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Review Article | DOI: https://doi.org/10.31579/2637-8892/241

Measurement Issues in Mental Health

  • Satyendra Nath Chakrabartty *

Indian Ports Association, Indian Statistical Institute, Indian Maritime University

*Corresponding Author: Satyendra Nath Chakrabartty, Indian Ports Association, Indian Statistical Institute, Indian Maritime University.

Citation: Satyendra N. Chakrabartty, (2024), Measurement Issues in Mental Health, Psychology and Mental Health Care, 8(1): DOI:10.31579/2637-8892/241

Copyright: © 2024, Satyendra Nath Chakrabartty. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 11 December 2023 | Accepted: 27 December 2023 | Published: 09 January 2024

Keywords: mental health; likert items; geometric mean; cosine similarity; monotonic; responsiveness

Abstract

The paper discusses limitations of existing self-reported measures of mental health and suggests transforming ordinal item scores to continuous, monotonic scores satisfying desired properties including meaningful aggregation. Here, an item scores with response-categories marked as 1, 2, 3, 4, 5, and so on are combined by [1] transforming to normally distributed scores, [2] angular similarity and [3] function of Geometric Mean (GM) for measuring mental health of  individuals. Each proposed measure avoids selection of weights, scaling and considers all chosen domains, even if they have different correlations with scale scores. Each method can identify poorly performing domains and assess overall improvement/decline of a patient across time. However, changes over time need to be validated with clinical findings. Proposed mental health scores help better comparisons, ranking, classifying and testing of mean and variance for a sample. Approach [3] may be preferred for additional features like constant domain-elasticity, time-reversal test, chain indices.

Introduction

Mental Health (MH), an integral part of general health and well-being is a basic human right (WHO, 2022). Measurement of multidimensional Mental Health is complex because of differences in cultures and social and psychological confounders, methodological limitations of measurement from scales/tests, etc. Psychological, social and behavioral features associated with mental illness vary in conceptualizations and are difficult to measure. Measurement of Mental Health is complex because of its multidimensional nature, differences in cultures and social and psychological confounders, methodological limitations of measurement from scales/tests, etc. Psychological, social and behavioral features associated with mental illness vary in conceptualizations and are difficult to measure. Need for community-based MH systems and services were outlined by World Health Organization (2021). Measurement issues of MH are important for accurate diagnosis, assessing severity; monitoring, tracking path of recovery of both individuals and sample. MH systems and services were outlined (WHO, 2022). Measurement issues of MH are important for accurate diagnosis, assessing severity; monitoring, tracking path of recovery of both individuals and sample. Attempts to measure outcomes of MH frequently using International standards for diagnosis of mental illnesses are: International Classification of Disease version 10 (ICD-10) and Diagnostic Statistical Manual version 5 (DSM-V).  However, DCM–V contains heterogeneous diagnostic categories since pragmatic criteria undermine the diagnostic model (Kate et al. 2019). Structured Clinical Interview for DSM-IV and Best-estimate consensus diagnoses showed poor agreements and use of diagnostic interviews in clinical contexts are questionable (Kvig  and Nilssen, 2023).Major purposes of such tools are to identify cases, screen those at risk of developing mental disorder and monitor the progress, classify, compare and rank individuals and also to track impact of interventions/ treatments. While diagnostic tools assess clinical symptoms involving clinical interviews and multi-expert assessments, screening tools attempt to assess severity of a mental health disorder and track changes of one or a group of patients or response to treatments.

Commonly used tools to assess MH include:

  • Self-reported Likert or Numerical rating scales (NRS) for psychiatric diagnoses or psychiatric medications
  • Rigorous psychiatric interview by trained psychiatrist or clinical psychologist

Self-assessed scales and interviews cover a limited range of problems like anxiety and depression and may not capture isolated, short-lived cases or mild-cases requiring early treatments.. Major concerns are scoring based on nature of data generated from such MH measuring tools and non-satisfaction of properties like monotonically increasing continuous scores along with their responsiveness, reliability, sensitivity, specificity, etc. Significant variations in the questionnaires for 16 common depression identification tools were found (Williams et al. 2002).

The paper aims at reviewing limitations of existing self-reported measures of mental health and suggesting transformations so that the transformed scores facilitate meaningful application of operations and satisfy desired properties of measurement.

Literature survey:

Tolls for assessing MH differ in terms of number and format of items, scoring methods, dimensions considered viz. clinical (depression, anxiety, schizophrenia, etc.) and social (social support, etc.), and are not comparable. For example, 109 different measurement tools in health literature were identified for social isolation only (Cordier, 2017). Illustrative assessment tools along with their uses, features and observations are given in Table-1.

