Routine Outcome Assessment Research Articles

Measuring recovery in participants with a schizophrenia spectrum disorder: validation of the Individual Recovery Outcomes Counter (I.ROC).

BackgroundTo improve recovery in mental health, validated instruments are needed.AimsThis study evaluates psychometric properties of the Individual Recovery Outcomes Counter (I.ROC) in a Dutch population of participants with a schizophrenia spectrum disorder (SSD).Methods326 participants completed the I.ROC at baseline (n = 326), six months (n = 155) and twelve months (n = 84) as part of a routine outcome assessment. Reliability, validity, sensitivity to change, and internal factor structure were examined.ResultsParticipants evaluated the I.ROC as comprehensive. Internal consistency of the I.ROC (α = 0.88) and test-retest reliability (r = .85, p < .001) are good. Negative moderate correlations with the total score of the PANSS (r=-.50, p < .001) and the HoNOS (r=-.52, p < .001) were found, and a small negative correlation with the FR tool (r=-.36, p < .001). Moderate positive correlation with the MANSA (r = .55, p < .001) and the RAS (r = .60, p < .001) were found. The mean total I.ROC scores increased significantly between time points (F(2,166) = 6.351, p < .005), although differences were small. Confirmatory factor analysis showed that fit indices for the one-, two-, and four-factor model are comparable.ConclusionsThe I.ROC is a valid and reliable instrument, with sensitivity to change, to map recovery in participants with SSD.

Eating disorder behaviors as a form of non-suicidal self-injury

Nonsuicidal Self-Injury (NSSI), the purposeful harming of one's body tissue without suicidal intent. NSSI frequently co-occurs with other self-destructive forms of psychopathology, such as eating disorders (ED); however, it remains unclear if ED behaviors are used as a form of NSSI. This exploratory study examined the occurrence of Self-Injurious Disordered Eating Symptoms (SIDES), as well as differences in clinical correlates and treatment outcomes between NSSI patients with and without SIDES. Participants included 1,327 patients admitted for partial hospitalization or intensive outpatient treatment for NSSI (87.4% female; 75.3% Non-Hispanic White). Data were collected at admission and discharge as part of routine clinical outcome assessment. Results indicate that 29.5% of the sample engaged in SIDES, while most were not diagnosed with an ED. Patients that engaged in SIDES reported greater clinical severity at baseline, including greater general psychopathology, lower quality of life, and worse functional impairment, as well as more clinically severe NSSI (e.g., greater number of methods, higher urge to self-injure, greater intrapersonal functions). No differences in treatment outcomes were found. These findings suggest that some NSSI patients perceive ED behaviors as a form of NSSI and that SIDES may be a marker for a more severe clinical presentation.

Development and validation of the Maudsley Modified Patient Health Questionnaire (MM-PHQ-9).

The Patient Health Questionnaire-9 (PHQ-9) is a widely used measure of depression in primary care. It was, however, originally designed as a diagnostic screening tool, and not for measuring change in response to antidepressant treatment. Although the Quick Inventory of Depressive Symptomology (QIDS-SR-16) has been extensively validated for outcome measurement, it is poorly adopted in UK primary care, and, although free for clinicians, has licensing restrictions for healthcare organisation use. We aimed to develop a modified version of the PHQ-9, the Maudsley Modified PHQ-9 (MM-PHQ-9), for tracking symptom changes in primary care. We tested the measure's validity, reliability and factor structure. A sample of 121 participants was recruited across three studies, and comprised 78 participants with major depressive disorder and 43 controls. MM-PHQ-9 scores were compared with the QIDS-SR-16 and Clinical Global Impressions improvement scale, for concurrent validity. Internal consistency of the scale was assessed, and principal component analysis was conducted to determine the items' factor structure. The MM-PHQ-9 demonstrated good concurrent validity with the QIDS-SR-16, and excellent internal consistency. Sensitivity to change over a 14-week period was d = 0.41 compared with d = 0.61 on the QIDS-SR-16. Concurrent validity between the paper and mobile app versions of the MM-PHQ-9 was r = 0.67. These results indicate that the MM-PHQ-9 is a valid and reliable measure of depressive symptoms in paper and mobile app format, although further validation is required. The measure was sensitive to change, demonstrating suitability for use in routine outcome assessment.

Measure of clinical improvement in children and adolescents with psychiatric disorders: an evaluation of multiple perspectives with HoNOSCA.

