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Soc Psychiatry Psychiatr Epidemiol (1997) 32: 76-83 @ Springer-Verlag 1997

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.}pRIGINAL PAPER

J.P.J. Oliver.P.J. Huxley.S. Priebe.W. Kaiser

Measuring the qualityof life of severelymentallyill people


usingthe Lancashire Qualityof LifeProfile

Accepted: 9 February 1996

Abstract Quality of life (QOL) has become an impor- LQOLP applications relating almost exclusively to
tant outcome measure for many disorders, including people with severe mental illness in community set-
mental illness. The Lancashire Quality of Life Profile tings. Two other large data-bases exist. One is based on
(LQOLP) was developed for use in operational con- the German version of the LQOLP (Priebe et al. 1995;
texts, and has been translated into several languages. It Kaiser et al. 1996; Hoffman et al. 1996);the other is
is in use in several European and North American based on Lehman's original QOL instrument .in the
community psychiatric services. The present paper ad- United States (Lehman 1983).
dresses the questions: how easy is it to use?; how re- There are many different ways of conceptualising
liableis it?;do the results of the LQO LP vary by setting QOL; the LQOLP combines objective and subjec~ive
in a meaningful way?; how do the results co-vary with measures in several areas of life (called 'domains'). This
measures of clinical symptoms and social functioning?; approach has been adopted because the variance in
how well does it measure change?; is it clinically useful? global well-being is mediated by objective well-being,
While most of the answers to these questions are fa- as well as subjective well-being.Lehman's model (1983)
vourable, there is a need for further research and devel- of the interaction of personal characteristics, and sub-
opment of the profile,in particular with reference to the jective and objective well-being accounts for up to 70%
consequences of the use of the profile as a routine of global well-being in our data. Other research sug-
monitoring instrument and the most appropriate form gests that subjective well-being is more closely related
of statistical analysis in longitudinal data-sets. to objective circumstances than had been thought in
the past. The present paper addresses the questions:
how easy is it to use?;how reliable is it?; do the results
of the LQOLP vary by setting in a meaningful way?;
Introduction
how do the results co-vary with measures of clinical
symptoms and social functioning?; how well does it
Quality of the (QOL) has become an important out- measure change?; is it clinically useful? This paper
come measure in many disorders, including mental addresses these questions using data from previously
illness (Bowling 1991).The Lancashire Quality of Life published studies of case management (Huxley and
Profile (LQOLP) has been developed for use in opera- Warner 1992),individual cases (Bridges et al. 1993)and
tional contexts, and its development and use is de- medical students (Priebe et al. 1995),and studies that
scribed in detail by Oliver et al. (1996).Since 1989 we are in press or in preparation on psychosocial rehabili-
have established a large data-base (11= c. 1500) of tation, a community mental health team, psychiatric
in-patients (Priebe et al. 1996), community mental
health support teams (Oliver et al. 1996)and alcoholic
J.P.!. Oliver (181)' P.J. Huxley women.
School of Psychiatry and Behavioural Sciences,
Manchester University, Mathematics Building, Oxford Road,
Manchester M13 9PL, UK
S. Priebe Thedevelopmentof the LQOLP
Department of Social Psychiatry, Freie Universitat Berlin,
Berlin,Germany I . The LQOLP is derived from Lehman's original inter-
W. Kaiser view (1983),and includes four similar types of informa-
Nervenklinik Spandau, Berlin, Germany tion, an additional lifedomain and additional measures
~ --~, _-: ~

