re: week 4 article

O R I G I N A L P A P E R

Evaluating a Measure of Social Health Derived from Two Mental Health Recovery Measures: The California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program Consumer Survey (MHSIP)

Jordan A. Carlson • Andrew J. Sarkin •

Ashley E. Levack • Marisa Sklar • Steven R. Tally •

Todd P. Gilmer • Erik J. Groessl

Received: 20 August 2009 / Accepted: 16 September 2010 / Published online: 28 September 2010

� The Author(s) 2010. This article is published with open access at Springerlink.com

Abstract Social health is important to measure when

assessing outcomes in community mental health. Our

objective was to validate social health scales using items

from two broader commonly used measures that assess

mental health outcomes. Participants were 609 adults

receiving psychological treatment services. Items were

identified from the California Quality of Life (CA-QOL)

and Mental Health Statistics Improvement Program

(MHSIP) outcome measures by their conceptual corre-

spondence with social health and compared to the Social

Functioning Questionnaire (SFQ) using correlational

analyses. Pearson correlations for the identified CA-QOL

and MSHIP items with the SFQ ranged from .42 to .62, and

the identified scale scores produced Pearson correlation

coefficients of .56, .70, and, .70 with the SFQ. Concurrent

validity with social health was supported for the identified

scales. The current inclusion of these assessment tools

allows community mental health programs to include

social health in their assessments.

Keywords Psychiatry � Assessment � Treatment � Mental illness � Functioning

Introduction

Social health is known for being a key tenet of recovery in

those with mental illness. Included in a broadening of the

concept of health in the middle of the 20th century (World

Health Organization 1949), the concept of social health

generally focuses on social activities, social well-being,

social network quality, interpersonal communication,

social support, and social role participation and satisfaction

(Castel et al. 2008). Russell (1973) has defined social

health as ‘‘that dimension of an individual’s well-being that

concerns how s/he gets along with other people, how other

people react to her/him, and how s/he interacts with social

institutions and social mores.’’ In 1957, Greenblatt pro-

posed five principal areas comprising recovery from mental

illness. Four of the five principal areas, vocational capacity,

educational capacity, family, and social aspects of the

community, address the constructs of social health. More

recently, Liberman (2008) suggests recovery from mental

illness be defined as a 2-year duration of satisfying peer

relationships, cordial family relations, and engagement in

productive activity (e.g. work or school), amongst other

things. Additionally, Luecht and Lasser (2006) believe

recovery from mental illness consists not only of symptom

remission, but quality of life and social functioning.

Social functioning is an important aspect of one’s

overall social health, referring to an individual’s ability to

function in community, social, or occupational domains

(Cornblatt et al. 2007). Specific components of social

functioning measured in current research include inde-

pendent living, work, recreation, romantic relationships,

family and social relationships, and financial concerns

(Keck et al. 1998; Rosa et al. 2007; Tohen et al. 2000;

Zarate et al. 2000). Measures of social functioning have

been widely used in social health assessment when

attempting to evaluate mental health recovery and identify

areas that can be improved with targeted mental health

services (Barnes et al. 2008; Bauwens et al. 1998; Birch-

wood et al. 1990; Dijkers et al. 2000; Eisen et al. 1994;

J. A. Carlson � A. J. Sarkin (&) � A. E. Levack � M. Sklar � S. R. Tally � T. P. Gilmer � E. J. Groessl Health Services Research Center and Department of Family

and Preventive Medicine, University of California, 9500 Gilman

Drive, La Jolla, San Diego, CA 92093, USA

e-mail: [email protected]

123

Community Ment Health J (2011) 47:454–462

DOI 10.1007/s10597-010-9347-8

Newton-Howes et al. 2008; Siegel et al. 2006; Zarate et al.

2000). Although good social functioning is not synony-

mous with a reduction in mental health symptoms, severity

of depression, or episodes of psychosis (Zanello et al.

2006), deficits in social functioning can inhibit long-term

recovery and even predict relapse (Barnes et al. 2008;

Bauwens et al. 1998; Cornblatt et al. 2007; Keck et al.

1998; Patterson et al. 1997; Zarate et al. 2000). Strakowski

and colleagues studied functional outcomes in psychiatric

patients and found that nearly all patients who were in

remission 8 months after hospitalization still had persistent

impairment in at least one area of social functioning. Less

than half of patients achieved good functional outcomes in

at least three of the four social functioning areas that were

measured (Strakowski et al. 2000).