Table 1: Illustrative Assessment Tools

Table 1: Illustrative Assessment ToolsObservations:

Most of the MH assessing tools use summative scores of Likert items/NRS suffer from following limitations:

  • Unequal and unknown distance between levels (Rutter and Brown, 2017)
  • Assumes equal weight to items and dimensions despite different item-total correlations, factor loadings, etc.
  • Strictly speaking, arithmetic mean is not defined for ordinal scales and  is meaningless. Use of mean and SD for ordinal scales was disfavored (Liu et al. 2005).
  • Different responses to different items can generate the same summative score for several respondents and cannot discriminate the respondents with tied score.
  • Mean and variance tend to increase with increase in number of levels. Estimated mean is more influenced by number of response-categories, than the underlying variable (Wu, 2007).
  • Likert scales with 2-point, 3-point, and 4-point items performed poorly on reliability, validity and discriminating power (Jamieson, 2004).
  • Zero as an anchor value lowers mean, variance and distorts skew, kurtosis of scales and does not permit computation of expected value as product of value and probability of the value. Too many zero responses to an item artificially lower correlation with that item.

Possible solutions:

  1. Convert scores of Likert items with equal number of response-categories, to ratio scale using frequencies of levels to get continuous, equidistant and monotonic scores (Chakrabartty, 2020).
  2. For items with different number of response-categories, transfer raw item-wise scores ensuring satisfaction of equidistant property, followed by normalizing and further rescaling to a desired range and combining such scores to obtain test scores which are normally distributed (Chakrabartty, 2020).

Major limitations of Kappa and weighted Kappa or kappa reliability coefficient as used in K 6 and K 10 to find degree of agreement among the raters are:

  • A low kappa does not imply low agreement (Chakrabartty, 2019 ; Bajpai et al. 2015) Confidence interval for Kappa may be surmised as large volume of incorrect evaluation of data (Simundic, 2008).  For ordered categories, methods of deciding weights for weighted kappa vary and may give different values of weighted kappa.
  • Concept of agreement in terms of Kappa or weighted kappa and concept of reliability of test/scale are different. No measure for inter-rater reliability is in line with definition of reliability as ratio of true score variance and observed score variance.

Other Limitations:

SF-36 was negatively correlated with GAD 7 and PHQ, presumably due to different domains measured by each of them. Multi-domains MH tools give equal importance to the domains. Such equal importance or no weights amounts to a compensatory approach, without differentiating essential and less important domains. As a result, low score of one domain gets countered by a high score of other domain. Theoretically, the domains may be given weights (considering relative importance of domains) and take MH score (Y) as a weighted sum. Here, ‘trade-off’ between a pair of domains since  is the amount of domain-2 that needs to be sacrificed to gain an extra unit of domain-1. Weights from Principal Component Analysis (PCA) poorly weigh those items which do not have strong correlations with Y, even if they are theoretically and practically important. Thus, PCA ignores judgments as to what are important. Assumptions of PCA include relatively homogeneous large sample size, normality of item scores, etc. If one variable has a SD which far exceeds the rest the variable, it will dominate the first eigenvector. Moreover, PCA weights vary over time and space and thus comparisons become difficult. No weighting system is above criticism (Greco et al. 2019).  Similarly, there is no perfect aggregation scheme.

Possible solution:

Multi-dimensional MH score (Y) may be defined by cosine similarity between the two vectors showing domain scores of the current period and base period or by geometric mean (GM) of ratios of current domain scores and respective domain score for the base period, to accommodate all relevant domains and facilitate computation of Y for an individual and also for a group of individuals.

Proposed methods:

Ignoring the issues of selection of indicators, following methods are proposed for measurement of multi-dimensional MH score (Y) avoiding scaling of raw data and choosing weights.

Pre-processing of data:

  • Assign 1, 2, 3, 4, 5, .. to the response-categories of items avoiding zero which keeps invariant the nature of generated data .
  • Ensure each item is positively related to MH. Take reciprocal of each item whose lower value implies higher MH value.
  • Convert Likert scores to Ratio scale.

Method 1: For Likert items with equal number of response-categories, method suggested by 33 is described below:

Let the raw score of the i-th individual in the j-th item, for and For a 5-point item, 1, 2, 3, 4 and 5.

I: For i-th item find positive weights (which are different for different levels and satisfying the equidistant condition i.e. forms an Arithmetic Progression. A positive value of the common difference will ensure

One way to find such weights are:

i) Let be the frequency of i-th item for the j-th level. For each item, find maximum         (and minimum frequency (

ii) Find proportions . Note, = 1.

iii) Put initial weights. Find the common difference  .

Define; and

Here, and .

iv)  Get final weights =  so that

Weighted sum of raw scores gives equidistant scores (E) and provides meaningful arithmetic aggregations. 

II:  Normalize the scores obtained at I by

III: Take further weights to items to satisfy additional property of making the test scores equi-correlated with the items i.e. equal item reliability and thus justify addition of such converted item scores.

Method 2: For Likert scale consisting of subtests consisting of 3-point, 4-point, 5-point, 6-points items.

I: Consider all 3-point items in sub-test 1. Similarly, constitute sub-tests 2, 3, 4 and 5 by considering respectively all 4-point, 5-point, 6-point7-point items and repeat Stage I of Method 1separately for each sub-test.