77

of global well-being, affect and self-esteem. The four produces a profile of scores and separate global well-
areas retained from Lehman's interview are: personal being assessments; it does not attempt to generate
characteristics, objective QOL indicators, subjective a single overall score to reflect the complexities of
QOL indicators and a global well-being measure. The people's circumstances. The subjective well-beingques-
objective and subjective indicators cover the eight orig- tions follow on immediately after the objective ques-
inal life domains, plus religion; these are: living situ- tions in the same life domain; this helps the respondent
ation, family, social relationships, leisure activities, to be clear that the subjective response is demanded in
work/education, finances, personal safety and health. respect of a specific life area, and avoids a halo effect
The lifedomains were derived originally from use of the that might result if all the subjective well-being ratings
critical incident technique, in which several thousand were made in succession.
subjects report several thousand specificincidents that
have had an impact on their well-being, and these are
subsequently classified into similar categories, or life
domains (see Flanagan 1982).The subjective aspects of Results
these domains are assessed using a modified version of
the Lehman 7-point scale, which is rated by the respon- Ease of use
dent [this scale is identified in the interview as the "life
satisfaction scale" (LSS);a rating of 1 means life "could Before presenting the more scientific evidence, we can
not be worse" and a rating of 7 means life"could not be say that individual anecdotal responses to the LQOLP
better" (used in Figs. 4-6 below)]. The global well- are almost universally positive. Both respondents and
being measure includes Cantril's Ladder (Cantril1965), their interviewers (a mixture of professionals) give pos-
which we altered from a 9-point categorical scale to itive feedback along the lines of: "that is the longest
a WO-pointcontinuous or analogue-type scale. Objec- anyone has spent asking me how I feel about things";
tive well-being is composed largely of social and eco- "no-one has ever asked me what I think about my
nomic indicators. The content of these questions has circumstances"; "when are you coming back to do this
remained largely unchanged from Lehman's originals, again?". When given individual graphic feedback of
but the form of some has been altered so that they are their own results, patients said: "so, I've done well
comparable to census data codes, in the United King- haven't IT'; "can I show this to my therapist?". Profes-
dom to facilitate comparison with national and local sional interviewers have said that the LQOLP is the
data. easiest assessment to use with people with severe men-
Baker and Intagliata (1982) have adopted a wider tal illness, it is liked by the respondents and that if
view of QOL than L-ehman, and we followed their a patient loses interest when a battery of research
example in includihg a measure of psychological well- instruments are applied, one can regain their attention
being [the Affect Balance Scale (Bradburn 1969)]. In by switching to the LQOLP.
this own research, Bradburn included the Happiness The interview can be conducted with severely ill
Scale (Gurin et al. 1960),which is related to satisfaction patients in a number of settings. Only those patients
and mental health but not identical, and we have also who are very floridly unwell, who are mute or who have
included.this~s an alternative measure of overall well- serious brain damage are unable to complete it, and it
being. FranlClin et al. (1986) have extended the range of can be applied in a variety of residential and commun-
measures to include a Self-Esteem Scale (Rosenberg ity contexts. We do not have adequate data on the
1965).We also included this measure, but amended the refusal rate since many studies use the LQOLP as one
scoring to simple yes/no choices after some patients of a battery of tests and for a number of different
found the original response scales too confusing. purposes (outcome of drug trials; evaluation of a day
Flanagan (1982) and his colleag\les have suggested centre, etc.). Refusal to complete the LQOLP under
that in order to compose QOL measures for disabled these circumstances might simply be a reflection of
individuals, respondents should be asked questions refusal to comply with the study as a whole. We are
that focus on problems created by the disability. We also aware that refusal rates can be affected by un-
included the' additional types of questions that they motivated and unsympathetic staff seeking the patient's
have suggested, dne of which was "what changes, consent. However, in our studies, when motivated staff
whether possible or not, would produce the greatest seeking the patient's consent and the patient receivesan
improvement in their quality of life". We were also adequate explanation, the refusal rate is always ex-
aware of the fact that the professionals interviewing the tremely low (rarely more than a few percent). We have
clients wished to be able to make their own assessment a better indication of the respondent's feelings about
of the client's QOL, and we therefore included a single the LQOLP from our data about agreement to be
QOL measure, the Quality of Life Uniscale (Spitzer reinterviewed. In 1498 LQOLP applications, 91%
and Dobson 1981). agreed to be reinterviewed, 3.5% of cases were unsure
The extensive testing of the LQO LP in operation is whether they would be reinterviewed and 5.6% refused.
reported in detail in Oliver et al. (1996).The LQOLP When an evaluation relies upon a repeated assessment
78