Routine outcome assessment is helpful to inform decision-making, resource allocation, and health policy design. Routine outcome assessment in the hospital setting for children and adolescents with psychiatric disorders remains limited. The clinical instrument HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents), which has recently become available in Spanish and Catalan, allows outcome assessment in this population from the perspective of patients, their parents or legal guardians, and clinicians. HoNOSCA measures 13 areas of health and psychosocial functioning. The aim of this study was to assess mental health outcomes in psychiatric day hospital pediatric patients from three perspectives (patient, par-ent/legal guardian, clinician), using the Spanish and Catalan versions of HoNOSCA. We recruited patients up to 18 years old with any psychiatric disorder at the day unit of the Salut Mental Parc Taulí Hospital Universitari (Sabadell, Catalonia, Spain). We obtained admission and discharge HoNOSCA scores for the patients, their parents or legal guardians, and their clinicians. We recruited 99 patients over the study period (January 2015 to December 2017), 11 of which were lost to follow-up. Among the remaining 88, we found significant improvement in HoNOSCA scores from admission to discharge. Agreement between the HoNOSCA scores for the three different groups of evaluators (patients, parents/legal guardians, and clinicians) was weak at admission but better at discharge. In general, evaluations from patients and their parents or legal guardians had lower HoNOSCA scores (indicating a better mental health status) at admis-sion compared to those from clinicians. At discharge, however, the scores were more homogenous across the three groups of stakeholders. Use of HoNOSCA allows for routine evaluation of mental health outcomes in the psychiatric day hospital setting from the perspective of pa-tients, their parents or legal guardians, and clinicians.

Complementing clinical cancer registry data with patient reported outcomes: A feasibility study on routine electronic patient-reported outcome assessment for the Austrian Myelome Registry.

ObjectivesRoutinely assessed patient‐reported outcomes (PROs), such as quality of life (QOL), are important to supplement clinical cancer data but requires rigorous implementation. This study aims at depicting the implementation procedure and evaluating the feasibility of routine electronic PRO monitoring (ePRO) for collecting data supplementing the Austrian Myeloma Registry (AMR).MethodsIntegration of ePRO monitoring into clinical routine was planned according to the Replicating Effective Programs framework. QOL data were assessed regularly during treatment and aftercare at the hematooncological outpatient unit at the Medical University of Innsbruck with the EORTC QLQ‐C30/ +MY20 and the EQ‐5D‐5L. Feasibility and usability testing were performed via a multimethod approach.ResultsWithin the first year, 94.4% of the MM patients (N = 142, mean age 65.4, SD 11.8, 60% male) provided 748 PRO assessment time points overall. Patients and clinicians were satisfied with ePRO monitoring and indicated no to little disruption in clinical routine. Patient preference on assessment time points and completion frequency became evident.ConclusionsComplementing the AMR with ePRO data proved to be feasible. Our findings provide useful insights for healthcare providers considering introducing ePRO monitoring to their units for informing clinical registries as well as individualised feedback to patients alike.

Impact of early telephone contact on 3-month follow-up rates following residential drug and alcohol treatment: A randomized controlled trial

Background: Routine outcome monitoring (ROM) is an important component of service provision and qualitity assurance procedures. However, a major logistical and financial challenge for organizations is successfully following up participants once they have left residential alcohol and other drug treatment. The aim of the current study was to assess the impact and effectiveness of an “early” follow-up contact and brief interview on subsequent 3-month ROM follow-up success. Methods: Participants were 800 clients attending specialist residential alcohol and other drug treatment provided by The Salvation Army. As part of routine outcome assessment procedures, all people attending these programs are asked to complete a 3-month follow-up assessment. Participants were randomly allocated either to the early contact condition (i.e., “early” 2-week follow-up contact prior to the 3-month follow-up assessment) or to the control condition (i.e., no “early” 2-week follow-up prior to the 3-month follow-up assessment). The primary outcomes were the proportion of participants who were followed up and surveyed at 3 months. Results: There were significantly higher follow-up rates at 3 months post discharge for participants in the early contact group (55.6%) compared with the control condition (46.1%). Although there were higher rates of 3-month follow-up for participants in the early contact group, rates of successful survey completion were not significantly different between the 2 groups. Conclusions: Including an early 2-week telephone call prior to the 3-month assessment increased the number of participants we were able to follow up at 3 months post discharge but did not improve the rate of survey participation at 3 months. The additional costs associated with this activity and the modest increase in follow-up rates need to be considered prior to organizations investing in these follow-up enhancement activities.

