Arti cl e

460 Am JPsychiatry 158:3, March 2001

A Comparison of Three Scales for Assessing
Social Functioning in Primary Care
Myrna M. Weissman, Ph.D.
Mark Olfson, M.D.
Marc J. Gameroff, M.A.
Adriana Feder, M.D.
Milton Fuentes, Psy.D.
Objective: Assessment of functional sta-
tus is increasingly important in clinical tri-
als and outcome research. Although sev-
eral scales for assessing functioning are
widely used, they vary in coverage, and
direct comparisons among them are rare.
Comparative information is useful in
guiding selection of appropriate scales for
research applications.
Method: Results from three scales that
measure functioningthe Medical Out-
comes Study 36-item Short-Form Health
Survey, the Social Adjustment Scale Self-
Report, and the Social Adaptation Self-
Evaluation Scalewere compared in a
consecutively selected sample of 211 pa-
tients coming to primary care. Patients
also received psychiatric assessments.
Results: All three scales were acceptable
to patients, showed few significant corre-
lations with demographic variables, and
were able to differentiate psychiatrically
ill and well patients. Correlations among
scales, even among scale items that as-
sessed similar domains of functioning,
were modest.
Conclusions: Although all three scales
are presumed to assess functional status,
their item content and coverage differ. Se-
lection of a scale requires a review of the
scale items and consideration of research
priorities and the characteristics of the
study group. If functional status is a criti-
cal outcome measure, use of more than
one scale may be necessary.
(Am J Psychi a t r y 2 0 0 1 ; 1 5 8 : 4 6 0 4 6 6 )
It is widely recognized that the major mental illnesses
impair daily functioning (14). Therefore, new psycho-
pharmacologic and psychosocial treatments are often
evaluated for their effects on symptoms, as well as func-
tional status (57). These latter assessments are increas-
ingly important in cost-effectiveness projections.
Official classifications also reflect an increasing interest
in functional assessment. The APAs DSM first included an
assessment of functioning on axis V in 1980 (DSM-III) and
subsequently added a separate Global Assessment of
Functioning scale in 1994 (DSM-IV). The World Health Or-
ganization has developed a separate classification system
for impairments, disabilities, and social consequences of
diseases (8, 9). A recent report from the National Institute
of Mental Health (NIMH) recommended continuing the
development of tools to assess functioning as a means of
measuring the economic and social burden of mental
disorders (10).
In clinical research, self-administered scales are widely
used to survey patients directly about their functional sta-
tus. Despite the popularity of self-administered scales,
surprisingly little attention has been given to the issue of
scale selection. Scales vary in breadth and in the variety of
covered dimensions, item content within each dimension,
and the range of function represented. Some definitions of
health implicit in functional scales emphasize the level of
impairment or functional disturbance (11), while others
conceive of health not simply as the absence of disease or
disability, but as the presence of affirmative capacities and
well-being (12, 13).
Because functional scales vary in coverage and content,
it is important to describe how response patterns on indi-
vidual scales differ from one another. Unfortunately, di-
rect comparisons are rare. To our knowledge, no published
study has compared scores on any two of the three func-
tional scales included in the study reported here: the Med-
ical Outcomes Study 36-item Short-Form Health Survey
(14) and the Social Adjustment Scale Self-Report (15)
both of which have been widely used in clinical trials and
outcomes researchand the more recently developed So-
cial Adaptation Self-Evaluation Scale (12, 13). The latter
scale has been used in European clinical trials (16, 17) and
is currently being studied in the United States.
In the study reported here, we first assessed the accept-
ability of the three scales in an adult primary care popula-
tion. Then we examined the demographic correlates of
scale scores and intercorrelations among the three scales.
Finally, we evaluated the ability of each scale to differenti-
ate patients with acute psychiatric symptoms from asymp-
tomatic patients.
Method
Pa t i en t Recr u i t m en t a n d D i a gn ost i c Assessm en t
This study was conducted at the Associates in Internal Medi-
cine at the College of Physicians and Surgeons of Columbia Uni-
versity. The clinic provides approximately 54,000 medical visits
Am JPsychiatry 158:3, March 2001 461
WEISSMAN, OLFSON, GAMEROFF, ET AL.
annually to 18,000 patients from an ethnically and racially diverse
community. Between October 1998 and April 1999, a systemati-
cally selected sample of primary care patients with scheduled ap-
pointments were approached in the waiting room and invited to
participate. To be eligible for the study, patients had to be 1) be-
tween 18 and 70 years of age, 2) scheduled for face-to-face con-
tact with a primary care physician, 3) not a first-time visitor to the
clinic, 4) able to understand Spanish or English, 5) of a general
health status that did not preclude survey completion, and 6) not
actively homicidal or suicidal. The latter patients were given ap-
propriate emergency care. The institutional review board of the
Departments of Medicine and Psychiatry approved the protocol.
All participants provided signed informed consent.
Of the approximately 3,400 patients who were prescreened,
1,266 met eligibility criteria for phase 1 of the study. The most
common reasons for exclusion were age (44%) and not having a
scheduled visit with a primary care physician (31%). Four patients
were excluded because of active suicidal plans. Of the 1,266 who
met eligibility criteria, 1,007 (79.5%) consented to participate.
Consenters were similar to nonconsenters in gender and race/
ethnicity; however, nonconsenters were slightly older (mean=
55.5 years, SD=11.3, versus mean=53.2 years, SD=12.2) (t=2.40,
df=1, 1188, p=0.02).
Of the 1,007 patients who participated in phase 1, a random
subsample (N=271) was invited to participate in the second
phase. Those who were selected for phase 2 and those who were
not selected did not differ significantly in age, gender or racial/
ethnic distribution, educational level, or household income. Of
the subsample of 271, consenters (N=223, 82.3%) did not differ
from nonconsenters (N=48, 17.7%) in age, gender or racial/ethnic
distribution, or household income. However, consenters were
somewhat more educated (median attainment of ninth to 11th
grade versus eighth grade or below for nonconsenters, Mann-
Whitney U=4024.50, z=2.81, p=0.005). Interview data for 12 sub-
jects were lost because of computer malfunction, resulting in a fi-
nal phase 2 sample of 211 subjects. These 211 subjects did not dif-
fer from the remainder of the original sample eligible for phase 1
(N=1,055) in age, gender, or race/ethnicity.
During phase 1, demographic, screening, treatment utilization,
and some social functioning data, described elsewhere (18), were
obtained. The second phase included a diagnostic assessment
with the Composite International Diagnostic Interview, version
2.1 (19) (for DSM-IV), conducted by experienced mental health
professionals (psychologists or social workers) who had com-
pleted training in the use of this instrument. All assessments were
translated from English to Spanish and back-translated by a bilin-
gual team of mental health professionals. The Composite Inter-
national Diagnostic Interview was conducted within a week of
screening for 77% of the sample (range=039 days, median=4).
The Social Adaptation Self-Evaluation Scale was completed dur-
ing phase 1, and the 36-item Short-Form Health Survey and Social
Adjustment Scale Self-Report were completed during phase 2.
Soci a l Fu n ct i on i n g Sca l es
Medical Outcomes Study 36-Item Short-Form Health Sur-
vey. The 36-item Short-Form Health Survey is a self-report scale
constructed to collect data on health status, functioning, and
well-being for the Medical Outcomes Study (3, 14, 20, 21). The
time period covered by most items is 4 weeks. The number of re-
sponse choices varies across items, from two (yes/no) to six (an-
chored by all of the time and none of the time). Eight health
concepts are assessed: physical functioning and limitations in
physical activities because of health problems; social functioning
and limitations in social activities because of physical or emo-
tional problems; rolephysical, and limitations in usual role ac-
tivities because of physical health problems; bodily pain; mental
health and psychological distress and well-being; roleemo-
tional, and limitations in usual role activities because of emo-
tional problems; vitality, energy, and fatigue; and perceptions of
ones general health.
In the current study, scores for the eight subscales and the
physical and mental component summary scales were calculated
by using official Short-Form Health Survey algorithms (20, 21).
The summary scales are computed by aggregating subscale
scores according to the factor structure of the subscales in the
general U.S. population. Unlike the eight subscales, the two sum-
mary scale scores have norms based on the general U.S. popula-
tion (mean=50, SD=10) (21).