in operational settings, 'then this is the level of accept- response. Because the LQOLP has only recently been
ance that will be required. An instrument that is so applied routinely in some services it is not possible to
unpopular with respondents that half refuse to do it provide examples of the effects of data collection and
again is uselessfor routine service evaluation purposes. feedback. We can only say that this important area
In 1582applications, 39% of respondents were rated as must be the subject of further consideration and de-
very reliable by the interviewer, 51% were generally tailed researchprojects. ~

reliable and only 10% were generally or very (1%)


unreliable.
Table 1 shows the mean time taken for the interview Reliability and consistency
in a dozen studies. One of the authors interviewed in
the two United States samples and his experience of The LQOLP is made up of a number of different
research interviewing may have reduced the time taken. sections, and each has been tested for aspects of reliabil-
On the other hand, one can say that in the hands of an ity and consistency. The profile was designed for use in
experienced clinician (of whatever discipline), the time operational contexts, and the formal testing of
taken can be reduced below the mean of 33 min.,The psychometric properties has taken place in service
only larger standard deviation than mean occurred in evaluations rather than in specific experiments. With
the sample with many interviewers where the condi- this limitation in mind, we can give a summary of the
tions of the survey were less well controlled than in main findings.The alpha coefficientsfor self-esteem(all
other studies. When the patients are already known to greater than 0.6), affect balance (all greater than 0.6)
the interviewer, as in the case of the resettled long-stay and subjective well-beingdomains (all greater than 0.8)
patients and the follow-up of the intensive case man- are all acceptable. Only one test of inter-rater reliability
agement cases, then the time taken is reduced to about (using the QOL Uniscale) has been conducted, and
20 min. there was a significant (if modest; r = 0.4) correlation
Because the interview is usually conducted with se- between the two raters. .

verely ill patients, some of whom might be acutely Internal consistency reliabilities have been calculated
unwell or deteriorating, we suggest that it is completed following Horst's (1954)formula. The ratings in Table 2
by adequately trained professionals. Another reason show that some items achieve a high internal consist-
for making this suggestion is that, unlike in externally ency (never less than 0.75);these are global well-being,
conducted research, the routine operational use of the finance, health and mental health. The reliability of
profile raises the matter of the feedback of the results to social relations is usually high (0.71-0.83), but a num-
clinical staff, case managers, other team members and ber of other items, while achieving a high of 0.8 or
to the patients themselves. The results can potentially more, can fall to nearer 0.50 in some samples; these
affect the nature of the relationship with the patient, include leisure and work. In the case of leisure, a score
and there may also be an effect upon compliance and of 0.8 is only achieved in one sample (in Lancashire).
The least internally consistent items according to this
method of analysis are safety, religion and living situ-
Table 1 Mean time taken to complete the Lancashire Quality of Life
ation (shown as "home" in the table).
Profile (LQOLP) in different studies One possible explanation is that the individual
items/questions making up these domain scores are
Sample (country) Mean time SD Number discrete and differentiated from one another, so that an
taken of cases
individual may reasonably achieve a high score on
Community mental some and a low one on others. For example, one could
health team (Wales) 42.3 17.4 100 argue that leisure activity outside the home requires
Out-patients (UK) 42.3 11.0 50 quite different material and personal resources than
Social services(UK) 39.0 53.4 713 leisure activities in the home [however, in at least one
Intensive case
36.2 10.4 17 of the samples these two items are congruent (UK
management (UK)
Community support CMHT = 0.8)].
team (UK) 33.5 14.2 174 Another explanation is that the samples in which the
Residential homes (UK) 28.7 14.7 88 QOL was assessed are particularly heterogeneous
Community drug within these domains. In Table 2, for instance, this
team (UK) 24.3 5.1 16
Intensive case would apply to safety in the United States clubhouse
management (USA) 19.5 8.2 86 samples (0.33 and 0.49) and living situation in the
Resettled long-stay clubhouse controls and the Welsh sample (0.53in both
hospital patients (UK) 19.0 7.0 241 cases). In the case of safety, there could easily be
Follow-up of intensive a marked contrast between personal general safety and
cases management (USA) 17.9 7.5 41
Total 33.1 11.3" 1526 the safety of the neighbourhood. While the city in the
United States where the study took place was not
"Standard deviation with highest and lowest outliers removed notoriously dangerous, there were areas in which some
-- -~-'-" ~~

79

Table 2 Internal consistency reliability in the LQOLP subjective well-being life domain scores in different studies

Study
Case Psychosocial Rehab. Community Commnunity
management rehab. control team mental health
(USA) (USA) group (USA) (Wales) team (England)
Domain
Global' 0.83 0.77 0.81 0.75 0.82
Mental healthb 0.82 0.78 0.77 0.81 0.81
Health 0.80 0.83 0.78 0.79 0.87
Finances 0.76 0.91 0.85 0.83 0.89
Living situation 0.76 0.62 0.53 0.53 0.72
Family 0.74 0.62 0.60 0.66 0.82
Leisure 0.65 0.59 0.65 0.62 0.80
Religion 0.65 0.85 0.73 0.45 0.76
Legal and safety 0.61 0.33 0.49 0.70 0.80
Work 0.53 0.80 0.77 0.72 0.72
Number of cases 84 38 38 100 298

'Global subjective well-being rating


bSubjective well-being rating for mental health

of the patients lived that could be so described. The


LOW INCOME GROUP (USA)
type of residence in the United States control town and
CASE MANAGEMENT (USA)
the Welsh town covered a wide range that included
a significant number of ordinary family (owned) homes COMM. SUPPORT TEAM (1)

in residential areas, as well as rented homes and apart- COMM.REHAB. TEAM


ments. COMM. SUPPORT TEAM (2)
COMMUNITY DRUG TEAM

SOCIAL SERVICES DEPARTMENT


Do the results of the LQO LP vary by setting? RESIDENTIAL HOMES

GERMAN ALCOHOUCS
The answer to this question is largely determined by
GERMAN IN.PATIENTS
the sample and the population from which it is taken.
The objective sections of the LQOLP will reflect the o 5 10 15 20 25 30 35
nature of the population from which the researchers 1-% ACCUSED 1

draw the sample or from which the service draws its


clientele. When several studies are compared (a number Fig. 1 Proportion of people accused of a crime in the last year:
a comparison of different study samples (comm.community, rehab.
of examples are given below), it is evident that the rehabilitation)
results have a degree of face validity.
Figure 1 shows the rate at which people have been
accused of a crime in different samples in different
countries. There are two or three aspects of these re- United Kingdom national rate. The non-patient low
sults that are worthy of comment. The sample that one income group.f-romthe United states experienced fewer
would expect to have the highest rate, the clients of crimes and the residential sample, none at all. There
a community drug team in central Manchester, does so. appears to be a differential effectivenessin protection
The next highest rate is in the long-term clients of a case from crime between the two community support teams;
management team referred in part because of their this could be due to inherently different base rates in
previous record of offendingbehaviour. The rates in the the local populations.
three community samples in the United Kingdom are Figure 3 (employment) shows the variation in unem-
at approximately the level one would expect in their ployment levels in different samples. All the drug team
respective populations. Finally, there is a very low rate clients were unemployed, and most of the severely ill
in the independent sector residential home sample. samples have rates above 60%. The case management
Figure 2 (victimof crime)also shows that the three team in the United States achieves a lower rate of
samples from large city services (the German samples unemployment through the use of sheltered work, club-
are from Berlin and the community drug team sample, house schemes and transitional employment. All of the
from Manchester) have the highest rates. The social British samples have much higher unemployment rates
services sample (from Lancashire) is closest to the than the local or national populations.
80