An Exploration of Intervention Augmentation in a Single Case.

Recent work has highlighted that process-outcome relationships are likely to vary depending on the client, yet much work remains to be done in the area of tailoring interventions to a given client. This naturalistic single-case analysis provides an example of augmenting a treatment protocol with "off protocol" relaxation methods, based on routinely collected outcome information to guide shared decision making. Intensive case study analyses were applied to one client with principal generalized anxiety disorder and comorbid major depressive disorder receiving transdiagnostic cognitive-behavioral therapy. The client completed two routine anxiety and depression symptom and functioning scales prior to each session of naturalistic treatment. Time series analyses were applied to the two symptom measures. Among the results, (a) significant linear decreases in anxiety and depression from baseline to posttreatment were observed; and (b) the introduction of relaxation methods had a significant impact on the course of anxiety symptom change. In conclusion, routine outcome assessment can be used to inform intervention augmentation with individual clients. Furthermore, regular assessment is needed to determine if a client may benefit from an alternative set of specific intervention strategies.

The clinical utility of the Personal Questionnaire (PQ): a mixed methods study

The demand to implement routine outcome assessment in mental health care services calls for measures with clinical utility, i.e. feasible to therapists, acceptable to clients and generalizable to settings. An exploratory sequential research design was used to study the clinical utility of an individualized outcome measure, the Personal Questionnaire (PQ). In a qualitative first phase, a focus group of therapists was conducted to guide the development of a survey. In a quantitative second phase, the survey was administered to an international sample of 25 therapists that integrate PQ in routine clinical work. Results suggested that the PQ is perceived as a clinically significant and fairly practical measure, useful not only in assessing outcome but also for various clinical tasks. Furthermore, it is relatively well accepted by clients and generalizable to different clients, clinical approaches and settings. However, therapists gave specific suggestions for increasing the PQ’s clinical utility. Exploring therapists’ perspectives and practices will improve the appropriateness of measures for real-world clinical settings.

The validity, reliability, and responsiveness of the modified Iowa Level of Assistance scale in hospitalized older adults in subacute care

Objective: The objective of this study was to investigate the psychometric properties of the Modified Iowa Level of Assistance scale in hospitalized older adults in subacute care.Design: A cohort, measurement-focused study.Participants and setting: Fifty-eight older adults, aged 65 years and older, were recruited from a subacute rehabilitation hospital.Methods: Inter-rater reliability was established by having two physiotherapists independently assess each participant within 24-h of each other. Construct validity was established using “known-groups” validity, while concurrent validity was also examined by correlating modified Iowa Level of Assistance scores with the Elderly Mobility Scale. Responsiveness was assessed by examining the difference in modified Iowa Level of Assistance scores from admission to discharge.Results: The mean age of participants was 82.8 years (SD 7.5; range 68–97). The modified Iowa Level of Assistance scale was found to be reliable, valid, and responsive in this sample of hospitalized older adults. It had excellent inter-rater reliability (intraclass correlation coefficient [2,1] 0.96; 95% confidence intervals (CI) 0.93, 0.98) and no systematic differences across the range of scores. The scale displayed a mean difference between two known groups of 11.4 points and correlated significantly and negatively with the Elderly Mobility Scale (Spearman’s rho − 0.90). The modified Iowa Level of Assistance score also changed significantly over the course of the hospital admission with an effect size of 1.2.Conclusions: The modified Iowa Level of Assistance scale is a valid measure with excellent inter-rater reliability in hospitalized older adults. It is responsive to functional change during hospital admission and may be useful for routine outcome assessment for hospitalized older adults in subacute care.Implications for RehabilitationThe mILOA scale is a valid, reliable, and responsive outcome measure that can be used to quantify the gait and mobility impairments in hospitalized older adults in subacute care.For optimal reliability and responsiveness, consistent administration of the mILOA scale will be required particularly for higher level mobility tasks such as negotiating a step.

Evaluating outcome of prophylaxis in haemophilia: objective and self-reported instruments should be combined.