II: Take Z- scores for each item. For the i-th item,    Sub-test score as a sum of item scores will also follow

III:  Convert Z-score of an item to in the range say [1, 100], by:

  + 1

Distributions of item scores for each K-point scale will be normal. However, range of sub-test scores as sum of converted item scores may vary. Variance of sub-test scores will also vary depending on correlations between pair of items.

IV: To have same distribution of different sub-test scores, further transformation may be used as follows:

Modified (

Modified test scores for each K-point scale will be Thus, the K-point subtests for various values of K could be considered as Equivalent Forms having features of parallel tests.

Methodology:

For one-dimensional tools:

Use Method 1 to find Y for a tool which is one-dimensional. For multi-dimensional tool, find scores of a domain consisting of Likert items by the above said method. Such scores of one-dimensional tools or domain scores are continuous satisfying equidistant property with a fixed zero point and has the following advantages:

i. Higher value indicates higher value of MH or domain score

ii. Generate monotonic scores since choice of j-th level will result in higher score than the choice of (j-1)-th level for any item for j =2, 3, 4, 5

iii. Rank a group of patients uniquely avoiding ties unlike the usual summative scores.

iv. Possible to find  sample mean and SD  for a group of patients.

v. If denotes  severity of the i-th patient in t-th time period,  then will indicate percentage of  progress/deterioration registered by the i-th patient in t-th time in comparison to (t-1)-th time period i.e. responsiveness of the scale.

For multi-dimensional tools:

Let be the matrix for m-persons and n-domains where each row vector = represents scores of n- domains in the current period of a person. Here, have been obtained after the data pre-processing presented above. Let corresponding base period vector is  =. Let 

Discussion:

(1) and (2) are simple, avoid scaling and selection of weights. Each of (1) and (2) may be multiplied by 100 for general convention. Each measure satisfies the following:

  • Reflects overall improvement/decline of a person across time by a continuous function which increases monotonically showing responsiveness of measurement of MHHH
  • Independent of change of scale
  • Reduced substitutability among the domains; not affected much by outliers and satisfies the principle of population replication (Herrero et al. 2010)
  • Can be computed for properly defined sub-groups say gender, socially and economically backward groups, elderly people with specific morbidity, etc.
  • Possible to compute mean and variance of MH score for a group of individuals.
  • Individuals may also be compared in terms of progress made from base period or on Year-to-Year basis

(2) has additional features like:

  • 1% increase in increase in Y if all others remain unchanged.
  • Critical domains are those for which or 
  • Relative contribution of the domains to Y can be quantified easily.
  • Satisfies Time-reversal test since.
  • Possible to form chain-indices since Chain-indices help to draw path of improvement/decline since the base period.

Thus, the proposed method in terms of (2) with higher desirable properties is an improvement over the existent measures.

Conclusions:

After reviewing major limitations of measuring mental health, the paper proposed methods of converting item-wise ordinal Likert scores to normally distributed scales, with equal and different number of response-categories for arithmetic aggregation of item scores. For combining domain scores, the paper proposed two indices in terms of angular similarity and function of Geometric Mean (GM) for measuring mental health. Each measure is non-parametric, simple, avoids scaling or finding weights or reduction of dimensionality and considers all chosen domains and indicators. Scores generated by each of the method were continuous, monotonic and assess progress/deterioration of a patient across time. Each depicts overall improvement or decline of a patient or a sample of patients in the current year with respect to base year or on Year-to-Year basis and facilitates better comparison, ranking, classification and assessing paths of progress. However, changes over time need to be validated with clinical findings. Measure based on of angular similarity and function of GM reduce level of substitutability among the indicators, not affected much by outliers and satisfies the principle of population replication. Both satisfy desired properties like monotonically increasing continuous function, assessment of responsiveness, which in turn helps drawing of path of improvement/decline over time. It is possible to compute mean and variance of mental health for a group of persons. Normality helps in estimating/testing population parameters.

Each proposed measure can be used to find mental health scores (Y) of a uni-dimensional tool or domain scores for multi-dimensional tool. GM approach is preferred for its additional features like linearity between gain in a domain and gain in mental health, time-reversal test, easy identification of critical areas requiring attention and contribution of the domains/indicators to the mental health.

Simulation studies with multi dataset to explore issues relating to dimensionality and rank robustness of tools and to find distribution of and relationship between  are suggested for future studies.

Declarations:

Funding details: No funds, grants, or other support was received

Conflicts of interest/Competing interests: The author has no conflicts of interest to declare

Ethical approval: Not applicable since the paper does not involve human participants.

Consent of the participants: Not applicable since the paper does not involve data from human participants

Data Availability statement: The paper did not use any datasets

Code availability: No application of software package or custom code

Authors' contributions: Sole Author

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Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

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Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

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Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

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Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

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Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

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Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

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S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

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Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad