Group 5 - Measuring Outcomes of Research

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I ~]NICALI O'I YI'?-'

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ROUTINE

EVALUATION

THERAPYASSESSMENTFORM V.2

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If\/) h ~ 03 rs~rJ~:J i co-I Sci-tn UV7Uf\ ;v-LI'J\~I o-f LL.I2..~ (aJ",o- ~ b'lj NHS \-v ~~ \avJ- COV\A.V\ -)

CD,'11\e<u?u..r(

b.J (ofi£-,

hO.l)

~Site ID ITJIJletters

CDAge

Referral date

First assessment dateattended

numbers

Client ID

TH ID number SC2 numbers SC3 numbers

Sub Codes ITIJ ITIJ ITIJReferrer(s) CD CD CD

rn, CC}ITIIJrn, rn, ITIIJ

Total number of assessments DEpisode

Previously seen for therapy YesD Din this service? No DMonths since last episodeDD MM Y Y Y Y

Last assessment date CD,CD,ITJIJ Is this a follow-up/reviewappointment?

ITIJYes ~ DNo D

Relationships/support Please tick as many boxes as appropriate

Living alone (not including dependents) DLiving with partner DCaring for children under 5 years DCaring for children over 5 years DLiving with parents/guardian DLiving with other relatives/friends D

Full time carer (of disabledlelderly etc)

Living in shared accommodation (eg lodgings)

Living in temporary accommodation (eg hostel)

Living in institution/hospital

Other D [

DDDD

]Current/previous use of services for psychological problems?Pleasetick as many boxes as appropriate

Primary

Secondary

Specialist

Other

~

~..~ ~':J>~(J /,..,,,,

DDDDDDDDDDD

#"'~

...,'

DDD0DDDDDDD

DDDDDDDDDDDNo

D

GP or other member of primary care team (egpracticenurse, counsellor)"'H"HH'

In primary care setting. H"""'''''''''''''''''''' H'" H'"''''''''''''''''''''''''''''''''

In community setting, , , ,.. H H ,....................

In hospital setting on sessional basis , H H''''''''',,,,,,,,,,,,,,

Day care services (eg day hospital) H H'"'''''''' H"""",,""

Hospital admission < =10 days H" H' H"""""""""'"''''''''''''''''''''

Hospital admission> =11 days ...H."""""",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Psychotherapy/psychological treatments from specialist team (sessional) .H,,'

Attendance at day therapeutic programme H"""''''''''''''''''''''''' H.. ...

Inpatient treatment H" H'''' H"""''''''','' H'" H' ...........

Counsellor in eg voluntary, religious, work, educational setting .................

Is the client currently prescribed medication to help with their psychological problem(s)? YesD

If yes, please indicate type of medication:

Anti-psychotics D(neuroleptics/major tranquillizers)

Anti-depressants D Anxiolytics/Hypnotics(minor tranquillizers)

D Other D

Survey: 354u- - ------ Copyright CORE System Group Page: 1--- --

Male D Female DEmployment D DEthnic Origin D D

~

, u_---------

'"

.Jrief description of reason for referral

ICD-10 CODES

F/Z Main code Sub-code

10 DJ. 0F/Z Main Code Sub-code

30 DJ.OF/Z Main Code Sub-code

20 DJ.OF/Z Main Code Sub-code

40 DJ.O

Positiveactions 0

What has the client done to cope with/avoid their problems? Please tick, and then specify actions

Negative actions 0

Assessment outcome (tickone box only)

Assessment/one session only

Accepted for therapy

Accepted for trial period of therapy

Long consultation* Referred to other service

* Unsuitable for therapy at this time

000000

Survey: 354- - u u --

1'\

*If the client is not entering therapy give brief reason

Copyright CORE System Group Page: 2

~

Identified Problems/Concerns

i-"" >S'''' >S'''' '" .. i-"" >S'''' >S'''' >S''''<I' ",<I' <> o<:s; <$ ",<I' ","" "" 01'>'»

...,,,, ... "v ,'\. .l' <><s..0} ... "v ,'\. "'' <>o

0 Depression

J-....' '1 ., ",<><>

OTrauma/abuse

J-....' '1 q; ",<>""

0 0 0 0 0 0 0 0

0 Anxiety/Stress 0 0 0 0 0 Bereavement/loss 0 0 0 0

0 Psychosis 0 0 0 0 0 Self esteem 0 0 0 0

0 Personality Problems 0 0 0 0

0 Cognitive/Learning 0 0 0 0

0 Eating Disorder 0 0 0 0

0 Physical Problems 0 0 0 0

0 Addictions 0 0 0 0., <> ...i'

Risk<><>

Suicide 0 0 0 0Self Harm 0 0 0 0Harm to others 0 0 0 0Legal/Forensic 0 0 0 0

0 Interpersonal/relationship 0 0 0 0

0 Living/Welfare 0 0 0 0

OWork/ Academic 0 0 0 0

OOther (specify below) 0 0 0 0

I

CI.,INI(~AL

OU,'rCOMES in

ROUI'INE

Ev

OUTCOMEMEASURE

Over the last week~,~ -" ~ ~o,.

~ §."".~~ .#~ ~'t>~ if ~~~ ~<:J' '?<;:,~ ~'{:.'V

<;:,\. ~

-"'<;:,<}~~ .;::.0,.'<-~.~~ ~~~ f<:~;.~ ~ ~:i~

14 I have felt like crying

Survey: 151--- - --

0° 0' 02 03 04 Dw

Copyright MHF and CORE System Group. Page: 1--- --

Over the last week~ ~,~""~ ~,~~ .#

~ t;S1>~ ~ ~~~ t::::>"'V t?~~ ~ 'l;

~ ~ ~~~~ ~":J

-,,~ ~ ~,~.~ *-~ ~~ ~ <:)

34 I have hurt myself physically or taken dangerous risks withmy health

0° 01 02 03 04 OR

Mean Scores(Total score for each dimension divided by

number of items completed in that dimension)

~ ~ c:=J c:=J~

DD DDc:=J~c:=JDD

Total Scores

(W) (P) (F) (R) All items

Page: 2

All minus R

Survey: 151 Copyright MHF and CORE System Group.