Routine outcome assessment of prophylaxis should use validated tools, while balancing comprehensiveness and burden. Collecting overlapping information should be avoided. To assess correlations between different outcome assessment tools in haemophilia. From an international cross-sectional study, data on objective outcome (Haemophilia Joint Health Score (HJHS 2.1, range 0-124), radiological Pettersson score) and self-reported joint bleeding, Haemophilia Activities List (HAL, range 100-0), health-related quality of life (SF-36, including five physical and five mental domain scores, range 100-0), and Utility (SF6D and EQ-5D, range 1.0-0) were extracted. Spearman's correlations were calculated: ≥0.8 very strong, 0.60-0.79 strong, 0.40-0.59 moderate. Ninety patients with severe haemophilia, on prophylaxis since median age 3.4 years, were evaluated at median 25.5 years (range 16.0-37.6). Objective outcome was favourable (median HJHS 2.1 6 points, Pettersson score 9 points). Self-reported outcome showed a median of 7 joint bleeds in 5 years, median HAL sum 96 points, high scores for physical domains of SF-36 (median 80-95) and high Utility values (median SF6D 0.87; EQ-5D 0.84). Physical examination (HJHS 2.1) showed strong correlation with radiological scores, moderate correlation with physical domains of the SF-36 and Utility, but no correlation with self-reported bleeding or limitations in activities (HAL). Bleeding was not associated with any other outcome parameter. The HAL was only correlated with the SF36 'Physical functioning' domain. For the evaluation of patients on early prophylaxis, information on bleeding should be complemented by objective joint assessment as well as self-reported limitations in activities and quality of life.

The Brief Symptom Inventory and the Outcome Questionnaire-45 in the Assessment of the Outcome Quality of Mental Health Interventions.

Self-report questionnaires are economical instruments for routine outcome assessment. In this study, the performance of the German version of the Outcome Questionnaire-45 (OQ-45) and the Brief Symptom Inventory (BSI) was evaluated when applied in analysis of the outcome quality of psychiatric and psychotherapeutic interventions. Pre-post data from two inpatient samples (N = 5711) and one outpatient sample (N = 239) were analyzed. Critical differences (reliable change index) and cut-off points between functional and dysfunctional populations were calculated using the Jacobson and Truax method of calculating clinical significance. Overall, the results indicated that the BSI was more accurate than the OQ-45 in correctly classifying patients as clinical subjects. Nonetheless, even with the BSI, about 25% of inpatients with schizophrenia attained a score at admission below the clinical cut-off. Both questionnaires exhibited the highest sensitivity to psychopathology with patients with personality disorders. When considering the differences in the prescores, both questionnaires showed the same sensitivity to change. The advantage of using these self-report measures is observed primarily in assessing outpatient psychotherapy outcome. In an inpatient setting two main problems—namely, the low response rate and the scarce sensitivity to psychopathology with severely ill patients—limit the usability of self-report questionnaires.

Implementing a routine outcome assessment procedure to evaluate the quality of assistive technology service delivery for children with physical or multiple disabilities: Perceived effectiveness, social cost, and user satisfaction

ABSTRACTThere is a lack of evidence on the effects and quality of assistive technology service delivery (ATSD). This study presents a quasi-experimental 3-months follow-up using a pre-test/post-test design aimed at evaluating outcomes of assistive technology (AT) interventions targeting children with physical and multiple disabilities. A secondary aim was to evaluate the feasibility of the follow-up assessment adopted in this study with a view to implement the procedure in routine clinical practice. Forty-five children aged 3–17 years were included. Parents were asked to complete the Individual Prioritised Problem Assessment (IPPA) for AT effectiveness; KWAZO (Kwaliteit van Zorg [Quality of Care]) and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) 2.0 for satisfaction with ATSD; Siva Cost Analysis Instrument (SCAI) for estimating the social cost of AT interventions. At follow-up, 25 children used the AT recommended. IPPA effect sizes ranged from 1.4 to 0.7, showing a large effect of AT interventions. Overall, parents were satisfied with ATSD, but Maintenance, Professional Services, and AT Delivery were rated not satisfactory. SCAI showed more resources spent for AT intervention compared to human assistance without technological supports. AT may be an effective intervention for children with disabilities. Issues concerning responsiveness and feasibility of the IPPA and the SCAI instruments are discussed with a view to inform routine clinical practice.

Outcomes from Italian community psychiatric services studies.