Social Adjustment Scale Self-Report. The Social Adjustment
Scale Self-Report (15, 22) is a self-report scale with 54 questions
that measure instrumental and expressive role performance over
the past 2 weeks. It includes questions on work for pay, unpaid
work, and work as a student; social and leisure activities, relation-
ships with the extended family, the marital partner, ones chil-
dren, and relationships within the family unit; and perception of
economic functioning. The questions within each area cover per-
formance at expected tasks, friction with people, finer aspects of
interpersonal relationships, and feelings and satisfactions. Each
item is scored on a 5-point scale with higher scores indicating
poorer functioning. The Social Adjustment Scale Self-Report con-
tains skip-outs, so that nonapplicable items are omitted. Scores
for each role area are calculated by averaging the scores for all an-
swered items within that area. The total Social Adjustment Scale
Self-Report score is calculated by averaging all applicable items
(however, only the work items pertaining to the primary work role
are included).
Social Adaptation Self-Evaluation Scale. The Social Adapta-
tion Self-Evaluation Scale is a 21-item self-rating scale developed
to detect presumed treatment differences in social motivation
and behavior that may not be discernible in psychiatric assess-
ment (13). The scale was developed by Pharmacia-Upjohn as a
tool for determining differential effects of a selective noradrena-
line reuptake inhibitor, which was presumed to have an increased
effect on drive and motivation toward action, as compared to se-
lective serotonin reuptake inhibitors (SSRIs) (17, 23). The Social
Adaptation Self-Evaluation Scale focuses on the patients self-per-
ception and motivation toward action rather than on objective
performance. The scale was validated in a large general popula-
tion survey, and its external and internal validity, test-retest reli-
ability, and sensitivity to change have been described (13). The
time period assessed is now. The first two items (interest in ones
occupation and ones home-related activities) are mutually exclu-
sive for scoring purposes. If the respondent endorses having an
occupation, the occupation item is used, otherwise the home-re-
lated item is used. A total of 20 items are summed for a possible
total score of 0 to 60. Higher scores indicate higher functioning.
Only data on total scores have been published.
St a t i st i ca l An a lyses
Statistical analyses were performed with SPSS for Windows,
version 9.0 (SPSS, Inc., Chicago). Feasibility of the three scales
was assessed by 1) the number of patients who refused to fill out
the scales and 2) the number of patients who answered all the
items. Skipped items on the Social Adjustment Scale Self-Report
were not considered missing if the corresponding role area did
not apply to the patient.
Pearson product-moment correlations were used to measure
associations among continuous variables, including age and all of
the social functioning scores. Students t test and analysis of vari-
ance were used, where appropriate, to compare functioning
scores among groups on the basis of gender, language of choice,
race/ethnicity, and diagnostic status. When group variances were
significantly different (p<0.05), we used the corrected degrees of
462 Am JPsychiatry 158:3, March 2001
SOCIAL FUNCTIONING SCALES
freedom (df ). In such cases, the df is reported with two decimal
places and the nominal df is provided in brackets. All tests were
two-tailed with an alpha of 0.05. To help control the rate of type I
error, we did multiple group comparisons only when the omnibus
F was significant at p<0.05.
Results
Su b j ect s
The 211 patients were primarily female (N=161, 76.3%).
The mean age of the overall group was 54 years (SD=12,
range=2170); 69.7% were Hispanic (N=147), 23.7% were
non-Hispanic African American (N=50), and 6.6% were
non-Hispanic white or other (N=14). Most of the Hispanic
subjects (N=122, 83.0%) selected the Spanish version of
the survey. Only 30.8% of the subjects (N=65) were mar-
ried or living with a partner, 37.0% (N=78) were separated
or divorced, 12.8% (N=27) were widowed, and 19.4% (N=
41) had never been married. A majority (N=180, 85.3%) re-
ported that their household income over the past year was
less than $12,000; 52.1% (N=110) had not graduated from
high school, 23.2% (N=49) were high school graduates,
and 24.6% (N=52) had attended at least some college.
Accep t a b i l i t y of Sca l es
Acceptability as measured by the patients completion
of questions was excellent for all three scales. The percent-
age of patients who filled out all questions was 96.2% (N=
203) for the Short-Form Health Survey, 88.2% (N=186) for
the Social Adjustment Scale Self-Report, and 98.6% (N=
208) for the Social Adaptation Self-Evaluation Scale. In
most cases, the number of questions left unanswered was
between one and three. Only a few patients left all scale
items blank. Four patients each refused to answer the
Short-Form Health Survey (1.9%) and the Social Adjust-
ment Scale Self-Report (1.9%), and no patients refused to
answer the Social Adaptation Self-Evaluation Scale (0%).
Cor r el a t i on s Wi t h D em ogr a p h i c Va r i a b l es
Gender. There were no significant gender differences in
the Short-Form Health Survey physical component sum-
mary scale or the Social Adaptation Self-Evaluation Scale
scores. However, women were significantly more impaired
than men according to their total scores on the Social Ad-
justment Scale Self-Report (t=2.00, df=205, p<0.05) and
their scores on the Short-Form Health Survey mental com-
ponent summary scale (t=3.61, df=94.48 [201], p=0.0005).
The significantly greater impairment of women was
largely accounted for by their scores on social (t=2.14, df=
205, p<0.05), marital (t=2.16, df=65, p<0.05), and parental
(t=2.70, df=91.47 [92], p<0.01) roles on the Social Adjust-
ment Scale Self-Report, and by scores on the vitality (t=
2.60, df=204, p=0.01), roleemotional (t=3.65, df=102.78
[204], p<0.0005), and mental health (t=2.83, df=204, p=
0.005) subscales of the Short-Form Health Survey.
Age. There were no significant correlations between age
and the total score or role area scores on the Social Adjust-
ment Scale Self-Report (total score: r=0.02, work: r=0.04,
social and leisure: r=0.08, extended family: r=0.02, mari-
tal: r=0.05, parental: r=0.12, family unit: r=0.06, eco-
nomic: r=0.02, df=65205, all n.s.); or scores on the men-
tal health-oriented Short-Form Health Survey subscales
(mental health: r=0.03, roleemotional: r=0.05, social
functioning: r=0.02, vitality: r=0.05, df=204205, all n.s.)
or the Social Adaptation Self-Evaluation Scale (r=0.05,
df=209, n.s.). However, age was significantly associated
with the physical health-oriented Short-Form Health Sur-
vey subscales (physical functioning: r=0.28, df=204,
p<0.0001; rolephysical: r=0.14, df=203, p<0.05; bodily
pain: r=0.14, df=205, p<0.05; general health: r=0.16, df=
203, p=0.02) and physical component summary scale
scores (r=0.31, df=201, p<0.0001), with older subjects rat-
ing themselves as more impaired.
Race/ethnicity. There were few racial/ethnic differences
in scores on the Short-Form Health Survey or the Social
Adjustment Scale Self-Report. Differences across the three
scales were significant only for the Social Adjustment
Scale Self-Report family unit role (F=3.20, df=2, 181,
p<0.05) and the mental health subscale of the Short-Form
Health Survey (F=6.05, df=2, 203, p<0.005). Multiple com-
parisons indicated that Hispanics had worse ratings than
the rest of the sample on mental health and worse ratings
than African Americans on family unit role. Social Adapta-
tion Self-Evaluation Scale scores differed by race/ethnicity
(F=6.92, df=2, 208, p=0.001), with Hispanics and African
Americans rating themselves as significantly more im-
paired than patients in the group of non-Hispanic whites
and others.
Language of choice. Respondents on the English and
Spanish versions of the instruments differed significantly
on five indices. English speakers rated themselves as sig-
nificantly less impaired than Spanish speakers on the
Short-Form Health Survey mental health subscale and
mental component summary scale, the Social Adjustment
Scale Self-Report family unit and economic roles, and the
Social Adaptation Self-Evaluation Scale. However, Span-
ish-speaking respondents had lived significantly less time
in the United States than English-speaking respondents
(mean=24 years, SD=11, versus mean=47 years, SD=17) (t=
10.38, df=126.88 [207], p<0.0001). To control for possible
acculturative effects, we covaried for years lived in the
United States on these five indices, and significant differ-
ences remained for only two, the Short-Form Health Sur-
vey mental health subscale (F=8.89, df=1, 201, p<0.005)
and the Social Adaptation Self-Evaluation Scale (F=7.06,
df=1, 206, p<0.01).
Cor r el a t i on s Am on g Sca l es
Correlations among the three scales were statistically
significant but modest for the Social Adjustment Scale
Self-Report and Social Adaptation Self-Evaluation Scale
total scores and for ratings of social functioning or mental
symptoms on the Short-Form Health Survey. Correlations
Am JPsychiatry 158:3, March 2001 463
WEISSMAN, OLFSON, GAMEROFF, ET AL.
between ratings of physical symptoms on the Short-Form
Health Survey and ratings of mental symptoms or social
functioning on the three scales were generally lower or not
statistically significant (Table 1).
Items measuring the same areas among the three scales
were compared. These areas included work, social, family,
and economic functioning (Table 2). Although all of the
correlations within each area among the assessments
were statistically significant, the overall correlations were
still modest (r=0.150.42) except for the higher correlation
between the Social Adjustment Scale Self-Report and So-
cial Adaptation Self-Evaluation Scale for social function-
ing (r=0.62).
D i f f er en t i a t i n g Bet w een I l l a n d Wel l Pa t i en t s
We next determined whether the scales differentiated
between some diagnostic groups. Because of the extensive
literature on the association between depression and func-
tional impairment (3, 4), we hypothesized that depressed
patients would exhibit the most impairment. The group of
patients with current major depressive disorder was com-
pared to the group without major depressive disorder but
TABLE 1. Correlation of Mean Total Scores and Subscale and Role Area Scores on Three Scales Measuring Social Function-
ing in a Consecutively Selected Sample of 211 Primary Care Patients
Correlation (r)
a
Total Scores on Short-Form
Health Survey Summary Scales
Total Scores on
Social Adjustment
Scale Self-Report
b
Total Scores on
Social Adaptation
Self-Evaluation Scale Variable
Physical
Component
Mental
Component
Total scores
Short-Form Health Survey
Physical component summary scale (N=203)
Mental component summary scale (N=203) 0.01
Social Adjustment Scale Self-Report (N=203207) 0.17* 0.62
Social Adaptation Self-Evaluation Scale (N=203207) 0.09 0.41 0.57
Subscale and role area scores
Short-Form Health Survey subscales
Physical functioning (N=203206) 0.82 0.19** 0.26*** 0.20**
Rolephysical (N=203205) 0.72 0.33 0.29 0.17*
Bodily pain (N=203207) 0.66 0.20** 0.23*** 0.05
General health (N=203205) 0.56 0.49 0.40 0.29
Vitality (N=203206) 0.39 0.74 0.55 0.41
Social functioning (N=203207) 0.40 0.66 0.42 0.24***
Roleemotional (N=203206) 0.13 0.80 0.51 0.26***
Mental health (N=203206) 0.16* 0.88 0.58 0.44
Social Adjustment Scale Self-Report role areas
Work (primary) (N=169173) 0.24** 0.48 0.67 0.34
Social and leisure (N=203207) 0.17* 0.47 0.80 0.63
Extended family (N=196200) 0.07 0.46 0.73 0.39
Marital (N=6667) 0.09 0.64 0.82 0.32**
Parental (N=9394) 0.00 0.24* 0.39*** 0.31**
Family unit (N=181184) 0.06 0.38 0.53 0.15*
Economic (N=203206) 0.21** 0.25*** 0.27*** 0.27***
a
df=64205.
b
For the correlation analysis, these scores were reversed so that higher scores would indicate better functioning.
*p<0.05. **p<0.01. ***p<0.001. p<0.0001.
TABLE 2. Correlation of Mean Role Area Scores From Three Scales Measuring Social Functioning in a Consecutively Se-
lected Sample of 211 Primary Care Patients
Role Area
Work (N=173)
a
Social (N=207)
b
Family (N=202)
c
Economic (N=206)
d
Social Functioning Scales Correlated r p r p r p r p
Short-Form Health Survey with Social
Adjustment Scale Self-Report 0.42 <0.0001 0.22 <0.005 0.25 <0.0005
Short-Form Health Survey with Social
Adaptation Self-Evaluation Scale 0.21 <0.01 0.15 <0.05 0.32 <0.0001
Social Adjustment Scale Self-Report with
Social Adaptation Self-Evaluation Scale 0.37 <0.0001 0.62 <0.0001 0.40 <0.0001 0.23 <0.001
a
The number of items contributing to the role area score was three for the Short-Form Health Survey, six for the Social Adjustment Scale Self-
Report, and two for the Social Adaptation Self-Evaluation Scale.
b
The number of items contributing to the role area score was two for the Short-Form Health Survey, seven for the Social Adjustment Scale Self-
Report, and nine for the Social Adaptation Self-Evaluation Scale.
c
The number of items contributing to the role area score was two for each of the Short-Form Health Survey and the Social Adaptation Self-
Evaluation Scale and eight for the Social Adjustment Scale Self-Report.
d
One item contributed to the role area score for the Social Adjustment Scale Self-Report, and two items contributed to the role area score for
the Social Adaptation Self-Evaluation Scale.
464 Am JPsychiatry 158:3, March 2001
SOCIAL FUNCTIONING SCALES
with at least one other current Composite International Di-
agnostic Interview disorder, and with a comparison group
of patients with no current Composite International Diag-
nostic Interview disorders. Seven of the 211 subjects were
excluded from the analysis because of missing diagnostic
data. The three groups did not differ significantly in gender
(
2
=5.63, df=2, p=0.06), age (F=0.58, df=2, 201, p=0.56), or
race/ethnicity (
2
=5.78, df=4, p=0.22).
Across nearly all of the scores there was a consistent pat-
tern of greater impairment from the normal comparison
group to the major depressive disorder group (Table 3).
Formal tests revealed that the Short-Form Health Survey
scores for all three groups were significantly different on
four subscales (general health, vitality, roleemotional,
and mental health) and the mental component summary
scale. In addition, the major depressive disorder group
rated themselves as more impaired on the social function-
ing subscale than both the group with other psychiatric
disorders and the normal comparison group. The major
depressive disorder group was significantly more im-
paired than the normal comparison group on the physical
functioning, rolephysical, and bodily pain subscales,
and there were no significant group differences in scores
on the Short-Form Health Survey physical component
summary scale. On the Social Adjustment Scale Self-Re-
port, all three groups were significantly different on total
scores, social and leisure role, and extended family role.
The major depressive disorder group was significantly
more impaired than normal comparison subjects on all
role areas of the Social Adjustment Scale Self-Report
except the parental role. On the Social Adaptation Self-
Evaluation Scale, those with any diagnosis were more im-
paired than those with no diagnosis. The social func-
tioning scales were also able to differentiate groups based
on the number of current Composite International Diag-
nostic Interview diagnoses (none, 1, or 2 or more). (Data
available on request.)
Discussion
Psychiatric clinical efficacy, effectiveness, and outcome
studies increasingly include measures of functional status.
We present the first direct comparison of three scales: the
Short-Form Health Survey, the Social Adjustment Scale
Self-Report, and the Social Adaptation Self-Evaluation
Scale. The Short-Form Health Survey and the Social Ad-
justment Scale Self-Report have been used together in a
large drug trial with dysthymic patients. The results were
reported as parallel outcome measures or in comparison
to published norms (5). One other study compared the
reading levels of the Short-Form Health Survey and the So-
TABLE 3. Mean Scores on Three Scales Measuring Social Functioning for Primary Care Patients With Major Depressive Dis-
order, Other Psychiatric Disorders, and No Psychiatric Disorders
a
Score
Significant Post Hoc
Comparisons
c,d
Patients With Major
Depressive Disorder
(N=27) (MDD)
Patients With
Other Disorders
(N=38) (OD)
Patients With No
Psychiatric Disorders
(N=139) (ND)
Scale, subscale, or role area
b
Mean SD Mean SD Mean SD
Short-Form Health Survey
Summary scales
Physical component 31.2 7.1 33.2 11.7 34.9 11.9
Mental component 30.7 11.0 43.0 12.9 52.9 11.5 ND>OD, MDD; OD>MDD
Subscales
Physical functioning 40.9 25.6 51.5 30.1 57.5 28.9 ND>MDD
Rolephysical 19.4 32.8 32.4 42.4 45.7 44.4 ND>MDD