In addition to identifying areas for further improvement

in mental illness recovery, the measurement of social

health and functioning has other implications. Impaired

social functioning has been shown to predict susceptibility

to schizophrenia, allowing care providers to target sus-

ceptible adolescents for early intervention (Cornblatt et al.

2007). Social functioning is positively related to quality of

life in older adults with psychiatric illnesses (Patterson

et al. 1997; Ritsner et al. 2000) and social dysfunction has

also been associated with depression severity, lack of full

remission from depression, and increased anxiety (Gift

et al. 1980; Rytsala et al. 2006; Upadhyaya et al. 2000).

Additionally, social health and functioning assessment can

provide insight into treating patients with personality dis-

orders (Quinton et al. 1995; Seivewright et al. 2004).

Studies investigating differences in social functioning

between psychiatric diagnostic categories have generally

found that patients with schizophrenia display the most

social dysfunction, followed by patients with bipolar,

depressive, and affective disorders (Cannon et al. 1997).

Patients with anxiety disorders typically display the least

dysfunction of the three groups (Sanderson and Andrews

2002).

Several brief assessment tools have been developed to

assess social health, including the Social Functioning

Questionnaire (SFQ; Tyrer et al. 2005), Functioning

Assessment Short Test (FAST; Rosa et al. 2007) and

Multidimensional Scale of Independent Functioning

(MSIF; Berns et al. 2007). Of these instruments, the 8-item

SFQ has been widely used and researched. However, in

many clinical and research settings, measures that are

solely designed to assess social health have not been used,

and adding even the brief 8-item SFQ to existing assess-

ments will increase overall assessment burden on both

clients and staff. In settings where provider time with

patients is limited and paperwork is already extensive, the

use of brief instruments to assess individual changes in

social health could help physicians and mental health

professionals individualize treatment strategies for their

clients’ recovery. Many broader assessment tools that are

already being used include items that can also be used to

measure social health. Therefore, in an effort to limit

assessment burden on clients and staff in both research and

clinical settings, and to allow clinicians already using

broader assessment tools to evaluate their clients’ social

health and functioning, it is useful to evaluate whether

items within currently used assessment tools can be used to

measure social health and functioning. This would also

allow researchers and/or clinicians to conduct retrospective

studies evaluating changes in social health in their patients

over time.

Our objective was to identify and evaluate a set of social

health scales comprised of items from two widely used

mental health recovery assessment tools: the California

Quality of Life (CA-QOL), used throughout California, and

the Mental Health Statistics Improvement Program Con-

sumer Survey (MHSIP) mental health outcomes assess-

ment tool, used across the United States. Since validated,

published measures of social health do not currently exist,

we identified a social functioning measure that overlaps

with the construct of social health to use as a comparison

measure in evaluating the new social health scales. The

identified items from the CA-QOL and MHSIP were

investigated to determine how they compared with the

validated Social Functioning Questionnaire (SFQ). Spe-

cifically, we sought to compare psychometric properties of

the identified CA-QOL Social Health Scale and MHSIP

Social Health Scale with those of the SFQ, to determine

whether the identified scales appear to measure the same

construct as the SFQ, and to determine whether the iden-

tified scales would replicate the SFQ’s pattern of results

when describing differences in social health between dif-

ferent demographic and diagnosis groups. In addition, we

sought to determine whether our proposed scales could

accurately describe levels of social health among people

receiving services within a large county adult mental health

system based on demographic and diagnosis information

(e.g. individuals living in supervised living facilities would

be expected to have poorer social health than individuals

living independently).

Methods

Participants

Data were obtained from a large scale assessment of client

reported outcomes in San Diego County Adult and Older

Adult Mental Health Services. Twice per year (May and

November), adults aged 18 and older receiving psycho-

logical and behavioral treatment services complete an

Community Ment Health J (2011) 47:454–462 455

123

anonymous self-report questionnaire in the presence of a

clinician at their provider site during a 2 week data col-

lection period. For this study, we used data collected in

November of 2007. The questionnaire was distributed in 2

parts: part 1 included demographic information, the

MHSIP, and the CA-QOL; part 2 included the SFQ and

questions regarding a recent local wildfire disaster. Eight

hundred ninety-two surveys were returned. Response rates

varied by clinic; however, the overall study response rate

for completing any portion of the survey was 77%. How-

ever, of the 892 respondents, 112 only answered demo-

graphic questions on page 1 and an additional 171 chose

not to or were not asked to complete any of part 2 of the

survey. Many clients are burdened by these questionnaires

so it is not unusual for them to skip part 2, which is referred

to as the ‘‘supplemental’’ section and is not required by

some clinics. Because this study examined survey items

from both sections of the survey, only participants who

responded to parts 1 and 2 were included in the analyses.

