did not have a concurrent UM-CIDI/DSM-III-R (Diagnostic and Statistical Manual 3, revised) diagnosis were defined as "treated without CIDI disorder". Their need for care was evaluated by comparing them to "treated depressed" and "healthy" respondents, using indicators of functional impairment, vulnerability to developing disorder, and risk of relapse. The match between need and care levels was examined by comparing their type and intensity of use with those of the treated depressed. Results present strong evidence for conceptualizing need as continuous, rather than discrete. The results for the group defined as "treated without CIDI disorder" were consistently between those for the other two groups (with the "treated depressed" always showing the highest need) on all indicators as well as on a summary need index. However, their type and intensity of service use appeared to be unrelated to their level of need. Although some of the "treated without CIDI disorder" group may require preventive or follow-up treatment, the need for service for others is not as convincingly demonstrated. Outcome studies are needed to provide comparative data to describe more fully the problems experienced by this group and indicate whether treatment is helpful. In an age of fiscal restraint, when resource reallocation (rather than generation of new resources) is the likely scenario, such close examination of the fit between need and care is critical if services are to be targeted appropriately.

In some studies, the outcome of interest is the time until some event occurs: readmission to hospital, the next manic episode, or even death. Survival analysis is a technique which can be used to analyze such data. It has added usefulness because it allows us to use data from subjects who drop out of sight over the course of the follow-up period as well as from those who do not experience the event by the time the study ends. This article introduces this technique and provides some guidelines for designing follow-up trials.

A 60-item short form of the MMPI with very high content validity and items that appear on both the MMPI and MMPI-2 was developed and named the MMPI-TRI. It contains three 20-item scales--the Subjective Distress, Acting-Out, and Psychosis scales. These three scales have excellent internal consistency and sufficient independence from each other. An anxiety and depression group of patients, prison inmate group, and a schizophrenic and other psychotic group had the highest mean scores on Subjective Distress, Acting-Out, and Psychosis, respectively. Correlations with the 13 regular scales of the MMPI and MMPI-2, their content and supplementary scales, and four other psychometric instruments provided very strong evidence for validity. Norms are provided.

Whenever two or more raters evaluate a patient or student, it may be necessary to determine the degree to which they assign the same label or rating to the subject. The major problem in deciding which statistic to use is the plethora of different techniques which are available. This paper reviews some of the more commonly used techniques, such as Raw Agreement, Cohen's kappa and weighted kappa, and shows that, in most circumstances, they can all be replaced by the intraclass correlation coefficient (ICC). This paper also shows how the ICC can be used in situations where the other statistics cannot be used and how to select the best subset of raters.

Millon Clinical Multiaxial Inventory II (MCMI-II; Millon, 1987) results from 134 patients were scored twice; with and without the item weights. The results showed that the correlations between the weighted and unweighted versions of the same scales were extremely high, exceeding .90 in all cases. Furthermore, weighting did not significantly reduce the correlations among the scales, either within each of the four syndrome/pattern categories of the MCMI-II, or between categories. It is concluded that item weighting reduces the access of the MCMI-II by clinicians, without increasing its psychometric properties.

Five modifier and correction indices are used in the Millon Clinical Multiaxial Inventory-II (MCMI-II; Millon, 1987) to improve the sensitivity and specificity of its scales; however, profile analyses indicated that they had little effect on the profiles of 141 psychiatric inpatients. The profiles generated within each MCMI-II section with and without the indices had the same shape and generally showed no significant differences on the various scales. A simple procedure applied to the initial, uncorrected scores provided a good estimate of the final base rate (BR) scores that are obtained when the correction and modifier indices are applied. Examination of individual profiles indicated that the 3-point codetypes were usually the same regardless of whether or not the correction indices were applied. When there were changes, these usually involved changes in rank order; new scales were rarely introduced in a code type. Although the utility of the indices for assessing test-taking attitude remains to be determined, these results argue against their use for modifying BR scores.

Rating scales of various sorts are very useful for both clinical and research purposes. However, they vary greatly regarding their reliability, validity, and utility. This article provides a guide for people who need to evaluate scales, either to incorporate them into their own research or clinical activities, or to determine if the results of studies which use scales are meaningful. The different types of reliability and validity are discussed and guidelines are offered to evaluate how well these were assessed. Finally, other aspects of scales which can affect their usefulness, such as completion time, training, and scoring ease, are discussed.

The ability of the MacAndrew Alcoholism Scale (MAC) and Scale B of the Millon Clinical Multiaxial Inventory (MCMI) to discriminate independently defined alcoholics with psychiatric diagnoses from other psychiatric patients was examined for males and all alcoholics, using three different criteria of alcoholism. The MAC identified from 80% to 87% of male alcoholics and 76% to 82% of all alcoholics, and from 25% to 52% of male nonalcoholics and 55% to 75% of all nonalcoholics, resulting in a large number of false positives. Scale B identified from 31% to 60% of male alcoholics and 33% to 43% of all alcoholics, and from 73% to 85% of male nonalcoholics and 85% to 94% of all nonalcoholics. The operating characteristics of Scale B showed that it was not as efficient in identifying alcoholics as previous work had indicated. We suggest that Scale B should not be used and the MAC should be used cautiously to discriminate alcoholics with psychiatric disorders from patients without alcoholism.

The authors describe the parent-therapist program, an innovative alternative to residential treatment for emotionally disturbed children. In the program, which is based on the extended family model, couples not only provide a residential milieu for a child placed with them, but also are trained to be therapists who can deal with specific emotional and behavioral problems. The parent-therapists work together in three treatment teams, each consisting of five couples. Education and supervision are ongoing. A total of 27 children have been treated in the program since it got under way in May 1972. Clinical impressions indicate that the children have made substantial gains in developing social and interpersonal skills and in their academic acievement.

Assessment of cognitive and emotional variables in 19 females with hyperthyroidism was made pretreatment, at 3 weeks, and after euthyroidism was established. A matched group of normal controls was similarly tested. Group differences on cognitive measures did not reach statistical significance, but cognitive deficits and symptoms of emotional disorder were significantly associated with the severity of thyroid toxicity previous to treatment. Measures of cognitive function and personality features moved towards control group values as euthyroidism was established. The implication of these findings is discussed in the context of a review of previous literature. The observed cognitive disturbance and emotional distress appear to be reflections of thyroid toxicity.

The subjectivity of the Harris-Lingoes MMPI content subscales was examined by asking expert judges (N = 13) to group items from appropriate clinical scales that represented similar content, attitudes or traits. The mean subgroups were compared to the Harris-Lingoes subscales, and item groupings were consensually validated and replicated. Judges developed more content categories per scale than Harris and Lingoes, but showed relatively little agreement on item groupings. Nine consensually validated and replicated subscales were highly similar to nine Harris-Lingoes subscales, while nine other replicated subscales were moderately similar to seven Harris-Lingoes subscales. Twelve Harris-Lingoes subscales were unrelated to the replicated subscales.