CLINICAL

OUT(~OMES in

ROLT]'INE

EVAL1JATION

Site ID

Client ID

Sub Codes

END OFTHERAPYFORM V.2

Date therapycommenced

Date therapycompleted

CIIIJletters

CDSC4 numbers SC5 numbers

Number of sessionsplanned

ITJJNumber of sessionsattended

ITJJNumber of sessionsunattended

ITJJ

Therapist ID

ITJJ ITJJ ITJJrn, rn, ITItJrn, rn, ITItJ

What type of therapy was undertaken with the client? Pleasetick as many boxes as appropriate

Psychodynamic

Psychoanalytic

CognitiveBehavioural

Cog nitive/Behaviou ralStructured/Brief

DDDDDD

Person-centred

Integrative

Systemic

SupportiveArt

Qther (specifybelow)

DDDDDD

What modality of therapy was undertaken with the client? Pleasetick as many boxes as appropriate

Individual

Group

DD

Family

Marital/Couple

DD

What was the frequency of therapy with the client?

More than once weekly

Weekly

DD

Less than once weekly

Not at a fixed frequency

DD

Which of the following best describes the ending of therapy?

Unplanned D Planned DD

Due to loss of contact DClient did not wish to continue DOther unplanned ending (specify below) D

Due to crisis Planned from outset

Agreed during therapy

Agreed at end of therapy

Other planned ending (specifybelow)

DDDD

]]

Survey: 78 Page: 1Copyright CORE System Group

Benefits of Therapy

DExpression of feelings/problems DExploration of feelings/problems D

DDD

Personal insight/understanding

Coping strategies/techniques

Access to practical help

Other benefitsTickbox and then specify below

I

Improved

Yes No

DDDDD

Has contact with this service resulted in a change of medication? Yes DIf yes, is this change likely to be of benefit to the client? Yes D

No

No

D Not applicable DD

Details of change: Started D Discontinued D Increased D Decreased D Modified D

Yes D No DHas the client been given a follow-up appointment? Number of months until appointment

ITJSurvey: 78

----

Page: 2Copyright CORE System Group

"Review of Identified Problems/Concerns'. . .

<If. <If.'? ,,,.." '? ,, ,.."

D Depression D D Trauma/Abuse D

D Anxiety/Stress D D Bereavement/Loss D

D Psychosis D D Self esteem D

D Personality ProblemsD D Interpersonal/relationship D

D Cognitive/Learning D D Living/Welfare D

D Physical Problems D D Work/Academic D

D Eating Disorder D D Other (specify below) D

D Addictions D

. <> '?Risk

<>

Suicide D D D DSelf Harm D D D DHarm to others D D D DLegal/Forensic D D D D

Contextual Factors11>"

(;.'I> 11><:J

Motivation D D DWorking Alliance D D DPsychological Mindedness D D D

'b.0>" Improved .0>"

Yes No<>"'

D Control/planning/decision making D D DD Subjective well-being D D DD Symptoms D D DD Day to day functioning D D DD Personal relationships D D D

.,,~

-~-

CILINICAL

OUTCOMES in

ROUTINE

Ev ALUATION

NHS (H-t.A

OUTCOMEMEASURE

Over the last week~ ~"~~

~ ~".~~ .~~ ~fb.~~ If ~

~~ ~~<;J e:J~~ ~*(b

()~

~~().}~, 1':>«-~. ~(b ~.;:s~~ x~ ~~ <§. ()~

;14 I have felt like crying D° 01 02 03 o4Dw

.. Survey: 151

11111111111111

Page: 1

111111111.

Copyright MHF and CORE System Group.

~

., .CLINICAL

OUTCO:MESin

ROUTINE

Ev ALUATION

.

CORE-tOScreeningMeasure

Stage CompletedS ScreeeningR ReferralA AssessmentF First Therapy Sessionp Pr~therapy (unspecified)D During TtwrapyL Last theraRY session

Sub codes x Followup)Y Follow up 2

CITI ICITI Io=IJ EpisodeD Stage DTherapist ID numbersonly (1) numbers only (2) ...'

Da!e form aiv~J1 '.' ,', (7ender .' '

DD. M M". Y Y Y Y 0 Male AgeDQ=J/~/~ OFem~le '

Site ID =Client ID

CDIletters only num~ersonly

IMPORT~NJ~...PI...EA~E~EAD THIS'"FIRSTThis form I)as 10 statell1eQts~b9ut howY~Q ~fve..been OVER THELA~,- WEEK.

Please read each statem~~tand t~i2~.hpw ~fte!1Yo~ felt that way las! wee~.Then tick th~ boxwbich is 'closest.tothis. ..

""\' 'J.,' , """ ",.,' ,'~, ,j, ' "

Please use a dark Pf?t1.(not pencil) {mc! t[q"kclearly M{itflin..the bOXf;$.",.". ,,' ,- ,,', "

;:\ 0- 0~ ~ 0C:J J- ~~'!,.~ 0 ~o<::' ~~, ~,~0~ 'liJ ~0 ~ ~

~~ d:f' C:JO o~ ~o1 I havef~lt tense, arixious ornervou~ Do 0 1 0 20 3 [J 4

2 I havefelt I have someoneto turn !gfor supportwbemneeded 0 4 0 3 0 2 [] 1 0 Q; , ," '

3 I hcW~~~Itable to copewhen things..~o wrong 04 0 3 q 2 [J 1 0 0

4 Talking to people has felt too muchfor me Do 0 1 q 2 Q 3 0 4

5 I hC!vef~ltpanicor terror Do 0 1 D 2 IJ 3 0 4

6 I hCjvelJ'ladeplans to end my life 0 0 0 1 q 2 q 3 q 4

7 I hCjvehad difficulty gE?ttingto sleep Qfstayingasleep Do 01 02 0 3 0 4

8 I hayefelt despairingor hopeless 0 0 0 1 0 2 0 3 D 4

9 I h~v~felt unhappy Do 0 1 0 2 0 3 0 4

10 Un'N,antedimagesor memoriesh~yebeen distressingme Do 0 1 0 2 0 3 0 4

Over the last week...

Tot~1 (Clinical Score*)

* Proce<tqre:Add together the item scores, then divide by th!1 f14mber of questions completed to get the !fIean ~yore,then rnultiplyby 10 to get the ClinicalScore. '

Quick m~thod for the CORE-10 (if all itel11~completed): Add together the item scores to get the CIiJ1icalScore.

Thank you for you([~ime in cO~pleting this questi9nn~;~r~',' "

.CORE-10 Cqpyright CORE SY~J~mTrust (February 2006)

11111111111111111111111111111111111 .

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.

LSNS-18

Page 1 of2

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FIGURE 1

~

LUBBEN SOCIAL NETWORK SCALE -18

FAMIL Y Considering thepeople to whom you are related either by birth or marriage ...

1. How many relatives do you see or hear from at least once a month?0 =none 1=one 2 = two 3 = three orfOllr 4 =jive thru eight 5 = nine or more

2. How often do you see or hear from relative with whom you have the most contact?0 = never 1 = seldom 2 = sometimes 3 = often 4 = velY often 5 = always

3. How many relatives do you feel at ease with that you can talk about private matters?0 = none 1 =one 2 = two 3 = three orfOllr 4 = jive thru eight 5 = nine or more

4. How many relatives do you feel close to such that you could call on them for help?0 = none 1= one 2 = two 3 = three orfour 4 =jive thnl eight 5 = nine or more

5. When one of your relatives has an important decision to make, how often do they talk to you about it?0 =never 1=seldom 2 =sometimes 3 =often 4 =very often 5 = always

6~ How often is one of your relatives available for you to talk to when you have an important decision tomake?

0 =never 1=seldom 2 =sometimes 3 =often 4 =velY often 5 =always

NEmHBORS: Considering those people who live in YOllr neighborhood....

7. How many of your neighbors do you see or hear from at least once a month?0 = none 1= one 2 = two 3 = three orfOllr 4 = jive thru eight 5 = nine or more

8. How often do you see or hear from the neighbor with whom you have the most contact?0 =never 1 =seldom 2 = sometimes 3 = often 4 = veryoften 5 = always

9. How many neighbors do you feel at ease with that you can talk about private matters?0 =none 1= one 2 = two 3 = three orfour 4 =jive thru eight 5 = nine or more

10. Hmv many neighbors do you feel close to such that you could call on them for help?0 = none 1 =one 2 = two 3 = three or four 4 = jive thrll eight 5 = nine or more

11. When one of your neighbors has an important decision to make, how often do they talk to you about it?0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always

12.How often is one of your neighbors available for you to talk to when you have an important decision tomake?

0 =never 1= seldom 2 = sometimes 3= often 4 = very'often 5 = always

FRJENDSHIPS: Considering your friends who do not live inyour neighborhood... .

13.How many of your friends do you see or hear from at least once a month?0 = none 1 = one 2 = two 3 = three orfour 4 = jive thru eight 5 = nine or more

14. How often do you see or hear from the friend with whom you have the most contact?0 =never 1=seldom 2 =sometimes 3 =often 4 =very often 5 =always

15. Hmv many friends do you feel at ease with that you can talk about private matters?0 =none 1=one 2 =two 3 =three or fOllr 4 =jive thru eight 5 =nine or more

16. How many friends do you feel close to such that you could call on them for help?0 = none 1 =one 2 = two 3 = three or fOil l' 4 =jive thru eight 5 = nine or more

17. When one of your friends has an important decision to make, how often do they talk to you about it?0 = never 1 = seldom 2 = sometimes 3 = often 4 = very often 5 = always

http://www2.bc.edu/~nofstraj/LSNS-18.htm 12/10/2009

FIGURE1 Page 2 of2

18.How often is one of your friends available for you to talk to when you have an important decision tomake?

0 =never 1= seldom 2 = sometimes 3 = often 4 = very often 5 = always

LSW.s'-R total score is an equally weighted sum o.lthese twelve items. Scores range from 0 to 90

a LSNS Home Page

http://www2.bc.eduJ~norstraj/LSNS-18.htm 12/10/2009

FIGURE1 Page 1 of 1

LUBBEN SOCIAL NETWORK SCALE - 6

LSNS-6

FAMIL Y Considering the people to whom you are related either by birth or marriage ...

1. How many relatives do you see or hear from at least once a month?0 =none 1=one 2 =two 3 = three orfour 4 =.five thru eight 5 = nine or more

2. Hmr many relatives do you.teel at ease with that you can talk about private matters?0 = none 1 = one 2 = two 3 = three orfour -I = five thru eight 5 = nine or more

3. How many relatives do you feel close to such that you could call on them for help?0 =none 1=one 2 = two 3 =three orfour 4 =five thru eight 5 = nine or more

FRIENDSHIPS: Considering all of your friends including those who live in your neighborhood....

4. How many of your friends do you see or hear from at least once a month?0 =none 1=one 2 = two 3 = three orfOllr 4 =five thru eight 5 = nine or more

5. How many friends do you feel at ease with that you can talk about private matters?0 =none 1 =one 2 = two 3 = three or four 4 =.five thrll eight 5 = nine or more

6. Hmv many friends do you feel close to such that you could call on them for help?0 = none 1= one 2 = two 3 = three orfour 4 =five thrll eight 5 = nine or more

LS'NS'-6 total score is an equally weighted sum of these six items. Scores rangefi-om 0 to 30

IrI LSNS Home Pa~

http://www2.bc.edul-norstraj/LSNS-6.htm 12/10/2009

FIGURE 1 Page 1 of 1

LUBBEN SOCIAL NETWORK SCALE - REVISED

LSNS-R

FAMILY Considering thepeople to "whomyou are related either by birth or marriage ...

1. How many relatives do you see or hear from at least once a month?0 =none 1= one 2 = two 3 = three orfOlIr 4 =five thru eight 5 = nine or more

2. How often do you see or hear n-omrelative with \vhom you have the most contact?0 = never 1 = seldom 2 = sometimes 3 = often -I = velY often 5 = always

3. How many relatives do you feel at ease with that you can talk about private matters?0 = none 1 = one 2 = two 3 = three orfour -! = five thnl eight 5 = nine or more

'4. How many relatives do you feel close to such that you could call on them for help?0 =none I =one 2 = two 3 = three orfour 4 =five thnl eight 5 =nine or more

5. When one of your relatives has an important decision to make, hO\"\7often do they talk to you about it?0 =never I =seldom 2 =sometimes 3 =often 4 =velY often 5 = always

6. HO\"\7often is one of your relatives available for you to talk to when you have an important decision tomake?

0 = never I = seldom 2 =sometimes 3 = often 4 = very often 5 =always


7. How many of your friends do you see or hear from at least once a month?0 = none I = one 2 = two 3 = three orfour 4 =five thru eight 5 = nine or more

8. How often do you see or hear from the friend with whom you have the most contact?0 =never I =seldom 2 =sometimes 3 =often 4 =very often 5 =always

9. How many friends do you feel at ease \vith that you can talk about private matters?.0 =none I = one 2 = two 3 = threeorfour 4 =five thrueight 5 = nineor more

10. How many friends do you feel close to such that you could call on them for help?0 = none I = one 2 = two 3 = three or four 4 = five thru eight 5 = nine or more

11. When one of your friends has an important decision to make, how often do they talk to you about it?0 = never 1 = seldom 2 = sometimes 3 = often -I= velY often 5 = always

12. How often is one of your friends available for you to talk to when you have an important decision tomake?

0 = never 1 = seldom 2 = sometimes 3 = often 4 = velY often 5 = always

LSNS-R total score is an equally weighted sum afthese twelve items. Scores range from 0 to 60

~ LSNS Home Pa~

http://www2.bc.edu/-norstraj/LSNS-Rhtm 12/10/2009

FIGURE 1 Page 1 of 1

LUBBEN SOCIAL NETWORK SCALE - REVISED

LSNS-R

FAMILY Considering thepeople to whom you are related either by birth or marriage...

1. How many relatives do you see or hear from at least once a month?0 = none I = one 2 = two 3 = three or four 4 =five thnt eight 5 = nine or more

2. Ho,,, often do you see or hear from relative with whom you have the most contact?0 = never 1 = seldom 2 = sometimes 3 = often -I = vety often 5 = always

3. How many relatives do you feel at ease with that you can talk about private matters?0 = none 1 = one 2 = two 3 = three orfour -I = five thnt eight 5 = nine or more

4. How many relatives do you feel close to such that you could call on them for help?0 =none 1=one 2 = two 3 = three orfour 4 =five thnt eight 5 =nine or more

5. When one of your relatives has an important decision to make. how often do they talk to you about it?0 = never 1=seldom 2 =sometimes 3 =often 4 =very often 5 =always

6. How often is one of your relatives available for you to talk to when you have an important decision tomake?

0 =never 1=seldom 2 =sometimes 3 =often 4 =vety often 5 =always


7. How many of your friends do you see or hear from at least once a month?0 =none 1=one 2 = two 3 =three orfour 4 =five thru eight 5 =nine or more

8. How often do you see or hear from the friend with whom you have the most contact?0 =never 1= seldom 2 =sometimes 3 =often 4 =very often 5 =always

9. How many friends do you feel at ease ,,,ith that you can talk about private matters?0 = none I = one 2 = two 3 = three Of'four 4 =five thnt eight 5 = nine or more

10. How many friends do you feel close to such that you could call on them for help?0 = none 1 = one 2 = two 3 = three or four 4 =five thnt eight 5 =nine or more

11. When one of your friends has an important decision to make. how often do they talk to you about it?0 = never 1 = seldom 2 = sometimes 3 = often -I= very often 5 = always

12. How often is one of your friends available for you to talk to ,,,hen you have an important decision tomake?

0 =never 1=seldom 2 =sometimes 3 =often 4 =very often 5 =always

LSNS-R total score is an equally weighted sum o.(these twelve items. Scores range from 0 to 60

m LSNS Home Pa~

http://www2.bc.edu/~norstraj/LSNS-R.htm 12/10/2009

,

!"