Thus, the study sample size was 609 participants. All

participants received the measures in the following order:

MHSIP, CA-QOL, and SFQ. Due to incomplete response

patterns, final sample size ranged from 566 to 609 for the

CA-QOL, MHSIP and SFQ comparisons.

Demographic characteristics for the sample were as

follows: 40.7% lived independently, 49.9% were Cauca-

sian, 43.6% were female, and mean age was 42.5

(SD = 14.6). We obtained diagnosis information from the

San Diego County Adult and Older Adult Medical Infor-

mation System, a patient record holding database. Partici-

pants fell into the following categories: 36.2% were

diagnosed with schizophrenia or schizoaffective disorder,

23.0% were diagnosed with major depressive disorder,

15.0% were diagnosed with bipolar disorder, 8.9% were

diagnosed with other depression disorder, 5.8% were

diagnosed with anxiety disorder, and 5.3% were diagnosed

with an unspecified psychotic disorder.

Measures

California Quality of Life (CA-QOL)

The CA-QOL is a 40-item survey that was developed to

assess patient reported outcomes in the California Adult

Performance Outcome System. The CA-QOL was modeled

after the Quality of Life Interview Short Form (Lehman

1988) which is based upon a conceptual model that

incorporates objective life conditions and subjective satis-

faction with life conditions (Andrews and Withey 1976;

Campbell et al. 1976). The main constructs of the CA-QOL

objective scales are family contacts, social contacts,

finances, and arrests. Items on the objective scales ask

about frequency of family and social contacts with the

following response options: at least once a day, at least

once a week, at least once a month, less than once a month,

not at all, or not applicable. Items asking about adequacy of

finances are rated as yes/no. One item asks about frequency

of arrest, with 5 response options ranging from 0 to 4 or

more arrests in the past month. The main constructs of the

CA-QOL subjective scales are satisfaction with life, living

situation, family relations, social relations, daily activities,

leisure activities, safety, and health. Items on the subjective

scales ask about level of feeling/satisfaction with various

outcomes on a 7-point scale. Response options for these

items are: delighted, pleased, mostly satisfied, mixed,

mostly dissatisfied, unhappy, or terrible. Work and reli-

gious activities are not included in the questionnaire. We

scored all items so that higher numbers corresponded with

more dissatisfaction/problems. Reliability of the CA-QOL

in the development pilot study was high (Cronbach’s

Table 1 Descriptive statistics and correlation coefficients between subjective CA-QOL items and SFQ total score

Item content N Mean (SD)

[1–7]

% reporting mostly

satisfied, pleased,

or delighted (%)

Pearson r

with SFQ

Feel about way spend spare time 586 3.41 (1.49) 53.4 .595

Feel about chance to enjoy pleasant things 593 3.22 (1.49) 60.5 .569

Feel about amount of fun 595 3.51 (1.58) 51.4 .615

Feel about amount of relaxation 593 3.40 (1.58) 55.6 .544

Feel about way you and family act toward each other 565 3.40 (1.77) 56.1 .475

Feel about way things are in general between you and family 574 3.34 (1.74) 56.9 .477

Feel about things do with other people 585 3.20 (1.40) 57.9 .558

Feel about amount of time spend with other people 586 3.29 (1.41) 54.7 .587

Feel about people see socially 566 3.19 (1.41) 58.9 .527

Feel about amount of friendship in life 579 3.41 (1.62) 52.2 .549

Note: All correlation coefficients were significant at the P \ .01 level

456 Community Ment Health J (2011) 47:454–462

123

alpha = .93; California Department of Mental Health

1999).