Bodily pain 23.5 14.6 34.9 31.3 42.0 30.7 ND>MDD
General health 25.4 14.1 38.4 26.6 51.5 23.7 ND>OD, MDD; OD>MDD
Vitality 28.5 24.4 45.1 24.6 59.2 25.2 ND>OD, MDD; OD>MDD
Social functioning 39.4 30.2 67.8 29.0 75.0 28.2 ND>MDD; OD>MDD
Roleemotional 19.8 34.9 52.6 46.3 73.3 40.1 ND>OD, MDD; OD>MDD
Mental health 32.5 18.5 52.4 25.0 73.8 20.7 ND>OD, MDD; OD>MDD
Social Adjustment Scale Self-Report
Total 2.5 0.6 2.1 0.4 1.7 0.3 ND<OD, MDD; OD<MDD
Role areas
Work (primary) 2.1 0.8 1.6 0.6 1.4 0.4 ND, OD<MDD
Social and leisure 3.1 0.7 2.7 0.7 2.2 0.6 ND<OD, MDD; OD<MDD
Extended family 2.2 0.8 1.7 0.5 1.4 0.4 ND<OD, MDD; OD<MDD
Marital 2.9 0.9 2.3 0.6 1.8 0.6 ND<MDD, OD
Parental 1.3 0.7 1.3 0.5 1.1 0.3
Family unit 2.4 1.2 2.4 1.0 1.7 0.7 ND<MDD, OD
Economic 3.7 1.4 3.0 1.7 2.4 1.4 ND<MDD
Social Adaptation Self-Evaluation Scale 33.6 8.0 36.7 9.2 40.9 7.7 ND>MDD, OD
a
Diagnoses based on assessment with the Composite International Diagnostic Interview, version 2.1 (19).
b
Data were missing for some patients for some variables.
c
Significant differences between groups on all scale and subscale scores except the Short-Form Health Survey physical component summary
scale score and the Social Adjustment Scale Self-Report parental role area score (F=3.949.5, df=2, 612, 201, p<0.05) .
d
Post hoc multiple comparisons used the least significant difference test (p<0.05) when variances were equal and Dunnetts test (p<0.05) when
variances were unequal.
Am JPsychiatry 158:3, March 2001 465
WEISSMAN, OLFSON, GAMEROFF, ET AL.
cial Adjustment Scale Self-Report and showed they were
comparable (24).
In our study all three scales were acceptable to patients,
in that patients were able to complete the forms. The So-
cial Adjustment Scale Self-Report and the Short-Form
Health Survey were sensitive to gender differences, proba-
bly because they include assessments of family and mari-
tal functioning. The Short-Form Health Survey was more
sensitive to age differences on items assessing physical
health. There were few race/ethnicity or language differ-
ences on any of the scales.
Correlations among scales were statistically significant
but modest. However, the physical component summary
scale of the Short-Form Health Survey had little correla-
tion with the other scales or with the mental health-ori-
ented subscales of the same scale. It is no surprise that the
Short-Form Health Survey physical and mental compo-
nents did not correlate, since they were originally created
from an orthogonal rotation of factor scores. The fact that
the physical component does not correlate with the other
scales suggests that this component is measuring a unique
domain. All scales were able to differentiate psychiatri-
cally ill from well subjects. The correlations between
scales were modest even in the areas covering similar do-
mains. A comparison of the questions used for work as-
sessment shows how the approaches of the three scales
differ (Figure 1). The Short-Form Health Survey focuses on
work performance; the Social Adjustment Scale Self-
Report differentiates between work roles and assesses the
actual number of days lost, affective performance, and in-
terpersonal relations; and the Social Adaptation Self-Eval-
uation Scale emphasizes interest and motivation for work.
The original purpose for which the scales were designed
is well represented in their content. The Short-Form Health
Survey was designed to determine outcomes of psychiatric
and medical conditions in a medical setting. It is the most
widely used of the three scales, and it is the only one of the
three that includes measures of physical functioning and
physical activities (lifting, climbing, bending, etc.). It also
includes assessment of depressive symptoms. There is an
effort to separate work limitation due to physical as com-
pared to emotional problems. Work role (e.g., homemaker,
student) and actual time lost from work are not differenti-
ated. Two questions deal with social activities with friends
and family. Marital and parental roles and perception of
economic functioning are not assessed.