Appendix 14Beck Depression Inventory

br ~rJ ~ rr:

..(Roche)

I

Beck DepressionInventoryCRTN:- CRFnumber:V0477 I Page 14

Baseline

Ipatient inits:

".011

~ ...I

Name:

Occupation:

Marital Status: Age: Sex:-

Education:

Instructions: 1his questionnaire consists of 21 groups of statements. Please read each group of statements carefully, andthen pick out the one statement in each group that best descnees the way you have been feeling during the past twoweeks. including today. Circle the number beside the statement you have picked. If several statements in the groupseem to apply equally well, circle the highest number for that group. Be sure that you do not cboose more than onestatement for any group, including Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).

1.Sadness0 I do not feel sad.I "1feel sadmuch of the time.2 I am sad all the time.

3 I am so sad or unhappythat J can't standit

2. Pessimism

0 I am not discouragedabout myfuture.1 I feel more discouragedaboutmyfuture thanI

used to be.

2 I do not expect thingsto workout for me.3 I fee] my future is hopelessandwill onlyget

worse.

3. PastFailure0 I do not fee1like a failure.1 I have failedmorethan I shouldhave.2 As I look back, I see a lot of failures.

3 I feel I am a total failure as a person.

4. Loss of Pleasure

0 I get as much pleasureas I ever did fromthethingsI enjoy.

1 I don't enjoythings as much as I usedto.2 ] get very little pleasurefromthe thingsI used

to enjoy.3 ] can't get any pleasurefromthe thingsI used

to enjoy.

5. GuiltyFeelings0 I don't feel particularlyguilty.1 I feel guilty overmany thingsI have doneor

shouldhave done.

2 I feel quite guiltymostof the time.3 I feel guiltyall of the time.

MhTHE PSYCHOLOGICAL CORPORATION"\;!;I HarcourtBraceI; Company

SAN AmONIOOtIIDdo'- 'l'Iow""'.-OIicap.s.a_-A--DaIIasSoADIt:p.~'--",",-'-'Loadoa's,docy

6. PunisllmentFeelings0 I don't feel I ambeingpunished.1 I feel I may be punished.2 I expectto be punished.3 I feelI am being punished.

7. Self-Dislike

0 I feel the sameabout myselfas ever.1 I havelost confidencein myself.2 I am disappointedin myself.3 I dislikemyself.

8.Self-Criticalness

0 I don't criticizeor blamemyselfmorethanusual.1 I am morecriticalof myselfthan I used to be.2 I criticizemyself for aDof my faults.3 I blamemyself for everythingbad that happens.

9. SuicidalThoughtsor Wishes0 I don't have any thoughtsof killingmyself.1 I havethoughtsof killingmyself,but I would

not carry themout.2 I wouldlike to kill myself.3 I wouldkill myselfif I had the chance.

10. Crying0 I don't cry anymorethanI used to.I I cry morethan I used to.2 I cry over everylittle thing.3 I feel like crying,but! can't.

'M Subtotal Page 1COpyIIgI1ICl ,. by Aaran T. Bec:t<AI rigI1IsreseMd. Printed in 1he United Slates of America. 0154018392

INR15645

....

I

Beck DepressionInventoryCRTN:- CRF number:

(Roche>V 0477

11. Agitation0 I am no more restless or wound up than usual.

1 I feel more restless or wound up than usual.2 I am so restless or agitated that it's hard to stay

still.

3 I am so restless or agitated that I have 10keepmoving or doing something.

12. loss of Interest

0 I bave not lost interest in other people oractivities.

I am less interested in other people or thingsthan before.

I have lost most of my interest in other peopleor mings.

It's hard to get interested in anything.

2

3

13. Indecisiveness0 I make decisions about as well as ever.

1 I find it more difficult to make decisions thanusual.

2 I have much greater difficulty in makingdecisions than I used to.

3 I have troublemakinganydecisions.

14. Wortblessness0 I do not feel I am word1less.

1 I don't consider myself as worthwhile and usefulas I used to.

2 I feel more worthless as compared to otherpeople.

3 I feel utterly worthless.

15. LossofEnergy0 I have as muchenergyas ever.1 I have lessenergythanI usedto have.2 I don't haveenoughenergyto do verymuch.:3 I don't haveenoughenergyto do anything.

1&. Cbanges in Sleeping Pattern0 I have not experienced any change in my

sleeping pattern.

la I sleep somewhat more than usual.Ib I sleep somewhat less tban usual.

2a I sleep a lot more than usual.2b I sleep a lot less than usual.

3a I sleep most ofthc day.3b I wake up 1-2 hours early and can't get back

to sleep.

I ~.15

Baseline

Ipatientinits:

17. Irrilability0 I am no more irritable than usual.

1 I am mQreirritable than usual.2 I am much more irritable than usual.

3 I am initable all the time.

18. Changesin Appetite0 I have not experienced any change in my

appetite.la My appetite is somewhat less than usual.

lb My appetite is somewhat greater than usual.2a My appetite is much less than before.2b My appetite is much greater than usual.3a I have no appetite at alL3b I crave food all the time.

19.ConcentrationDifficulty0 I canconcentrateas wellas ever.1 I can't concentrateas wellas usual.

2 It's hardto keepmymindon anythingforveryloog.

3 r findI can't concentrateon anything.

20. Tiredness orFatigue0 I am DOmore tired or fatigued than usual.

1 I get more tired or fatigued more easily manusual.

2 I am too tired or fatigued to do a lot of the thingsI used to do.

3 I am too tired or fatigued to do most of thethings I used to do.

21. Lossof Interest in SIX

0 I have not noticed any recent change in myinterest in sex.

I axnless interested in sex than I used to be.I am much less interested in sex now.

I have lost interest in sex completely.

