The Quick Inventory of Depressive Symptomatology, Adolescent Version (QIDS-A17): A Psychometric Evaluation

Objective

The current study aimed to evaluate the psychometric features of the Quick Inventory of Depressive Symptomatology, Adolescent version (QIDS-A₁₇) and the clinician-rated Children's Depression Rating Scale-Revised (CDRS-R).

Methods

Altogether, 103 outpatients (8 to 17 years) completed the self-report QIDS-A₁₇-SR. Clinician interviews of adolescents (QIDS-A₁₇-C (Adolescent)) and of parents (QIDS-A₁₇-C (Parent)) were combined to create the QIDS-A₁₇-C(Composite) and the CDRS-R.

Results

All QIDS-A₁₇ measures and the CDRS-R evidenced high total score correlations and internal consistency. Factor analysis found all four measures to be unidimensional. Item Response Theory (IRT) analysis found results that complemented the reliability results found in CTT. All four also demonstrated discriminant diagnostic validity based on logistic regression and ANOVA analyses.

Conclusion

The psychometric properties of the self-report and composite versions of the QIDS-A₁₇ suggest acceptability as a measure of depression in adolescents either as a measure of depressive symptoms or severity of illness in adolescents. The self-report version may be a helpful tool in busy clinical practices.

Attitudes and Beliefs of Pediatric Surgical Specialists on Costs of Care and High Deductible Health Plans

Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists' experience and attitude towards patients' out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons' experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients' choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients' preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.

Attitudes and Beliefs of Pediatric Surgical Specialists on Costs of Care and High Deductible Health Plans

Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists’ experience and attitude towards patients’ out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons’ experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients’ choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients’ preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.

The Treatment of Chronic Coccydynia and Postcoccygectomy Pain With Pelvic Floor Physical Therapy

BACKGROUND

Coccydynia is a challenging disorder that often is refractory to treatments such as medications and injections. Physical therapy for coccydynia rarely has been studied.

OBJECTIVE

To evaluate the efficacy of pelvic floor physical therapy for reducing pain levels in patients with coccydynia.

DESIGN

Retrospective chart review.

SETTING

The pelvic floor rehabilitation clinic of a major university hospital.

PATIENTS

A total of 124 consecutive patients over age 18 with a chief complaint of coccydynia between 2009 and 2012. A subgroup of 17 of the 124 patients had previously undergone coccygectomy with continued pain postoperatively.

METHODS OR INTERVENTIONS

The primary treatment intervention was pelvic floor physical therapy aimed at pelvic floor muscle relaxation. Secondary treatment interventions included the prescription of baclofen for muscle relaxation (19% of patients), ganglion impar blocks (8%), or coccygeus trigger point injections (17%).

MAIN OUTCOME MEASURES

Primary outcome measures included final minimum, average, and maximum pain numeric rating scales. A secondary outcome measure was the patient's subjective percent global improvement assessment. Baseline demographics were used to determine which pretreatment characteristics were correlated with treatment outcomes.

RESULTS

Of the 124 patients, 93 participated in pelvic floor physical therapy and were included in statistical analysis. For the 79 patients who completed treatment (with a mean of 9 physical therapy sessions), the mean average pain ratings decreased from 5.08 to 1.91 (P < .001) and mean highest pain ratings decreased from 8.81 to 4.75 (P < .001). The mean percent global improvement was 71.9%. Mean average pain ratings in postcoccygectomy patients improved from 6.64 to 3.27 (P < .001). Greater initial pain scores and a history of previous injections were correlated with P < .001 pain scores on completion of physical therapy. Pain duration and history of trauma did not affect treatment outcomes.

CONCLUSIONS

Pelvic floor physical therapy is a safe and effective method of treating coccydynia.

LEVEL OF EVIDENCE

III.

Artifacts Can Replicate

Consistent with Burnkrant and Page (1984), Piliavin and Charng (1988) support the view that Fenigstein, Scheier, and Buss's (1975) Self-Consciousness Scale actually measures four different traits, rather than the three traits proposed by the original authors. The current aulhors note that they ignore important statistical problems in reaching this conclusion and suggest that their factor-analytic results reflect the same problems that Bernstein, Teng, and Garbin (1986) point out in Burnkrant and Page's (1984) analysis. A simple BASIC computer program is presented that illustrates these points. The authors acknowledge a possible basis for separating "internal state awareness" and "self-reflectiveness" using other evidence, but they further note that this evidence is relatively weak. They conclude by noting a philiosophical problem in proliferating narrowly defined "miniscales. "

The Parkland Burn Center experience with 297 cases of child abuse from 1974 to 2010

INTRODUCTION

Pediatric burns due to abuse are unfortunately relatively common, accounting for 5.8-8.8% of all cases of abuse annually. Our goal was to evaluate our 36-year experience in the evaluation and management of the victims of abuse in the North Texas area.

METHODS

A prospectively maintained database containing records on all admissions from 1974 through 2010 was queried for all patients aged less than 18 years. Patients admitted for management of a non-burn injury were excluded from the analysis.

RESULTS

Of 5,553 pediatric burn admissions, 297 (5.3%) were due to abuse. Children with non-accidental injuries tended to be younger (2.1 vs. 5.0 years, p<0.0001) and male (66.0 vs. 56.5%, p=0.0008). Scald was the most common mechanism of injury overall (44.8%), and was also the predominant cause of inflicted burns (89.6 vs. 42.3%, p<0.0001). Multivariate logistic regression identified age, gender, presence of a scald, contact, or chemical burn, and injury to the hands, bilateral feet, buttocks, back, and perineum to be significant predictors of abuse. Victims of abuse were also found to have worse outcomes, including mortality (5.4 vs. 2.3%, p=0.0005). After adjusting for age, mechanism of injury, and burn size, abuse remained a significant predictor of mortality (OR 3.3, 95% CI 1.5-7.2) CONCLUSIONS: Clinicians should approach all burn injuries in young children with a high index of suspicion, but in particular those with scalds, or injuries to the buttocks, perineum, or bilateral feet should provoke suspicion. Burns due to abuse are associated with worse outcomes, including length of stay and mortality.