Outcome measurement, to be valid, reliable, and useful to both program planning and evaluation of interventions, should be based on the principle of multiaxiality (i.e., considering the perspectives of all those involved in the care process, including clinicians, patients, caregivers, users' representatives, third-party payers) and of multidimensionality (i.e., considering an intervention's effect on various dimensions of patients' life, including clinical outcomes such as psychopathology, disability, and needs for care and self-perceived outcomes such as quality of life and service satisfaction). Unfortunately, in Italy, this methodology has not been applied on a large scale. However, some Italian centers with a long-lasting tradition in the area of psychiatric epidemiology have provided evidence that outcome assessment in routine practice is not only sustainable but also advantageous in the medium- and long-term. This article summarizes the results obtained in some of these studies, including three longitudinal studies on the outcome of community psychiatric care promoted by the research group of South Verona, such as the South Verona Outcome Project, the Psychosis Incident Cohort Outcome Study, and the Genetics Endophenotypes and Treatment: Understanding early Psychosis - &bullet; Psychosis: early Intervention and Assessment of Needs and Outcome trial.Implementation of routine outcome assessment can lead-and to a certain extent has already led-to a cultural change among Italian mental health service staff members, to facilitate a) the establishment of a revision-of-practice process, b) greater acceptance of the importance of evidence, and a predisposition to put it into practice.

Expert Consensus on Best Practices for Post–Acute Rehabilitation After Total Hip and Knee Arthroplasty: A Canada and United States Delphi Study

To synthesize professional and patient expertise with available evidence to recommend best practices for post-acute rehabilitation following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA). Two expert panels of clinicians, researchers, and patients from Canada and the US participated in a 3-round, online Delphi survey. Consensus was reached on 22 THA and 24 TKA best practice key statements. Recommendations common to both procedures included the need for supervised rehabilitation interventions provided by trained health professionals early after discharge from the acute care setting to optimize patient outcomes. Personal and environmental contextual factors were identified as influencing the process and outcomes of THA and TKA rehabilitation. Routine outcome assessment was recommended and several standardized outcome tools identified. Short-term followup care in the first 2 years postsurgery was recommended for both procedures. Specifics on timing, rehabilitation providers, need for long-term followup, and interventions differed for THA and TKA. Some recommendations received different levels of support based on the type of panelist (patient, physical therapist, surgeon), professional role (clinician, researcher), and/or country. A rigorous consensus method led to key recommendations for post-acute rehabilitation after primary THA and TKA for OA, which together with available evidence and acknowledgment of contextual factors will inform the development of clinical practice guidelines. This is an important step toward reducing practice variation, closing the evidence-practice gap, and improving the quality of rehabilitation services after THA and TKA.

Defining multiple criteria for meaningful outcome in routine outcome measurement using the Health of the Nation Outcome Scales

Using the reliable and clinically significant change approach, we aimed to identify meaningful outcome indicators for the Health of the Nation Outcome Scales (HoNOS) and to combine them in a single model. We applied these indicators to the 1-year outcome of two large samples of people attending community mental health services in Italy (cohort 1) and the Netherlands (cohort 2). Data were drawn from two studies on routine outcome assessment. The criteria for meaningful outcome were defined on both study cohorts and both language versions of the scale. The model combined (a) two criteria for adequate change (at least 4 or 8 points change), (b) two cut-offs for clinically significant change (a total score of 10 was the threshold between mild and moderate illness, 13 between moderate and severe illness), and (c) a method for classifying stable subjects in three degrees of severity (stable in mild, moderate or severe illness). Results were compared with those given by the effect size (ES) and analysis of variance and covariance (ANOVA and ANCOVA). For the proposed approach the outcome of cohort 1 was better than cohort 2, with 65-67% of its subjects showing a positive outcome compared to only 45-46%. The other reference methods (ES and ANOVA), however, showed a greater improvement for cohort 2. ANCOVA indicated that the differences were due to regression to the mean (RTM) which showed opposite effects across the two cohorts. The proposed approach proved valuable and generalizable for interpreting outcome on HoNOS, scarcely influenced by the RTM effect. Its introduction could benefit outcome evaluation and management.

Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions

This article reviews the benefits, obstacles, and challenges that can hinder (and have hindered) implementation of routine outcome monitoring in clinical practice. Recommendations for future routine outcome assessment efforts are also provided. Spanning three generations, as well as multiple developed tools and approaches, the four authors of this article have spent much of their careers working to address these issues and attempt to consolidate this learning and experience briefly here. Potential “elephants in the room” are brought into the discussion wherever relevant, rather than leaving them to obstruct silently the field's efforts. Some of these topics have been largely ignored, yet must be addressed if we are to fulfill our promise of integrating science and practice. This article is an attempt to identify these important issues and start an honest and open dialogue.