123

IIIQCo)ID<~-~Cl>ca~........t')

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Appendix 15Mood/Depression Assessment Questionnaire

r

V 0477 I

Mood/depressionquestionnaireCRTN:- CRFnumber: I~w patientinlts:Week 2 I

(Roche>

MoodlDepression Assessment Questionnaire

1. Since your last visit have you felt depressed, sad or blue much of the time?yes 0no 0

2. Sinceyourlastvisithaveyouoftenfelthelplessaboutthefuture?yes 0no 0

3. Since yom-last visithave you had littleinterest or pleasure in doingthings?yes 0no 0

4. Since your last visithave you had troublesleeping many nights?yes.Ono 0

Are two (2) or more of the above questions marked YES while undergoing treatment in this protocol?

yes 0 completea Beck DepressionInventory. If score is 30 or less.patient may continue in the study. "score is ~ 31. patient willneedto complete all final assessments and be dropped from the study.The investigator may recommend that the patient be referred for aprofessional psychiatric assessment.

no 0

47 NR1-5645I

J\IL.Q...()./) 'L-~~. d

6~~rdu-n~ ~SF-36(tm) Health Survey &fCfI?f ~ lj ?

Instructions for completing the questionnaire: Please answer every question. Some questions may look like others, but eachone is different. Please take the time to read and answer each question carefully by fillingin the bubble that best representsyour response.

Patient Name:

SSN#: Da1B:

Person he lingto complete this form:

1. In general, would you say your health is:

a Excellenta Verygooda Gooda Faira Poor

2. Compared to one year ago, how would you rate your health in general now?

a Muchbetter nowthan a year agoa Somewhatbetternowthan a year agoa Aboutthe same as one year agoa Somewhatworse nowthan one year agoa Muchworse nowthan one year ago

3. The followingi1Bmsare about activities you might do during a typical day. Does your health now limityou in theseactivities? Ifso, how much?

a. Vigorousactivities,such as running,liftingheavyobjects, participatinginstrenuous sports.a Yes, limiteda lot.a Yes, limiteda little.a No,not limitedat all.

b. Moderateactivities,such as movinga table, pushinga vacuumcleaner, bowling,or playinggolf?a Yes, limiteda lot.a Yes,limiteda little.a No,not limitedat all.

c. Liftingor carryinggroceries.a Yes, limiteda lot.a Yes,limiteda little.a No,not Iimi1Bdat all.

d. Climbingseveral flightsofstairs.a Yes, limiteda lot.a Yes, limiteda little.a No,not limitedat all.

e. Climbingone flightof stairs.a Yes, limiteda lot.a Yes, limiteda little.a No,not limitedat all.

f. Bending,kneelingpr stooping.a Yes, limiteda lot.a Yes, limiteda little.a No,not limitedat all.

SF-36 1

g. Walking more 1han one mile.0 Yes, limited a lot0 Yes, limited a little.0 No, not limited at all.

h. Walking several blocks.0 Yes, limited a lot.0 Yes,limited a little.0 No, not limitedat all.

i. Walking one block.0 Yes, limited a lot.0 Yes, limited a little.0 No, not limited at all.

j. Bathing or dressing yourself.0 Yes, limited a lot.0 Yes, limited a little.0 No, not limited at all.

4. During the past 4 weeks, have you had any of the followingproblems with your work or other regular daily activities as aresult of your physical heal1h?

a. Cut down the amount of time you spent on work or o1her activities?DYes 0 No

b. Accomplished less than you would like?DYes 0 No

c. Were limited in 1he kind of work or o1her activitiesDYes 0 No

d. Had difficultyperforming the work or o1heractivities (for example, it took extra time)DYes 0 No

5. During the past 4 weeks, have you had any of 1hefollowingproblems wi1hyour work or other regular daily activities as aresult of any emotional problems (such as feeling depressed or anxious)?

a. Cut down the amount of time you spent on work or o1heractivities?DYes 0 No

b. Accomplished less 1han you would likeDYes 0 No

c. Didn't do work or other activities as carefully as usualDYes 0 No

6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal socialactivities wi1hfamily, friends, neighbors, or groups?

0 Not at all0 Slightly0 Moderately0 Quite a bit0 Extremely

7. How much bodily pain have you had during 1he past 4 weeks?0 Not at all0 Slightly0 Moderately0 Quite a bit0 Extremely

SF-36 2

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home andhousework)?

Q

QQ

QQ

Not at allSlightlyModeratelyQuite a bitExtremely

9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question,please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4weeks.

a. did you feel fullof pep?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

b. have you been a very nervous person?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

c. have you felt so down in the dumps nothing could cheer you up?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

d. have you felt calm and peaceful?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

e. did you have a lot of energy?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

f. have you felt downhearted and blue?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

SF-36 3

g. did you feel worn out?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

h. have you been a happy person?Q Allofthe timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

i. did you feel tired?Q Allof the timeQ Most of the timeQ A good bit of the timeQ Some of the timeQ A little of the timeQ None of the time

10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with yoursocial activities (like visiting friends, relatives, etc.)?