Use of the Montreal Cognitive Assessment and Alzheimer's Disease-8 as cognitive screening measures in Parkinson's disease

OBJECTIVE

To examine the sensitivity and specificity of the Montreal Cognitive Assessment (MoCA), a brief cognitive screening measure previously validated for use in Parkinson's disease (PD), and Alzheimer's Disease-8 (AD8), an eight-item informant report used to screen for dementia, but not yet validated for use in PD, to identify cognitive impairment in a sample of 111 patients with PD.

METHODS

Cognitive impairment was determined based on a battery of neuropsychological measures, excluding the MoCA and AD8. Classification rates of both the MoCA and AD8 in identifying cognitive impairment were examined using logistic regression and receiver operator characteristic (ROC) analysis. Optimal cutoff scores were determined to maximize sensitivity and specificity.

RESULTS

The MoCA correctly classified 78.4% of participants (p < 0.001), and ROC analysis yielded an area under the curve (AUC) of 0.82. A MoCA cutoff score of <25 yielded optimal sensitivity (0.77) and specificity (0.79) for identifying PD patients with cognitive impairment. Similar analyses for the AD8 were statistically nonsignificant, although the classification rate was 70.5%, with an AUC of 0.50.

CONCLUSIONS

These results provide additional support for the MoCA, but not the AD8, in identifying cognitive impairment in patients with PD.

Evaluation of anhedonia with the Snaith-Hamilton Pleasure Scale (SHAPS) in adult outpatients with major depressive disorder

Anhedonia or inability to experience pleasure not only is a core symptom of major depressive disorder (MDD), but also is identified as an important component of the positive valence system in the NIMH Research Domain Criteria. The Snaith-Hamilton Pleasure Scale (SHAPS) has been developed for the assessment of hedonic experience or positive valence, but has not been well-studied in depressed outpatient populations. The current study examined the reliability and validity of the SHAPS using a sample of adult outpatients with treatment resistant MDD. Data for the current study were obtained from 122 adult outpatients with a diagnosis of MDD and non-response to adequate treatment with an SSRI and who participated in Project TReatment with Exercise Augmentation for Depression (TREAD). A Principal Components Analysis was used to define the dimensionality of the SHAPS. Convergent and discriminant validity were evaluated via correlations of the SHAPS total score with "gold standard" measures of depression severity and quality of life. The SHAPS was found to have high internal consistency (Cronbach's coefficient α = .82). A Principal Components Analysis suggests that the SHAPS is mainly "unidimensional" and limited to hedonic experience among adult outpatients with MDD. Convergent and discriminant validity were assessed by examining the Spearman rank-order correlation coefficient between the SHAPS total score and the HRSD17 (rs = 0.22, p < .03), IDS-C30 (rs = 0.26, p < .01), IDS-SR30 (rs = 0.23, p < .02), QIDS-C16 (rs = 0.22, p < .03), QIDS-SR16 (rs = 0.17, p < .10), QLES-Q (rs = -0.32, p < .002), and the pleasure/enjoyment item (sub-item 21) of the IDS-C (rs = 0.44, p < .0001) and IDS-SR (rs = 0.38, p < .0002). The self-administered SHAPS showed modest sensitivity (76%) and specificity (54%) with the self-administered pleasure/enjoyment single item (sub-item 21) of IDS-SR30. The current study shows that the SHAPS is a reliable and valid instrument to assess hedonic experience or positive valence in adult outpatients with MDD and provides a broader assessment of this important domain.

Health-related quality of life in morphoea

BACKGROUND

Little is known about the health-related quality of life (HRQoL) of patients with morphoea, and previous studies have yielded conflicting results.

OBJECTIVES

To determine the impact of morphoea on HRQoL, and clinical and demographic correlates of HRQoL in adults.

METHODS

This was a cross-sectional survey (n = 73) of the Morphea in Adults and Children cohort.

RESULTS

Morphoea impairs HRQoL in adults. Patients were most impaired by emotional well-being and concerns that the disease would progress to internal organs. Patients with morphoea had worse skin-specific HRQoL than those with nonmelanoma skin cancer, vitiligo and alopecia (lowest P < 0·01). Participants had significantly worse global HRQoL scores than the general U.S. population for all subscales (all P < 0·01), with the exception of bodily pain. Comorbidity (r = 0·35-0·51, all P < 0·01), and symptoms of pruritus (r = 0·38-0·64, all P < 0·01) and pain (r = 0·46-0·74, all P < 0·01) were associated with impairment in multiple domains of skin-specific and global HRQoL. Physician-based measures of disease severity correlated with patient-reported HRQoL.

CONCLUSIONS

Patients with morphoea experience a negative impact on HRQoL, particularly if symptoms (pruritus and pain) or concerns regarding internal manifestations are present. Providers should be aware of this when evaluating and treating patients.

The Parkland Protocol's modified Berne-Norwood criteria predict two tiers of risk for traumatic brain injury progression

As a basis for venous thromboembolism (VTE) prophylaxis after traumatic brain injury (TBI), we have previously published an algorithm known as the Parkland Protocol. Patients are classified by risk for spontaneous progression of hemorrhage with chemoprophylaxis regimens tailored to each tier. We sought to validate this schema. In our algorithm, patients with any of the following are classified "low risk" for spontaneous progression: subdural hemorrhage ≤8 mm thick; epidural hemorrhage ≤8 mm thick; contusions ≤20 mm in diameter; a single contusion per lobe; any amount of subarachnoid hemorrhage; or any amount of intraventricular hemorrhage. Patients with any injury exceeding these are "moderate risk" for progression, and any patient receiving a monitor or craniotomy is "high risk." From February 2010 to November 2012, TBI patients were entered into a dedicated database tracking injury types and sizes, risk category at presentation, and progression on subsequent computed tomgraphies (CTs). The cohort (n=414) was classified as low risk (n=200), moderate risk (n=75), or high risk (n=139) after first CT. After repeat CT scan, radiographic progression was noted in 27% of low-risk, 53% of moderate-risk, and 58% of high-risk subjects. Omnibus analysis of variance test for differences in progression rates was highly significant (p<0.0001). Tukey's post-hoc test showed the low-risk progression rate to be significantly different than both the moderate- and high-risk arms; no difference was noted between the moderate- and high-risk arms themselves. These criteria are a valid tool for classifying TBI patients into two categories of risk for spontaneous progression. This supports tailored chemoprophylaxis regimens for each arm.

Smooth pursuit eye movement, prepulse inhibition, and auditory paired stimuli processing endophenotypes across the schizophrenia-bipolar disorder psychosis dimension

BACKGROUND

This study examined smooth pursuit eye movement (SPEM), prepulse inhibition (PPI), and auditory event-related potentials (ERP) to paired stimuli as putative endophenotypes of psychosis across the schizophrenia-bipolar disorder dimension.

METHODS

Sixty-four schizophrenia probands (SZP), 40 psychotic bipolar I disorder probands (BDP), 31 relatives of SZP (SZR), 26 relatives of BDP (BDR), and 53 healthy controls (HC) were tested. Standard clinical characterization, SPEM, PPI, and ERP measures were administered.

RESULTS

There were no differences between either SZP and BDP or SZR and BDR on any of the SPEM, PPI, or ERP measure. Compared with HC, SZP and BDP had lower SPEM maintenance and predictive pursuit gain and ERP theta/alpha and beta magnitudes to the initial stimulus. PPI did not differ between the psychosis probands and HC. Compared with HC, SZR and BDR had lower predictive pursuit gain and ERP theta/alpha and beta magnitudes to the first stimulus with differences ranging from a significant to a trend level. Neither active symptoms severity nor concomitant medications were associated with neurophysiological outcomes. SPEM, PPI, and ERP scores had low intercorrelations.

CONCLUSION

These findings support SPEM predictive pursuit and lower frequency auditory ERP activity in a paired stimuli paradigm as putative endophenotypes of psychosis common to SZ and BD probands and relatives. PPI did not differ between the psychosis probands and HC. Future studies in larger scale psychosis family samples targeting putative psychosis endophenotypes and underlying molecular and genetic mediators may aid in the development of biology-based diagnostic definitions.

Separate and overlapping relationships of inattention and hyperactivity/impulsivity in children and adolescents with attention-deficit/hyperactivity disorder

There is debate regarding the dimensional versus categorical nature of attention-deficit/hyperactivity disorder (ADHD). This study utilized confirmatory factor analysis to examine this issue. ADHD symptoms rated on interviews and rating scales from a large sample of individuals (ages 3-17, 74 % male, 75 % Caucasian) with ADHD were examined (n = 242). Four potential factor structures were tested to replicate prior findings in a sample with a wide age range and included only participants who met DSM-IV-TR diagnostic criteria for ADHD. Correlations with executive function measures were performed to further assess the separability and validity of the derived factors. The data support a bifactor model with a general ADHD factor and two specific factors, inattention and hyperactivity/impulsivity. Importantly, the individual factors were also differentially correlated with executive functioning measures. This study adds to a growing literature suggesting both a general component to ADHD, as well as dimensional traits of inattention and hyperactivity/impulsivity, associated with distinct executive functioning profiles. The presence of a general underlying factor contraindicates separating the inattentive and combined subtypes of ADHD into distinct disorders.

Low HDL predicts differential blood pressure effects from two weight-loss approaches: a secondary analysis of blood pressure from a randomized, clinical weight-loss trial

Examining predictors of blood-pressure (BP) response to weight-loss diets might provide insight into mechanisms and help guide clinical care. We examined whether certain baseline patient characteristics (e.g. diet, medical history and laboratory tests) predicted BP response to two weight-loss diet approaches that differ in macronutrient content. One hundred and forty-six overweight adult outpatients were randomized to either a low-carbohydrate diet (N = 72) or orlistat plus a low-fat diet (N = 74) for 48 weeks. Predictors of BP reduction were evaluated using a structured approach and random effects regression models. Participants were 56% African-American, 72% male and 53 (±10) years-old. Of the variables considered, low baseline high-density lipoprotein (HDL) predicted greater reduction in BP in those patients who received the low-carbohydrate diet (p = 0.03 for systolic BP; p = 0.03 for diastolic BP and p = 0.02 for mean arterial pressure). A low HDL level may identify patients who will have greater BP improvement on a low-carbohydrate diet.

The dimensionality and measurement properties of alcohol outcome expectancies across Hispanic national groups

This study examines the psychometric properties of alcohol expectancies among Hispanic subgroups. Face-to-face interviews were conducted as part of the 2006 Hispanic Americans Baseline Alcohol Survey (HABLAS), which employed a multistage cluster sample design. A total of 5224 individuals (18+ years of age) representing four Hispanic national groups (Puerto Ricans, Cuban Americans, Mexican Americans, and South/Central Americans) were selected at random from the household population in five metropolitan areas (Miami, New York, Philadelphia, Houston, and Los Angeles). Alcohol expectancies included 18 items covering positive (e.g., laugh more, become more talkative) and negative dimensions (e.g., become aggressive, lose control) when alcohol is consumed. Confirmatory factor models replicated a previously proposed three-factor dimensional structure with a substantial majority of items exhibiting measurement invariance across Hispanic national group and gender. Items covering social extroversion were an exception, showing a lack of invariance for female Cuban and South/Central Americans. Latent mean differences across groups were detected for expectancies concerning emotional fluidity, and the pattern of differences largely mirrored known differences in alcohol consumption patterns. Results suggest that caution should be exercised in interpreting differences in expectancies concerning social extroversion across Hispanic groups, and additional work is needed to identify indices of this construct with invariant measurement properties. However, measures of emotional/behavioral impairment and emotional fluidity expectancies can be validly compared across gender and Hispanic national groups.

Assessing anxious features in depressed outpatients

Both the 17-item Hamilton Rating Scale for Depression (HRSD(17)) and 30-item Inventory of Depressive Symptomatology - Clinician-rated (IDS-C(30) ) contain a subscale that assesses anxious symptoms. We used classical test theory and item response theory methods to assess and compare the psychometric properties of the two anxiety subscales (HRSD(ANX) and IDS-C(ANX)) in a large sample (N = 3453) of outpatients with non-psychotic major depressive disorder in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Approximately 48% of evaluable participants had at least one concurrent anxiety disorder by the self-report Psychiatric Diagnostic Screening Questionnaire (PDSQ). The HRSD(ANX) and IDS-C(ANX) were highly correlated (r = 0.75) and both had moderate internal consistency given their limited number of items (HRSD(ANX) Cronbach's alpha = 0.48; IDS-C(ANX) Cronbach's alpha = 0.58). The optimal threshold for ascribing the presence/absence of anxious features was found at a total score of eight or nine for the HRSD(ANX) and seven or eight for the IDS-C(ANX) . It would seem beneficial to delete item 17 (loss of insight) from the HRSD(ANX) as it negatively correlated with the scale's total score. Both the HRSD(ANX) and IDS-C(ANX) subscales have acceptable psychometric properties and can be used to identify anxious features for clinical or research purposes.

Psychometric evaluation of the Montreal Cognitive Assessment (MoCA) in three diverse samples

Our objective was to evaluate the utility of the Montreal Cognitive Assessment (MoCA) in both non-clinical and clinical populations. The MoCA, a tool used widely in clinical geriatric practice to detect and quantify cognitive impairment, was administered to three diverse samples to assess the psychometric properties of the instrument. Participants were 482 healthy persons seen in the Cooper Center Longitudinal Study (CCLS), 1923 healthy volunteers evaluated by the Dallas Heart Study (DHS), a population-based sample of Dallas County residents and 69 persons with known or suspected brain pathology, seen for clinical evaluation. The standard deviations in the CCLS and DHS groups were small (2.81, 3.87) and moderate in the clinical group (5.22). The corresponding raw coefficients alpha were. 50,. 63, and. 75. Thus, variability and internal consistency were associated. MoCA scores generally did not correlate with gender and correlated with age only in the clinical group. However, there were moderately strong positive correlations between MoCA scores and education in all three samples. The reliability of the MoCA was extremely low in the two non-clinical groups, but was high in the clinical group. Although useful in large non-clinical studies, the MoCA is best suited to detect and quantify cognitive impairment in clinical patients.

Psychometric properties of the Children's Depression Rating Scale-Revised in adolescents

OBJECTIVE

The aim of this study was to present the reliability and validity of the Children's Depression Rating Scale-Revised (CDRS-R) in the adolescent age group.

METHOD

Adolescents with symptoms of depression were assessed using the CDRS-R and global severity and functioning scales at screening, baseline, and after 12 weeks of fluoxetine treatment. Global improvement was also assessed at week 12 (or exit). Reliability and validity were analyzed using Classical Test Theory (item-total correlations and internal consistency) and correlations between the CDRS-R and other outcomes.

RESULTS

Adolescents (n = 145) were evaluated at screening; 113 (77.9%) met criteria for major depressive disorder, 8 (5.5%) had subthreshold depressive symptoms, and 24 (16.6%) had minimal depressive symptoms. Ninety-four adolescents had a baseline visit after 1 week, and 88 were treated with fluoxetine. Internal consistency for the CDRS-R was good at all three visits (screening: 0.79; baseline: 0.74; exit: 0.92), and total score was highly correlated with global severity (r = 0.87, 0.80, and 0.93; p < 0.01). Only exit CDRS-R score was significantly correlated with global functioning (Children's Global Assessment Scale; r = -0.77; p < 0.01). Reductions on the CDRS-R total score were highly correlated with improvement scores at exit (Clinical Global Impressions-Improvement; r = -0.83; p < 0.01).

CONCLUSIONS

The results demonstrate good reliability and validity in adolescents with depression.

Psychometric properties of the Quick Inventory of Depressive Symptomatology in adolescents

OBJECTIVE

The clinician-rated (QIDS-C₁₆) and self-report (QIDS-SR₁₆) versions of the 16-item Quick Inventory of Depressive Symptomatology have been extensively examined in adult populations. This study evaluated both versions of the QIDS and the 17-item Children's Depressive Rating Scale - Revised (CDRS-R) in an adolescent outpatient sample.

METHOD

Both the QIDS-C₁₆ and QIDS-SR₁₆ were completed for the adolescents. Three different methods were used to complete the QIDS-C₁₆: (a) adolescents' responses to clinician interviews; (b) parents' responses to clinician interview; and (c) a composite score using the most pathological response from the two interviews. Both classical and item response theory methods were used. Factor analyses evaluated the dimensionality of each scale.

RESULTS

The sample included 140 adolescent outpatients. All versions of the QIDS, save the parent interview, and the CDRS-R were very reliable (α ≥ 0.8). All four versions of the QIDS are reasonably effective and unidimensional. The CDRS-R was clearly at least two-dimensional. The CDRS-R was the most discriminating among low and extremely high levels of depression. The QIDS-SR₁₆ was the most discriminating at moderate levels of depression. There was no relation between the QIDS scores and concurrent Axis III comorbidities.

CONCLUSION

The QIDS-C₁₆ and the QIDS-SR₁₆ are suitable for use in adolescents.

Diagnostic utility of the Quick Inventory of Depressive Symptomatology (QIDS-C16 and QIDS-SR16) in the elderly

OBJECTIVE

To evaluate psychometric properties and comparability ability of the Montgomery-Asberg Depression Rating Scale (MADRS) vs. the Quick Inventory of Depressive Symptomatology-Clinician-rated (QIDS-C(16)) and Self-report (QIDS-SR(16)) scales to detect a current major depressive episode in the elderly.

METHOD

Community and clinic subjects (age >or=60 years) were administered the Mini-International Neuropsychiatric Interview (MINI) for DSM-IV and three depression scales randomly. Statistics included classical test and Samejima item response theories, factor analyzes, and receiver operating characteristic methods.

RESULTS

In 229 elderly patients (mean age = 73 years, 39% male, 54% current depression), all three scales were unidimensional and with nearly equal Cronbach alpha reliability (0.85-0.89). Each scale discriminated persons with major depression from the non-depressed, but the QIDS-C(16) was slightly more accurate.

CONCLUSION

All three tests are valid for detecting geriatric major depression with the QIDS-C(16) being slightly better. Self-rated QIDS-SR(16) is recommended as a screening tool as it is least expensive and least time consuming.