Mental Health Statistics Improvement Program Consumer

Survey (MHSIP)

The version of the MHSIP Consumer Survey used in this

study consists of 36-items designed to assess the care of

persons with mental illness and is widely used in public

mental health systems (Center for Mental Health Services

1996). Seven domains are assessed: general satisfaction,

perception of access to services, perception of quality and

appropriateness of care, perception of participation in

treatment planning, perception of outcomes of services,

perception of functioning, and perception of social con-

nectedness. Each item is a declarative statement. Response

options ranged on a 5-point scale from strongly agree to

strongly disagree, where higher numbers corresponded

with greater disagreement, and thus greater dysfunction.

Of forty-eight states using consumer surveys in 2001, 45

of these states targeted adults with serious mental illnesses,

while 26 surveyed adults with other mental illnesses

(NASMHPD Research Inc. 2002). Thirty-seven of these

states distribute the surveys state-wide and 11 limit the

distribution to select areas or sampling frames. As of 2001,

thirty-eight states had implemented a version of the MHSIP

consumer survey to assess consumer perception of care,

with the number of items on the MHSIP versions ranging

from 19 to 40 (NASMHPD Research Inc. 2002). Reliability

of the MHSIP was high in a pilot study (Cronbach’s

alpha = .95; Minsky and Lloyd 1996).

Social Functioning Questionnaire (SFQ)

The SFQ is an 8-item instrument measuring an individual’s

perception of functioning and was adapted from the longer

Social Functioning Schedule (Remington and Tyrer 1979;

Tyrer et al. 2005). The items cover aspects of work and

home tasks, financial concerns, relationships with family,

sexual activities, social contacts, and spare time activities.

The exact 8 items are: completed my tasks at work and

home satisfactorily; find my tasks at work and at home very

stressful; have no money problems; have difficulties in

getting and keeping close relationships; have problems in

my sex life; get on well with my family and other relatives;

feel lonely and isolated from other people; and enjoy my

spare time. Response options are: 0 (most of the time), 1

(quite often), 2 (sometimes), and 3 (not at all). Items were

all coded so that 0 corresponded to no problems with social

functioning and 3 corresponded to severe problems with

social functioning. The total SFQ score is a sum of the

individual item scores, and can range from 0 to 24. Reli-

ability and construct validity has been shown to be good

(Remington and Tyrer 1979).

Procedures

We identified items from the CA-QOL and MHSIP based

on their conceptual correspondence with the construct of

social health. Ten items from the CA-QOL subjective

scales assessing satisfaction with family relations, social

relations, daily activities, and leisure activities; 4 items

from the CA-QOL objective scales assessing frequency of

family contacts, frequency of social contacts, and arrests;

and 8 items from the MHSIP assessing functioning and

social connectedness were retained for further investiga-

tion. The items from the CA-QOL and MHSIP are pre-

sented in Table 1 and Table 2, respectively. Three scales

were created from retained items that produced moderate

or large correlations with the SFQ (C.40; REF). The

identified CA-QOL Social Health Scale and MHSIP Social

Health Scale were then examined for their relationship with

the SFQ total score. This study was approved by the Uni-

versity of California, San Diego Institutional Review Board

and the San Diego County Mental Health Services

Research Committee. The authors have no known conflicts

Table 2 Descriptive statistics and correlation coefficients between MHSIP items and SFQ total score

Item content N Mean (SD) [1–5] % reporting agree

or strongly agree (%)

Pearson r

with SFQ

I do things that are more meaningful to me 581 2.11 (0.98) 70.4 .460

I am better able to take care of my needs 578 2.05 (0.93) 74.3 .457

I am better able to handle things when they go wrong 584 2.16 (0.96) 67.9 .417

I am better able to do things that I want to do 579 2.16 (0.98) 69.0 .472

I am happy with the friendships I have 583 2.04 (0.97) 72.5 .435

I have people with whom I can do enjoyable things 584 2.10 (1.03) 71.2 .439

I feel I belong in my community 582 2.28 (1.06) 61.7 .497

In a crisis, I would have the support I need from family or friends 586 2.04 (1.06) 73.6 .428

Note: All correlation coefficients were significant at the P \ .01 level

Community Ment Health J (2011) 47:454–462 457

123

of interest and certify their responsibility for this

manuscript.