LOW INCOME GROUP (USA) is an assumption that these mental health servicesare
CASE MANAGEMENT (USA) using potent interventions that are capable of produ-
COMM. SUPPORT TEAM (1) cing change (we return to this point again). In fact, for
COMM.REHAB.TEAM most of the services that are offered to psychiatric
COMM. SUPPORT TEAM (2)
patients in the community by social care agencies, the
COMMUNITY DRUG TEAM interventions are of unknown efficacy(because they are
SOCIAL SERVICES DEPARTMENT
usually untested) and rarely conform to the dimensions
RESIDENTIAL HOMES of model programmes. This makes generalisation and
UK NATIONAL FIGURE comparison problematic, especially when, even if
GERMAN ALCOHOLICS
a model intervention is supposed to be followed, there
may be drift from the model (a lack of "programme
GERMAN IN-PATIENTS~
o 5 10 15 20 25
fidelity").
1-%YEsl
In spite of these limitations, it is important to know
whether the assessment of subjective well-being can
Fig. 2 Percentage of people who were a victim of crime in the last reflect change over time (see below) and whether sub-
year: a comparison of different study samples jective well-being ratings distinguish mental health
samples from "normal" samples, so that in the event,
QOL could be used to evaluate servicesunder the most
LOW INCOME GROUP (USA)
rigorous designs possible when studying community-
based services. Figure 4 shows that an in-patient
CASE MANAGEMENT (USA)
sample has a different profile from two normal popula-
COMM. SUPPORT TEAM (1)
tions. Figure 5 is one example selected to illustrate that
"COMM. SUPPORT TEAM (2)
LQOLP results can discriminate between index and
"(RATE IN THIS AREA) control conditions.
COMMUNITY DRUG TEAM
SOCIAL SERVICES DEPARTMENT
RESIDENTIAL HOMES

H COMM. REHAB. TEAM


Construct validity
H(RATE IN THIS AREA)
A number of opportunities have arisen to compare the
UK NATIONAL FIGURE
assessment made on the LQOLP with that made on
other standardised instruments measuring different
constructs. Corrigan et al. (1995)have shown, in a small
sample of 49 patients with severe mental illness, that
depression, social adjustment, social network and ver-
bal intelligence are independently associated with
QOL. The present paper examines this from the point
of view of the relationships with psychopathology and
The LQOLP was designed to provide a psychosocial social functioning.The results show that QOL is not
profile following a structured psychosocial interview.
To understand the differences in psychosocial profiles
between services one needs a representative sample of
serviceusers, and not one dictated by diagnostic classi- WORKlEDUCA TION
fication, except in instances where this may have been LEISURE
used as an eligibility determinant. If the service has RELIGION
determined its eligibility criteria, and if these criteria or FINANCES
similar items are included in the LQOLP, one can LIVING SITUATION
assess whether the profiles of the service users reflect LEGAL & SAFETY
targeting criteria, and therefore, whether and to what
FAMILY RELATIONS
extent the serviceis off target. (If a service only includes
SOCIAL RELATIONS
cases that meet the target criteria it has a high "vertical
target efficiency"- see Challis and Davies 1986). HEALTH
GLOBAL WELL-BEING
,
1 2 3 4 5 6
Subjective well-being results DIAGNOSTIC STATUS
*UK NORMALS 0 GERMAN NORMALS £:JGERMAN IN-PATIENTS

Comparing services according to subjective well-being Fig. 4 A comparison of the subjective well-being scores of German
ratings made by the respondents may reflect, logically, in-patients (staying longer than 6 months) and two normal samples,
the impact of the service upon the users. However, there one German and one English
81