The Hispanic Americans Baseline Alcohol Survey (HABLAS):Predictive invariance of Demographic Characteristics on Attitudes towards Alcohol across Hispanic National Groups

This study compares the demographic predictors of items assessing attitudes towards drinking across Hispanic national groups. Data were from the 2006 Hispanic Americans Baseline Alcohol Survey (HABLAS), which used a multistage cluster sample design to interview 5,224 individuals randomly selected from the household population in Miami, New York, Philadelphia, Houston, and Los Angeles. Predictive invariance of demographic predictors of alcohol attitudes over four Hispanic national groups (Puerto Rican, Cuban, Mexican, and South/Central Americans) was examined using multiple-group seemingly unrelated probit regression. The analyses examined whether the influence of various demographic predictors varied across the Hispanic national groups in their regression coefficients, item intercepts, and error correlations. The hypothesis of predictive invariance was supported. Hispanic groups did not differ in how demographic predictors related to individual attitudinal items (regression slopes were invariant). In addition, the groups did not differ in attitudinal endorsement rates once demographic covariates were taken into account (item intercepts were invariant). Although Hispanic groups have different attitudes about alcohol, the influence of multiple demographic characteristics on alcohol attitudes operates similarly across Hispanic groups. Future models of drinking behavior in adult Hispanics need not posit moderating effects of group on the relation between these background characteristics and attitudes.

The safety, acceptability, and effectiveness of acupuncture as an adjunctive treatment for acute symptoms in bipolar disorder

OBJECTIVE

There is growing interest in the utility of nonpharmacologic treatments for mood symptoms, including mood elevation and depression associated with bipolar disorders. The purpose of this research was to provide preliminary data on the safety, effectiveness, and acceptability of adjunctive acupuncture in the acute treatment of hypomania and depression associated with bipolar disorder.

METHOD

Two randomized trials were conducted to assess the benefits of adjunctive acupuncture for symptoms of depression and hypomania in patients with bipolar disorder (DSM-IV criteria). For 20 patients experiencing symptoms of hypomania, targeted acupuncture (points specific to symptoms) was compared to acupuncture points off the acupuncture meridian over 12 weeks (from May 2000 through May 2003). For patients experiencing symptoms of depression (n = 26), targeted acupuncture was compared to acupuncture for nonpsychiatric health concerns over 8 weeks (from November 2001 through May 2003). Preexisting psychotropic medications were maintained at stable doses throughout study participation.

RESULTS

Regardless of acupuncture assignment or symptom pattern at entry, all patients experienced improvement over the course of study participation. There was evidence that acupuncture treatment did target the symptom dimension of interest (mood elevation in Study I, depression in Study II). There were few negative side effects and no attrition directly associated with adjunctive acupuncture.

CONCLUSIONS

Novel methodologies are needed to assess the utility of acupuncture as adjunctive treatment of mood episodes associated with bipolar disorder. We observed similar benefits associated with "placebo" acupuncture experiences and active treatment. Further studies are warranted. TRIAL REGISTRATION (STUDY II): (ClinicalTrials.gov) Identifier: NCT00071669.

A psychometric evaluation of the clinician-rated Quick Inventory of Depressive Symptomatology (QIDS-C16) in patients with bipolar disorder

The clinician-rated, 16-item Quick Inventory of Depressive Symptomatology (QIDS-C16) has been extensively evaluated in patients with major depressive disorder (MDD). This report assesses the psychometric properties of the QIDS-C16 in outpatients with bipolar disorder (BD, N = 405) and MDD (N = 547) and in bipolar patients in the depressed phase only (BD-D) (N = 99) enrolled in the Texas Medication Algorithm Project (TMAP) using classical test theory (CTT) and the Samejima graded item response theory (IRT) model. Values of coefficient alpha were very similar in BD, MDD, and BD-D groups at baseline (alpha = 0.80-0.81) and at exit (alpha = 0.82-0.85). The QIDS-C16 was unidimensional for all three groups. MDD and BD-D patients (n = 99) had comparable symptom levels. The BD-D patients (n = 99) had the most, and bipolar patients in the manic phase had the least depressive symptoms at baseline. IRT analyses indicated that the QIDS-C16 was most sensitive to the measurement of depression for both MDD patients and for BD-D patients in the average range. The QIDS-C16 is suitable for use with patients with BD and can be used as an outcome measure in trials enrolling both BD and MDD patients.

Are bipolar mood symptoms affected by the phase of the menstrual cycle?

BACKGROUND

Evidence suggests gender differences may exist in bipolar disorder, and a review of the literature shows that more women than men may experience rapid-cycling bipolar disorder. The issues contributing to these gender differences are unknown; a number of case reports have indicated the possibility of mood changes secondary to hormonal influences during the menstrual cycle. We sought to examine the relationship between bipolar disorder and menstrual cycle-related mood changes. To our knowledge, this is one of the largest samples in the literature addressing this issue.

METHODS

Outpatient women with bipolar disorder I, bipolar disorder II, and not otherwise specified (NOS), between the ages of 18 and 45, were evaluated. The National Institute of Mental Health Life Chart Method-p (NIMH-LCM-p) was used for daily mood ratings of depression and mania. Repeated measures of ANOVA and t tests were conducted separately for depressive and for manic symptom scores.

RESULTS

One hundred nineteen women met the age criterion, and only 41 women met the rest of the inclusion criteria. In this sample of 41 women, there was no significant relationship between phases of the menstrual cycle (early and late follicular and early and late luteal phases) and changes in depression or mania. In an exploratory examination, 8 of 41 women showed a numerically higher mean depression score in the luteal phase than in the follicular phase; 5 of 41 women showed a numerically higher mean mania score in the luteal phase than in the follicular phase of the menstrual cycle.

CONCLUSIONS

Different phases of the menstrual cycle were unrelated to depression and mania in a heterogeneous group of women with bipolar disorder. Prospective studies are needed to identify a vulnerable subpopulation in a homogeneous clinical sample.

Symptom features of postpartum depression: are they distinct?

The clinical features of postpartum depression and depression occurring outside of the postpartum period have rarely been compared. The 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR(16)) provides a means to assess core depressive symptoms. Item response theory and classical test theory analyses were conducted to examine differences between postpartum (n=95) and nonpostpartum (n=50) women using the QIDS-SR(16). The two groups of females were matched on the basis of age. All met DSM-IV criteria for nonpsychotic major depressive disorder. Low energy level and restlessness/agitation were major characteristics of depression in both groups. The nonpostpartum group reported more sad mood, more suicidal ideation, and more reduced interest. In contrast, for postpartum depression sad mood was less prominent, while psychomotor symptoms (restlessness/agitation) and impaired concentration/decision-making were most prominent. These symptomatic differences between postpartum and other depressives suggest the need to include agitation/restlessness and impaired concentration/decision-making among screening questions for postpartum depression.