Statistical Analysis

Data were analyzed using Statistical Package for the Social

Sciences (SPSS), Version 16.0 (SPSS Inc. 2008). We

examined Pearson correlations for the identified CA-QOL

and MHSIP items with the SFQ total score. We then

evaluated psychometric properties of the identified scales,

including calculating scale reliability coefficients. Finally,

we examined Pearson correlations for the identified CA-

QOL Social Health Scale and MHSIP Social Health Scale

with the SFQ total score. We dichotomized items (strongly

agree and agree vs. neutral, strongly disagree, and disagree;

delighted, pleased, and mostly satisfied vs. mixed, terrible,

unhappy, and mostly dissatisfied) to examine percent of

clients reporting agreement with MHSIP items and satis-

faction with CA-QOL items. We then examined means for

each of the social health scales as a function of demo-

graphic and other descriptive statistics, including gender,

ethnicity, education, living situation, and psychiatric

diagnosis. We used MANOVAs and follow up ANOVAs to

test whether means differed significantly, and Bonferroni

Post-Hoc tests to determine which groups differed.

Results

Pearson correlations resulting from the identified CA-QOL

objective scale single item comparisons with SFQ total

scores were weaker, ranging from .07 to .22. Due to these

weak correlations with the SFQ, we did not evaluate these

items further in our analysis.

Pearson correlations for the identified CA-QOL subjective

items with SFQ ranged from .48 to .62, and all were signifi-

cant at the 0.01 level (see Table 1). Seven of the 10 CA-QOL

items produced correlation coefficients greater than .54 when

compared to the SFQ. The CA-QOL item assessing satis-

faction with family relations demonstrated the weakest

correlation with SFQ, while CA-QOL items assessing satis-

faction with fun, spare time, and time spent with other people

demonstrated the strongest correlations with SFQ.

Pearson correlations identified MSHIP items with SFQ

ranged from .42 to .50, and all were significant at the 0.01

level (see Table 2). Four of the 8 MHSIP item by SFQ

matches produced correlation coefficients greater than .45.

MHSIP items assessing ability to handle situations when

they go wrong and having needed support in a crisis

demonstrated the weakest correlations with SFQ. MHSIP

items assessing feeling of belonging in the community and

ability to do desired activities demonstrated the strongest

correlation coefficients with SFQ.

All of the identified CA-QOL subjective items and all

identified MHSIP items met criteria for inclusion in the

scales. Scale 1 (CA-QOL Social Health Scale) was a mean

of the 10 CA-QOL items and scores ranged from 1 to 7;

scale 2 (MHSIP Social Health Scale) was a mean of the 8

MHSIP items and ranged from 1 to 5; and scale 3 (Com-

bined Social Health Scale) was a mean of all 18 items that

were recoded so that items from the CA-QOL and MHSIP

were weighted equally and had a possible range of 0–12

(CA-QOL items had possible values of 0, 2, 4, 6, 8, 10, and

12, and the MHSIP items had possible values of 0, 3, 6, 9,

and 12).

As shown in Table 3, comparisons of the identified CA-

QOL Social Health Scale and MSHIP Social Health Scale

with SFQ produced Pearson correlation coefficients of .70

and .56, respectively. The Pearson correlation coefficient

for the Combined Social Health Scale with SFQ was .70.

Cronbach’s alpha for the scales ranged from .93 to .94.

Means for each of the scales across gender, ethnicity,

education, living situation, and diagnosis groups are pre-

sented in Table 4. Participants who reported being Amer-

ican Indian, homeless, and having major depressive

disorder also reported the most dysfunction on the identi-

fied scales and on the SFQ.

For the MANOVAs, Box’s M test of homogeneity of

covariance was significant (P \ .001) for 4 of the 5 models (i.e. gender, ethnicity, education, living situation, and

diagnosis). However, Levene’s homogeneity of variance

test was not statistically significant for any of the four DVs

at the P = .05 level, indicating that the assumptions of

homogeneity of variance were not violated. Using Wilk’s

criterion (K) as the omnibus test statistic, the combined dependent variables resulted in significant main effects for

living situation, F(28, 1956) = 1.98, P = .002, partial

g2 = .025, and diagnosis group, F(24, 1930) = 3.16, P \ .001, partial g2 = .033. There were no overall differ- ences in social health between gender, ethnicity, and edu-

cation groups.