Implementing validated routine outcome assessment in psychiatry: a field study

Implementing validated routine outcome assessment in psychiatry: a field study

Universal Health Outcome Measures for Older Persons with Multiple Chronic Conditions

Older adults with multiple chronic conditions (MCCs) require considerable health services and complex care. Because the persistence and progression of diseases and courses of treatments affect health status in multiple dimensions, well-validated universal outcome measures across diseases are needed for research, clinical care, and administrative purposes. An expert panel meeting held by the National Institute on Aging in September 2011 recommends that older persons with MCCs complete a brief initial composite measure that includes general health; pain; fatigue; and physical health, mental health, and social role function, along with gait speed measurement. Suitable composite measures include the Medical Outcomes Study 8 (SF-8) and 36 (SF-36) -item Short-Form Survey and the Patient Reported Outcomes Measurement Information System 29-item Health Profile. Based on responses to items in the initial measure, short follow-on measures should be selectively targeted to symptom burden, depression, anxiety, and daily activities. Persons unable to walk a short distance to assess gait speed should be assessed using a physical function scale. Remaining gaps to be considered for measure development include disease burden, cognitive function, and caregiver burden. Routine outcome assessment of individuals with MCCs could facilitate system-based care improvement and clinical effectiveness research.

Outcome measurement in adult Indigenous mental health consumers

Little is known about the performance of outcome instruments with consumers of different cultural backgrounds. We report a study of using routine outcome measures with Indigenous adult mental health consumers, whereby mental health clinicians used two leading Australian measures with consumers who self-identifi ed as Indigenous. Mean scores on most items were different from the predominantly non-Indigenous national averages; some, particularly those assessing accommodation and occupation, were worse while others (those assessing depression) were better. Scores were consistently worse when more informants were involved in the assessment. A set of good practice principles for the use of standardized measures with Indigenous consumers was developed. They recommend using informants whenever possible, ratings should objectively refl ect underlying disadvantage and behaviours that are not sanctioned or accepted within the local culture, but not phenomena that are socially or culturally accepted. Despite the advice and training, most assessments did not involve additional informants. The (mainly non-Indigenous) clinicians mostly indicated no additional diffi culty in using the outcome measures with the Indigenous consumers, although clinicians reported greater diffi culty in completing them when additional informants were present. In 52% of assessments, clinicians felt that the scales refl ected the consumer’s problems reasonably, and in 22%, well. Perceived validity was positively associated with consumer engagement. The study provides qualifi ed support for the practice of using the HoNOS and LSP for routine outcome assessment with Indigenous consumers. The main provisos are that clinicians need to maximize the engagement of consumers and try to ensure involvement of additional informants to reduce the chances of invalid assessments.

Outcome Measurement in Adult Indigenous Mental Health Consumers

Little is known about the performance of outcome instruments with consumers of different cultural backgrounds. We report a study of using routine outcome measures with Indigenous adult mental health consumers, whereby mental health clinicians used two leading Australian measures with consumers who self-identifi ed as Indigenous. Mean scores on most items were different from the predominantly non-Indigenous national averages; some, particularly those assessing accommodation and occupation, were worse while others (those assessing depression) were better. Scores were consistently worse when more informants were involved in the assessment. A set of good practice principles for the use of standardized measures with Indigenous consumers was developed. They recommend using informants whenever possible, ratings should objectively refl ect underlying disadvantage and behaviours that are not sanctioned or accepted within the local culture, but not phenomena that are socially or culturally accepted. Despite the advice and training, most assessments did not involve additional informants. The (mainly non-Indigenous) clinicians mostly indicated no additional diffi culty in using the outcome measures with the Indigenous consumers, although clinicians reported greater diffi culty in completing them when additional informants were present. In 52% of assessments, clinicians felt that the scales refl ected the consumer’s problems reasonably, and in 22%, well. Perceived validity was positively associated with consumer engagement. The study provides qualifi ed support for the practice of using the HoNOS and LSP for routine outcome assessment with Indigenous consumers. The main provisos are that clinicians need to maximize the engagement of consumers and try to ensure involvement of additional informants to reduce the chances of invalid assessments.