A pilot study of an electronic, adolescent version of the quick inventory of depressive symptomatology

BACKGROUND

Adolescent depression assessments are time-intensive, often requiring separate interviews with an adolescent and a parent/ informant. In adults, a self-rated, interactive voice response (IVR) version of the Quick Inventory of Depressive Symptomatology (QIDS-IVR) has been shown to be reliable, valid, and sensitive to change. An adolescent version of the QIDS (QIDS-A-IVR) was created using speaker-independent voice recognition technology. An informant version, QIDS-P-IVR, collects ratings from parents or other knowledgeable adults.

METHOD

The study included 27 adolescents ranging from 12 to 17 years of age, 48% of whom were female. During a single office visit, adolescents completed the QIDS-A-IVR and parents completed the QIDS-P-IVR. A clinician completed the clinician-rated adult version of the QIDS separately for adolescents (QIDS-C-A) and parents (QIDS-C-P) and the Children's Depression Rating Scale-Revised (CDRS-R). The study was conducted from October 2005 to April 2006.

RESULTS

Cronbach alpha of the QIDS-A-IVR was .85. The QIDS-A-IVR correlated significantly with the QIDS-C-A (r = 0.95) and the CDRS-R (r = 0.76), both p < .01. Conversely, the correlations of the QIDS-A-IVR with the QIDS-P-IVR and the QIDS-C-P were small and nonsignificant. The QIDS-A-IVR required adolescents a mean of 6 minutes and 31 seconds to complete (SD = 41 seconds). The voice recognition technology correctly identified the adolescents' spoken words in 92% of the 483 spoken responses. The system recognized a response from all adolescents on all items.

CONCLUSIONS

This study supports the reliability and validity of the QIDS-A-IVR as an adolescent depression measure. The QIDS-A-IVR may provide clinicians and researchers with a sound, technology-based method of assessing adolescent depression. Future research is needed on the informational value of parent ratings of adolescent depression.

A psychometric evaluation of the CDRS and MADRS in assessing depressive symptoms in children

OBJECTIVE

This study compared the psychometric properties of the Children's Depression Rating Scale-Revised (CDRS-R) and the Montgomery-Asberg Depression Rating Scale (MADRS) in children with major depressive disorder.

METHOD

Children (N = 96; ages 8 to 11 years inclusive) with nonpsychotic major depressive disorder were enrolled. Participants were part of a multisite, outpatient, randomized, placebo-controlled, 9-week trial of fluoxetine (10 mg/day for the first week and 20 mg/day thereafter). The CDRS-R and MADRS were completed based on clinician interviews with both parents and children. Classic test theory and item response theory analyses were conducted.

RESULTS

The MADRS and CDRS-R total scores were correlated at baseline (r = 0.51) and at study exit (r = 0.85). Cronbach's alpha was .86 (CDRS-R) and .82 (MADRS) at exit. The effect sizes for change from baseline to exit between the fluoxetine and placebo groups were 0.78 (CDRS-R) and 0.61 (MADRS). There was agreement between the CDRS-R and MADRS in the declaration of treatment response (50% improvement from baseline to exit) in 84.2% of children. Test information function favored the CDRS-R.

CONCLUSIONS

The CDRS-R showed greater effect size for differentiating drug and placebo and better test information than the MADRS in this study of depressed children.

Clinical vs. self-report versions of the quick inventory of depressive symptomatology in a public sector sample

OBJECTIVES

Recent work using classical test theory (CTT) and item response theory (IRT) has found that the self-report (QIDS-SR(16)) and clinician-rated (QIDS-C(16)) versions of the 16-item quick inventory of depressive symptomatology were generally comparable in outpatients with nonpsychotic major depressive disorder (MDD). This report extends this comparison to a less well-educated, more treatment-resistant sample that included more ethnic/racial minorities using IRT and selected classical test analyses.

METHODS

The QIDS-SR(16) and QIDS-C(16) were obtained in a sample of 441 outpatients with nonpsychotic MDD seen in the public sector in the Texas Medication Algorithm Project (TMAP). The Samejima graded response IRT model was used to compare the QIDS-SR(16) and QIDS-C(16).

RESULTS

The nine symptom domains in the QIDS-SR(16) and QIDS-C(16) related well to overall depression. The slopes of the item response functions, a, which index the strength of relationship between overall depression and each symptom, were extremely similar with the two measures. Likewise, the CTT and IRT indices of symptom frequency (item means and locations of the item response functions, b(i) were also similar with these two measures. For example, sad mood and difficulty with concentration/decision making were highly related to the overall depression severity with both the QIDS-C(16) and QIDS-SR(16). Likewise, sleeping difficulties were commonly reported, even though they were not as strongly related to overall magnitude of depression.

CONCLUSION

In this less educated, socially disadvantaged sample, differences between the QIDS-C(16) and QIDS-SR(16) were minor. The QIDS-SR(16) is a satisfactory substitute for the more time-consuming QIDS-C(16) in a broad range of adult, nonpsychotic, depressed outpatients.

Item Response Analysis of the Inventory of Depressive Symptomatology

BACKGROUND: Both the clinician (IDS-C(30)) and self-report (IDS-SR(30)) versions of the 30-item Inventory of Depressive Symptomatology have acceptable psychiatric properties and have been used in various clinical studies. These two scales, however, have not been compared using item response theory (IRT) methods to determine whether the standard scoring methods are optimal. METHODS: Data were derived from 428 adult public sector outpatients with nonpsychotic major depressive disorder. The IDS-C(30) and IDS-SR(30) were compared using Samejima's graded response model. RESULTS: A model was constructed jointly fitting the IDS-C(30) and IDS-SR(30). An improvement in scale performance was obtained by grouping selected items into domains (specifically sleep, psychomotor, and appetite/weight domains) analogous to the standard scoring of the 16-item Quick Inventory of Depressive Symptomatology. CONCLUSIONS: For the IDS-C(30) and IDS-SR(30), standard scoring (ie, computing total score using all individual items) provides simplicity, comparability to published data, and a basis for clinical decision making. The revised scoring method, however, improves the utility of both scales when comparing groups as it provides explicit tests of item parameters.