Follow up ANOVAs revealed an overall effect of edu-

cation on mean scores for the SFQ, F(8, 556) = 2.24, P =

.023, and CA-QOL Social Health Scale, F(8, 556) = 1.98;

P = .048, and an overall effect of living situation on mean

scores for the SFQ, F(7, 545) = 4.01; P \ .001, CA-QOL

Table 3 Correlation coefficients between SFQ total score and iden- tified scales from the CA-QOL and MHSIP

Identified scale Cronbach’s alpha Pearson r with SFQ

All 18 item scale .942 .698

CA-QOL 10 item scale .934 .698

MSHIP 8 item scale .927 .563

Note: N = 609; all correlation coefficients were significant at the P \ .01 level

458 Community Ment Health J (2011) 47:454–462

123

Social Health Scale, F(7, 545) = 2.53; P = .014, MHSIP

Social Health Scale, F(7, 545) = 2.99; P = .004, and

Combined Social Health Scale, F(7, 545) = 3.21;

P = .002. There was also an overall effect of diagnosis

on mean scores for the SFQ, F(6, 556) = 8.35; P \ .001,

CA-QOL Social Health Scale, F(6, 556) = 4.82; P \ .001, MHSIP Social Health Scale, F(6, 556) = 4.41; P \ .001, and Combined Social Health Scale, F(6, 556) = 5.74;

P \ .001. Results from the Post-Hoc tests can be found in Table 4.

Table 4 Descriptive characteristics and Social Health Scale means across gender, ethnicity, education, living situation, and diagnosis groups

Item N Social health scale mean (SD)

SFQ total

[0–24]

CA-QOL 10 item

scale [1–7]

MHSIP 8 item

scale [1–5]

All 18 item

scale [0–12]

Gender (N = 588)

Male 302 9.75 (4.51) 3.37 (1.24) 2.13 (0.76) 4.18 (2.16)

Female 286 9.67 (4.58) 3.32 (1.20) 2.10 (0.81) 4.10 (2.18)

Ethnicity (N = 488)

Caucasian 350 10.01 (4.62) 3.40 (1.23) 2.14 (0.76) 4.23 (2.20)

Hispanic 23 8.74 (4.23) 3.14 (1.43) 2.05 (0.74) 3.92 (2.39)

Black 69 9.82 (4.48) 3.26 (1.13) 2.18 (0.90) 4.14 (2.17)

Asian 27 7.60 (4.90) 3.02 (1.24) 1.87 (0.76) 3.61 (2.14)

American Indian 13 11.23 (4.94) 3.47 (1.53) 2.05 (0.86) 4.10 (2.63)

Pacific Islander 6 8.50 (3.83) 4.02 (0.46) 2.25 (0.76) 4.99 (1.43)

Education (N = 585)

Not interested in education 244 9.36 (4.51) 3.36 (1.22) 2.08 (0.73) 4.17 (2.13)

Considering education 163 10.53 (4.68) 3.48 (1.19) 2.24 (0.80) 4.41 (2.22)

Actively exploring education 61 8.52 (4.33) 3.02 (1.14) 1.90 (0.70) 3.47 (1.99)

Enrolled in high school or GED 19 11.16 (3.98) 3.48 (1.21) 1.94 (0.69) 4.01 (2.01)

Enrolled in vocational school 9 9.44 (5.00) 3.30 (1.45) 2.21 (1.20) 4.14 (3.15)

Enrolled in community college 25 8.36 (3.49) 2.72 (1.28) 1.99 (0.75) 3.27 (2.14)

Enrolled in 4-year college 8 9.38 (5.07) 3.63 (1.14) 2.34 (0.41) 4.71 (1.55)

Enrolled in non-degree seeking education 39 10.26 (4.85) 3.54 (1.36) 2.14 (0.79) 4.34 (2.24)

Enrolled in other education program 16 8.31 (3.84) 2.84 (1.18) 1.95 (0.84) 3.31 (2.09)

Living situation (N = 572)

Homeless and not seeking change (a) 4 11.75 (3.30) 2.90 (1.44) 1.94 (1.09) 3.36 (2.76)

Homeless and seeking change (b) 20 13.25 (4.69) e,f,h

4.20 (1.29) e,f,h

2.64 (1.03) e,f

5.76 (2.40) e,f,h

Shelter, mission, or temporary living (c) 52 10.48 (4.39) 3.70 (1.20) 2.30 (0.89) 4.73 (2.30)

Treatment institution (d) 17 10.76 (4.40) 3.11 (1.34) 1.66 (0.43) 3.24 (1.81)