different life domains in terms of their satisfaction


WORK/EDUCATION
ratings.
LEISURE
In a study involving repeat me,?-suresof the Social
RELIGION
Functioning Scale (SFS; Birchwood et al. 1990)and the
FINANCES (*) LQOLP, 100 patients in the community completed
LIVING SITUATION both measures (Barr, personal communication). The
LEGAL & SAFETY (*) results showed that there were substantial and signifi-
FAMILY RELATIONS
cant correlations between comparable items and, in
SOCIAL RELATIONS
other respects, there was no association. Whether the
respondent went out shopping (LQOLP) was asso-
HEALTH
ciated with higher prosocial activity scores and higher
GLOBAL WELL-BEING (*) , independence scores (in both competence and perfor-
1 2 3 4 6 mance, on the SFS). Similarly, going for a ride in a bus
.PSYCHOSOCIAL REHABILITATION mCONTROLS or car (other than to work) was also associated with the
same three subscores, as well as with better functioning
Fig.5 A comparison of clients of a psychosocial rehabilitation in recreation. Having another family member in the
service and a matched comparison group. (*) Indicates that the home was associated with less social withdrawal and
subjective well-beingdifferencesare significant
better functioning in recreation, and with both inde-
pendence subscales.
For self-conceptjself-esteem, there were 14 possible
dominated by these other constructs and that QOL associations between the LQOLP and the SFS, and
results can be distinguished from findings on other none reached significance; this finding is consistent
measures. with the literature. For example, Arns and Linney
In his original work, Lehman (1983) addressed the (1995)have demonstrated that better social functioning
question of the confounding effectsof psychopathology is associated with residential and vocational status, but
on the assessment of QOL. He found that there was not with self-esteem or life satisfaction. Of the 14 rela-
27% shared variance between his QOL and psycho- tionships between the SFS subsections and the affect
pathology measures. German and Welsh results balance scale of the LQOLP, 4 (29%) were significant
(Kaiser et al. 1996) using the BPRS show that the (three of them at the 0.01 level).A higher positive affect
shared variance between BPRS and SWB domain score was associated with better functioning in inter-
scores is low. In six samples (three in-patient and three personal relationships, pro social activity, recreation,
out-patient samples; n = 440), the BPRS total score and independence-performance. In summary, meaning-
was compared to subjective well-being scores in the ful associations emerged where the questionnaires
nine domains and to global well-being (60 possible covered similar items, but the total amount of overlap
associations).Three-quarters of the associations had no was very low. The concept of QOL embodied in the
substantial shared variance. In the three in-patient LQOLP encompasses affect and self-concept, and the
samples (total n = 243),the BPRS total score was asso- former is certainly important in social functioning,
ciated with 10% or more (maximum 19%) of the vari- where a reciprocal relationship probably exists. It is
ance of sJ.!bjectivewell-being ratings five times (twice probably reasonable to conclude, from the results of
with family; once each with leisure, safety and social the single study cited here, that social functioning and
relationships), and the average amount of shared vari- QOL can be related (if similar items are included in the
ance was 16%. In the three out-patient samples (total questionnaires), but as presently constituted in the SFS
n = 197) there were ten associations greater than 10% and LQOLP, they are conceptually distinct.
of shared variance (maximum 22%); three times with
global well-being; twice with leisure; once with finan-
ces, social relationships, work, living situation and Change over time
family), and the average amount of shared variance
was 15%. The discussion of changes in QOL over time needs to
On the basis of results from our data-set of over 1500 be addressed from both a clinical and a statistical
cases, and from the German results, we arrive at the perspective. This is because the LQOLP is an opera-
same conclusion as Lehman, that "mental health does tional tool, and the significance of change can be small
not significantly alter the results derived from quality of statistically speaking, but have important clinical
life surveys" (p 149). We also agree with Lehman's consequences. In clinical terms, one can produce mean-
major caveat that one should control for the effects of ingful results that show QOL change over time in
some mental health problems, especially depression. In individual cases (seeBridges et al. 1993),and that reflect
patients suffering clinical depression, subjective well- a real change in circumstances. One can also produce
being scores are lowered in every domain, but, never- useful evidence that an individual (or group) has been
theless, patients remain able to discriminate between successfully maintained at an optimal or maximum
82