Making clinicians lives easier: guidance on use of the QIDS self-report in place of the MADRS

BACKGROUND

The ability to convert total scores from one scale to another facilitates the interpretation of research findings and facilitates the use of systematic measurement in clinical practice.

METHODS

Item Response Theory methods were used to convert total scores between the 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16) and the Montgomery Asberg Depression Rating Scale (MADRS) total scores. Data were obtained from a sample of 233 outpatients with highly treatment-resistant, nonpsychotic major depressive episodes participating in a one-year open label study of vagus nerve stimulation to augment psychotropic medication treatment.

RESULTS

MADRS total scores averaged 31.9 (SD = 6.7) at baseline and 21.9 (SD = 11.0) at one year. QIDS-SR16 total scores averaged 17.6 (SD = 3.6) at baseline and 12.5 (SD = 5.8) at one year. Based on one-year data (or exit if the patient did not complete one year), corresponding QIDS-SR16 and MADRS total scores were presented for each possible QIDS-SR16 and MADRS total score. A QIDS-SR16 total score of 5 was comparable to a MADRS total score of 7 or 8 (7.5).

LIMITATION

The degree to which these results generalize to less treatment-resistant samples is unknown.

CONCLUSION

The conversion of QIDS-SR16 and MADRS total scores provides a basis for clinicians who wish to use the QIDS-SR16 to understand what MADRS total scores reported in clinical trials approximate QIDS-SR16 total scores obtained with their patients.

An evaluation of the quick inventory of depressive symptomatology and the hamilton rating scale for depression: a sequenced treatment alternatives to relieve depression trial report

BACKGROUND

Nine DSM-IV-TR criterion symptom domains are evaluated to diagnose major depressive disorder (MDD). The Quick Inventory of Depressive Symptomatology (QIDS) provides an efficient assessment of these domains and is available as a clinician rating (QIDS-C16), a self-report (QIDS-SR16), and in an automated, interactive voice response (IVR) (QIDS-IVR16) telephone system. This report compares the performance of these three versions of the QIDS and the 17-item Hamilton Rating Scale for Depression (HRSD17).

METHODS

Data were acquired at baseline and exit from the first treatment step (citalopram) in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. Outpatients with nonpsychotic MDD who completed all four ratings within +/-2 days were identified from the first 1500 STAR*D subjects. Both item response theory and classical test theory analyses were conducted.

RESULTS

The three methods for obtaining QIDS data produced consistent findings regarding relationships between the nine symptom domains and overall depression, demonstrating interchangeability among the three methods. The HRSD17, while generally satisfactory, rarely utilized the full range of item scores, and evidence suggested multidimensional measurement properties.

CONCLUSIONS

In nonpsychotic MDD outpatients without overt cognitive impairment, clinician assessment of depression severity using either the QIDS-C16 or HRSD17 may be successfully replaced by either the self-report or IVR version of the QIDS.

Pharmacist recognition of potential drug interactions

The ability of pharmacists to identify potential drug interactions was studied. Simulated medication profiles were created from a list of 16 drugs. Staff pharmacists and soon-to-graduate student pharmacists at a Veterans Affairs medical center each received a set of eight 2-drug profiles, four 4-drug profiles, two 8-drug profiles, and one 16-drug profile. Each set of profiles contained a number of pairs of drugs rated by the Drug Therapy Screening System as producing an interaction of moderate or major importance. The subjects were given one hour to screen the profile for the potentially interacting pairs. The subjects detected only 66% of the interactions in the 2-drug profiles, 34% of the interactions in the 4-drug profiles, 20% of the interactions in the 8-drug profiles, and 17% of the interactions in the 16-drug profile. None of the subjects detected all interactions in the 8- or 16-drug profiles. Both true-positive and false-positive rates of identification decreased significantly as the number of drugs listed on the profile increased. This primarily reflected a reduced tendency to report the presence of drug interactions, but there was additional evidence that the accuracy of identification also declined. The number of years of pharmacy training was the only demographic characteristic highly correlated with accuracy. More years of pharmacy education seemed to improve the ability to detect drug interactions. However, none of the pharmacists or students was able to detect all potentially interacting pairs in a profile containing 8 or 16 drugs. Computerized drug interaction profiles should be used by pharmacists to ensure recognition of all potential drug interactions.

On the dimensionality of the Buss/Perry Aggression Questionnaire

Buss and Perry (1992, Personality and Social Psychology, 63, 452-459) developed a 29-item test that presumably measures four aggression-related dimensions (physical aggression, verbal aggression, hostility, and anger). This study examined the factor structure of the items with particular concern towards seeing how much of the structure previously noted was an artifact of differences in item distributions. Although the scales are intercorrelated to the point that they may not span four dimensions, the scales are in fact multivariate in that the structure is not an artifact of differences in item distributions found with other presumed multifactor scales.

On the utility of the West Haven-Yale Multidimensional Pain Inventory

STUDY DESIGN

Two studies evaluated the West Haven-Yale Multidimensional Pain Inventory. This 52-item inventory contains 12 scales divided into 3 parts: 1) interference, support, pain severity, self-control, and negative mood; 2) punishing responses, solicitous responses, and distracting responses; and 3) household chores, outdoor work, activities away from home, and social activities.

OBJECTIVES

The objective of study 1 was to investigate the internal structure of the Multidimensional Pain Inventory and its demographic correlates. The objective of study 2 was to explore its external correlates (construct validity).

SUMMARY OF BACKGROUND DATA

The Multidimensional Pain Inventory appears promising because of its brevity, scope, ease of administration, and initial results. Despite this, it has attracted very little attention in the orthopedic literature since its introduction nearly a decade ago.

METHOD

The internal structure was examined using oblique multiple group confirmatory factor analysis. Demographic correlates were examined using discriminant analysis. The external correlates were examined using multiple regression and discriminant analysis.

RESULTS

The items' proposed structure fit well except that two pairs of scales are poorly separated: 1) activities away from home and social activities, and 2) solicitous responses and distracting responses. Correlations with external criteria are meaningful.

CONCLUSIONS

The Multidimensional Pain Inventory meets standards of reliability and convergent validity, and it may be an improvement over current psychometric devices used to this same end.