Group home or supervised living (e) 85 8.18 (3.66) b

3.14 (1.13) b

2.00 (0.63) b

3.76 (1.92) b

Assisted living (f) 78 9.03 (4.27) b

3.20 (1.13) b

2.06 (0.76) b

3.88 (2.08) b

Independent living with meals provided (g) 56 10.05 (4.53) 3.41 (1.32) 2.16 (0.82) 4.26 (2.21)

Independent living with no meals provided (h) 260 9.65 (4.83) b

3.32 (1.25) b

2.09 (0.75) 4.08 (2.20) b

Diagnosis (N = 584)

Schizophrenia (a) 134 7.82 (4.43) c,d,e,f

3.03 (1.24) c

1.96 (0.68) c

3.62 (2.05) c

Schizoaffective (b) 75 8.97 (4.15) c

3.15 (1.06) c

1.98 (0.73) c

3.70 (1.98) c

Major depressive disorder (c) 131 11.18 (4.22) a,b

3.76 (1.21) a,b,g

2.39 (0.87) a,b

4.98 (2.29) a,b,g

Bipolar disorder (d) 103 10.16 (5.03) a

3.40 (1.34) 2.12 (0.75) 4.20 (2.24)

Other depression disorder (e) 68 10.16 (4.14) a

3.48 (1.14) 2.12 (0.82) 4.25 (2.08)

Anxiety disorder (f) 34 11.38 (4.56) a

3.36 (1.03) 2.02 (0.70) 4.02 (1.92)

Other psychotic disorder (g) 39 8.87 (4.15) 3.02 (1.21) c

2.05 (0.67) 3.73 (1.93) c

Overall (N = 609) 9.66 (4.68) 3.35 (1.23) 2.12 (0.78) 4.16 (2.18)

Note: a, b, c, d, e, f, g, and h indicate the between group comparisons that significantly differ as indicated by Post-Hoc tests; groupwise P \ .05 with Bonferroni correction

Community Ment Health J (2011) 47:454–462 459

123

The mean SFQ score for this study population, where

higher scores indicate more dysfunction, was 9.66

(SD = 4.68). As expected, mean SFQ score was signifi-

cantly higher than previously reported norms in community

samples, Mean = 4.60; SD = 3.6; T(695, 1) = 28.535;

P \ .001. Mean SFQ score for this study was similar to previously reported norms in hospital patients at the point of

discharge and with recurrent psychotic disorders, Mean =

9.80; SD = 5.0; T(695, 1) = -0.784; P = .433, and was

significantly lower than previously reported norms in psy-

chiatric emergency patients, Mean = 11.40; SD = 4.4;

T(695, 1) = -9.805; P \ .001 (Tyrer et al. 2005).

Discussion

Our study describes levels of social health and functioning

in a large adult public mental health program and proposes

a general framework for the creation of social health scales

using items from questionnaires currently administered in

public mental health systems (NASMHPD Research Inc.

2002). Since these individual instruments have been widely

used for several years, the identification of a social health

scale within these instruments allows researchers to con-

duct retrospective studies evaluating changes in social

health in their patient population over time. Furthermore,

the availability of a scale within instruments that are

already used provides the added ability to individualize

client treatment planning according to reported social

health outcomes without increasing the time devoted to

survey administration or increasing response burden.

Measures of social health are also useful at the patient level

by allowing the clinician to observe pre- and post-treatment

changes when assessing recovery. Thus, this identification

of a social health scale within these pre-existing measures

allows programs to incorporate social health assessment

into current evaluation modalities to track program level

changes in outcomes and enhance treatment planning and

delivery nationwide.

The social health scales identified in this study demon-

strated good psychometric properties and moderate to

strong relationships with the validated SFQ. Specifically,

the scales demonstrated good internal reliability and face

validity. Concurrent validity for the identified CA-QOL

Social Health Scale and MHSIP Social Health Scale was

supported by acceptable correlations with the SFQ in a

large sample of mental health clients. Based on the amount

of overlap in variance accounted for by the SFQ, CA-QOL

Social Health Scale, and MHSIP Social Health Scale, it is

likely that these scales are assessing similar (overlapping)

constructs.

