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Project director:

Dr. Sylke Andreas

PD. Dr. Holger Schulz


Anna Levke Brütt
Zentrum für Psychosoziale Medizin
Institut und Poliklinik für Medizinische Psychologie
Universitätsklinikum Hamburg-Eppendorf
Martinistr. 52, Haus W 26
20246 Hamburg

Tel. ++49(0)40/7410-57313
Fax ++49(0)40/7410-54940

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Development, psychometric testing and implementation of an ICF-oriented instrument for measuring activities and participation in patients with mental illnesses

Mental illnesses are not only frequently occurring, but also strongly impairing diseases. Besides the burden caused by the symptoms, patients often suffer from the difficulty of coping with everyday tasks. In order to also systematically measure such problems, in this project, a questionnaire is developed which specifically surveys activities and participation in social life of these suffers.


The "International classification of functional ability, disability and health" (ICF), which was published in 2001 by the World Health Organisation and classifies functional ability on different levels, serves in this respect as the framework concept.


In the further course of the project, moreover, it will be examined whether the use of the questionnaire and consequently the specific survey of problems in activities and participation can exert an influence on the course of therapy. In a follow-up survey, it will be investigated whether the inpatient treatment has led to a sustained improvement of activities and participation in the sufferers' everyday lives.

Brütt, A. L., Schulz, H., Koch, U. und Andreas, S.



Rehabilitation treatments encompass a broad range of offers, in which not only mental and physical symptoms should be reduced, but the participation of the patient in various areas of life should also be fostered (Schulz & Koch, 2002). With the "International classification of functional ability, disability and health (ICF) (WHO, 2001), a concept has been available since 2001 which extends the biomedical diseases model with the levels of activities and participation as well as environmental and personality factors. Consequently, it is possible to systematically classify not only physical functions and structures, but also impairments in patients' everyday life reality. Although the ICF has established itself as a conceptual reference system for rehabilitation treatments, its implementation in practice is still in its early stages. For several, predominantly physical illnesses, so-called core sets, which depict disease-specific important ICF categories, have been developed (Cieza et al., 2004). For mental illnesses, however, practicable, reliable and valid self-assessment instruments for measuring activities and participation are still lacking.



The development of the instrument ensued in a three-step procedure. First, an ICF-based instrument specifically on activities and participation for patients with mental illnesses should be developed. This should then be psychometrically tested in a sample, and finally, in the third work phase, should be integrated as an instrument in clinical practice.


In the first step, on the basis of a literature review, outcome instruments were identified which were examined in terms of their content relating to the ICF dimension activities and participation. The importance of the ICF categories from the patients' perspective was elicited through focus groups. Finally, by means of an expert workshop, the relevance of the ICF categories identified so far for treatment was checked. Following the multi-perspective development phase of the instruments, in a final step, the items were examined in terms of their comprehensibility and acceptance by means of the method of cognitive debriefing with patients. To this aim, in-depth interviews were conducted with 6 patients in inpatient psychotherapeutic treatment. At the end of this first work phase, a 52-item questionnaire was produced.


In the second work phase of the project, 2256 patients in psychosomatic psychotherapeutic treatment were recruited in cooperating specialist clinics. In addition to the pilot version of the ICF -PsychA&P (52 items), questions on sociodemographics and instruments on symptom severity, on personal problems and on quality of life were employed at three measurement time points (pre, post, 6-month follow-up). By means of factor analysis, 31 items were extracted, which explained 65% of the total variance. The six subscales (functional ability, leisure time, communication, interaction, relationships and mobility) and the total value show good internal consistencies. First subgroup analyses provide indications of convergent and discriminant validity (e.g. high correlations with symptom scales in line with expectations). For the further validation of the instruments, in-depth interviews were carried out in a subsample of patients (N=35) at the follow-up time point. The scales of functional ability, mobility as well as the total value, and to a limited extent also relationships, can be well depicted by the patient interviews. The scale of leisure time correlates with functional ability and mobility, albeit not significantly with aspects which were classified to the theme of leisure time in the interviews. Interaction and communication are areas in which the patients' questionnaire information do not concur with the statements.


In the third work phase, in a cohort control group design, the influence of a systematic feedback of the ICF-PsychoA&P questionnaire was examined. During the starting phase, in each of the cooperating establishments, an ICF workshop for clinic therapists was included. In the following weeks (experimental phase), the therapists in the clinics were provided with feedback of the patient information in the ICF-PsychA&P questionnaire. The treatment providers received the results of the self-report at the beginning and end of treatment in graph and text form and were able to use this information for the further treatment planning. However, the effects on the outcome of the treatment proved to be low. In this survey phase, again over 2000 patients were surveyed. Consequently, the practicability and applicability of the instrument in routine clinical care was demonstrated.


The instrument can be downloaded free of charge.





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