On the utility of the SCL-90-R with low-back pain patients

The SCL-90-R has become an increasingly popular measure of maladjustment. Its use beyond simply screening chronic low-back pain (CLBP) patients has been criticized, however, in part, because it appears to be a single-factor instrument. In fact, its nine major scales do share only one important common factor, i.e., general psychological discomfort. The scale most applicable to CLBP, however, somatization (SOM), has sufficient specific variance that it does not simply measure discomfort and predicts several other measures better than the SCL-90-Rs more reliable composite measure (GSI). Using SOM in conjunction with the GSI to separate psychological from physical discomfort is therefore both clinically and psychometrically appropriate. Other objections to the test are critically evaluated. The potential clinical relevance of the SCL-90-R is discussed.

Concurrent processes: the affect-cognition relationship within the context of the "mere exposure" phenomenon

The affect-cognition relationship and Zajonc's (1968) "mere exposure" hypothesis were examined in two studies that involved ratings of: (1) preference and familiarity for geometric forms previously scaled for complexity and (2) preference or height and familiarity for male yearbook pictures previously scaled for attractiveness or height. Two exceptions to his hypothesis were noted: simple geometric forms and unattractive faces showed satiation, and faces seen once before were rated more attractive than both novel faces and faces seen twice before. Moreover, mere exposure effects were noted with a nonaffective dimension (height). The major finding was that presentation frequency generally manifested independent relations to affect and rated familiarity, as well as to height and rated familiarity, therefore evoking a concurrent response process (Eriksen, 1960).

Reexamination of Eisen, Zellman, and McAlister's Health Belief Model questionnaire

Eisen, Zellman, and McAlister proposed a 22-item scale to measure four Health Belief Model (HBM) constructs as applied to adolescent contraceptive behavior. Their factor analysis led them to conclude that there were several discrepancies in their proposed scales. We suggest that they were unduly pessimistic. Although their proposed scales could stand improvement, they are adequate preliminary tools. The major reason they concluded that the scales were deficient was that they applied criteria that are generally appropriate for continuous data to their inherently discrete (categorical) item response data. A secondary consideration is that confirmatory methods of factor analysis can yield results that bear more directly on their proposed organization of items than the traditional exploratory methods that they used. A reanalysis of their data suggests that their proposed scales have fewer problems than they believed they had. Our results increase the likelihood of standardizing HBM measures.

Perceptual and response interactions in semantic priming

In two experiments, subjects made pairs of lexical decisions verbally. In Experiment 1, masked stimuli appeared concurrently to the left and right of fixation; in Experiment 2, nonmasked stimuli appeared sequentially at fixation. The left-hand letter strings were judged more accurately in in Experiment 1, and the second letter strings were judged more accurately in Experiment 2. Each string in the pair could be either a word (e.g., fork) or a nonword anagram (e.g., frok). Consequently, the two strings in the pair could be related (e.g., fork-spoon, frok-spoon, etc.) or unrelated (e.g., fork-door, frok-door, etc.), independently of whether neither, either, or both strings were words. Semantically related stimuli induced consistent biases to respond "word," as noted in other studies. These biases were typically stronger for the event reported second. Minimal evidence was found for perceptual priming effects. The asymmetrical effects were consistent with spreading-activation-type mechanisms, but other considerations support a multiple-process view.

Cognitive biases and depression

Compared symptomatically depressed, clinically remitted, and normal controls using cognitive measures designed to be traitlike and statelike in cross-sectional and longitudinal designs, respectively. Remitted depressives and normal subjects did not differ in their attributional biases, endorsement of dysfunctional attitudes, or interpretation of schema-relevant ambiguous events, but both groups differed from symptomatic depressives. Depressive episodes thus affect cognition, but cognitions measured by self-reports are more statelike than traitlike.

Semantic priming: subliminal perception or context?

Briefly presented, masked priming stimuli that cannot be identified by themselves can affect the processing of subsequent targets. The effect, which is sometimes viewed as a demonstration of unconscious processing, has been linked to the subliminal perception literature. Experiments 1 and 2 indicated that the identification of primes in the context of semantically related targets is superior to the identification of primes presented alone, and that the identification of primes in the context of semantically unrelated targets is inferior to the identification of primes presented alone. Experiment 3 indicated parallel findings in a recognition task. Consequently, an explanation of semantic priming in terms of the interactive nature of stimuli that are near to one another in time seems preferable to one based upon concepts of unconscious processing and subliminal perception.

Cognitive biases and depression

Compared symptomatically depressed, clinically remitted, and normal controls using cognitive measures designed to be traitlike and statelike in cross-sectional and longitudinal designs, respectively. Remitted depressives and normal subjects did not differ in their attributional biases, endorsement of dysfunctional attitudes, or interpretation of schema-relevant ambiguous events, but both groups differed from symptomatic depressives. Depressive episodes thus affect cognition, but cognitions measured by self-reports are more statelike than traitlike.

Invariance in the MMPI's component structure

Bernstein and Garbin (1985b) suggested that the Minnesota Multiphasic Personality Inventory's major clinical scales (excluding Scales ? and 5) can be approximated by an oblique three-component structure: (a) Profile Elevation, (b) Test-taking Attitudes, and (c) Optimism-Pessimism, collectively termed the salient weight model. In this study, we found that both this model and the MMPI's principal component structure remain invariant across race, sex, and, as previously noted, context of testing (job applicants vs. inmates in correctional institutions). We further noted that several alternative definitions of Profile Elevation provide equally satisfactory representation of the relations among the scales. This factor invariance is necessary, but not sufficient, for the MMPI to be viewed as unbiased.

A Confirmatory Factoring of the Self-Consciousness Scale

Fenigstein, Scheier, and Buss (1975) developed a three subscale inventory designed to measure self-consciousness. Burnkrant and Page (1984) used confirmatory factor analysis to evaluate the scale and concluded that five items did not belong to their assigned scales and that one of the original subscales really measured two separable traits. Burnkrant and Page's conclusions may simply reflect incidental properties of the item statistics and could weaken the scale if adopted. Fenigstein et al.'s representation fits the data quite well in its original form. However, items on their social anxiety scale also tend to evoke relatively large variability over subjects and items on their public self-consciousness scale tend to evoke relatively little variability. In other words, items on their subscales differ nearly as much statistically as they do substantively.