Currently, no normative data exists for the identified

CA-QOL Social Health Scale and MHSIP Social Health

Scale. The few reports that provide normative scores on the

MHSIP used a shorter version than the version used in this

study. Although this study identified a social health scale

from the 36-item version of the MHSIP, it is likely that a

similar scale could be identified from a shorter version. The

mean SFQ score in this population was nearly the same as

that of the SFQ’s norming population of hospital patients at

the point of discharge with recurrent psychotic disorders.

This indicates that the level of social health in this general

psychiatric population is quite low.

Many of the between group differences in social health

in our unique sample are not unexpected. The identified

items demonstrated similar patterns of results as previous

studies with respect to social health and quality of life

when describing different demographic groups. Specifi-

cally, our sample demonstrated higher social health among

those who reside in homes with supervised or assisted

living, and worse social health among those who are

homeless (Pinikahana et al. 2002), thus adding validity to

the scoring of the identified social health scales.

It is important to note the differences in our study’s

results from those found in other studies investigating dif-

ferences in social health between psychiatric disorders. In

general psychiatric populations, patients with schizophrenia

have reported the poorest social health, while those with

depressive, affective, and anxiety disorders have reported

the best social health (Cannon et al. 1997; Sanderson and

Andrews 2002). On average, our study showed that those

with major depressive disorders reported the poorest social

health, while those with schizophrenia reported the best

social health. The most likely explanation for this discrep-

ancy is the different sampling frame of this study. For

individuals with mental illness, previous studies have

shown social health varies as a function of illness severity

(Kennedy et al. 2007, Koivumma-Honkanen et al. 1996,

Lehman 1983), allowing for highly functioning individuals

with schizophrenia to express greater social health than

poorly functioning individuals with depression. Conse-

quently, the possible range of social health in patients with

major depression is thought to vary in severity, such that

many patients have high enough social health to maintain a

job and have private health insurance. These people would

not qualify for Medi-Cal (government assisted health care)

or meet the other income eligibility requirements for

treatment at the county mental health services and thus

would have been less likely than depressed patients with

lower social health (i.e. without a job or health insurance) to

be included in this study. Also, a patient treated for a bout of

depression may only receive treatment for a limited amount

of time after remission. Although the range of social health

among patients with schizophrenia or psychotic disorders

can also vary, these patients often require continual man-

agement and may be more likely to receive ongoing

460 Community Ment Health J (2011) 47:454–462

123

treatment at the county mental health services. While only

the most severe depression cases would be represented in

our sample as explained above, the full range of schizo-

phrenia severity may be present.

Although the construct of social health is not synony-

mous with that of quality of life, overlapping concepts exist

between the two constructs such that a deficit in one is

likely to weaken the other. Some of these overlapping

domains measured across quality of life and social health

instruments include ability to go out, community,

employability, family and children, friends, interpersonal

relations, partner and sexuality, and relationships/social

supports (Korr and Ford 2003). Adding validation for the

overlap between these two constructs, the differences we

found between diagnoses groups on all scales replicate

those found in the research on quality of life in the men-

tally ill. Atkinson et al. (1997) also found that patients with

schizophrenia reported higher quality of life than patients

with affective disorders. Pukrop et al. (2003) not only

found higher self-rated quality of life greater in patients

with schizophrenia than patients with depression, but found

a similar pattern of differences within the social health

domain of their quality of life measure such that patients

with schizophrenia reported greater social health than

patients with depression.

Limitations of this study include the lack of validation

against objective measures or clinician-rated outcomes and

the low response rate among this population. There may be

important differences between responders and non-

responders in this study which may have affected our

evaluation of the social health scales. Also, because of the

self-report nature of questionnaire research, psychiatric

symptoms such as mood or psychosis could skew percep-

tions of outcomes (Atkinson et al. 1997; Winter et al.

2007). Further studies are needed to examine the ability of

the CA-QOL Social Health Scale and MHSIP Social

Health Scale to assess and predict patient recovery in the

mental health system.

In summary, social health measures have value in

mental health service outcome assessments. However,

adding even a brief social health measure to an already

lengthy assessment survey is problematic, especially due to

time constraints. The present analyses supported items

from two widely used mental health outcome assessment

measures, the CA-QOL and MHSIP, as valid self-report

measures of social health. Thus, when lengthy surveys are

not feasible, CA-QOL and/or MHSIP items can be used to

assess social health for research and assessment purposes.

Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per-

mits any noncommercial use, distribution, and reproduction in any

medium, provided the original author(s) and source are credited.

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