Page 1 of 19http://spider.apa.org/ftdocs/ccp/1999/june/ccp673320.html 8/30/2000Quality of Life Expanding the Scope of Clinical Significance Madeline M. GladisDepartment of Psychiatry Elizabeth A. GoschDepartment of Psychiatry Nicole M. DishukDepartment of Psychiatry Paul Crits-ChristophDepartment of Psychiatry ABSTRACTClinical researchers have turned their attention to quality of life assessment as a means of broadening the evaluation of treatment outcomes. This article examines conceptual and methodological issues related to the use of quality of life measures in mental health. These include the lack of a good operational definition of the construct, the use of subjective versus objective quality of life indicators, and the nature of the relationship between symptoms and quality of life judgments. Of special concern is the ability of quality of life measures to detect treatment-related changes. The authors review the application of quality of life assessment across diverse patient groups and therapies and provide recommendations for developing comprehensive, psychometrically sophisticated quality of life measures. Preparation of this article was funded in part by Grants P50-MH-45178, K02-MH00756, and R01-MH40472 from the National Institute of Mental Health. We thank Peter Bachman for his research assistance and help in preparing this article. Correspondence may be addressed to Madeline M. Gladis, Department of Psychiatry, Center for Psychotherapy Research, University of Pennsylvania, 3600 Market Street, Suite 768, Philadelphia, Pennsylvania, 19104. Electronic mail may be sent to [email protected] Received: August 24, 1998 Revised: December 7, 1998 Accepted: December 9, 1998 In their attempts to evaluate the full range of effects of health care interventions, clinical researchers have broadened their definition of clinical outcome to include a concern for the patient's psychological, social, and material well-being. The enormous appeal and, one would hope, utility of assessing "quality of life" is reflected in the literature on the topic and the development of hundreds of measures over the past 2 decades. It has been noted that interest among psychologists and psychiatrists in quality of life as a distinct, measurable entity has lagged behind that of their counterparts in medicine (for reasons to be described later). This Journal of Consulting and Clinical Psychology © 1999 by the American Psychological Association June 1999 Vol. 67, No. 3, 320-331 For personal use only--not for distribution.Page 2 of 19http://spider.apa.org/ftdocs/ccp/1999/june/ccp673320.html 8/30/2000situation appears to be changing rapidly as quality of life instruments are adapted, or created, for use with different psychiatric populations and for evaluation of diverse therapies. Because of the problems that continue to plague quality of life research, this can be viewed as a mixed blessing. The purpose of this article is to review the conceptual and methodological issues that need to be addressed to ensure the appropriate and successful use of quality of life measures in the evaluation of psychological treatments. Rationale The current enthusiasm for quality of life measures is not ill-founded. Although symptom relief remains a major goal of treatment efforts, there are many reasons to expand outcome assessment to include other, less familiar parameters of clinical progress or decline. These rationales have been detailed by a number of authors (see Frisch, 1998 ; Hunt, 1998 ; Katschnig, 1997 ), who have pointed out that a fundamental problem with the symptom-focused approach is that it is based on a narrow, outdated notion of health and disease. Modern conceptions of health can be traced back to the World Health Organization's (WHO) definition of health as "a state of complete physical, mental, and social well-being and not merely the absence of disease" ( WHO, 1948 , p. 1). This definition has, in turn, given rise to theoretical and philosophical ideas of what constitutes mental health and to arguments for assessing positive as well as negative outcomes. In some circles, mental health is synonymous with "happiness" and "well-being" ( Frisch, Cornell, Villañueva, &Retzlaff, 1992 ). A number of studies have shown that it is the patients' subjective well-being, rather than objective medical condition, that determines their treatment-seeking behavior, their compliance, and their evaluation of treatment ( Hunt & McKenna, 1993 ). Presenting complaints of patients do not always conform to Diagnostic and Statistical Manual of Mental Disorders categories ( Strupp, 1996 ); further, there is evidence that these target complaints shift during the course of treatment ( Sorenson, Gorusch, &Mintz, 1985 ). The need to look beyond symptoms also comes from empirical data on the pervasive and pernicious effects of mental illness on psychological state, role functioning, and social and economic status ( Broadhead, Blazer, George, & Tse, 1990 ; Greenberg, Stiglin, Finkelstein, & Berndt, 1993 ; Hays, Wells,Sherbourne, Rogers, & Spritzer, 1995 ; Ormel et al., 1994 ; Sherbourne, Wells, & Judd, 1996 ). Many mental health disorders, even those that are less severe, can be viewed as "lifetime" or chronic illnesses that have long-term effects despite extended periods of symptom remission. Consequently, to fully evaluate the effectiveness of an intervention means to document its broad effects on all domains, taking into account not only the clinician's subjective perspective but those of the patient and other involved parties as well. The use of quality of life measures can therefore be viewed as an alternative to statistical approaches of defining clinical significance that are applied to traditional symptom-based measures ( N. S. Jacobson, Follette, &Revenstorf, 1984 ; N. S. Jacobson & Truax, 1991 ; Kendall & Grove, 1988 ). Although it is important to know whether a clinically significant reduction in symptoms has occurred, it is also of central clinical significance to determine whether the patient's quality of life has improved. The changing structure of health care in the United States is also a factor in the popularity of quality of life measures. Managed care providers are developing their own criteria for mental health and are keen on exploring a wide array of indicators of mental health status, many of which bear the quality of life label. On an individual level, these are used to determine length and type of
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