RELIGiON Clinical usefulness

HEALTH We have reported that LQOLP has been used in ser-


vice evaluations to demonstrate change, and that, in
SOCIAL RELATIONS
addition, it has a number of clinically important uses.
LEGAL & SAFETY Graphic feedback of the profile scores has been attem-
pted, and this proved to be popular. Another clinical
LEISURE use is the scrutiny of routine LQOLP reassessments as
part of the process of professional supervision. This is
WORK & EDUCATION said to facilitate a focus on those areas of greatest
concern to the client.
FINANCES. Of perhaps greater significancein the present contract
1 2 3 4 5 6 7 culture is the use of the profile as an outcome measure
1+1991 1919891 in service evaluations. Service commissioners (pur-
chasers) have been impressed by the results produced
Fig.6 A comparison of one individual's quality of life changes
between 1989and 1991 by the LQOLP, which tend to be readily understand-
able and meaningful in individual or aggregated for-
mat. In individual studies where the outcome has been
assessed using the LQOLP, there has been a renewal of
findings or additional funding for the programme con-
QOL over time and that relatively little adverse change cerned. This has happened in respect of community
has taken place (Fig. 6). support teams (renewed funding and extension to the
For scientificwork, one needs to be able tpshow that whole local authority), family support workers, day
the instrument is sensitive to change. Gater (personal centre and residential services (renewed funding), and
communication) used data from a study of traditional clubhouse services (investment in new premises).In all
hospital services compared to an innovative commun- instances, the services concerned improved or main-
ity team in order to estimate the sample sizes required tained the QOL of the recipients, and then LQOLP
to demonstrate change in several life domains (using played a major part in demonstrating this success.
Lehman's original scale). Only three of the nine life These undoubted successesneed to be tempered by the
domains (employment; living situation and family rela- reservations expressed above about the consequences
tions) required a sample size ofless than 100 to achieve of using the profile routinely in community services,
a power of 80%. Global well-being required a sample when, it has to be said, we have a less than adequate
size of 354. Warner (personal communication) in con- understanding of the process and its consequences.
trast, on the basis of data from a clubhouse comparison
study (Huxley et al. 1995) found that only 46 case-
ratings of global well-being were needed to produce Discussion
a power of 75%, and that 66 cases would produce
a power calculation of 87%. When one uses results Although there can be little doubt that the measure-
from a study with essentially ineffective interventions, ment of QOL is an important consideration in the
the outcome can be a sample size requirement of im- assessment of the outcome of community-based mental
mense proportions. However, when one is comparing health programmes, there are several outstanding
potent interventions that can produce change over time issues that should be addressed by further research. The
then the means change scores willproduce a reasonable first of these is to undertake more investigations into
requirement for sample size. the psychometric properties of the LQOLP and similar
One can argue that QOL is not like symptoms, some instruments. Since these investigations need to be ex-
of which go away on their own or are alleviated by perimental or quasi-experimental, they are only likely
powerful medication; QOL only improves with some to be conducted with dedicated research funds. Further
specific event or intervention, and for some of the life work could usefully be conducted outside service set-
domains a fairly massive social intervention may be tings on inter-rater and test-retest reliabilities.
needed to produce an improvement. Finally, in the The second issue concerns the assessment of self-
analysis of change, power is lowered when mean scores, esteem, which a number of investigators regard as a
especiallywith heavy-tailed distributions, are used (this problem. The wording of the negative self-esteemques-
tends to be the case with most subjective well-being tigns is so negatively loaded that investigators fear that
scales).There are now a number of methods of solving they might have an adverse effecton people's affect.Ac-
this problem (Wilcox 1995; including M-estimators), cording to these investigators another way of assessing
and these are being applied to our data-sets where self-conceptwould be preferable, although at the time of
change has been assessed, and will be reported else- the construction of the LQOLP, no other short, opera-
where. tionally viable,well-validatedinstrument could be found.
83

A third issue concerns the placing of these negatively Baker F, Intagliata J (1982) Quality of life in the evaluation of
loaded questions immediately prior to the final global community support systems. Eval Program PIann 5: 69-79
Birchwood M, Smith J, Cochrane R et al. (1990)The Social Fun-
well-beingscales. An experiment replacing the negative ctioning Scale:the development and validation of a scale of social
self-conceptquestions with the positive affect questions adjustment for use in family intervention programmes with
could assess whether there is any impact on the final schizophrenic patients. Br J Psychiatry 157: 853-859
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iver et al. 1996)that people who are depressed or who and quality of life: a case study of a man with an enduring
have a diagnosis of chronic depressive disorder can be psychotic illness. Int J Soc Psychiatry 39: 142-151
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Further aspects of work on the. measurement of Hoffman K, Priebe S, Isermann M, Kaiser W (1996)Quality of life,
QOL that require investigation are the effectsof differ- needs and assessment of treatment in long-term hospitalized
ent statistical approaches to the analysis of change over patients - part 11of the Berlin De-Institutionalisation Study (in
German). Psychiatr Praxis (in press)
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LQOLP, we can see the possibility of not only using impact of clubhouse membership on quality of lifeand treatment
the instrument as an outcome measure, but also to help utilization. J Psychosoc Rehab (submitted)
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Kaiser W, Priebe S, Hoffman K, Isermann (1996)Subjectivequality
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