Q Allof the timeQ Most of the timeQ Some of the timeQ A little of the timeQ None of the time

11. How TRUE or FALSE is each of the followingstatements for you?

a. I seem to get sick a littleeasier than other peopleQ DefinitelytrueQ MostlytrueQ Don't knowQ MostlyfalseQ Definitelyfalse

b. Iam as healthy as anybody I knowQ DefinitelytrueQ MostlytrueQ Don't knowQ MostlyfalseQ Definitelyfalse

c. I expect my health to get worseQ DefinitelytrueQ MostlytrueQ Don't knowQ MostlyfalseQ Definitelyfalse

d. Myhealth is excellentQ DefinitelytrueQ MostlytrueQ Don't knowQ MostlyfalseQ Definitelyfalse

SF-36 4

--~

(IVV.-<vJ"GLK-d b:J ~IT1fiSI-)

NAME AGE DATESEX-

~ -- ~--~

(b~J dvP"1 J f-uZ)

Cornell Scale for Depression in DementiaRatings should be based on symptoms and signs occurring during the week before interview. No score should begiven if symptoms result from physical disability or illness.

a = Unable to evaluate

1 = Mild to Intermittent

SCORING SYSTEM

0 = Absent

2 = SevereScore greater than 12 = Probable Depression

A. MOOD-RELATED SIGNS

1. Anxiety; anxious expression, rumination, worrying

2. Sadness; sad expression, sad voice, tearfulness

3. Lack of reaction to pleasant events

4. Irritability; annoyed, short tempered

B. BEHAVIORAL DISTURBANCE

5. Agitation; restlessness, hand wringing, hair pulling

6. Retardation; slow movements, slow speech, slow reactions

7. Multiple physical complaints (score0 if gastrointestinalsymptomson!Y)

8. Loss of interest; less involved in usual activities (score0 only ifchange oCCUJTedacutely, i.e., in less than one month)

C. PHYSICAL SIGNS

9. Appetite loss; eating less than usual

10. Weight loss (score 2 if greater than 5 pounds in one month)

11. Lack of energy; fatigues easily, unable to sustain activities

D. CYCLIC FUNCTIONS

12. Diurnal variation of mood; symptoms worse in the morning

13. Difficulty falling asleep; later than usual for this individual

14. Multiple awakenings during sleep

15. Early morning awakening; earlier than usual for this individual

E. IDEATIONAL DISTURBANCE

16. Suicidal; feels life is not worth living

17. Poor self-esteem; self-blame, self-depreciation, feelings of failure

18. Pessimism; anticipation of the worst

19. Mood congruent delusions; delusions of poverty, illness or loss

NOTES/CURRENT MEDICATIONS:

ASSESSOR:

a 0 21

a 0 21

a 0 1 2

§§§§a 0 21

a 0 21

Score

DInstruction for use: (CorneD Dementia Depression Assessment Tool)1. The same CNA (certified nursing assistant) should conduct the interviewed ly numbered answer- (a=unable to evaluate. O=absent. l=mild to intermit-

each time to assure consistency in the response- tent. 2=severe).2. The assessment should be based on the patient's normal weekly routine- 5- Add the total score for all numbers checked for each question.3- If uncertain of answers. questioning other caregivers may further define the 6- Place the total score in the "SCORE" box and record any subjective observa-

answer- tion notes in the "Notes/Current Medications" section-

4- Answer all questions by placing a check in the column under the appropriate- 7 - Scores totaling twelve (12) points or more indicate probable depression.

4-8 Consult Phann 1996; 11 (Suppl4)

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Mu!ti~dimensiQnal IQ109 questions, 40 min.

PROGRESS STATUS:.1.

2.

3.

4.

one of the following five is least like the other four?

Celery - Lettuce - Onion - Grape - Asparagus

CeleryLettuceOnion

GrapeAsparagusI don't know

Juice - Egg - Steak -Salad - Cheese

Juice

EggSteakSaladCheese

I don't know

Milkshake - Juice - Gin -Whiskey - Milk

Milkshake

Juice

Gin

WhiskeyMilk

I don't know

Unctuous - Greasy - Adipose - Sinewy - Oleaginous

Unctuous

Greasy

Adipose

Sinewy

Oleaginous

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Multi-dimensional IQ109 questions, 40 min,

PROGRESSSTATUS:.hose meaning is opposite to the word in capita! letters.

ImproveYour Brain

MemDry

Attention

Fotus

Fluid

Str"$$

'f!m$

GefHH3! Hanith

ewp

5.

6.

7.

8.

INTIMIDATING: Scary -Formidable -Entertaining -Approachable

Scary

Formidable

Entertaining

Approachable

I don't know

IRREVERENT: Blasphemous - Respectful - Contemptuous - Unnecessary

Blasphemous

Respectful

Contemptuous

Unnecessary

I don't know

VERTIGINOUS: Virtuous - Confused - Balanced -Lingering

Virtuous

Confused

Balanced

LingeringI don't know

CORUSCATE:Extinguish - Scintillate - Encounter - Redolence

ExtinguishScintillate

Encounter

Redolence

I don't know -

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MomoryAttention

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Visual

Spatial

PrdbJem

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!#iHlOral Health

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Multi-dimensional IQ Test1 09 questions, 40 min.

PROGRESSSTATUS:.9.

10.

11.

12.

Page 1 of 1

I

word whose meaning is closest to the word in capita! letters.

LITHE: Young. Rigid - Flexible - Brittle

Young

RigidFlexible

Brittle

I don't know

OBSOLETE: Cutting-edge - Discharge - Complete. Antiquated

Cutting.edge

Discharge

Complete

Antiquated

I don't know

TRIBULATION: Ministration. Recreation - Suffering. Blessing

Ministration

Recreation

Suffering

BlessingI don't know

OFFICIOUS: Meddlesome - Honorary - Smelly - Business.like

Meddlesome

Honorary

SmellyBusiness.like

I don't know -

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Multl-dimensionallQ109 questions, 40 min.

PROGRESSSTATUS:.13.

Choose the set ot words that tjt best into the blank spaces.

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Me>rnory

Attention

1"0(:\1$

SpiHld

Visual

Fh.dd

Strews

Rit$(:tiOfl Tlffle

Health

Ip

--

14.

15.