The Social Adjustment Scale Self-Report was originally
developed as an assessment tool for a clinical trial with
drugs and psychotherapy for depressed patients in their
child-rearing years. This background is reflected in the
item content, in which instrumental and affective func-
tioning in the extended family, with the spouse or partner,
and with children are assessed separately. Work roles are
differentiated so that a person who does not work for pay
is also assessed on work. However, it is the longest of the
three scales and, like the Social Adaptation Self-Evaluation
Scale, does not assess physical functioning or general
health status.
The Social Adaptation Self-Evaluation Scale is the new-
est of the scales and was designed for testing the efficacy
of a new selective noradrenaline reuptake inhibitor, which
is hypothesized to have an additional effect on drive and
motivation, as compared to an SSRI. Like the Short-Form
Health Survey, the Social Adaptation Self-Evaluation Scale
does not include work role or actual time lost from work
and does not differentiate family roles.
These findings provide general guidelines for instru-
ment selection. For studies that include elderly subjects or
that are being conducted in a primary care setting, re-
searchers may find the Short-Form Health Surveys cover-
age of physical, as well as mental, functioning useful. Also,
the Short-Form Health Survey is now so widely used that it
has become a standard, enabling comparison between
studies. The Social Adjustment Scale Self-Report covers
instrumental role performance and different family roles,
which may be useful in economic projections. The Social
Adjustment Scale Self-Report may be appropriate for in-
vestigations of effects on marital and parental function-
ing, which may include homemakers and students, for
whom a different concept of work role functioning may
apply, or may require estimates of actual days lost from
work. Studies including noradrenergic drugs with specific
FIGURE 1. Questions Assessing Work Functioning From
Three Scales Measuring Social Functioning
Short-Form Health Survey
During the past 4 weeks, have you had any of the following
problems with your work or other regular daily activities as a
result of any emotional problems?
Cut down the amount of time you spent on work or other
activities.
Accomplished less than you would like.
Didnt do work or other activities as carefully as usual.
Social Adjustment Scale Self-Report
Please check the situation that best describes you
I am
___ a worker for pay
___ a homemaker
___ a student
___ retired
___ unemployed
Do you usually work for pay more than 15 hours per week?
Did you work any hours for pay in the last 2 weeks?
How many days did you miss from work?
Have you been ashamed of how you do your work?
Have you had any arguments with people at work?
Have you felt upset, worried, or uncomfortable while doing
your work?
Have you found your work interesting?
Social Adaptation Self-Evaluation Scale
Do you have an occupation?
How interested are you in your occupation?
How interested are you in your home-related activities?
Do you pursue this occupation/these activities with enjoyment?
466 Am JPsychiatry 158:3, March 2001
SOCIAL FUNCTIONING SCALES
hypothesis about target of action might use the Social Ad-
aptation Self-Evaluation Scale (16).
The limitations of this study include the modest sample
size. Although the sample was representative of primary
care clinic patients, it was not representative of the U.S.
population. Finally, we did not report data on the ability of
these scales to differentially predict treatment effective-
ness or clinical course.
A recent NIMH workgroup on translating behavioral
science into action concluded that impaired functioning
cuts across the range of mental illness and creates sub-
stantial economic burden (10). The workgroup noted a
need for new standardized assessments, so that health
care costs can be accurately estimated. They called for an
integration of basic behavioral science theory and meth-
ods in the development of scales. Until this is achieved,
our data suggest that investigators selecting a functional
status scale should carefully review the content of avail-
able scales. If functional status is a critical outcome mea-
sure, more than one scale should be included in the study.
Received April 25, 2000; revision received Aug. 22, 2000; ac-
cepted Sept. 6, 2000. From the Division of Clinical and Genetic Epi-
demiology, New York State Psychiatric Institute; the College of Phy-
sicians and Surgeons of Columbia University, New York; and the
Department of Psychology, Montclair State University, Upper Mont-
clair, N.J. Address reprint requests to Dr. Weissman, New York State
Psychiatric Institute, 1051 Riverside Dr., Unit 24, New York, NY
10032; weissman@child.cpmc.columbia.edu (e-mail).
Supported by investigator-initiated grants from Eli Lilly & Co. and
Pharmacia-Upjohn.
Dr. Weissman developed the Social Adjustment Scale Self-Report
and receives royalties from its sale.
The authors thank Dr. Carlos Blanco and Dr. Raz Gross for their
comments.
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