The little boy's - handling of the neighbor's kitten made his parents realize that he was now- enough to have a pet of his own.

strong, oldcautious, mature

careless, big

gentle, cunningI don't know

The woman sat back in her chair,essay - designed to puzzle her professor.

pondering, explicit

contemplating, enigmatic

cogitating, perspicuous

determining, daffyI don't know

the best way to conclude her purposefully

The doctor's - wasa hugerelief. Shethoughtshewouldhaveto spendweeksin physicaltherapy in order to -'

advice, rejuvenate

prediction, be cured

prognosis, be rehabilitated

expression, recoverI don't know -

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Multi-dimensional IQ Test109 questions. 40 min.

PROGRESS STATUS:.16.

17.

18.

19.

20.

Niece is to nephew as brother is to: Cousin - Aunt - Mother - Daughter - Sister

Cousin

Aunt

Mother

DaughterSister

I don't know

Vacuum cleaner is to carpet as broom is to: Dust -Carpet -Rug-Dust pan - Floor

Dust

Carpet

Rug

Dust panFloor

I don't know

Thread is to cloth as hair is to: Shave - Headband -Head - Braid -Shampoo

Shave

Headband

Head

Braid

ShampooI don't know

Date is to divorce as interview is to: Fire - Work - Hire - Annulment - Taxes

Fire

Work

Hire

Annulment

Taxes

I don't know

Scared is to fear as happy is to: Anger - Joy - Yellow - Tears - Ambivalence

Anger

JoyYellowTears

Ambivalence

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Numerical Reasoning Samples

One Week's Temperatures in 3 Capitals16

h' 14,::; 12~ 10:J"j;j S

~!: 6E 4<i't- 2

0 '..""-'-""'.,-,"---' New'York

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Q1. Which day showed the largest increase in temperature in Paris?

Friday

Tuesday

Saturday

Answer? (Show...)

Number of carssold in the UK...........--...

oth ers

Seat

w'PeLlgee't

Ford2000 201)1 2002 2003 2004

Q2. By what percentage did Vauxhall car sales increase over the period 2000 to2004?

300%

400%

500%

Samples Page 3 of3

."Verbal Reasoning Samples

The mango is a tropical fruit of the mango tree. The exact origins of the mango areunknown but it is believed that it is native to Southern and Southeast Asia owing to thewide range of genetic diversity in the region and fossil records dating back 25 to 30 millionyears. Mangos retain a special significance in the culture of South Asia where they havebeen cultivated for millennia. Mangos have also been the national symbol of thePhilippines. Reference to mangos as the "food of the gods" can be found in the HinduVedas and the leaves are rituallyused for floral decorations at Hindu marriages andreligious ceremonies.

Mango trees are large trees, reaching 35 - 40 metres in height. When mature the mangofruit hangs from the tree on long stems. They are variable in size, from 10-25 cm long and7-12 cm diameter, and may weigh up to 2.5 kg. The ripe fruit is coloured yellow, orangeand red. It is reddest on the side facing the sun and yellow where shaded; green usuallyindicates that the fruit is not yet ripe. When ripe, the unpeeled fruit gives off a distinctive,slightly sweet smell. The fruit flesh of a ripe mango contains about 15% sugar, up to 1%protein, and significant amounts of vitamins A, Band C. The taste of the fruit is very sweetand it tastes roughly like a cross between a peach and a pineapple.

Q1. Mangos are a good healthy option

True

False

Can not say

Answer? (Showm)

The cat is a small carnivorous mammal that is often valued by humans for itscompanionship. The cat is a skilled predator and is known to hunt over 1000 species forfood. Cats use a variety of vocalisations and body language for communication, such aspurring, mewing, hissing, and growling. The cat is an intelligent mammal and can betrained to obey simple commands. Typically a cat will weigh between 2.5 and 7kg. Catsare extremely sensitive as they have highly advanced hearing, eyesight, touch, and tastereceptors.

People's belief that cats are solitary animals is incorrect, they are actually highly social.This misconception is due to cats not having a social survival strategy ('pack mentality')like animals such as dogs. This means that they look after their own needs, even whenliving in a group.

Q2. Cats make good companions for humans

True

False

Can not say

Answer? (Show...)

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Sample 1 of 9 . Abstract Reasoning

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fMt] ~J~1~N4Lookto the future...

look at the siring of beads. PJ. the end of each string you willsee two question marks (71) where the next twobeads willgo. Choose the first and second missing beads from the lettered beads on the right. You may choose thesame bead twice.

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PRACT!CE TESTS

:2of9 Gener<*i ~ Verbal Part 1

look at the first line 01 six 1,1IOrd5.Four 01 !he words have something in common, but t,\'o do no! belong with the

o!her rour. For each question decide which two words do not belong with !he other four.

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Look at the firsl queslion beIO'#. The two words in the left hand box go togelher in a certain way. For each question

choose Iwo words, one from each long box, which go logether in the same way.

Heavy is 10Light

Field is to Grass

Leg is to Foot

El. 'I Glass is toWindow I asLm_.. m__mm.m.J

wide day jump isto

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17Th] ~1'~ r..J:\"3-U...J!.2 ~ I, ;J.:.1!,IJiLook to the future...

PRACTICE TESTS

Sample 4 of 9. General Ability - Numerica! Part 1

Look at !he rows of numbers.Each rowgcesin a certainorder. For each question work out the orderandpick the two missing numbers. Choose thefirstmissingnumberfromtheboxontheleftandthesecondmissing number from the box on the right.

2 . 4 . 6 . 8 . 10 .

10

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12

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50 . 45 . 40 . 35 . 30 .

25 30

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isor 9 ~ . Numerical 2

Productslook at the squares of numbers. The numbers are arranged in a certain way. For e&ch question work out hew

!he numbers are arranged, and find the missing number /rom the six possible answers.

Practice Test

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Group 5 - Measuring Outcomes of Research

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